Every finding on record at Christian City Rehabilitation Center

Based on observations, staff interviews, and a review of the facility's policy titled Labeling, Dating, and Storage and Pot/Pan Washing and Sanitation the facility failed to properly store, label, date, and discard food items. In addition, the facility failed to maintain sanitary conditions with dishes. These deficiencies created a potential risk for 168 out of 171 residents who received an oral diet from the kitchen, increasing their risk of foodborne illnesses.Findings Include:Review of the facility's policy titled Labeling, Dating, and Storage, dated 11/11/2022, documented in Procedures 1. Food and beverage items will have an identifying label as well as a received date and opened date, as applicable; for items prepared onsite, a 'use by' date will also be indicated. 2. Foods will be stored in their original or approved container and, if opened, shall be wrapped tightly with film, foil, etc.Review of facility's policy titled, Pot/Pan Washing and Sanitation, dated 10/20/2025, documented in Procedures Inspect for cleanliness and store pots and pans inverted in a clean, dry, protected area. Keep pots and pans area clean and free of clutter.During the initial kitchen tour on 08/04/2026 at 8:52 AM, revealed on the bread rack two opened 20 oz. loaves of honey wheat bread and roughly 50 counts of croissants without labeling or dating. The Regional Director confirmed the count and the presence of open, unlabeled food items. Observation of the refrigerator revealed two large-size plastic containers of raw, unthawed chicken with a single date of 08/03/2026. In addition, (77) 1 oz. sour cream packs with an expiration date of 07/27/2026. The Regional Director confirmed approximately 96 pieces of chicken and the 77 expired packs of sour cream.During kitchen follow-up on 08/05/2026 at 12:06 PM, it was observed during the lunch meal tray pass that several plates stacked in the plate warmer, which the cook had placed on the tray line, were wet. The Regional Director randomly selected plates from the right side of the two-holder plate warmer and found five plates with a wet substance on them.Observation on 08/06/2026 at 8:52 AM revealed cook HH without a beard guard, with the oven open and operating a stacked double oven. At 8:55 AM, Dietary Aide (DA) FF was observed entering the kitchen without proper hand hygiene or a beard guard, walking throughout the kitchen, and retrieving liquid hydration.On 08/06/2026, at 9:32 AM, an interview was conducted with DA FF, who confirmed that he had not washed his hands, was not wearing a beard guard, and entered the kitchen to access liquid hydration for his medication.On 08/06/2026, at 9:51 AM, an interview was held with [NAME] HH, who confirmed that he had gone to the bathroom. When he returned, he noticed the back station lacked beard guards and took a moment to check the ovens before retrieving one.On 08/06/2026, at 9:57 AM, an interview with the Dietary Manager (DM) revealed that all staff members are mandated to check food labels, dates, and open-and-discard dates. The DM stated that all prepared foods should display both a preparation date and a use-by date; however, [NAME] HH is new and is not yet accustomed to the long-term facility environment. The DM also disclosed that the back station of the kitchen may have run out of beard guards, but another station in the front had more beard guards available. Staff typically pass through the kitchen to wash their hands before donning beard guards, but it was confirmed that both parties were engaged in other tasks in the kitchen during the observation without wearing beard guards.

Based on observations, staff interviews, record review, and review of the facility's policy titled Elopement Prevention, the facility failed to implement adequate supervision and elopement prevention measures to safeguard one of three sampled residents (R) (R1). This failure allowed the resident to leave the facility without staff knowledge, resulting in an elopement.On July 23, 2026, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause serious injury, harm, impairment, or death to residents.The facility's Administrator, Director of Health Services (DHS), and Corporate Nurse Consultant were informed of the Immediate Jeopardy (IJ) on July 23, 2026, at 6:05 PM. The noncompliance related to the IJ was identified to have existed on July 16, 2026.Additionally, Substandard Quality of Care was identified with the requirements at 42 CFR 483.25- Quality of Care (F689 (S/S): J).An Acceptable IJ Removal Plan was received on July 27, 2026. Based on observation, record reviews, review of facility policies as outlined in the Removal Plan, and staff interviews, it was validated that the corrective plans and the immediacy of the deficient practice were removed on July 27, 2026. The facility remained out of compliance while the facility continues to develop and implement a Plan of Correction (POC). This oversight process includes analyzing the facility's staff's conformance with the facility's policies and procedures related to ensuring resident safety, including care plan review and interventions, risk assessments, resident checks, and maintaining functional locking doors.The Immediate Jeopardy was related to the facility's noncompliance with the program requirements as follows: F689: S/S: J, F835: S/S: J. The Immediate Jeopardy was validated as removed on July 27, 2026, and the following Scope and Severity were downgraded: F689: S/S: D, F835: S/S: D. Findings include:Review of the policy titled Elopement Prevention, Last Revised May 6, 2025, documented Policy: The center has the responsibility for the care and safety of its residents. At the same time, the residents have the right to free access to their private residential area, all center common areas including outdoor spaces, and (excluding the Memory Support Unit) has the right to leave the assisted living campus at will. The center's care partner team members shall be vigilant in its care and supervision of all residents, especially those deemed as vulnerable, such as those who are confused or require assistance with tasks due to a physical or medical condition. Residents of the center with cognitive deficits which place them at risk for elopement or engaging in unsafe wandering, will be referred for residency in the Memory Support Unit, where applicable, or for transfer/discharge to an environment secure enough to accommodate their needs.Review of the Electronic Medical Record (EMR) revealed that R1 was admitted on [DATE] with diagnoses of, but not limited to, Alzheimer's disease, dementia in other diseases classified elsewhere, psychotic disturbance, mood disturbance, and anxiety.Review of the admission Minimum Data Set (MDS) for R1 dated 7/13/2026 revealed a Brief Interview for Mental Status (BIMS) of 3, indicating severe cognitive impairment. Section E: Has the resident wandered? Behavior of this type occurred 1 to 3 days. Does the wandering place the resident at significant risk of getting to a potentially dangerous place (e.g., stairs, outside of the facility)? Yes. Section GG: Walk 150 feet: once standing, the ability to walk at least 150 feet in a corridor or similar space, supervision or touching assistance. Walking 10 feet on uneven surfaces: The ability to walk 10 feet on uneven or sloping surfaces (indoor or outdoor), such as turf or gravel, not attempted due to medical condition or safety concerns.Review of the admission Elopement Risk Assessment for R1, dated 7/13/2206, revealed that R1 was assessed to be at high risk for elopement.Review of the facility incident report documented that on 7/16/2026, R1 was seen at 3:30 AM in his room by a Certified Nursing Assistant (CNA). The receptionist last saw the resident at 4:30 AM sitting in the front lobby. At 5:45 AM, staff were unable to locate R1. The elopement protocol was initiated at 6:10 AM. R1 was located at approximately 7:10 AM by Licensed Practical Nurse (LPN) AA three miles away from the facility.Review of a facility-provided document, dated 7/16/2026, revealed that the Unit Manager (UM) was instructed to place a wander guard on the resident and prepare to move him to the Memory Unit. Further review revealed that the Administrator's instructions had not been followed and the UM was terminated from employment.Review of a facility-provided document, dated 7/20/2026, from Front Desk Receptionist 1T documented that on 07/16/2026 a man came downstairs and sat in the lobby at approximately 4:00 AM. At approximately 4:30 AM, Front Desk Receptionist 1T stepped outside through the front door for a break and was unaware that the resident had gone out the door after her. Further review revealed Front Desk Receptionist 1T was unaware he was an elopement risk.Interview on 7/22/2026 at 5:00 PM, the Administrator stated there was no picture of R1 in the elopement book at the receptionist's desk until after his elopement.Review of the Police Report dated 7/16/2026 at 7:31 AM documented that the Police Department arrived at the facility, was met by CNA 1R, and spoke with LPN 1S regarding the missing resident. While on the scene, the officer was advised that a facility staff member had located the resident on the {highway name}.Interview on 7/22/2026 at 11:42 AM, the Director of Nursing (DON) revealed that the Memory Unit was always locked. He stated that a few residents tended to wander toward the doorway and that they also had Wander Guard devices on. He revealed that an elopement assessment was performed on admission and that a dementia diagnosis helped determine if the resident was suitable for the Memory Unit.Interview on 7/22/2026 at 2:32 PM, the Administrator revealed that when the resident was admitted on [DATE], it was reported to her that he had wandering tendencies. The Unit Manager was instructed to place a Wander Guard device on the resident and move him to the Memory Unit. The Administrator further stated the instructions were not followed, resulting in the UM's termination.Observation on 07/23/2026 at 8:45 AM revealed two sets of automatic doors at the facility's main entrance. Both sets of doors opened automatically, and visitors were not required to sign in.Interview on 7/23/2026 at 9:31 AM, the Administrator revealed that R1 was found by a staff member on {road name} near {highway name}.Interview on 07/23/2026, the Corporate Nurse Consultant revealed that visitation was 24/7 and staff had no way to identify visitors from residents. She stated that visitors could come and go as they pleased.Observation on 7/23/2026 between 11:15 AM and 11:28 AM, a drive on {road name}revealed that after leaving the facility campus, there was no sidewalk. The route revealed a two lane highway with traffic in both directions, with woods, creeks, and ponds along the path. The route led to {highway name}, which was an extremely busy area where electrical surges were present. Additional observation of the surrounding area after exiting the facility property revealed there was no lighting, walking paths, or sidewalks, and the neighboring area was approximately three miles away.Observation on 7/23/2026 at 11:35 AM, upon returning to the facility, both of the facility's main entry doors opened automatically. Residents were observed ambulating in the common area near the facility's entrance and exit doors.Interview on 7/23/2026 at 11:42 AM, Receptionist 1Q revealed she had been with the facility for 11 months as a receptionist. She stated that the entrance doors were open 24/7.Interview and observation on 7/23/2026 at 4:38 PM, the Maintenance Assistant LLLL stated that there was no delay mechanism on the facility's main entry door. He reported that he conducted daily rounds on the doors each morning. He confirmed that the main entry door remained open and that a Wander Guard system was not connected to the door to provide an alarm if a resident attempted to exit. The Maintenance Director approached the doors with an active Wander Guard device, and the door did not alarm. The Maintenance Director stated that the facility was in the process of implementing a system to address the issue.

Based on observations, staff interviews, and reviews of the Administrator and Director of Nursing (DON) Job Descriptions, the facility administration failed to manage the facility in a manner that protects residents and safeguards them from elopement. Specifically, the administration was aware that the front entry door did not have an operational Wander Guard system to ensure residents at risk for elopement were protected. Despite this known hazard, corrective measures were not implemented. Resident (R) (R1) was placed in imminent danger due to the facility's failure to implement interventions for R1 upon admission. As a result, R1 was able to exit the facility unsupervised, exposing the resident to serious injury, harm, or death.On July 23, 2026, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause serious injury, harm, impairment, or death to residents.The facility's Administrator, Director of Health Services (DHS), and Corporate Nurse Consultant were informed of the Immediate Jeopardy (IJ) on July 23, 2026, at 6:05 PM. The noncompliance related to the IJ was identified to have existed on July 16, 2026. Additionally, Substandard Quality of Care was identified with the requirements at 42 CFR 483.25- Quality of Care (F689 (S/S): J).An Acceptable IJ Removal Plan was received on July 27, 2026. Based on observations, staff interviews, record reviews, and review of facility policies as outlined in the Removal Plan, it was validated that the corrective plans and the immediacy of the deficient practice were removed on July 27, 2026. The facility remained out of compliance while the facility continues to develop and implement a Plan of Correction (POC). This oversight process includes analyzing the facility's staff's conformance with the facility's policies and procedures related to ensuring resident safety, including care plan review and interventions, risk assessments, resident checks, and maintaining functional locking doors.The Immediate Jeopardy was related to the facility's noncompliance with the programrequirements as follows: F689: S/S: J, F835: S/S: J. The Immediate Jeopardy was validated as removed on July 27, 2026, and the following Scope and Severity were downgraded: F689: S/S: D, F835: S/S: D. Findings included:Review of the Administrator Job Description, modified 12/16, revealed that the Administrator directs day-to-day functions of the nursing center in accordance with current federal, state, and local regulations that govern long-term care centers, and as may be directed by the Area [NAME] President, to provide appropriate care for our patients/residents.Review of the Director of Nursing Job Description, modified 12/16, documented that the DON plans, organizes, develops, and directs the overall operation of our Nursing Services Department in accordance with current federal, state, and local regulations governing our nursing center, and as directed by the Administrator and the Medical Director, to provide appropriate care.The facility failed to implement adequate supervision and elopement prevention measures to safeguard one of three sampled residents (R) (R1).Cross Reference: F689Review of the facility incident report documented that on 7/16/2026, R1 was seen at 3:30 AM in his room by a Certified Nursing Assistant (CNA). The receptionist last saw the resident at 4:30 AM sitting in the front lobby. At 5:45 AM, staff were unable to locate R1. The elopement protocol was initiated at 6:10 AM. R1 was located at approximately 7:10 AM by Licensed Practical Nurse (LPN) AA three miles away from the facility.Review of a statement dated 7/20/2026 by the Front Desk Receptionist 1T documented that she was a new employee and stated the resident had been seated in the lobby and walked out after she left for her break around 4:30 AM. She stated she did not recognize him as a resident.Interview on 7/22/2026 at 5:00 PM, the Administrator stated that the facility did not have a picture of R1 in the elopement book at the receptionist's desk until after his elopement.Interview on 7/22/2026 at 11:42 AM, the DON revealed that an elopement assessment was performed on admission for R1 and that a dementia diagnosis helped determine that the resident was suitable for the Secured Memory Unit.Interview on 7/22/2026 at 1:02 PM, the Administrator revealed that R1 went out to the front lobby and asked if he could wait on his friend (between 3:30 AM and 4:30 AM) and was told yes. The Administrator further revealed the front desk receptionist thought R1 was a visitor, and he (R1) got up and left the building. The Administrator revealed that when the resident was admitted on [DATE], it was reported to her that he had wandering tendencies. The Unit Manager was instructed to put a Wander Guard device on the resident and move him to the Secured Memory Unit, and these instructions were not followed.

Based on observations, family and staff interviews, record reviews, and review of the facility's policy titled Care Plans, the facility failed to follow the care plan for one of three sampled residents (R) R1 related to a two-person assist with transfers. This failure caused R1 to suffer a fall while being assisted by one staff member and placed the resident at risk of injury. Findings include:Review of the facility's policy titled, Care Plans last revised 10/21/2025, documented on page 3: the comprehensive care plan should describe the services to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.Review of the Electronic Medical Record (EMR) revealed R1 was admitted to the facility on [DATE] with diagnoses that included but not limited to: Muscle weakness (generalized), Other abnormalities of gait and mobility, Body mass index [BMI] 45.0-49.9, other muscle spasm, and spinal stenosis of cervical region.Review of the most recent Quarterly Minimum Data Set (MDS) dated [DATE] documented in section C that R1 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident had intact cognition.Review of the Care Plan dated 10/29/2025 documented under Activities of Daily Living approaches that R1 required a two person assist for transfers.Review of the Physician orders dated 10/28/2025 documented that R1 should receive physical therapy services six days a week for eight weeks regarding weakness, gait, and mobility.Phone interview with R1's family member on 11/20/2025 at 12:23 pm revealed that R1 suffered a fall on 11/6/2025 due to being transferred by one Certified Nursing Assistant (CNA) and confirmed R1 was initially care planned to receive two person assistance for transfers.Interview on 11/21/2025 at 1:47 pm with CNA AA revealed she has been employed for seven months. CNA AA revealed that when a resident is admitted to the facility, the resident is assessed by the nurses, and the nurses inform the CNAs if a resident is a one person or two person assistance. CNA AA further revealed when a resident needed maximal care, a Hoyer lift is used. CNA AA also stated she reviews the care plan to see if a resident needs one or two people to assist. Interview on 11/21/2025 at 2:28 pm with CNA BB revealed she has been employed with the facility for 9 months. CNA BB stated she reviews the care plan to know if a resident requires one person or two people to assist with transfers. CNA BB revealed if a resident requires more assistance, a Hoyer lift along with a two-person assist is required.Interview on 11/21/2025 at 2:38 pm with CNA CC revealed she has been employed with the facility for three years. CNA CC stated she reviews the care plan to know if a resident requires one person or two people to assist with transfers. Interview on 11/21/2025 at 4:00 pm with the Director of Nursing (DON) and Administrator confirmed CNA DD did not follow the care plan by transferring R1 without the assistance of a second staff member. Both confirmed R1 fell to the floor as a result. Both confirmed R1 was care planned on 10/29/2025 for two-person assistance during transfers.Interview on 11/21/2025 at 4:29 pm with CNA DD confirmed R1 sustained a fall on 11/6/2025. CNA DD stated she was the only staff member assigned to care for R1. CNA DD stated R1 requested a bedside commode so that she could comfortably have a bowel movement. CNA DD stated that she asked R1 to stand with her hands on the bed so that CNA DD could clean her and her legs gave out, and she fell onto her knees. CNA DD stated she immediately called for help and multiple staff came to assist. CNA DD stated it was her understanding that R1 was required to have one CNA to assist with transfers prior to 11/6/2025 and the care plan was updated after the fall on 11/6/2025 to have two people for transfers. CNA DD revealed she reviews the care plan to see if a resident requires one or two person assistance.

Based on family and staff interviews, record review, and review of the facility's policy titled, Occurrences, the facility failed to provide assistance to prevent a fall for one of three sampled residents (R) (R1) assessed for falls. This deficient practice had the potential to cause injury to the resident. Findings include:Review of the facility's policy titled, Occurrences last revised on 11/17/2025 documented on page 1: Occurrence hazards are physical features in the healthcare center environment which may pose a risk to a patient/resident's safety, including but not limited to any event, accident, or incident, on or off healthcare center property which results in an injury or has the potential for an injury.Review of the Electronic Medical Record (EMR) revealed R1 was admitted to the facility on [DATE] with diagnoses that included but not limited to: Muscle weakness (generalized), Other abnormalities of gait and mobility, Body mass index [BMI] 45.0-49.9, other muscle spasm, and spinal stenosis of cervical region.Review of the most recent Quarterly Minimum Data Set (MDS) dated [DATE] documented in section C that R1 had a Brief Interview for Mental Status (BIMS) score of 15 indicated the resident had little to no cognitive impairment.Review of the Care Plan dated 10/29/2025 documented under Activities of Daily Living approaches that R1 required a two person assist for transfers.Review of the Physician orders dated 10/28/2025 documented that R1 should receive physical therapy services six days a week for eight weeks regarding weakness, gait, and mobility.Review of the progress note dated 11/6/2025 documented for R1 revealed, observed the patient kneeling on her knees at her BS [bedside] with both therapy staff and nursing staff attempting to get her off the floor into bed. A Hoyer lift was used to safely get patient back onto the bed.Review of the progress note dated 11/7/2025 at 10:18 am for R1 revealed, Report for x-rays done on resident when she went down on her knees were completed. The results of her bilateral hips, knees, femur and skull were negative for any fractures or dislocation. Resident, MD [Medical Doctor] and family was notified.Review of the progress note dated 11/7/2025 at 5:01 pm for R1 revealed, Fall/slide to floor Day 2 - Patient has been resting quietly most of shift with no complaints voiced. CNA [Certified Nursing Assistant] making rounds every two hours checking on patient needs and providing care. Two CNAs provide care for bed mobility care. Mobile imaging here this shift to complete imaging. Patient took all medications offered. No sxs [signs or symptoms] of delayed injuries noted related to her slide to the floor incident.Review of the progress note dated 11/8/2025 at 4:44 am by LPN GG revealed, F/u [follow-up] Fall, res in bed resting call light within reach for safety. Incontinent of B/B [bowel and bladder] 2 people assist needed with care. No s/s [signs or symptoms] of discomfort at time, plan of care ongoingPhone interview with R1's family member on 11/20/2025 at 12:23 pm revealed that R1 suffered a fall on 11/6/2025 due to being transferred by one Certified Nursing Assistant (CNA) and confirmed R1 was initially care planned to receive two person assistance for transfers.Interview on 11/21/2025 at 1:47 pm with CNA AA revealed she has been employed for seven months. CNA AA revealed that when a resident is admitted to the facility, the resident is assessed by the nurses, and the nurses inform the CNAs if a resident is a one- person or two-person assistance. CNA AA further revealed when a resident needed maximal care, a Hoyer lift is used. CNA AA also stated she reviews the care plan to see if a resident needs one or two people to assist.Interview on 11/21/2025 at 2:28 pm with CNA BB revealed she has been employed with the facility for 9 months. CNA BB stated she reviews the care plan to know if a resident requires one person or two people to assist with transfers. CNA BB revealed if a resident requires more assistance, a Hoyer lift along with a two-person assist is required.Interview on 11/21/2025 at 2:38 pm with CNA CC revealed she has been employed with the facility for three years. CNA CC stated she reviews the care plan to know if a resident requires one person or two people to assist with transfers. Interview on 11/21/2025 at 2:48 pm with Licensed Practical Nurse (LPN) EE revealed she has been employed with the facility for one year. LPN EE revealed the incident with R1 occurred before she entered the room. LPN EE confirmed R1 was on her knees in a prayer position, and six staff members were in the room attempting to get her back into bed. LPN EE stated R1 was assessed for injuries, and no injuries were reported. LPN EE continued and stated R1 complained of pain in her lower extremities, and imaging was ordered, performed and resulted with no injuries. Interview on 11/21/2025 at 4:00 pm with the Director of Nursing (DON) and Administrator confirmed CNA DD transferred R1 without the assistance of a second staff member, which resulted in R1 falling on the floor. Both confirmed R1 was care-planned on 10/29/2025 for two person assistance during transfers. It was confirmed R1 was discharged from the facility on 11/9/2025 due to respiratory distress and not because of injuries from the fall.Interview on 11/21/2025 at 4:29 pm with CNA DD confirmed R1 sustained a fall on 11/6/2025. CNA DD stated she was the only staff member assigned to care for R1. CNA DD stated R1 requested a bedside commode so that she could comfortably have a bowel movement. CNA DD stated that she asked R1 to stand with her hands on the bed so that CNA DD could clean her when her legs gave out and she fell onto her knees. CNA DD stated she immediately called for help and multiple staff came to assist. CNA DD stated it was her understanding that R1 was required to have one CNA to assist with transfers prior to 11/6/2025 and the care plan was updated after the fall on 11/6/2025 to have two people for transfers. CNA DD revealed she reviews the care plan to see if a resident requires one or two person assistance.

Based on observations, staff interviews, record reviews, and a review of the facility's policy, the facility failed to ensure medication was refilled before the medication ran out and over-the-counter medication was available for one of six residents (Residents (R) 129) observed during the medication administration and two residents (R436 and R98) out of a total of 51 sampled residents. This failure had the potential for adverse effects if medications were not administered due to a lack of timely refills or short supply. Findings include: Review of the facility's policy titled, Ordering Medications from the Pharmacy, revised [DATE], stated The healthcare center will transmit physician orders to the pharmacy using facsimile or other technology in order to receive medications on a timely basis. Facilities with EMAR: All orders will be entered into the system and transmitted to pharmacy. The policy under Reordered Medications (Refills) section stated some of the requirements as follows: Medication orders requiring refill are recorded on a Medication Reorder Sheet. Medication carts should be checked for additional available punch cards prior to reordering. Medications should be reordered four (4) days in advance of need in order to maintain an adequate supply on hand. Schedule II controlled substances should be reordered seven (7) days in advance of need. 1. During a medication administration observation on [DATE] at 9:06 am, Licensed Practical Nurse (LPN) 2 emptied an expired bottle of Nephro-Vite into the biohazard container on the medication cart one. LPN2 stated she would look for a new bottle of Nephro-Vite for R129 from the fourth-floor medication storage room. Observation conducted with LPN2 in the fourth-floor medication storage room revealed that a new bottle of Nephro-Vite was unavailable for R129. LPN2 stated she would hold the Nephro-Vite temporarily and look for it later. During a follow-up fourth-floor medication storage room observation on [DATE] at 9:12 am with Unit Manager (UM) 2, UM2 confirmed that there was no Nephro-Vite available. UM2 stated that if over-the-counter medications were unavailable in the medication storage room, nurses would look for them on other medication carts or in the medication storage room on another floor. 2. Review of R436's undated Face Sheet located under the Resident tab of the electronic medical record (EMR) revealed R436 was admitted to the facility on [DATE] with diagnoses including lung cancer and brain cancer. Review of R436's Medication Administration Report (MAR) located in the Resident tab of the EMR under Report revealed that the nursing staff had not administered medications because the medications were unavailable. Examples include the following: Atorvastatin (for high cholesterol) tablet 20 milligram (mg), give one tablet by mouth at bedtime for long-term drug therapy, start date [DATE]: [DATE] at 9:00 am: Not Administered: Drug/Item Unavailable. Pantoprazole (for acid reflux) tablet, delayed release 40 mg, give one tablet by mouth once a day for long-term drug therapy. Start date [DATE]. [DATE] 9:00 am and [DATE] 9:00 am: Not Administered: Drug/Item Unavailable. [DATE] 9:00 am: Not Administered: Drug/Item Unavailable Comment: Not available. Levetiracetam (seizure medication) tablet 500 mg, give one tablet by mouth twice a day for long-term drug therapy. Start date [DATE]. [DATE] 5:00 pm: Not Administered: Drug/Item Unavailable. Tamsulosin (treats symptoms of enlarged prostate) capsule 0.4 mg, give two capsules by mouth nightly at bedtime for long-term drug therapy. Start date [DATE]. [DATE] at 9:00 am: Not Administered: Drug/Item Unavailable. B Complex w-Vit C: Take one tablet by mouth daily for long-term drug therapy. Start date [DATE]. [DATE] 9:00 am: Not Administered: Other Comment: Other. [DATE] 9:00 am: Not Administered: Drug/Item Unavailable Comment: Y. 3. Review of R98's undated Face Sheet located under the Resident tab of the EMR revealed R98 was admitted to the facility on [DATE] with diagnoses including diabetes, multiple sclerosis (a chronic and unpredictable neurological disorder that affects the brain, spinal cord, and optic nerves). Review of R98's MAR located in the Resident tab of the EMR under Report revealed that the nursing staff did not administer medications because the medications were unavailable. Examples include the following: Tizanidine (muscle relaxant) capsule 4 mg, give one capsule by mouth at bedtime for pain. Start date [DATE]. [DATE] 9:00 pm: Not Administered: Drug/Item Unavailable. [DATE] 9:00 pm: Not Administered: Drug/Item Unavailable Comment: 2525 Venlafaxine tablet extended release 24 hr 150 mg, give one tablet by mouth one time a day for major depressive disorder. Start date [DATE]. [DATE] 9:00 Am, [DATE] 9:00 am, [DATE] 9:00 am, [DATE] 9:00 am, [DATE] 9:00 am, [DATE] 9:00 am, [DATE] 9:00 am, [DATE] 9:00 am, [DATE] 9:00 am, [DATE] 9:00 am, and [DATE] 9:00 am: Not Administered: Drug/Item Unavailable, [DATE] 9:00 am: Not Administered: Drug/Item Unavailable. [DATE] 9:00 am: Not Administered: Drug/Item Unavailable. [DATE] 9:00 am, [DATE] 9:00 am, [DATE] 9:00 am, and [DATE] 9:00 am: Not Administered: Drug/Item Unavailable. During the fourth-floor medication administration observation on [DATE] at 8:42 am with UM2, when asked, UM2 stated if there was no medication available for the resident, the staff would contact the pharmacy first to confirm if the medication would be delivered that day and if not, the facility had an emergency medications machine on the 3rd floor, the staff would go there to get the medication, except for the narcotic control medications. UM2 stated that for the narcotics medication, the nurse needed to call the resident's physician to obtain an order and contact the pharmacy. UM2 said that if the emergency medications machine had no medication, the nurse would contact the resident's physician for further instructions. During the interview on [DATE] at 3:00 pm, the Director of Nursing (DON) reviewed R98 and R436's MARs and confirmed all the medication documentation in the MARs, including the blank areas, documented not administered, or medication not available. During this interview on [DATE] at 3:00 pm, the DON stated it was unacceptable that some of the medications that were not given or not available as documented in the MAR were over-the-counter in-house medications. The DON stated the facility had plenty of them in stock. She expected the nurse to contact the physician if the medication was unavailable or not given.

Based on observations, resident and staff interviews, and policy review, the facility failed to ensure the call devices used were tailored to meet the individual physical needs of the residents and failed to respond promptly to the call system for two residents, (Resident (R) 25 and R238), out of a sample of 51 residents. This failure placed R25 and R238 at risk of experiencing unmet care needs. Findings include: Review of the facility's policy titled, Nursing: Patient/Resident Rights, Accommodation of Needs, revised 12/02/23 stated, It is the policy of this healthcare center to promote and protect the rights of the patients/residents residing in the center. The call light system procedure included the following: .Essentia Points .Unless indicated in the care plan, each patient/resident, when in their room or in bed, must have the call light placed within reach at all times, regardless of staff assessment of patient/resident's ability to use it. When the patient/resident is in bed, the call bell should be fastened to the side rail he/she is facing. When out of bed, call bell is to be draped across the bed, so it is accessible from wheelchair or bedside chair only. 1. Review of R25's undated Face Sheet located under the Resident tab of the electronic medical record (EMR) revealed R25 was admitted to the facility on [DATE] with diagnoses including cerebral palsy (a brain disorder that appeared early childhood and permanently affects body movement and muscle,) contracture to bilateral knees, ankles, and respiratory failure. Review of R25's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/07/25, located in the RAI [Resident Assessment Instruments] tab of the EMR, revealed a Brief Interview for Mental Status (BIMS) score of 10 out of 15 which indicated he was moderately cognitively impaired. During an observation on 04/27/25 at 12:03 PM, R25 was lying on the bed. Both of his arms and hands were contracted and resting on his chest. R25 had a call bell placed about eight inches away from his head on the left side rail. He was unable to reach it. When asked, R25 kept shaking his head to express no that he could not press the call bell to get help, and he kept nodding his head to express yes, that he needed help and O2. During this interview with R25, this surveyor called for Certified Nursing Assistant (CNA) 5 to come to R25's room to assist R25. CNA5 confirmed that R25 did not have the ability to press the call bell and there was no call pad or any other type of call device that R25 could use to ask for help. During an interview on 04/27/25 at 12:05 PM, CNA6 confirmed that R25 had no ability to use the current call bell on his bed and there was no other call device that R25 could use to ask for help. During an observation and interview on 04/28/25 at 4:15 PM, R25 was observed on the bed with his bilateral arms rested on top of his chest outside of the cover. R25 could only move his head and neck. R25's call bell was placed on his bed sheet on top of his left knee location. The unit manager (UM) 5 walked into R25's room and moved R25's call bell from the top of his bed sheet near his left knee to near R25's left side of the bed, near his left side bed rail. When asked if R25 could press that call bell, the UM5 said, No. At the same time, when asked R25 if he could press this call bell, R25 shook his head, expressing that he could not. UM5 said he was not sure if the facility had another type of call device for R25. Observation on 04/29/25 at 9:30 AM, UM5 walked into R25's room and there was no suitable call device R25 could use to call for help. During an interview on 04/29/25 at 02:16 PM, the Director of Nursing (DON) stated that depending on the resident's needs, we could use a call pad or call bell. Observation on 04/30/25 at 8:45AM, walked into R25's room with UM5 and a small palm size call pad was placed under his right forehead. When asked, R25 expressed no by shaking his head that he could not press the new call pad. When asked, R25 showed how he pressed the new call pad. R25 tried to put pressure on the new call pad located under his right forehead head by turning his head to his right side and left trying very hard to hit the call pad, and he could not always hit the small call pad to activate the call light alarm. When R25 finally made the call pad activated by showing a green light on the control panel to the wall at the head of the bed, there was no sound or indicator to alert R25 to stop hitting the call pad. R25 just keep turning his head left and right and trying to activate the call light. 40415 2. Review of R238's diagnosis located under the Profile tab of the electronic medical record (EMR), revealed R238 was admitted to the facility on [DATE] with diagnoses which included blindness in both eyes. Review of R238's Care Plan located in the EMR under the Care Plan tab and last revised 04/21/25, revealed R238 was at risk for falling, due to history of falls, cognitive impairments, decreased safety awareness, required assistance of daily living (ADL) related to impaired mobility, blindness, vascular dementia, pacemaker, difficulty walking, muscle weakness, and incontinence of bowel and bladder. Review of R238's admission MDS with an ARD of 04/21/25 and located under the RAI (Resident Assessment Instrument) tab, revealed R238 had a Brief Interview for Mental Status (BIMS) score of five out of 15, which indicated R238 was cognitively impaired. Further review of this MDS revealed R238 was, vision severely impaired, dependent for eating, and required substantial maximum assist for toileting and personal hygiene. During an observation on 04/28/25 at 9:56 AM, R238 was observed lying in his bed pulling at his briefs stating pee, poo. His call light was lying in the bed to the right of him. When asked if he could push the call light for assistance, R238 did not know where his call light was and was unable to see due to blindness. He patted on the bed, feeling for the call light and was unable to retrieve it or push to call for help. This surveyor pushed the call light at 9:58 AM and at 10:16 AM a Client Transport Aide came to the room and spoke with R238 briefly, then went for assistance. During an observation on 04/29/25 at 2:30 PM, R238 was asleep in his bed, the call light and a hand bell were observed on the nightstand and out of the resident's reach. During an interview on 04/29/25 at 2:16 PM, the DON confirmed that was she not aware that R238 was unable to use his call light and all staff were responsible for answering all lights and ensuring call lights were in reach of the residents and able to use.

Based on observations, resident and staff interviews, and document review, the facility failed to create a homelike environment by ensuring resident rooms were clean or in good repair for four residents (Resident (R) 125, R106, R98, and R56) in the sample of 51 residents. Findings include: Review of the facility's undated Admission Agreement revealed residents' rights: The Facility desires to provide the Resident with a homelike environment. 1. Observation on 04/27/25 at 10:50 AM of R125's room revealed the molding under the wall mounted air unit was peeled back with approximately 15 inches of it protruding into the room and exposing wood underneath. Paint was missing in spots around the bathroom door frame. During an interview on 04/27/25 at 10:50 AM, R125 reported the room did not look homelike. 2. Observation on 04/27/25 at 12:44 PM of R106's room revealed an area of the wall where the outer layer of drywall was missing in patches with the largest two areas measuring approximately six to eight inches by five inches. During an interview on 04/27/25 at 12:45 PM, R106 stated the room was not homelike. It doesn't look nice. During an interview on 04/30/25 at 10:34 AM, the Maintenance Director stated all the rooms were scheduled to be remodeled. The Maintenance Director verified that some areas had not been remodeled and may not look homelike. During an interview on 04/30/25 at 3:40 PM, the Director of Nursing (DON) stated she expected rooms to look homelike and molding to not be sticking out. During an interview on 04/30/25 at 6:33 PM, the Administrator stated the remodeling was expected to start on the fourth floor by the end of May 2025, and to the fifth floor after that, with completion anticipated for the end of the year. 52323 3. During an observation on 04/27/25 at 3:25 PM, R98 and R56's bathroom had a black mold-like color throughout the edge of the ceiling and the cream color tiles on the wall-to-wall edge at the corner facing the bathroom entrance. The bathroom smelled damp and moldy. R98 and R56 both stated the moldy smell was not pleasant, and when they expressed their concerns to the facility care staff, the staff told them they were under renovation on the other floors, and soon the facility will be going to renovate their floor. R89 stated but they did not send any staff to clean it. Observation of R98 and R56's shared bathroom with the housekeeping supervisor (HSKS) and the Maintenance Director (MD) on 04/30/25 at 8:51 AM revealed a white colored mold-like area on the wall near the toilet area just under the ceiling. The HSKS stated that it was about four inches wide, and there were multiple grey/dark water drip marks and brown rusting-like water drip marks on the area between the edge of the ceiling and the wall. The ceiling had three areas that had dried water leak marks. The MD stated the name of the company had recently conducted mold inspection services around end of last year. The Administrator provided a copy of an Invoice from the company, dated 11/21/24 which indicated Mold Remediation-Kitchen and Dining. During an interview with the Administrator on 04/30/25 at 10:33AM, when asked if the mold service was conducted in other areas in the facility outside of the kitchen and dining area. The Administrator stated, No, the company did not inspect the facility's other areas including residents' rooms and bathrooms.

Based on staff interviews, record review, and facility policy review, the facility failed to report allegations of abuse in a timely manner for two (Residents (R) 202 and 197) of six residents reviewed for abuse out of a total sample of 51 residents. This failure that allegations of abuse would not be reported increased the risk for abuse to continue. Findings include: The facility's Reporting of Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property policy, revised 07/29/19, states, The state survey agency and the state agency for adult protective services should be notified in accordance with state law through established procedures of any allegations of abuse, neglect, exploitation or mistreatment including injuries of unknown source and misappropriation of patient property, within 2 hours after the allegation is made if the events upon which the allegation is based involve abuse or result in serious bodily injury . 1. Review of the Face Sheet in the electronic medical record (EMR) Resident tab R202 was admitted to the facility on [DATE] for rehabilitation following a left below the knee amputation. Review of the admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/05/24 revealed R202 had a Brief Interview for Mental Status (BIMS) score of 14 out of 15, indicating intact cognition. Review of a facility reported incident form, dated 12/09/24, revealed that on 12/07/24 at 2:30 AM R202 had a large bowel movement and was assisted with incontinence care by Certified Nursing Assistant (CNA) 10. The report indicated that following the care episode, R202's family member contacted the facility on 12/07/24 after being told by R202 that the CNA10 was rough and rude. Per the report CNA10 spoke with the resident's family member on 12/07/24 and advised in detail that the resident had a large bowel movement, and she took care to be sure to clean the resident thoroughly to avoid the possibility for a urinary tract infection (UTI). Review of the investigation revealed CNA10 did not feel that the family was alleging abuse. Review of a complaint filed by R202's representative revealed that the facility was notified of concerns regarding rough care provided to R202 on the morning of 12/07/24. Per the complaint, the complainant felt the facility did not take their concerns seriously and on 12/08/24 they presented in person to the facility. The complaint indicated that the complainant spoke with Unit Manager (UM) 3 who was to document and report their concerns. UM3 was interviewed on 04/29/25 at 2:10 PM, and she stated that she reported the incident to the Administrator immediately, as with any allegation of abuse. During an interview with the Administrator on 04/29/25 at 1:45 PM, she stated that she reported the allegation as soon as it was reported to her and suspended CNA10 on 12/09/24. She was also asked about her investigation, and she stated that interviews with the resident by law enforcement revealed that R202 felt CNA10 was wiping her aggressively and was unprofessional and cruel but made no mention of abuse of any kind. The Administrator stated that she interviewed CNA10 and LPN7, who was also present during R202's incontinence care. CNA10 disputed being rude or unprofessional and that she never intended to be rough with the R202, but wanted to make sure the resident was clean. LPN7 stated that she did not hear CNA10 say anything unprofessional and did not believe she was being rough with the resident. The Administrator added that she interviewed the other residents on CNA10's assignment and they did not indicate any concerns. Her conclusion was that there was no evidence that abuse occurred. 52323 2. Review of R197's undated Face Sheet located under the Resident tab of EMR revealed R197 was admitted to the facility on [DATE] with diagnoses including acute respiratory failure and encounter for orthopedic aftercare, cognitive communication deficit. R197 was discharged to an assisted living facility on 04/09/24. Review of R197's Grievance/ Complaint Form: Health Center, dated 10/23/24, provided by the Administrator, documented there was a late grievance received by the facility Administrator on 10/23/24 after R197 was discharged on [DATE]. The Grievance form documented the following: wound RP [responsible party] not informed. fall-p't [patient] trapped by male nurse. showers. feeding. weight lost. Resident RP reported issues to [R197's Insurance company name] .forward concerns to facility. Review of R197's Grievance/ Complaint Form: Health Center, dated 10/23/24 under the Summary documented the following: no male was assigned to Resident during stay. Res. (resident) did have fall on 4/21 from bed unwitnessed. So, it was not during care. wt [weight] 191 upon admission appetite . Res feed self. bed baths given. nurse notifies son who was present upon admission of wound status. During an interview on 04/30/25 at 9:47 AM, the Administrator stated on 10/3/24 she received a call from R197's insurance company stating R197's family member filed a list of complaints for abuse and neglect concerns as follows: A male care giver dropped R197 on the floor caused bruise. Someone force fed R194. Lost weight thirty pounds (lb.). Never received a bed bath or shower. Developed a Pressure Ulcer. The Administrator stated that the facility collaborated with R197's insurance company to investigate the case, which was unsubstantiated. When asked about the reporting process for suspected abuse or neglect, the Administrator stated that she would report such incidents to the State immediately. However, in this particular case, since abuse was unsubstantiated and the resident had been discharged from the facility several months ago, she felt there was no need to report it to the state. Instead, she conducted her own investigation and logged the case as a grievance.

Based on staff interviews, record review, and review of Centers for Medicare & Medicaid Services' Long-Term Care Facility Resident Assessment Instrument (RAI), the facility failed to complete a significant change Minimum Data Set (MDS) assessment following a decline in a resident's status for one of eight residents reviewed for a change in condition (Resident (R) 120) out of a total sample of 51 residents. This failure placed the residents at risk for unmet care needs. Findings include: Review of the RAI dated 10/01/24 and located at https://www.cms.gov/medicare/quality/nursing-home-improvement/resident-assessment-instrument-manual revealed a significant change in status MDS assessment must be completed when the IDT [interdisciplinary team] has determined that a resident meets the significant change guidelines for either major improvement or decline. A 'significant change' is a major decline or improvement in a resident's status that: 1. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions, the decline is not considered 'self-limiting'; 2. Impacts more than one area of the resident's health status; and 3. Requires interdisciplinary review and/or revision of the care plan. the nursing home may take up to 14 days to determine whether the criteria are met. Review of the Face Sheet tab of the electronic medical record (EMR) revealed R120 was admitted to the facility on [DATE]. R120 was in the hospital from 02/19/25 to 02/25/25 and had a diagnosis of fracture of unspecified part of the neck of right femur (hip fracture). Review of a quarterly MDS with an Assessment Reference Date (ARD) of 11/28/24 and located in the RAI tab of the EMR revealed R120 received supervision or touching assistance for eating, oral hygiene, toileting, showering/bathing, upper and lower body dressing, hygiene, rolling side-to-side, transferring, and walking up to 50 feet. Review of an Observation Detail List Report dated 02/18/25 and located in the Observations tab of the EMR revealed R120 fell on [DATE] at 2:30 AM in her bathroom. R120's usual ambulatory status was independent. Review of a hospital Discharge Summary dated 02/25/25 and located in the Documents tab of the EMR revealed R120 had a right femoral fracture and underwent surgery on 02/21/25. Review of a quarterly MDS with an ARD of 02/28/25 and located in the RAI tab of the EMR revealed R120 had an impairment in functional range of motion in one lower extremity. R120 required substantial/maximal assistance for eating, oral hygiene, upper body dressing, personal hygiene, and rolling side-to-side. R120 was dependent on staff for toileting hygiene, showering/bathing, lower body dressing, and transfers. R120 was unable to walk. Review of the RAI tab revealed no significant change MDS assessment completed following the fall with hip fracture. During an interview on 04/30/25 at 8:46 AM, Certified Nursing Assistant (CNA) 7 reported R120 required substantial/maximal assistance for upper body dressing with the CNA doing most of the work. R120 was unable to assist much with lower body dressing and required substantial assistance of one or two staff to transfer. During an interview on 04/30/25 at 9:29 AM, Licensed Practical Nurse (LPN) 1 reported R120 was independent and very self-sufficient at the time of her fall. Since the fall, she had declined and mostly stayed in bed and needed staff to assist her with mobility. During an interview on 04/30/25 at 2:24 PM, the MDS Coordinator (MDSC) reported the quarterly assessment with an ARD of 02/28/25 was completed a few days after R120 returned from the hospital. It reflected a decline in activities of daily living (ADLs). R120 had been monitored after the assessment to see if her decline was self-limiting. After the observation period, when she continued to require more assistance, the facility should have completed a significant change MDS. During an interview on 04/30/25 at 3:40 PM, the Director of Nursing (DON) reported she expected completion of a significant change MDS when a resident declined from needing supervision assistance to requiring substantial/maximal assistance or being dependent on staff for ADLs.

Based on staff interviews, record review, and review of Centers for Medicare & Medicaid Services' Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, the facility failed to complete a discharge Minimum Data Set (MDS) assessment within 14 days of a resident's discharge and submit it to the Centers for Medicare and Medicaid Services (CMS) system for two out of 51 sampled Residents (R) (R 131 and R154) reviewed for MDS completion. This failure prevented the transmission and compilation of resident-specific information for payment and quality measure purposes. Findings include: Review of the Centers for Medicare & Medicaid Services' Long-Term Care Facility Resident Assessment Instrument RAI (Resident Assessment Instrument) Manual, dated 10/1/2024 and located at https://www.cms.gov/medicare/quality/nursing-home-improvement/resident-assessment-instrument-manual revealed discharge assessments were to be completed no later than the discharge date plus 14 calendar days. In addition, they were to be transmitted within 14 days of completion. 1. Review of R131's Face Sheet tab of the Electronic Medical Record (EMR) revealed R131 was admitted to the facility on [DATE] with diagnoses which included periprosthetic fracture around internal prosthetic left should joint. R131 discharged from the facility on 2/14/2025. Review of the Census tab of the EMR revealed R131 discharged on [DATE] and did not return to the facility. Review of the RAI tab of the EMR revealed a discharge - return anticipated MDS with an assessment reference date (ARD) of 2/14/2025 had a status of in process. 2. Review of R154's Face Sheet tab of the EMR revealed R154 was admitted to the facility on [DATE] with diagnoses which included osteomyelitis (bone infection) and diabetes. R154 discharged from the facility on 12/30/2024. Review of the Census tab of the EMR revealed R154 discharged on [DATE] and did not return to the facility. Review of the RAI tab of the EMR revealed the last MDS assessment was an Admission MDS assessment with an ARD of 12/13/2024. There was no discharge MDS. During an interview on 4/29/2025 at 1:13 pm, the MDS Coordinator (MDSC) reported discharge MDSs were to be completed within 14 days of the ARD, which was the discharge date , according to the RAI manual. The MDSC confirmed she did not see a discharge MDS for R154. A discharge MDS was initiated for R131 but not closed or transmitted. During an interview on 4/30/2024 at 3:40 pm, the Director of Nursing (DON) stated she expected MDS assessments to be completed and submitted timely.

Based on staff interviews, record review, review of the Centers for Medicare & Medicaid Services' Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual and review of the facility's policy titled, MDS Assessment Accuracy, the facility failed to code pressure ulcers on a Minimum Data Set (MDS) assessment for two of 11 Resident (R) (R194 and R98) reviewed for pressure ulcers. This had the potential to cause the residents to have unmet care needs. Findings include: Review of the RAI (Resident Assessment Instrument) Manual, dated 10/01/2024 and located at https://www.cms.gov/medicare/quality/nursing-home-improvement/resident-assessment-instrument-manual revealed . items on the assessment should be validated for accuracy (what the resident's actual status was during that observation period) by the IDT [interdisciplinary team] completing the assessment. Review of the facility's policy titled, MDS Assessment Accuracy revised 12/6/2022 revealed, Each ARD [Assessment Reference Date] will be chosen to capture services rendered and reflect an accurate clinical profile of each patient/resident. 1.Review of R194's Face Sheet tab of the Electronic Medical Record (EMR) revealed the resident was admitted to the facility on [DATE] and had a hospital stay from 7/17/2024 to 7/20/2024. R194 had diagnoses which included hemiplegia and hemiparesis following cerebral infarction (stroke) and diabetes. Review of the hospital's Ticket to Ride document located in the Documents section of the EMR revealed R194 was admitted to the hospital on 7/17/2024 with pressure injuries to the left medial ankle, left heel, right heel, and sacrum. Review of R194's Admission Observation dated 7/20/2024 and located in the Observations section of the EMR revealed: Areas noted to coccyx area. Resident with skin alterations to [right] #1 digit and side of foot and notes area to 5th digit and side of foot, area noted to ankles, and heels with blacke [sic] tissue noted, elevated heels off bed. Review of R194's Skin Note dated 7/22/2024 and located in the Observations section of the EMR revealed: Left outer ankle noted with open area with slough noted to wound bed, left heel noted with DTI [deep tissue injury], left lateral foot near 5th digit open area, pink. Left great toe DTI. Left bunion noted with DTI. Right heel noted with DTI; Right ankle noted with redness. Review of R194's Order History located in the Orders section of the EMR revealed treatment orders for wounds to the left bunion, left great toe, left heel, left lateral foot near the 5th digit, outer ankle, and right heel and outer ankle, with start dates of 7/22/2024. Review of R194's Quarterly MDS assessment with an ARD of 7/24/2024 and located in the RAI section of the EMR for Section M (Skin Conditions) revealed R194 was at risk for pressure ulcer/injury but had no unhealed pressure ulcers/injuries. During an interview on 4/29/2025 at 1:18 pm, the MDS Coordinator (MDSC) stated that MDSCs reviewed EMR documentation, hospital records, and coding by wound nurses to determine if there were pressure ulcers. The MDSC reviewed the Skin Note dated 7/22/2024 and acknowledged the coding of DTIs. The MDSC stated the MDS assessment with ARD of 7/24/2024 should have coded the pressure ulcers/injuries. During an interview on 4/30/2025 at 3:40 pm, the Director of Nursing (DON) reported the expectation that MDS assessments are coded accurately. Pressure ulcers/injuries should be reflected to ensure treatment and interventions. 52323 2. Review of R98's Face Sheet located under the Resident tab of the EMR revealed R98 was originally admitted [DATE] and readmitted to the facility on [DATE] with diagnoses including diabetes and multiple sclerosis (chronic and unpredictable neurological disorder that affects the brain, spinal cord, and optic nerves.) Review of R98's Wound Management Detail Report, dated 12/26/2024, located in the EMR under Wound Management, revealed R98 developed a new unstageable pressure ulcer on 12/26/2024, the size was measured at 3.5 centimeters (cm) x 4.5 cmx 0.2 cm. Review of R98's Medication Administration Report (MAR) located in the Resident tab of the EMR under Report included documentation that revealed R98 was receiving wound care of Medi Honey (honey) (honey) gel; 80 %, once a day on Monday, Wednesday, and Friday for pressure ulcer of sacral region, unstageable. Start date on 12/26/2024, discontinued on 2/17/2025. Review of R98's Quarterly MDS with an ARD of 1/9/2025, located in the RAI tab of the EMR, documented under Section M-Skin Conditions the MDS documented No, R98 did not have any unhealed pressure ulcer in any stage. Interview on 4/29/2025 at 1:15 pm, with the MDS Coordinator (MDSC) reviewed R98's EMR and stated the facility first identified R98's new pressure ulcer was on 12/26/2024. The MDSC confirmed that R98's pressure ulcer was unstageable and later became a stage III. The MDSC said R98 continued to receive pressure ulcer treatment from 12/26/2024 until it was healed on 3/10/2025. The MDSC confirmed R98's quarterly MDS assessment dated [DATE], was documented incorrectly and that it should have indicated one unhealed unstageable pressure ulcer.

Based on staff interviews, record review, and review of the facility's policy titled, Care Plans, the facility failed to ensure a baseline care plan was created within 48 hours of admission for one of 51 sampled Residents (R) (R192) reviewed for baseline care plan. This failure had the potential for the residents to have unmet care needs. Findings include: Review of the facility's policy titled, Care Plans dated 7/27/2023 revealed, Upon a new admission. A baseline care plan will be developed .The baseline care plan should be initiated in 24 hours and will be completed and implemented within 48 hours of admission. Review of R192's Electronic Medical Record (EMR) Admission Record located under the Profile tab indicated R192 was admitted to the facility on [DATE] with a diagnosis of: Orthopedic aftercare following surgical amputation (amputation of Left Lower Leg), Type II Diabetes Mellitus (too much sugar in the blood) End Stage Renal Disease (a condition in which the kidneys lose the ability to remove waste and balance fluids) and Peripheral vascular Disease (reduced circulation of blood to a body part). Review of R192's EMR indicated R192's Care Plan located under the Admission tab was created on 5/15/2024. During an interview on 4/29/2025 at 1:40 pm with the Director of Nursing (DON) she stated that she was not aware R192 did not have a baseline care plan but indicated the Admitting Nurse initiates the baseline care plan. The DON stated the baseline care plan was to occur within 48 hours of admission and that R192 should have had one created prior to 5/15/2024.

Based on staff interview, record review, and review of the facility's policy titled Care Plans, the facility failed to develop a comprehensive care plan for one of 11 Residents (R194) reviewed for pressure ulcers. This had the potential to cause the residents to have unmet care needs. Findings include: Review of the facility's policy titled Care Plans revised 7/27/2023 revealed: Comprehensive care plans should be reviewed not less than quarterly according to the OBRA MDS schedule, following the completion of the assessment. Care plan updates/reviews will be performed within 7 days of each quarterly assessment, each acute change in condition, and as needed following each hospital stay. Care plans will be updated by nurses, Case Mix Directors [CMD], or any other interdisciplinary team member so that the care plan will reflect the patient/resident's needs at any given moment. Review of R194's Face Sheet tab of the Electronic Medical Record (EMR) revealed the resident was admitted to the facility on [DATE] and had a hospital stay from 7/17/2024 to 7/20/2024. Further review revealed that R194 had diagnoses which included hemiplegia and hemiparesis following cerebral infarction (stroke) and diabetes. Review of the hospital's Ticket to Ride document located in the Documents section of the EMR revealed R194 was admitted to the hospital on 7/17/2024 with pressure injuries to the left medial ankle, left heel, right heel, and sacrum. Review of R194's Admission Observation dated 7/20/2024 and located in the Observations section of the EMR revealed: Areas noted to coccyx area. Resident with skin alterations to [right] #1 digit and side of foot and notes area to 5th digit and side of foot, area noted to ankles, and heels with blacke [sic] tissue noted, elevated heels off bed. Review of R194's Skin Note dated 7/22/2024 and located in the Observations section of the EMR revealed, Left outer ankle noted with open area with slough noted to wound bed, left heel noted with DTI [deep tissue injury], left lateral foot near 5th digit open area, pink. Left great toe DTI. Left bunion noted with DTI. Right heel noted with DTI; Right ankle noted with redness. Resident has pressure reduction boots and was encouraged to wear them or to float heels while in the bed. Review of R194's Order History located in the Orders section of the EMR revealed treatment orders for wounds to the left bunion, left great toe, left heel, left lateral foot near the 5th digit, outer ankle, and right heel and outer ankle, with start dates of 7/22/2024. Review of R194's Care Plan located in the RAI section of the EMR revealed a problem area, Resident is at risk for pressure ulcers dated 11/25/2023 with approaches which included keep bony prominences from direct contact with one another with pillows, foam wedges, keep resident off bony prominences, conduct a systematic skin inspection weekly paying attention to the bony prominences, use boots or pillows to relieve pressure on the heels, and turn and reposition every two hours. The Care Plan failed to reflect any actual pressure ulcers or approaches. During an interview on 4/29/2025 at 10:42 am, Wound Nurse (WN) 1 stated she tried to care plan wounds when residents were admitted or readmitted from the hospital with wounds. During an interview on 4/30/2025 at 10:16 am, WN1 reported the R194's Care Plan was not correctly updated when he returned from the hospital with identified pressure ulcers. During an interview on 4/30/2025 at 3:40 pm, the Director of Nursing (DON) reported everything related to pressure ulcers was expected to be care planned with interventions which were in place to ensure proper care.

Based on observations, staff interviews, record reviews, and review of the facility's policy titled, Nursing: Patient/Resident Rights, Accommodation of Needs, the facility did not ensure that two of the 51 sampled Residents (R) (R98 and R151) received nail care. This failure had potential to increase the risk of infectious disease and nail damage for R98 and R151. Findings include: Review of the facility's policy titled, Nursing: Patient/Resident Rights, Accommodation of Needs, revised 12/2/2023 stated It is the policy of this healthcare center to promote and protect the rights of the patients/residents residing in the center. 1. Review of R98's Face Sheet located under the Resident tab of the Electronic Medical Record (EMR) revealed R98 was admitted to the facility with diagnoses that included but not limited to diabetes and multiple sclerosis (chronic and unpredictable neurological disorder that affects the brain, spinal cord, and optic nerves.) Review of R98's Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/25/2025 located in the RAI [Resident Assessment Instruments] tab of the EMR, for Section C (Cognitive Patterns) revealed, a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated she was cognitively intact; Section GG (Functional Abilities and Goals) revealed, R98 was dependent on staff for ADLs and for personal hygiene including combing hair, washing, drying hands, and nail care. Review of R98's Care Plan located in the residents EMR under RAI tab revealed for ADL Functional care plan, dated 10/8/2021, included the following interventions: Daily grooming- hair, skin, nails. Observation on 4/27/2025 at 2:46 pm revealed, R98's fingernails were observed longer than one centimeter (cm) past her fingertips. R98 said that the podiatrist had come to trim her toenails. However, there was a designated nail day activity every Monday for filing fingernails, but she had not received assistance to get out of bed to attend. R98 stated she had repeatedly asked the Certified Nursing Assistant (CNA) to trim her fingernails, but the CNAs always told her they could not trim her fingernails because she had diabetes. Observation and interview on 4/29/2025 at 9:22 am with Unit Manager (UM) 2 in R98's room confirmed that R98's fingernails were too long and should be trimmed. UM2 explained that the podiatrist only trims resident's toenails. CNAs were responsible for trimming residents' fingernails unless the residents had diabetes, in which nurses would handle the trimming. During an observation and interview on 4/29/2025 at 9:52 am, with Licensed Practical Nurse (LPN) 2 revealed, R98's fingernails on right hand were examined. The length of the longest overgrown fingernail that needed trimming was measured at one centimeter (cm) on her little finger while the shortest was measured at 0.4 cm on her thumb. LPN 2 then measured all R98's fingernails on her left hand. The length of the longest overgrown fingernail that needed trimming was measured at 1.2 cm on her fourth finger, and the shortest was measured at 0.4 cm on her fourth finger. LPN2 stated she was not sure who was responsible for trimming the fingernails of a resident with diabetes. 2. Review of R151's Face Sheet located under the Resident tab of the EMR revealed R151 was admitted to the facility with diagnoses that included but not limited to hemiplegia (paralysis on one side of the body) following a stroke. Review of R151's Quarterly MDS with an ARD of 2/27/2025, located in the RAI tab of the EMR, for Section C (Cognitive Patterns) revealed, a BIMS score of six out of 15 which indicated she was severely cognitively impaired; Section GG (Functional Abilities and Goals) revealed, R151 required partial/ moderate assistance for personal hygiene including combing hair, washing, drying hands, and trimming nails. Review of R151's Care Plan located in the residents' EMR under RAI tab revealed for ADL Functional dated 11/3/2024, included the following interventions: Set up for ADL's, assist with bathing, dressing, personal hygiene and oral hygiene daily and prn. Observation on 4/27/2025 at 1:47 pm revealed R151's right fingernails were long and dirty, with dark gray, dirt-like stains on the edges of her fingers and beneath her overgrown nails. Observation and interview on 4/29/2025 at 9:13 am with LPN2 confirmed that R151's fingernails appeared long and yellowish, with black and grayish discolorations that resembled dirt. LPN2 then measured the fingernails on R151's right hand; The length of the longest fingernail that needed trimming was measured at 0.4 cm on her middle finger, and the shortest was measured at 0.3 cm on her little finger. LPN2 then measured the fingernails on R151's left hand. The length of the longest overgrown fingernail that needed trimming was measured at 0.5 cm on her fourth finger, while the shortest was measured at 0.4 cm on her little finger. When asked, LPN2 was not sure who was responsible to trim diabetic residents' fingernails and if the podiatrist trim them. During an interview on 4/29/2025 at 9:21 am, UM2 confirmed that R151's fingernails were too long and should be trimmed. UM2 stated that for diabetic residents, the nurse would be responsible for trimming their fingernails. For residents without diabetes, the CNA would take care of the trimming. UM2 further stated that the podiatrist was only responsible for toenail care.

Based on record reviews, staff interviews, and a review of the facility's policy, the facility failed to administer long-acting insulin in accordance with physician orders for two residents (Resident (R) 436 and R98) out of 51 sampled residents. This failure had the potential to have adverse effects on residents if their insulin was not given or their dose was reduced without a physician's order. Findings include: 1. Review of R436's undated Face Sheet located under the Resident tab of the electronic medical record (EMR) revealed R436 was admitted to the facility on [DATE] with diagnoses including diabetes. Review of R436's Medication Administration Report (MAR) located in the Resident tab of the EMR under Report revealed the nursing staff documented R436's blood glucose (BG) as low at 123 and 142. The nurse withheld R436's insulin Lantus (long-acting insulin) without a physician's order as follows: Physician's order: Lantus Solostar U-100 Insulin (long-acting insulin) pen 100 units/ml (3ml), give 10 units subcutaneous once a day in the morning for long-term drug therapy. Start date 3/28/2025. MAR documented on 4/1/2025 at 6:00 am: Not Administered: Due to Condition Comment: 123 [BG]. MAR documented on 4/2/2025 at 6:00 am: Not Administered: Due to Condition Comment: 142 [BG]. 2. Review of R98's undated Face Sheet located under the Resident tab of the EMR revealed R98 was admitted to the facility on [DATE] with diagnoses including diabetes. Review of R98's MAR located in the Resident tab of the EMR under Report revealed the nursing staff documented R98's BG low at 186, 103, and 197. The nurse withheld R98's insulin Lantus (long-acting insulin) or reduced its dose to half of the ordered dose without a physician's order as follows: Physician's order: Lantus Solostar U-100 Insulin (long-acting insulin) pen 100 units/ml (3ml) give 10 units subcutaneous once a day at bedtime for diabetes. Start date 1/27/2025. MAR documented on 2/17/2025 at 9:00 pm: Not Administered: Other Comment: 186 [BG]- 5 units given. MAR documented on 2/25/2025 at 9:00 pm: Not Administered: Other Comment: 103 [BG]. MAR documented on 2/27/2025 at 9:00 pm: Not Administered: Other Comment: [given] Previous shift. MAR documented on 4/4/2025 at 9:00 pm: Not Administered: Other Comment: 197 [BG] - 5 units given. MAR documented on 04/24/25 at 9:00 PM: Not Administered: Other Comment: 5 units given. Further review of the MARs revealed each of the above entries was documented as Licensed Practical Nurse (LPN)8, who made the decision to either not administer or administer half the amount ordered of Lantus. During an interview on 4/29/2025 at 8:42 am, the Unit Manager (UM) 2 stated that staff should follow the physician's orders on when to hold Lantus. If there were no orders, the requirement was to hold Lantus when BG was equal to or lower than 150. Staff should also offer sugary drinks or snacks at the same time as holding the insulin. During an interview on 4/29/2025 at 3:00 pm, the Director of Nursing (DON) stated that UM2's statement of holding insulin Lantus when BG was equal to or lower than 150 was incorrect. She stated that Lantus was a long-acting insulin and that nurses should never hold it.

Based on record review, interview, and policy review, the facility failed to identify pressure ulcers and initiate treatment orders in a timely manner for one of 11 residents reviewed for pressure ulcers (Resident (R) 194) out of 51 total sampled residents. This had the potential for residents' pressure ulcers to decline. Findings include: Review of R194's Face Sheet tab of the electronic medical record (EMR) revealed the resident was admitted to the facility on [DATE] and had a hospital stay from 7/17/2024 to 7/20/2024. R194 had diagnoses including hemiplegia and hemiparesis following cerebral infarction (stroke) and diabetes. Review of R194's Braden Scale for Predicting Pressure Sore Risk dated 6/27/2024 and located in the Observations section of the EMR revealed the resident scored at high risk for developing pressure ulcers. Review of a Skin Note dated 6/28/2024 and located in the Observations section of the EMR revealed R194 had no skin issues. No further Skin Notes were found from 6/28/2024 through when R194 went to the hospital for a planned surgery on 7/17/2024. Review of R194's Progress Notes section of the EMR revealed no documentation of any skin check from 6/28/2024 until the resident went to the hospital on 7/17/2024. There was no documentation of any existing pressure ulcers when R194 was discharged to the hospital. Review of the hospital's Ticket to Ride document located in the Documents section of the EMR revealed R194 was admitted to the hospital on 7/17/2024 with pressure ulcers to the left medial ankle, left heel, right heel, and sacrum. During an interview on 4/28/2025 at 9:38 am, Family Member (F1) reported she met R194 at the hospital when he arrived there on 7/17/2024. The hospital staff removed his socks for a skin check, and R194 had wounds on both heels, above his buttocks, and on his left big toe, of which she was unaware. Review of R194's Progress Notes section of the EMR revealed an entry dated 7/20/2024 at 3:05 pm that he had returned from the hospital and had skin alterations. Review of R194's Admission Observation dated 7/20/2024 and located in the Observations section of the EMR revealed: Areas noted to the coccyx area. Resident with skin alterations to [right] #1 digit and side of foot and notes area to 5th digit and side of foot, area noted to ankles, and heels with black tissue noted, elevated heels off bed. Review of R194's Skin Note dated 7/22/2024 and located in the Observations section of the EMR revealed: Left outer ankle noted with open area with slough noted to wound bed, left heel noted with DTI [deep tissue injury], left lateral foot near 5th digit open area, pink. Left great toe DTI. Left bunion noted with DTI. Right heel noted with DTI, Right ankle noted with redness . Review of R194's Order History located in the Orders section of the EMR revealed treatment orders for wounds to the left bunion, left great toe, left heel, left lateral foot near the 5th digit, outer ankle, and right heel and outer ankle, with start dates of 7/22/2024, two days after R194 returned from the hospital. The left bunion, left great toe, and right heel received skin prep. The left lateral foot and ankle had orders for hydrogel. Review of R194's Medication Administration Record (MAR) dated 7/1/2024 to 7/31/2024 revealed he had no treatment orders in place for his pressure ulcers from when he returned from the hospital on 7/20/2024 until 7/22/2024. Review of a wound nurse practitioner Progress Note Report dated 7/26/2024 and located in the Documents section of the EMR revealed R194 had a left heel in-house acquired deep tissue injury which measured 2.5 centimeters (cm) x 3cm x 0.3cm. R194 also had a left lateral ankle wound, in-house acquired, which was assessed as measuring 2.2 cm x 1.2 cm x approximately 0.3 cm and was 65% necrotic (dead) tissue. The note recorded, Both wounds are documented as in-house pressure areas as they were first discovered by hospital staff on 7/17 . During an interview on 4/29/2025 at 9:22 am, Certified Nursing Assistant (CNA) 1 stated CNAs check residents' skin with care and report anything of concern to the nurse. Skin concerns are also documented on shower sheets, which the nurse signs off. During an interview on 4/29/2025 at 9:32 am, Wound Nurse (WN) 2 stated that if a resident was admitted from the hospital with wounds, the floor nurse was to get treatment orders from the doctor. During an interview on 4/29/2025 at 10:25 am, Unit Manager (UM) 1 stated that the wound nurses obtain wound treatment orders. If there was no wound nurse available, the floor nurse was responsible for obtaining treatment orders from the physician. Skin checks were expected to be done at least weekly and documented in the Observations section of the EMR. The shower sheets were just a tool, but UM1 stated he would check if any still existed for R194. UM1 was unable to locate any shower sheets for R194. During an interview on 4/29/2025 at 10:42 am, WN1 stated that if a resident was admitted from the hospital with wounds, the floor nurse was to get treatment orders from the doctor if no orders were provided by the hospital. The floor nurses completed weekly skin assessments, and CNAs were to notify nurses of any skin changes. The wound nurse practitioner did not follow wounds that were only getting skin prep as a treatment. During an interview on 4/30/2025 at 10:16 am, WN1 stated that, from what she observed on 7/22/2024 after R194 returned from the hospital, the nursing staff should have noticed the wounds and addressed them before he went to the hospital. Orders should be in place promptly after identifying a wound and not two days later. WN1 reviewed R194's EMR and stated there were no orders from 7/20/2024 to 7/22/2024 and no documentation of wounds prior to him going to the hospital, but from what she saw on 7/22/2024 and from the hospital records, the wounds appeared to be there when he left (for the hospital). During an interview on 4/30/2025 at 3:40 pm, the Director of Nursing (DON) reported she expected a wound nurse to assess and obtain treatment orders within 24 hours of a wound being identified. Review of the facility's Pressure Injury Prevention Program revised 3/18/2021 stated: . Documentation of pressure injuries should be completed in the resident's [EMR] . Monitor the skin of all at-risk residents daily during ADLs [activities of daily living] and report any abnormal findings to the Charge Nurse.

Based on observations, record reviews, and interviews, the facility failed to provide restorative nursing services for one of two residents (Resident (R) 98) reviewed for position and mobility out of a total sample of 51 residents. This failure had the potential to negatively affect Resident 98's ability to perform activities of daily living (ADL) and place R98 at risk of ADL decline. Findings include: Review of the facility's policy titled, Restorative Nursing Program, revised 11/4/2021, included the statement as follows: It is the policy of this healthcare center to provide restorative nursing which actively focuses on achieving and maintaining optimal physical, mental, and psychological functioning and wellbeing of the patient/resident. Restorative nursing program is under the supervision of a Registered Nurse (RN) or a Licensed Practical Nurse (LPN), and restorative nursing services are provided by Restorative Nursing Assistants (RNAs), Certified Nursing Assistants (CNAs), and other qualified staff. Restorative nursing program refers to nursing interventions that promote the resident's ability to adapt and adjust to living as independently and safely as possible .Active Range of Motion (AROM) - exercises performed by the resident, with cueing. supervision, or physical assistance by the staff. Review of R98's undated Face Sheet located under the Resident tab of the electronic medical record (EMR) revealed R98 was admitted to the facility on [DATE] with diagnoses including diabetes and multiple sclerosis (MS: chronic and unpredictable neurological disorder that affects the brain, spinal cord, and optic nerves.) Review of R98's annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/25/2025, located in the RAI [Resident Assessment Instruments] tab of the EMR, revealed a Brief Interview for Mental Status (BIMS) score of fifteen out of 15 which indicated she was cognitively intact. R98 had an impaired range of motion (ROM) on both sides of her upper and lower extremities. R98 was dependent on staff (the staff does all the effort) for toileting, bathing, lower body dressing, putting on and taking off footwear, personal hygiene, sitting to lying, chair to bed to chair transfer, and shower transfer. R98 did not walk and was dependent on staff to wheel her as she was not able to wheel herself. Review of R98's Care Plan located in the resident's EMR under RAI tab revealed that for the ADL Functional care plan, dated 10/8/2021, included the following interventions: - Total lift with 2-person assists for transfers. - PT/ OT/ST to evaluate and treat as warranted. Review of R98's Care Plan located in the resident's EMR under RAI tab revealed that for the Nutritional Status care plan, dated 10/8/2021, included the following interventions: - Increase physical activity/exercise as tolerated. The assigned discipline included Restorative Nursing. During an observation on 4/27/2025 at 3:10 pm, R98 stated she had MS and she could move her left leg a bit, but she could not move her right leg at all. R98 said she did not receive any of the range of motion services. During an interview on 4/29/2025 at 4:57 pm, the Director of Rehabilitation (DOR) stated that R98 was on physical therapy (PT) from 10/27/2024 to 12/5/2024 and on occupational therapy (OT) from 10/27/2024 to 12/2/2024. The DOR stated the therapy department had referred R98 to the Restorative Nursing Program. The DOR provided a record for R98's PT and OT discharge summary, and he pointed out where it documented the following: 1. On page four of the PT Discharge Summary, Date of Service: 10/27/2024-12/5/2024, under Discharge Recommendations and Status: - Restorative Program Established/Trained = Restorative Range of Motion Program, Restorative Bed Mobility Program. - Range of Motion Program Established / Trained: Patient is currently able to move feet up and down, raise arms above head, and raise arms straight out from shoulders, and tier is progressive and with Restorative Nursing Program, patient will be able to move feet up and down, raise arms above head and raise arms straight out from shoulders by performing the following Restorative Nursing interventions: active ROM, encourage resident to participate, face the resident in order to observe for signs of fatigue or discomfort, introduce self and explain procedure and refer to PT/OT as needed. - Bed Mobility Program Established / Trained: Patient is currently able to move from a lying position to a sitting position,, move from a sitting position to a lying position, and pull self up in bed, and tier is progressive and with Restorative Nursing Program, patient will maintain/prevent decline of current status, as demonstrated by the ability to move from a lying position to a sitting position, move from a sitting position to a lying position and pull self up in bed by performing the following Restorative Nursing interventions: assist resident to turn from side to side, provide a verbal prompt to assist with lying down from a sitting position, provide verbal prompts to assist with moving up in bed, provide verbal prompts to sit up from a lying position and provide verbal prompts to assist patient with turning from side to side. - Prognosis: . Good with consistent staff follow-through. 2. On page three of the PT Discharge Summary, Date of Service: 10/27/2024-12/2/2024, under Discharge Recommendations and Status: - Restorative Program Established/Trained = Restorative Range of Motion Program. - Range of Motion Program Established / Trained: BUE [bilateral upper extremities] AROM [active range of motion] in all planes as tolerated with resistance. During an interview with the Director of Nursing (DON) and the Unit Manager (UM) 2 on 4/29/2025 at 5:00 pm, UM2 stated that R98 was not currently in the restorative nursing program. She thought R98 had just been discharged from the PT and OT recently. UM2 stated she would review the referral and place R98 in the restorative nursing program. Upon record request on 4/29/2025 at 5:00 pm, the DON confirmed that no documentation indicated that R98 was receiving restorative nursing ROM as per the therapists' referral. The DON stated she was overseeing the restorative program, and R98 was never enrolled and received ROM since both PT and OT had discontinued their services.

Based on observations, interviews, and record reviews, the facility failed to have physician orders and an indication for an indwelling catheter for one (Resident (R) 85) of three residents reviewed for urinary catheters out of a total sample of 51 residents. This failure increased the risk of urinary catheters being implemented without an acceptable indication. Findings include: Review of the Face Sheet located under the Resident tab of the electronic medical record (EMR) revealed R85 was originally admitted to the facility on [DATE]. An observation of R85 on 4/27/2025 at 10:09 am revealed the resident in bed resting. On the right side of the resident's bed, hung a catheter bag, covered in a blue privacy bag. Review of the Minimum Data Set (MDS), located in the EMR under the RAI tab, with an Assessment Reference Date (ARD) of 3/3/2025, indicated that R85 had an indwelling catheter and Brief Interview for Mental Status (BIMS) of five out of 15 indicating severely impaired cognition. Review of the Progress Notes from 1/23/2025 at 7:08 am revealed the resident was not voiding and a straight catheter was ordered. A subsequent note at 6:55 pm revealed the resident still had not voided unassisted and the Nurse Practitioner (NP) ordered an indwelling catheter. A review of R85's physician's orders, found under the Resident tab, revealed no order for the use and care of a catheter. A review of R85's Care Plan revealed a focus that indicated the resident had an indwelling urinary catheter, dated 3/13/2025. The goal for this care plan focus was for R85 to not exhibit signs of infection or urethral trauma using approaches that included changing the catheter bag as needed, changing the catheter per the physician's order, and providing catheter care every shift and as needed. During an interview with the Director of Nursing (DON) on 4/29/2025 at 2:44 pm, she confirmed that there were no orders for the use of a catheter or for catheter care for R85. The DON verified that a resident who had a catheter should have orders indicating diagnosis and need for use and orders for care of the catheter. A policy for the use of catheters was requested, and the DON stated that the facility did not have a policy but did have a procedure for catheter care. The first two steps of the procedure include: 1) Identify resident; and 2) Verify orders. During an interview on 4/30/2025 at 9:23 am, Registered Nurse (RN) 4 verified there was no order for the catheter but stated that the staff followed standards of care and the care plan when providing catheter care.

Based on record review, interview, and policy review, the facility failed to obtain and document weight for one of nine residents (Resident (R) 197) reviewed for nutrition out of a total of 51 sampled residents. This failure had the potential to place R197 at risk of weight loss if the weight was not obtained and monitored in a timely manner to provide accurate information for nutrition need calculation. Findings include: Review of the facility's policy titled, Weight Monitoring Program, revised 6/2/2023, documented New Admissions. Initial weight and height will be obtained and documented on the Yearly Weight Record Form within 24 hours of admission to the healthcare center. New admissions will be weighed weekly for four weeks and/or until weight is stable. Review of R197's undated Face Sheet located under the Resident tab of the electronic medical record (EMR) revealed R98 was admitted to the facility on [DATE] with diagnoses including acute respiratory failure and pneumonia. R197 was discharged to an assisted living facility on 4/9/2024. Review of R197's Care Plan located in the resident's EMR under RAI tab revealed that for Psychosocial Well-Being care plan, dated 3/22/2024, included the intervention of Monitor for decreased intake, weight loss, and social isolation. Review of R197's Care Plan located in the resident's EMR under RAI tab revealed that for the Nutritional Status care plan, dated 3/29/2024, included the intervention of Monitor/record weight. Notify MD and family of significant weight change. Review of R197's weight report located under the Resident tab of the electronic medical record (EMR) revealed R197 had only one weight recorded on 3/20/2024 when R197 was admitted . R197 was 191 pounds (lbs.) During an interview on 4/30/2025 at 11:51 am, the DON stated there was no second weight measured for R197. The DON verified that since R197 was newly admitted , his weight should have been taken once a week for four weeks.