Every finding on record at Clarksville Health & Rehab Center

Based on observation, staff interview, and facility documentation review, the facility staff failed to store, prepare, and serve food in accordance with food safety standards in the main kitchen, which had the potential to affect residents on all six units. The findings included:On 6/9/26 at 12:27 pm, initial observations of the kitchen and food storage areas were conducted with the Food Services Director (FSD).In the dry storage area there was a package of Jello mix which had a labeled open date of 4/3/26 and a use by date of 5/3/26, which was available for use. In the walk-in cooler there was a tray with a lid that appeared to have a food product that was red in color and jelly like consistency. The label on the container appeared old and was not legible. There was no indication of the contents, when it was prepared or to be used by. There was a container of tuna salad that had a use by date of 6/3/26 from manufacturer. The facility label noted it was opened 6/3/26 and was to be used by 6/8/26. The FSD removed the tuna salad and indicated it should not be used as it was beyond the expiration date. There was a pan that contained what was labeled as uncooked sausage and had dates of 6/5/26 and 6/8/26. The FSD confirmed the observations and stated it was not acceptable and removed the product. In the walk-in freezer there was an opened bag of tater rounds and bag of chicken tenders that were both open to air, not closed or secured and had no dates of when it was opened or to be used by. , so we don't serve old food and nobody gets sick from it.The FSD reported the chicken tenders were used today but should have been closed and labeled. We don't want to serve anyone any bad food or them get sick. On 6/9/26 at 4:37 PM, during a follow-up visit to the kitchen, within the stand alone cooler there was a pitcher of a dark colored liquid that appeared to be tea that was labeled with a use by date of 6/8/26. The FSM was shown the item and removed it. The facility policy titled, Storage of Refrigerated Foods Policy with a revision date of 3/9/2025, was received and reviewed. The policy read in part, . Label and note pull date on all food items when removing from freezer . 12. Refrigerated, TSC [Time/Temperature Control for Safety] foods, prepared and held for more than 24 hours will be marked to indicate the date .On 6/10/26, during an end of day meeting, the facility Administrator and Director of Nursing were made aware of the above findings. No additional information was provided.

Based on observation, resident interview, staff interview, facility document review and clinical record review, the facility staff failed to ensure a complete and accurate clinical record for five of thirty-six residents in the survey sample (Residents #5, #6, #12, #14 and #152). The findings include: 1. Resident #5's clinical record documented a tracheostomy inner cannula was changed once every three months when the resident did not have/use an inner cannula. Resident #5 (R5) was admitted to the facility with diagnoses that included peripheral vascular disease, history of vocal cord paralysis with tracheostomy, diabetes, hypertension, anemia, atrial fibrillation, depression, anxiety, schizophrenia and bradycardia. The minimum data set (MDS) dated [DATE] assessed R5 with moderately impaired cognitive skills. R5's clinical record documented a physician's order dated 3/6/25 for tracheostomy care with instructions to change the inner cannula once every three months. R5's treatment administration record documented the inner cannula was changed on 12/1/25, 3/1/26 and 6/1/26. On 6/10/26 at 1:46 p.m., with R5's permission, daily tracheostomy care performed by the licensed practical nurse unit manager (LPN #1) was observed. During this treatment, R5 stated he did not use an inner cannula with his tracheostomy and that he had never had an inner cannula. R5 stated the tracheostomy tube was changed and/or cleaned every three months. LPN #1 also stated at this time that R5's tracheostomy did not have an inner cannula. On 6/10/26 at 1:55 p.m., the unit manager (LPN #1) was interviewed about the physician's order referencing an inner cannula change. LPN #1 stated regarding the order for the inner cannula change, I know the order says inner cannula but he [R5] only has the trach [tracheostomy] tube. LPN #1 stated the resident's tracheostomy tube was disposable and that the tube was changed once every three months, not the inner cannula as listed. LPN #1 was not sure why the physician's order had not been revised or clarified. On 6/10/26 at 3:50 p.m., the director of nursing (DON) was interviewed about R5's order for inner cannula change and nurses documenting an inner cannula change when the resident had no inner cannula. The DON stated the physician's order needed to be clarified as the resident did not use an inner cannula and had never had/used an inner cannula. The facility's policy titled Physician/Provider Orders Policy (revised 10/7/24) documented, .The Charge Nurse shall transcribe and review all physician/provide orders .Orders will [be] reviewed at the frequency required by state regulation but not less than bi-monthly . These findings were reviewed with the administrator and DON during a meeting on 6/10/26 at 5:30 p.m. with no further information presented prior to the end of the survey. 2. For Resident #6 (R6), the facility failed to ensure an accurate clinical record by documenting continued monitoring for side effects of a medication that had been discontinued. Diagnoses for R6 include dementia with other behavioral disturbances, Alzheimer's disease, atrial fibrillation, hypertension, generalized anxiety disorder, and diabetes mellitus. On the most recent Minimum Data Set (MDS), a quarterly assessment with an assessment reference date (ARD) of 3/7/26, R6 scored two out of 15 on the Brief Interview for Mental Status (BIMS) indicating severe cognitive impairment. On 2/19/26 a physician's order for risperdone (an antipsychotic medication) 0.5 milligrams (mg) three tablets daily was placed into the clinical record. An additional physician's order to monitor for side effects of risperdone (tremors, gait issues, agitation, restlessness, and involuntary movements of the mouth/tongue) every shift was concurrently placed in the clinical record on the same date. Review of the clinical record demonstrated that risperdone was discontinued on 3/2/26. Following the discontinuation of the medication, the physician's order to monitor side effects of risperdone remained active. Review of the medication administration record (MAR) revealed that nursing documented continued monitoring for the side effects of risperdone every shift in March, April, May, and June. An interview was conducted with Licensed Practical Nurse (LPN) #6 on 6/11/2026 at 9:18 AM. LPN #6 stated that they monitor the side effects of this medication every shift. LPN #6 checked the clinical record and verified that R6 was no longer on this medication. LPN #6 was not aware of the date the medication had been discontinued. LPN #6 stated it would not be indicated to continue to monitor for side effects of a medication that had been discontinued. LPN #6 stated that the order to monitor side effects of risperdone could be discontinued in the clinical record by nursing. Review of a facility policy titled, Physician/Provider Orders Policy, effective 1/27/11 and most recently revised/reviewed 10/7/24 revealed that physician's orders are to be reviewed at the frequency required by state regulation but not less than bi-monthly. This information was presented to the facility administrative staff on 6/11/26 at 2:00 PM. No additional information was provided prior to exit. 3. For Resident #12 (R12), the facility failed to ensure an accurate clinical record by documenting continued monitoring for side effects of a medication that had been discontinued. Diagnoses for R12 include dementia without behavioral disturbance, mood disorder, atrial fibrillation, and major depressive disorder. On the most recent Minimum Data Set (MDS), an annual assessment with an assessment reference date (ARD) of 5/10/26, R12 was unable to perform the Brief Interview for Mental Status (BIMS) indicating severe cognitive impairment. On 5/23/24, a physician's order for Zoloft (an antidepressant medication) 50 milligrams (mg) daily was placed into the clinical record. An additional physician's order to monitor for side effects of Zoloft (withdrawn, anxious, talking to self) every shift was placed into the clinical record on 8/19/25. Review of the clinical record demonstrated that Zoloft was discontinued on 1/5/26. Following the discontinuation of the medication, the physician's order to monitor for side effects of Zoloft remained active. Review of the medication administration record (MAR) revealed that nursing documented continued monitoring for the side effects of Zoloft every shift in March, April, May, and June. An interview was conducted with Licensed Practical Nurse, LPN#6 on 6/11/2026 at 9:18 AM. LPN #6 stated that they monitor the side effects of this medication every shift. LPN #6 stated that it would not be indicated to continue monitoring for side effects of a medication that had been discontinued for months. LPN #6 stated that the order to monitor for side effects of Zoloft could be discontinued in the clinical record by nursing. Review of a facility policy titled, Physician/Provider Orders Policy, effective 1/27/11 and most recently revised/reviewed 10/7/24 revealed that physician's orders are to be, reviewed at the frequency required by state regulation but not less than bi-monthly. This information was presented to the facility administrative staff on 6/11/26 at 2:00 PM. No additional information was provided prior to exit. 4. For resident #14, the Registered Dietician (RD) documented the resident's weight as 119 lbs. instead of 219 lbs. on a document entitled, Medical Nutritional Therapy Observation dated 3/26/26. The Resident Face Sheet indicated the facility admitted the resident on 3/15/24 with a medical history that included recent stroke, vascular dementia, type 2 diabetes, morbid obesity and moderate protein-calorie malnutrition. Resident #14's comprehensive care plan included a focus that read, Resident has increased nutrition/hydration risk related to: dx (diagnoses) of cerebral infarction (stroke), HLD (hyperlipidemia or high cholesterol), dementia, HTN (hypertension), T2DM (type 2 diabetes) muscle wasting and atrophy, hemiplegia and hemiparesis affecting left non-dominant side, morbid obesity and moderate protein-calorie malnutrition. One of the interventions listed was to monitor weight per protocol. The weight record for resident #14 was reviewed and included a weight documented in February of 219 lbs. and a reweight of 229 lbs. 06/11/2026 9:19 AM The RD was interviewed. When asked to review her March assessment the RD stated, That was a clerical error on my part. The RD provided documentation that she recommended a reweight due to a significant weight loss from 234 lbs. to 219 lbs. The reweight was done and documented which revealed the resident did not in fact have a significant weight loss. I honestly just hit the wrong numbers when I was typing it in. On 6/11/26 at 1:36 PM the survey team met with the Administrator, Director of Nursing and Regional Director of Clinical Services (RDCS). This concern was discussed with them at that time. The RDCS stated they had no policy related to accurate documentation. No further information was provided to the survey team prior to the exit conference. 5. For Resident #152, the facility staff failed to maintain accepted professional standards of practice, accurate representation, and/or a systemically organized accounting of the events that occurred during a fall that resulted in a right humerus fracture on 09/09/2024. Findings included: Resident #152's diagnosis list indicated diagnoses that included, but were not limited to, muscle wasting and atrophy, difficulty in walking, history of falling, unspecified fracture of upper end of right humerus, and adult failure to thrive. The most recent quarterly minimum data set (MDS) with an assessment reference date (ARD) of 12/05/2024, assigned the resident a brief interview for mental status (BIMS) summary score of 0 out of 15 for cognitive abilities, indicating the resident was severely impaired in cognition. A review of Resident #152's clinical record disclosed the following: A nursing progress note dated 09/09/2024 at 16:19 (4:19 PM) disclosed the resident hit elbow while a CNA (Certified Nursing Assistant) was weighing resident with a Hoyer lift (an assistive medical device used to transfer individuals with limited mobility between surfaces (like a bed, wheelchair, or toilet) without physically lifting them, using a supportive sling and a mechanical frame), the resident complained of pain in the arm. A review of a Post Fall Huddle Form dated 09/09/2024 disclosed the resident's legs gave away and the resident was assisted off the floor with a mechanical lift. A medical provider progress note dated 09/12/2024 with a service date of 09/10/2024, disclosed Resident #152 was seen for right shoulder pain and the medical provider indicated notification earlier in the day that while the patient was being assisted for measurement of weight, the resident experienced sudden weakness to the legs and was lowered in a controlled manner, as a gait belt was being appropriately used, to the floor. While the patient was being lowered to the floor it was reported that the resident was observed by a care companion in the room and that the resident's elbow struck the bed. After a Hoyer lift was used to help lift the patient off the floor and placed back in bed, the patient reported right shoulder pain. The mobile x-ray of the right arm and shoulder did demonstrate an acute fracture of the upper humerus with 17 mm displacement. The patient's right arm was appropriately placed into a sling. This concern was discussed on 06/10/2026 at 11:25 AM, with the Administrator, Director of Nursing, and an Administrator from a sister facility. Requested all information related to this incident. The Administrator stated that the Certified Nursing Assistant (CNA) who cared for Resident #152 at the time of the incident was no longer employed at the facility. For purposes of this investigation, the CNA was identified and will be referred to as (CNA#1). On 06/10/2026 at 12:44 PM, the Director of Nursing (DON) reviewed the information and agreed there is a discrepancy in what actually happened, as the nurse's note revealed the resident bumped the arm while on the Hoyer lift and the medical provider note stated the resident was being transferred with a gait belt and the resident's legs buckled. On 06/10/2026 at 1:17 PM, the discrepancies in the documentation were reviewed with the Administrator (ADM). On 06/10/2026 at 1:33 PM, the ADM stated the resident sat self-up on the side of the bed and bumped elbow on bed frame and then slid off the bed and staff used the Hoyer lift to get the resident back up off the floor. On 06/10/2026 at 1:59 PM, Licensed Practical Nurse #3 (LPN#3) was interviewed via phone conversation and stated she recalled the resident's fall in September 2024. LPN#3 stated she was not in the resident's room at the time of the incident, but Certified Nursing Assistant #1 (CNA#1) told her that the resident was placed in a wheelchair to be taken for a weight and the resident got upset when they found out they were leaving the room. Resident #152 did not want to leave the room, so the resident attempted to get out of the wheelchair unassisted and fell and bumped the arm. There were no witness statements for this incident for further review. No other facility staff who cared for Resident #152 in September 2024 continued to be employed by the facility at the time of the investigation and/or were unavailable for interview. This concern was discussed at the pre-exit meeting on 06/11/2026 at 1:36 PM, with the Administrator, Director of Nursing, and Regional Nurse. The Regional Nurse stated they do not have a policy for accuracy of documentation. No further information was provided prior to exit on 06/11/2026.

Based on resident interview, staff interview, facility document review and clinical record review, the facility staff failed to complete an accurate minimum data set (MDS) for one of thirty-six residents in the survey sample (Resident #15). The findings include:Resident #15's admission MDS listed the resident was assessed with an unstageable pressure ulcer and inaccurately documented that the pressure ulcer was not present upon admission. Resident #15 (R15) was admitted to the facility with diagnoses that included hip fracture, rhabdomyolysis, anemia and cognitive communication deficit. The MDS dated [DATE] assessed R15 as cognitively intact. Review of R15's hospital records dated 3/13/26 documented the resident was assessed with a large, evolving deep tissue injury on the sacrum prior to admission to the facility. The facility's admission nursing assessment dated [DATE] documented the resident was admitted with a pressure injury to the sacrum in addition to a left hip surgical wound. R15 had physician orders upon admission to the facility dated 3/17/26 for treatment for an unstageable pressure injury to the sacrum that included cleansing, superabsorbent dressing with instructions to change each day and as needed. The facility's wound nurse assessed R15 on 3/17/26 and documented the resident with an unstageable pressure injury on the sacrum that was present on admission. The wound nurse documented the pressure injury measured 7 cm x 12 cm (length by width in centimeters) with no depth measurable due to coverage with slough and deep purple ecchymosis. On 6/10/26 at 1:00 p.m., R15 was interviewed about the sacrum pressure injury. R15 stated she had the sacrum wound prior to admission to the facility. The resident stated the wound occurred when she sat on the floor for three days waiting for help after falling at home. Section M of R15's MDS dated [DATE] documented the resident had an unstageable pressure ulcer/injury. This section inaccurately documented that the unstageable pressure injury was not present on admission. A zero was entered in Section M0300 F.2. indicating how many pressure ulcers were noted at the time of admission, indicating the pressure injury was acquired at the facility. On 6/11/26 at 8:20 a.m., the registered nurse (RN #2) that completed R15's MDS assessment was interviewed. RN #2 stated an error was made in recording the pressure ulcer on the MDS. RN #2 stated she did not recognize that the pressure injury was present upon admission. RN #2 stated she reviewed the admission assessment, and the pressure injury was listed. RN #2 stated the MDS should have indicated the pressure injury as present upon admission. Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual documented on pages M-8 and M-9 concerning coding of pressure injuries in section M, .For each pressure ulcer/injury, determine if the pressure ulcer/injury was present at the time of admission/entry or reentry and not acquired while the resident was in the care of the nursing home. Consider current and historical levels of tissue involvement .Review the medical record for the history of the ulcer/injury .Review for location and stage at the time of admission/entry or reentry .If a pressure ulcer/injury was unstageable on admission/entry or reentry and then becomes unstageable for another reason, it should be considered 'present on admission' at the new unstageable status. For example, if a resident is admitted with a deep tissue injury, but later the injury opens, the wound bed is covered with slough, and the wound is still unstageable, this wound would still be considered 'present on admission' . (1) This finding was reviewed with the administrator and director of nursing during a meeting on 6/11/26 at 1:40 p.m. with no further information presented prior to the end of the survey. (1) Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, Version 1.20.1, Centers for Medicare & Medicaid Services, Revised October 2025.

Based on observation, resident interview, staff interview, facility document review and clinical record review, the facility staff failed to provide accurate orders and maintain equipment for tracheostomy care for one of thirty-six residents (Resident #5) and failed to administer oxygen as ordered by the physician for one of thirty-six residents in the survey sample (Resident #99). The findings include: 1. Resident #5 had physician orders for tracheostomy care that included changing an inner cannula when the resident's tracheostomy did not have an inner cannula. Suction equipment at R15's bedside for emergency use, was not supplied with a suction catheter or canister. The plastic bag covering the suction machine and the table where the machine was positioned was covered with dust. Resident #5 (R5) was admitted to the facility with diagnoses that included peripheral vascular disease, history of vocal cord paralysis with tracheostomy, diabetes, hypertension, anemia, atrial fibrillation, depression, anxiety, schizophrenia and bradycardia. The minimum data set (MDS) dated [DATE] assessed R5 with moderately impaired cognitive skills. R5's clinical record documented a physician's order dated 3/6/25 for tracheostomy care with instructions to change the inner cannula once every three months. The record documented a physician's order dated 11/29/24 to suction the tracheostomy as needed. R5's clinical record documented that nursing changed the inner cannula as ordered on 12/1/25, 3/1/26 and 6/1/26. R5's clinical record, reviewed since November 2025, documented no complications with the tracheostomy and no instances of needed suctioning. On 6/10/26 at 1:46 p.m., with R5's permission, daily tracheostomy care performed by the licensed practical nurse unit manager (LPN #1) was observed. During this treatment, R5 stated he did not use an inner cannula with his tracheostomy and that he had never had an inner cannula. R5 stated the tracheostomy tube was changed and/or cleaned every three months. R5 stated the skin around the tube was healed and denied any concerns with his tracheostomy. R5 stated he had no issues with secretions and had never required suctioning. LPN #1 also stated at this time that R5's tracheostomy did not have an inner cannula. The tracheostomy and surrounding skin were observed with no signs of any complications. On 6/10/26 at 1:50 p.m., accompanied by LPN #1, R5's bedside suction machine and tracheostomy equipment were inspected. The suction machine was covered with a plastic bag that had been torn open. The plastic bag and table where the suction machine was positioned was covered with gray lint. There was an extra tracheostomy tube in a sealed container stored in the plastic bag. The suction machine did not have a canister and there was no suction catheter stored with the machine. On 6/10/26 at 1:55 p.m., LPN #1 was interviewed about the physician's order regarding an inner cannula change and the suction machine with no canister or catheter. LPN #1 stated R5 had a history of taking the supplies from the plastic bag covering the suction machine. LPN #1 stated the resident frequently removed items from the bag and discarded them. LPN #1 displayed that a supply of suction catheters and tracheostomy care kits were available in the unit's supply room and that the crash cart also had a suction machine and emergency resuscitation supplies. LPN #1 stated regarding the order for the inner cannula change, I know the order says inner cannula, but he only has the trach [tracheostomy] tube. LPN #1 stated the resident's tracheostomy tube was disposable and that the tube was changed once every three months. LPN #1 was not sure why the physician's order had not been revised or clarified. On 6/10/26 at 3:50 p.m., the director of nursing (DON) was interviewed about R5's order for inner cannula change and the lack of maintenance for the bedside suction equipment. The DON stated the resident had never had an inner cannula with the tracheostomy. The DON stated the hospital attempted to place one about two years ago and the resident had breathing difficulties, so it was removed. The DON stated the physician's order needed to be clarified as the resident did not use an inner cannula. The DON stated R5 was known to rummage and at times removed bedside tracheostomy supplies including the suction catheters. The DON stated the crash cart had suction equipment and all resuscitation supplies but agreed that if the suction equipment was kept in the resident's room that it should be maintained and ready for use. R5's plan of care (revised 3/23/26) documented the resident used a tracheostomy tube (6 mm size) due to history of vocal cord paralysis and documented the resident at times removed the extra trach supplies from the room. Interventions for care of the tracheostomy included educating resident on the importance of having trach supplies in the room, suctioning as needed and trach care as ordered by the physician. The facility's policy titled Tracheostomy Care Policy (revised 8/19/2025) documented, .The goals of tracheostomy care are to maintain the patency of the airway, prevent breakdown of the skin surrounding the site, and prevent infection .A spare tracheostomy tube of the same/size/type or equivalent should be in the resident's room at bedside at all times for emergency purposes . This policy listed under equipment needed for tracheostomy care, .Suction equipment (if needed) . The facility's policy titled Physician/Provider Orders Policy (revised 10/7/24) documented, .The Charge Nurse shall transcribe and review all physician/provide orders .Orders will [be] reviewed at the frequency required by state regulation but not less than bi-monthly . These findings were reviewed with the administrator and DON during a meeting on 6/10/26 at 5:30 p.m. with no further information presented prior to the end of the survey. 2. The facility staff failed to administered oxygen according to physician's orders for Resident #99 (R99) and failed to have the ordered humidifier bottle connected and in use. On 6/09/2026 at 3:53 PM, an observation was conducted. Observed saline nasal spray that was on R99's bedside table and Oxygen being administered to R99 and was set on two liters per minute with humidity bottle not in use. On 6/9/26 at 3:53 PM, an interview was conducted with R99. During the interview, R99 stated that she was using the nasal spray due to nasal dryness from the oxygen use. On 6/11/2026 at 8:49 AM, an interview was conducted with a licensed practical nurse, LPN5. During the interview, LPN5 stated the oxygen was to be set at two liters per minute and she checked the oxygen concentrator and it was set on two liters per minute. LPN5 then checked the physician's order to see what the oxygen was and she said, Oxygen order states four liters per minute continuous and add humidity for comfort if needed and I thought her oxygen was as needed. On 6/11/26 at 9:00 AM, an interview with LPN1, unit manager on the unit was conducted. LPN1 stated that R99's oxygen order was as needed (prn). LPN1 printed the oxygen order and the frequency was prn. She confirmed the order was confusing when the order reads, 4lpm [liters per minute] continuous, and the frequency is prn. On 6/11/2026 at 1:18 PM, an interview was conducted with the Director of Nursing (DON). R99's oxygen order was discussed, oxygen incorrect liter flow being administered and no humidification being provided per the physician orders. 02 The DON stated she was not aware of her oxygen order specifics and reviewed the orders. After the DON reviewed the physician's oxygen orders for R99 she stated she would correct the oxygen orders. On 6/11/26, a clinical record review was conducted. R99's clinical record was reviewed and a progress note dated 5/19/2026 by the family Advanced Practice Provider Nurse Practitioner (NP) was reviewed. The progress note was for an acute visit for nose bleeds and read in part, . R99 [name redacted] is seen today per her request for the complaint of nosebleeds. She had one nosebleed this morning that lasted approximately 5 minutes and was effectively managed by applying pressure with a tissue. She does not have an active nosebleed at this time. She reports having on and off nosebleeds for the past 3 weeks. Reviewed an order that was dated 05/15/2026 and received by a registered nurse, RN1, unit manager of the unit. The order read in part, .Start Date: 05/15/2026 End Date: Open Ended Order Description: Oxygen: Administer oxygen (O2) via nasal cannula (NC) continuously: 4LPM [liters per minute]. Add humidification if > [greater than] 4 L/min [liters per minute] or for comfort, if needed : No Frequency: Every Shift - PRN [as needed] Times / Shifts: Description Check concentrator to ensure functioning and appropriate setting. Check SPO2 [peripheral capillary oxygen saturation]. Check humidifier if applicable. Record: Before: Pulse, O2 [oxygen] Saturation, Minutes, SOB [shortness of breath] HOB [head of bed] elevated. A progress note dated 5/4/26 and was written by the Advance Practice Provider NP for a follow up visit for complaint of shortness of breath was reviewed. The progress note read in part, .R99 [name redacted] is seen today for follow-up on shortness of breath from her readmission last week. She reports feeling better today and was sitting up in her wheelchair at the time of assessment. She continues to require continuous oxygen at all times. Current therapy will be continued. She is here for a long-term stay. On 6/11/26, facility documentation review was conducted. The facility policy titled, Oxygen Administration, read in part, Licensed clinicians with demonstrated competence will administer oxygen via the specified route as ordered by a provider. In an emergency situation, clinicians may administer oxygen and obtain a provider's order as soon as practicably possible after patient stabilization or transfer. On 6/11/26 at 1:36 PM, a pre-exit meeting was held with the Administrator, Director of Nursing, and Regional Director of Clinical Services and they were informed of the above concerns. No additional information was provided prior to the exit conference.

Based on observation, staff interview, and facility documentation review, the facility staff failed to maintain an enviornment free of accident hazards regarding water temperatures on two of six units (Sundrop and [NAME] Lane). The findings included:The facility failed to maintain water temperatures at a safe level to prevent the risk of scalding on two units. On 6/10/26 at 8:37 AM, during observations several resident rooms were noted to have water temperatures that were too hot for you to hold your hand under. On 6/10/26 at 9:16 AM, an interview was conducted with licensed practical nurse #5 (LPN #5), who worked on the Sundrop unit. When asked about the water temperature, LPN #5 confirmed she was aware there was a problem a while back and someone had to come in and fix it. On 6/10/26 at 1:30 PM, during the resident council group interview, multiple residents expressed concern that the water never gets hot and other times it gets hot just like that. On 6/10/26 at 4:17 PM, a tour of the facility was conducted with the maintenance director, and water temperatures were taken at various points within the facility. The maintenance director stated that he wants to maintain hot water temperatures between 105 and 120 degrees [NAME] height. The water temperature in room [ROOM NUMBER], which was unoccupied measured 125.1 degrees. The maintenance director commented, That's a little warm. When asked what the potential risk to residents is, the maintenance director said, potential scalding. During the above tour with the maintenance director the water temperature in room [ROOM NUMBER] was identified to be 129.4 degrees. The maintenance director reported he had a contractor coming the following day to research the potential problem. On 6/10/26, during an end-of-day meeting with the facility Administrator and Director of Nursing, the above findings were discussed. The administrator reported they had adjusted and turned the water temperature down. When a facility policy regarding water temperatures was requested, the Administrator reported they had no policy for this.No additional information was provided.

Based on observation, staff interview, record review and facility document review, the facility staff failed to maintain an infection prevention and control program to help prevent the development and transmission of communicable diseases and infections for one of 36 residents in the survey sample, resident #2. The findings included: A facility policy entitled, Indwelling Urinary Catheter Care Procedure with a review date of 7/15/2025 read in part, 10. Check drainage tubing and bag to ensure that the catheter is draining properly, and no kinks are present. The urinary bag must be placed below the bladder level but not on the floor. The Resident Face Sheet indicated the facility admitted the resident 3/10/2025. According to the Resident Face Sheet resident #2 had a medical history that included quadriplegia, neuromuscular dysfunction bladder, stage IV pressure ulcer to sacrum, and a history of urinary tract infection (UTI). The annual minimum data set (MDS) assessment with an assessment reference date of 5/26/26 assigned the resident a brief interview for mental status (BIMS) score of 15 indicating intact cognition. Resident #2 was coded as having a foley catheter. Resident #2's comprehensive care plan included a focus that read, Resident requires a foley catheter use R/T (related to): neuromuscular dysfunction of bladder. Under interventions, Do not allow tubing or any part of the drainage bag system to touch floor. Another focus of the care plan read, Resident is at risk for infection R/T hx (history) of UTI, history of infection, incontinence, open wounds, catheter use, hx of wound infection. On 06/09/2026 at 1:33 PM resident #2 was observed lying in bed, the foley drainage bag was resting on the floor. 06/09/2026 5:14 PM resident #2 was observed lying in bed. The foley drainage bad was still resting on the floor. 06/11/2026 10:52 AM interview with Director of Nursing (DON) and the Regional Director of Clinical Services (RDCS). Both agreed that the foley drainage bag should not be resting on the floor and the RDCS stated that since resident raises and lowers the bed independently, they will place a basin or chucks pad as a barrier between the floor and the drainage bag. On 6/11/26 at 1:36 PM this concern was reviewed with the Administrator, DON and RDCS. No further information was provided prior to the exit conference.

Based on staff interview, clinical record review, and facility document review, the facility staff failed to ensure a medical provider documented the rationale for the action on a pharmacy recommendation dated 04/24/2026 as part of a medication regimen review for (1) one of (5) five residents sampled for medication regimen reviews, Resident #10. Findings included:A facility policy titled, Medication Regimen Review with a revision date of 06/01/2024, specified under the heading, Procedure item #9.2.1 if the attending physician/prescriber has decided to make no change in the medication, the attending physician should document the rationale in the resident's health record. Resident 10's diagnosis list indicated diagnoses, which included, but not limited to, dementia with other behavioral disturbance, anxiety disorder, restlessness, and agitation. The most recent quarterly minimum data set (MDS) with an assessment reference date (ARD) of 04/03/26 was coded to reflect in Section C (Cognitive Patterns) the resident exhibited short and long-term memory problems and was severely impaired in cognitive skills for daily decision making. Progress notes within Resident #10's clinical record indicated drug regimen reviews were completed on 04/24/2026 and 05/27/2026 with recommendations. The pharmacy recommendation reports were not located in the resident's clinical record. Requested and received the medication regimen review Consultation Report for 04/24/2026 that indicated a recommendation for a gradual dose reduction (GDR) for the medication venlafaxine. Further review of the recommendation disclosed a medical provider had reviewed the report and declined the recommendation. The area on the report for the medical provider's rationale for the declination of the GDR was left blank. The report was reviewed and signed by the medical provider and by the psych NP (nurse practitioner). A review of the medication regimen review Consultation Report dated 05/27/2026 disclosed the consultant pharmacist's recommendation from 04/26/2026 was declined by a medical provider to perform a GDR and did not provide documentation to support that a GDR for venlafaxine was clinically contraindicated. The report continued with a recommendation to follow up with the prescriber to obtain documentation of clinical contraindication for a GDR. The area of the report for the medical provider's rationale for the declination of the GDR was completed and indicated a GDR would be attempted later due to a GDR at this time would likely distress the patient, as the patient was treated for a UTI (urinary tract infection). The report was signed by a medical provider on 06/01/2026. On 06/11/2026 at 8:25 AM, the Director of Nursing (DON) was interviewed and stated the pharmacist had contacted the facility about the medical provider(s) failing to provide rationale on the 04/24/2026 pharmacy Consultation Report. The DON agreed nurses are to review recommendations after a provider looks at them. This concern was discussed at the pre-exit meeting on 06/11/2026 at 1:36 PM, with the Administrator, Director of Nursing, and Regional Nurse. No further information was provided prior to exit on 06/11/2026.

Based on staff interview, clinical record review and facility documentation review the facility failed to ensure appropriate monitoring and assessment of a change in condition related to a urinary catheter for one resident, Resident #156 (R156) out of a survey sample of 36 residents. The findings included:The facility failed to monitor R156's urinary catheter when hematuria (blood in urine) was observed and failed to notify the medical provider of the change in condition. On 6/11/2026 at 9:43 AM, an interview was conducted with a registered nurse, RN1. She stated that if she was to observe blood in a residents urine she would notify the doctor unless it was something the doctor was already aware of or if it was expected example kidney stones. RN1 stated if the blood in the urine was a new finding then the doctor should be notified. She also stated if the progress note stated to monitor then, I would expect a follow up note after the note that said to continue to monitor. On 6/11/26 at 9:22 AM, an interview was conducted with RN3. She stated if blood in the urine was observed, I would report to the doctor, follow the doctor's instructions, report it to the next shift , and document that the report was given to the on coming shift to monitor.On 6/11/26, a clinical record review was conducted. R156's progress notes were reviewed. A note dated 1/1/26 at 1:38 PM, written by a registered nurse, RN4 read, resident lying in bed moaning and groaning prn [as needed] pain med [medication] given Vital signs stable 111/66,97.4,78,18 o2sats [oxygen saturations] 96%on RA [room air] catheter draining bloody urine will continue to monitor. There was no follow up note in the medical record and no progress note of notification to the medical doctor. R156 was sent out to the hospital on 1/4/26 and did not return to the facility.On 6/11/26, facility documentation was reviewed. The facility document was titled, Indwelling Urinary Catheter Care Procedure, read in part, . Clinical staff with demonstrated competence may provide urinary catheter care. Such care will help to prevent catheter association urinary tract infections (CAUTIs) and prolong the life of the catheter system. A second facility documentation was reviewed. The facility document was titled, Resident Change in Condition Policy, read in part, .The facility will inform the resident; consult with the resident's physician/provider; and notify the resident representative(s) when there is: a) An accident involving the resident which results in injury and has the potential for requiring physician/provider intervention; b) A significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications); c) adverse A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to consequences, or to commence a new form of treatment); d) A decision to transfer or discharge the resident from the facility.On 6/11/26 at 1:36 PM, a pre-exit meeting was held with the Administrator, Director of Nursing, and Regional of Clinical Services. They were informed of the above concerns.No additional information was provided prior to exit conference.

Based on observation, staff interview, resident interview, clinical record review and facility document review the facility staff failed to review and revise a comprehensive care plan for 2 of 36 residents, Resident #3 and Resident #16. The findings included: 1. For Resident #3 the facility staff failed to revise the care plan when the resident's oxygen was discontinued. Resident #3's clinical record listed diagnoses which included but not limited to obstructive sleep apnea, chronic obstructive pulmonary disease, unspecified asthma, dyspnea, and acute and chronic respiratory failure with hypoxia. Resident #3's most recent admission minimum data set (MDS) with an assessment reference date of 05/18/26 assigned the resident a brief interview for mental status score of 12 out of 15 in section C, cognitive patterns. This indicates that the resident is cognitively intact. Resident #3's comprehensive care plan was reviewed and contained a plan for Resident requires oxygen therapy r/t (related to) chronic respiratory failure. This plan was revised on 05/22/26. Resident #3's clinical record was reviewed and contained a physician's order summary which read in part, Oxygen: Administer oxygen 2L (liters) via nasal cannula (NC) continuously. This order was discontinued on 05/12/26. Surveyor observed Resident #3 on 06/10/26 at 2:30 pm. Resident was seated in common area of facility. No oxygen was observed. Surveyor asked Resident #3 if they use oxygen and resident stated they do not. Surveyor spoke with MDS coordinator on 06/11/26 at 9:50 am regarding Resident #3. MDS coordinator stated that the care plan for oxygen should have been removed when the resident's oxygen was discontinued. MDS coordinator stated, I will do that now. Surveyor requested and was provided with a facility policy entitled Comprehensive Care Planning Policy which read in part, The care plan is reviewed on an ongoing basis and revised as indicated by the resident's needs, wishes, or a change in condition. The concern of not revising Resident #3's care plan was discussed with the administrator, director of nursing and regional director of clinical services on 06/11/25 at 1:35 pm. No further information was provided prior to exit. 2. The facility failed to ensure revision of Resident #16's (R16) care plan following a fall. On 6/09/2026 at 2:00 PM, R16 was interviewed. During the interview, R16 stated that he had a fall about two weeks ago and was having pain in his back. R16 stated that he had an x-ray on his back and it revealed a fracture. On 6/10/26 at 4:00 PM, and interview was conducted with the unit manager on the 400 nursing unit, a registered nurse (RN1). She stated that R16 notified us of the fall the next morning. RN1 stated according to the staff that was working the shift when he fell that no one heard a call bell and they went to check his room and found nothing in the bathroom floor. R16 told me that he went to the nurses station and informed them he had fallen in the bathroom. RN1 stated that we checked his call bell light to make sure it would activate when pushed and it was working. RN1 stated that the nurse practitioner ordered an x-ray and that the fracture was an aged fracture and if R16 was not improving she would order a MRI (magnetic resonance imaging) of his back. On 6/10/26 at 4:30 PM, an interview was conducted with the Director of Nursing, (DON). The DON stated that R16 had an unwitnessed fall on 5/9/26, all the post fall paperwork was completed and the NP ordered an x-ray that showed an aged fracture to R16's lower back. On 6/11/26 at 8:32 AM, an interview was conducted with the Minimum Data Set (MDS) coordinator. During the interview, she stated that all falls should be care planned with an intervention when the fall happens. MDS coordinator stated that she was made aware of falls in the morning meetings and at risk meetings. On 6/11/2026, a clinical record review was conducted for R16. During the review, it was determined that the resident experienced a fall on 5/9/26. The care plan was reviewed and there was no revision made to R16's care plan following the fall and no documented fall interventions were implemented. On 6/11/26, a review of facility documentation was conducted. The facility document titled, Comprehensive Care Planning Policy, read in part, An interdisciplinary plan of care will be established and updated as indicated for every resident in accordance with state and federal regulatory requirements. The care plan is reviewed on an ongoing basis and revised as indicated by the resident's needs, wishes, or a change in condition. At a minimum, this will occur with each comprehensive and quarterly assessment in accordance with Resident Assessment Instrument (RAI) requirements. On 6/11/26 at 1:44 PM, a meeting was held with the Administrator, Director of Nursing, and Administrator of a sister facility and they were informed of the above concerns. No additional information was provided prior to the exit conference.

Based on observation, resident interview, staff interview, and facility documentation review, the staff failed to uphold the residents right to receive services with reasonable accommodation of individual needs for one resident, Resident #76 (76) out of a survey sample of 36 residents. The findings included:The facility staff failed to respond to resident call lights in a timely manner and turned off call lights before care or assistance was provided. On 6/9/26 at 1:00 pm, an observation was conducted. R76 had activated her call light requesting assistance for incontinence care. A certified nursing assistant entered the room to pick up R76's lunch tray and asked the resident what assistance was needed, and informed the resident she would return to assist her. Shortly after that a registered nurse, RN1 entered the room and turned off the call light without determining the resident's needs or ensuring the requested assistance had been provided. On 6/9/26 at 1:45 pm, an interview was conducted with R76. During the interview, R76 said. I have not received any care yet and I am wet and needed changing for a long time. R76 activated her call light again for assistance. The Administrator entered the room and asked R76 what assistance was needed. The Administrator then left the room to obtain staff assistance for the resident. Observation revealed that R76 was waiting for over 45 minutes for incontinence care to be provided. On 6/10/26 at 8:30 am, an observation was made of R76's call light that was activated and needed assistance with moving her over bed table from one side of her bed to the other side. The call bell was activated for approximately 12 minutes before assistance was provided. Two staff members went in the room, a certified nursing assistance (CNA) and a housekeeping employee and did not acknowledge that the call light was activated or offer any assistance. It was observed, that several facility employees walked by the room with the call light activated and never responded to the call light. CNA6 went into the room to pick up R76's breakfast tray and acknowledged the call light and provided assistance. On 6/10/26 at 9:00 am, an interview was conducted with a certified nursing assistant, CNA6. During the interview, CNA6 stated that she answers the call light and provides the assistance at that time; however, if she was unable to provide the assistance at that time she would come back and give the assistance. CNA6 stated that the call bell lights was not to be turned off until the resident received their care or assistance they were requesting. On 6/10/26 at 10:00 am, an interview was conducted with RN1, who was the unit manager of the 400 unit. She stated anyone can answer call lights. If someone was unable to provide the assistance needed then they would go get staff for assistance. RN1 stated the call light should not be turned off until assistance is provided. On 6/10/26, a review of facility documentation was conducted. The facility policy titled, Call Light Resident Communication System Policy, read in part, It is the policy of the facility to provide residents with a means of communicating with staff. A call system is installed in each resident room and toilet/bath areas. The facility responds to resident needs and requests. Steps in Procedure: 1. Turn off the call light. 2. Identify yourself and call the resident by his/her name (use Mr. or Mrs.) and ask 'how may I help you?' 3. Listen to the resident's request. 4. Do what the resident requests, if capable/allowed. Otherwise seek assistance of charge nurse or someone who can assist If you have promised the resident you will return with an item or information, do so promptly.On 6/10/26 at 5:24 pm, an end of day meeting was held with the Administrator, Director of Nursing, Regional Director of Clinical Services and Administrator from a sister facility and they were informed of the above concerns.No additional information was provided prior to the end of the survey.

Based on observation, resident interview, staff interview, and facility documenation review, the facility staff failed to maintain a homelike environment on two of six units (Sundrop and [NAME] Lane units). The findings included: For the Sundrop and [NAME] Lane units, the facility staff failed to maintain comfortable water temperatures and provide consistent hot water for residents. On 6/10/26 at 8:37 AM, during observations of Resident #145's (R145) room, it was noted that the water in the bathroom never reached a temperature above lukewarm despite the water running for about five minutes. On 6/10/26 at 9:16 AM, an interview was conducted with licensed practical nurse #5 (LPN #5), who worked on the Sundrop unit. When asked about the water temperature, LPN #5 confirmed she was aware there was a problem a while back and someone had to come in and fix it. On 6/10/26 at 9:20 AM, the water in Resident #18's (R18) room was checked. It was noted that the water never reached a comfortable temperature and was barely lukewarm even after running for several minutes. On 6/10/26 at 9:27 AM, an interview was conducted with certified nursing assistant #5 (CNA #5). CNA #5 reported that the water on the Sundrop unit doesn't get hot and she comes in and turns all her water faucets on to let it run to get hot so she can give baths. CNA #5 went on to say, Resident's complain and say the water is cold. I have to go to the spa and get hot water. The maintenance director says we are too far from the water heater. On 6/10/26 at 9:36 AM, during an interview with Resident #99 (R99) the resident said, the water only gets warm, not hot and it takes a long time to get warm. I would like it hotter. On 6/10/26 at 1:30 PM, during the resident council group interview, multiple residents expressed concern that the water never gets hot and other times it gets hot just like that. On 6/10/26 at 4:17 PM, a tour of the facility was conducted with the maintenance director, and water temperatures were taken at various points within the facility. The maintenance director stated that he wants to maintain hot water temperatures between 105 and 120 degrees [NAME] height. When checking water temperatures, the maintenance director commented when the water in one room on the [NAME] Lane didn't get hot, he said, This is the one hall that has trouble getting to temperature. I have [contractor company name redacted] coming tomorrow to research the potential problem. In another room on the [NAME] Lane unit the water ran for several minutes and only reached a lukewarm status, the maintenance director commented, I don't understand, it is almost like a mixing valve is open. During the above interview, the maintenance director reported that several months ago they lost a water heater and they had to take it offline for about a week while repairs were being made. Review of the resident council minutes revealed in March and May 2025 meetings, Residents reported water turning cold during bathing. On 6/10/26, during an end-of-day meeting with the facility Administrator and Director of Nursing, the above findings were discussed. No additional information was provided. 2. The facility failed to ensure the fish aquarium located in the dining room on the 400 nursing unit was maintained in a clean and sanitary condition. On 6/09/2026 at 2:09 PM, an observation was made of the fish tank on the 400 nursing unit in the dining area. The glass was black with algae like material and unable to see the fish inside the tank. The top of the fish tank had food particles noted and the motor/filter had corrosion like material noted. On 6/10/26 at 8:15 AM, a second observation was made of the fish aquarium on the 400 nursing unit in the dining area and pictures were taken of the fish aquarium. On 6/10/2026 at 8:53 AM, an interview was conducted with a licensed practical nurse, LPN7. LPN7 stated that she tried to keep it clean. She said, once a month I try to clean it. I do feed them and I try to vacuum out the rocks. LPN7 stated to ask the Administrator who was responsible for the cleaning of the fish tank. On 6/10/26 at 9:00 AM, an interview was conducted with the Administrator about the cleaning of the fish aquarium on the 400 nursing unit in the dining room. She stated that LPN7 was suppose to be in charge of cleaning the fish aquarium. The Administrator stated she would buy the supplies when LPN7 requested. On 6/10/2026 at 11:00 AM, another observation was made of [NAME] units dining room and the fish aquarium was removed from the dining room area. On 6/10/26, a request for a home like environment/cleanliness/or any policy pertaining to the cleaning of the fish aquarium was requested and the Administrator stated that there was no policy for these areas to offer. On 6/10/26 at 5:24 PM, an end of day meeting was held with the Administrator, Director of Nursing, Regional Director of Clinical Services, and Administrator from a sister facility. They were informed of the above concerns. No additional information was provided prior to the end of the survey.

Based on staff interview, facility documentation review, and clinical record review, the facility staff failed to provide care and services to ensure residents received care to prevent development of pressure ulcer(s) for one resident (Resident # 3- R3) in a survey sample of 5 residents, resulting in harm for R3. Findings included: For R3, the facility staff failed to implement interventions to prevent the development of and failed to identify and treat a pressure injury until at an advanced stage of wound deterioration, requiring sharps debridement (cutting the dead tissue out), which constituted harm. Review of the clinical record was conducted on 6/17/2024 -6/18/2024 and 6/20/2024. R3 was admitted on [DATE] with diagnoses including but not limited to: Cerebral infarction, difficulty in walking, muscle wasting and atrophy, type 2 diabetes mellitus without complications, hyperlipidemia, and essential (primary) hypertension. R3 was discharged from the facility on 4/29/24. R3's Admission MDS (Minimum Data Set - assessment tool) with an ARD (Assessment Reference Date) of 4/14/2024, coded R3 as having had range of motion impairments bilaterally in upper and lower extremities. R3 was coded as having been dependent in all ADLs (Activities of Daily Living), except eating and oral hygiene. This assessment had no coding for a pressure wound noted but R3 was coded to be at risk for development of pressure ulcer/injuries, based on formal assessments and clinical assessments. R3's baseline care plan did not address any skin breakdown and/or wound. The only notation regarding skin was an approach that read as follows: . SKIN: Resident will be provided skin care to prevent skin breakdown. Review of R3's progress notes and assessments revealed no documentation of any skin issues being present upon admission. On 4/10/24, R3 had labs drawn. A CBC (complete blood count) and CMP (complete metabolic panel). R3's prealbumin, albumin and protein were within normal limits and R3's physician gave no new orders in response to the lab values. According to R3's Braden scale for predicting pressure sore risk assessment, conducted on 4/16/24, R3 was assessed having a score of 12, which indicated high risk for pressure ulcer development. In the section for interventions, nothing was checked/selected. Under the section for plan of care, nothing was checked. On the same day, a weekly skin observation was conducted and documented no skin issues noted. On 4/23/24, R3 had another Braden scale for predicting pressure sore risk assessment conducted. R3 was assessed as having a score of 13, which indicated a moderate risk. Under the interventions section, it noted, skin and ulcer/injury treatments, which included but were not limited to: pressure reducing device for chair, pressure reducing device for bed, turning/repositioning program, nutrition or hydration intervention to manage skin problems, pressure ulcer/injury care ., none of which were selected. This assessment's alternative option, none of the above were provided, was selected. On the same day, 4/23/24, a weekly skin observation was conducted at 3:07 p.m. and noted no skin issues noted. On 4/30/24, a Braden scale for predicting pressure sore risk was completed, which was the day following R3's discharge home. This assessment identified R3 as being high risk and the interventions of pressure reducing device for chair, pressure reducing device for bed, turning/repositioning program, nutrition or hydration intervention to manage skin problems, pressure ulcer/injury care, and application of dressings to feet, were all selected. R3's physical therapy notes dated 4/22/24, read in part, .Directed pt [patient] in rolling bilaterally w/ [with] total A [assistance] w/ pt observed to moan in pain throughout. Pt's wife was present this date and reported that pt has significant skin breakdown on his sacral/buttocks region which causes him pain w/ movement. Repositioned pt in R [right] side lying to offload his sacral/buttocks region. Then immediately reported the wife's concerns to the nurse who reports that the wound care nurse will assess and provide tx [treatment] as needed . On 4/22/24, R3 was seen by the nurse practitioner. The NP's note read in part, Chief complaint/Reason for this visit: . Has an abrasion on coccyx . Has a small abrasion on sacral area about 3 cm circular with superficial depth. Pink with granulation tissue in base. No drainage or erythema. Will change daily and refer to wound team . On 4/25/24, R3 was seen by a wound specialist. The wound specialist's note read in part, . pt [patient] was noted a few days ago to have some peeling of the skin and discoloration at his sacral region. Aid was present today and reported that when she was cleansing the pt the skin peeled at there was an ulceration underneath . Sacrum (+) full thickness ulceration that measures 5.4 x 5.5 x 0.2 cm. wound base 40% intact, 20% slough, 5% deep purple, 35% granular before debridement . Performed excisional debridement [cutting dead tissue out] of sacrum wound(s) consisted of: Ulceration site(s) was/were prepped and conservative sharp debridement was performed. Depth of debridement was at level of subcutaneous tissue, and within wound margins. Removal of devitalized necrotic [dead] tissue with a 5mm curette [sharp cutting tool]. There was scant bleeding that quickly subsided with light pressure and cleansing. Patient appeared to tolerate procedure without pain or signs of discomfort . The wound specialist also documented that the wound to be a stage 3 pressure injury. Orders from the wound specialist for treatment of the wound were to -Cleanse site with normal saline or sterile water (Do not use wound cleanser, this may decrease effectiveness of Santyl (collagenase), Apply Santyl (collagenase) ointment (nickel thickness) to wound base- (tx for enzymatic debridement), Cover with foam dressing, provide this care daily and as needed for saturation or soilage . On 04/27/2024 at 7:24 a.m., a late entry was made for 04/23/2024 of a nursing note about R3 that that read, CNA [certified nursing assistant] reported open area to sacrum. Nurse approximated edges 2cm x 1 cm no depth. Wound base red in color. Small amount of serous drainage noted. Area cleansed with wound cleanser; zinc-based cream applied. Speaking with CNA and looking through chart resident is eating less than 25% at meals. NP aware of findings. Air mattress and wedge for turning and repositioning in place. On 4/27/24, a wound management detail report was entered into R3's chart, by the wound treatment nurse. This document noted the following: Pressure Ulcer: wound type: pressure ulcer, wound location: sacrum, Date/time identified: 4/23/24 13:00, Present on admission/re-entry? No . Observation: Date/time observed pressure ulcer: 4/25/24 at 7:08 a.m. length: 5.4 cm, width: 5.5 cm, can depth be measured? Yes, depth: 0.2, exudate: moderate, . stage: Stage III, tissue type: slough, percent of wound covered by granulation tissue: 35, percent of wound covered by eschar tissue: 5, percent of wound covered by clean, non-granulation tissue: 40, wound edges/margins: edge attached to base, skin surrounding wound: pink/normal, wound healing status: declining, created date/time: 4/27/24 7:14 a.m The above noted form went on to note a second observation that was listed as the following: date/time observed pressure ulcer: 4/23/24 13:00, length: 2 cm, width 1 cm, can depth be measured: no, exudate: light, exudate color and consistency: serous (clear, amber, thin and watery), tissue type: closed/resurfaced, percent of wound covered by clean, non-granulation tissue: 100, wound edges/margins: edge attached to base, skin surrounding wound: assess within 4 cm of wound edge: pink/normal, wound healing status: stable, created date/time: 4/27/24 at 7:08 a.m According to R3's physician orders, on 4/27/24, orders were entered that read, Air mattress to bed, and wedge in place for turning and repositioning, with an effective date of 4/23/24. According to the MAR (medication administration record), neither were signed off as being in place until the night shift on 4/26/24. On 4/23/24, R3 was ordered and started on pro-stat, vitamin C, and zinc for wound healing. The were no record of these interventions prior to R3's wound development, including being in place as preventative measures. According to the medication administration record, R3 had heel protectors bunny boots ordered 4/27/24. Based on the Braden assessments, R3 was identified to be at high risk for development of pressure ulcer development, but there was no evidence of any interventions other than routine care and services provided to all residents. Additionally, R3 had no orders for any wound care implemented until 4/26/24. On 6/17/24 at 3:17 p.m., an interview was conducted with LPN #1. LPN #1 recalled R3 and said, He was very debilitated and was completely dependent on staff for bathing and even eating . he didn't get out of bed daily . he did have a problem on his bottom. When asked if it was present on admission, LPN #1 said, I don't believe it was present on admission. When asked if R3 was on an air mattress, LPN #1 said, We were trying to do turning and repositioning as he would allow, and we put an air mattress on after the wound. LPN #1 confirmed the air mattress was in response to the wound and not placed prior to wound development as a preventative measure. On 6/18/24 at 9 a.m., the facility administrator and Director of Nursing (DON) were asked to provide any evidence they had for consideration of past non-compliance, in light of these findings. They provided a binder that they said was their risk documents. The surveyor asked them to provide a summary of what they found to be the deficient practice, what they did, and when they felt they were in compliance. The facility administrator returned and said, There wasn't any deficient practice, and provided a statement that read as follows, [R3's name redacted]- open area identified. On 4/23/24 CNA reported to nurse that while she was bathing resident his skin peeled off on his sacrum. Nurse cleansed area with wound cleanser and treatments put in place. MD notified. Treatment initiated. Seen by wound provider on 4/25. Treatment changed. 4/26 nurse notified wound provider. Sacral wound worsening. Requesting telehealth visit for 4/29 to determine if sacral may be a KTU [Kennedy terminal ulcer] vs. PI [pressure injury]. Patient discharged prior to telehealth visit. Date of compliance 5/23/24. Ongoing monitoring of any impaired skin integrity. Within this facility provided risk binder with regards to R3, it included staff education and sign-in sheet that had written, pressure ulcer prevention/basic skin care education. Included were documents that read, basic skin care for the CNA/STNA [certified nursing assistant/state tested nurse aide]. It was noted that 28 of the nursing staff had not signed as having received the education. Also within this facility provided risk binder with regards to R3, there was a document titled, Facility Acquired Injuries Investigation Tool, which read in part, Date ulcer identified: 4/23/24, Ulcer us [sic] properly diagnosed as a pressure ulcer? yes . Is the new ulcer in a site of a previously healed ulcer of any type? no. Location of ulcer: Sacrum. Stage of PU [pressure ulcer] at discovery: 3, Is the resident diabetic? no. Prevention strategies that were in place prior to ulcer development: air mattress, turning and repositioning program, heels floated, chair cushion, heel protector/prevalon boots. Nutritional Interventional: multivitamins, Vitamin C, zinc, pro stat 30 ml BID [twice daily] and boost . Is nutritional intake what registered dietician recommends? yes . Another exerpt from this facility acquired injuries investigation tool document went on to read, 1. Is the injury to the patient's skin a pressure ulcer? yes . 3. Discovery date and stage of facility acquired pressure ulcer; 4/23/24, stage 3. 4. document details of event: CNA reported doing incontinence care . Root cause identified for pressure ulcer development? no responses were recorded; this section was blank. What the pressure injury: avoidable or unavoidable (Circle) was blank, with neither option circled. Action Plan for Improvement/Treatment of Pressure Injury, was blank with nothing listed. This document was signed by the facility's wound treatment nurse and dated 4/23/24. On 6/18/24 at 1:56 p.m., the wound treatment nurse was interviewed. The wound treatment nurse reported that the residents' have their skin assessed on admission and then weekly thereafter. The wound treatment nurse said that if a wound is noted, staff would let her know, she woud have the wound specialist see the resident to stage the wound, and get an order from the resident's doctor for treatment, until the wound specialist sees the resident. The wound treatment nurse went on to say that she rounds with the wound specialist, who would tell me what she wants for orders, and we discuss it during our at-risk meeting. The wound treatment nurse also said, If at risk, we put things in place like air mattress, turn and repositioning, and talk to the dietician about vitamins, prostat, etc. During this interview, the treatment nurse was asked about the turning and repositioning and barrier cream, which she confirmed is routine care for all residents. When asked to describe what additional measures were put in place, since R3 was total care, unable to reposition to alleviate pressure, and had a Braden score that identified him to be high risk for wound development, the treatment nurse asked if she could get back to the surveyor. When asked about the treatment to R3's wound, the wound treatment nurse stated that on 4/26/24, she identified the wound had worsened, and had an onion odor. The treatment nurse stated she called the wound practitioner who gave the order to cleanse with Dakin's. The clinical record revealed that, on 4/27/24, the wound care order was entered as a late entry for 4/26/24, and read, Cleanse stage 3 PI [pressure injury] to sacrum with Dakins, apply Santyl and foam dressing change QD [every day] and PRN [as needed]. According to the medication administration record (MAR), treatment to the wound was not performed until 4/27/24. When asked about these findings, the wound treatment nurse stated that the Santyl had to be ordered and they had to wait for it to arrive. When asked about the late entry, the wound treatment nurse said that at times she gets busy and will remember later and go back in and chart. On 6/18/24 at 3:30 p.m., a follow-up interview was conducted with the treatment nurse. When asked about R3's air mattress, the wound treatment nurse said, We put the air mattress on right after found [referring to the wound]. The wound treatment nurse was shown R3's MAR and asked why the air mattress was showing as having been ordered on 4/23/24 but was not signed off as being in place until 4/26/24. The wound treatment nurse said, I recall putting the air mattress on, on the 23rd, when we found it [the wound], but didn't address that the order had not been entered until 4/27/24. On 6/18/24 at 4:05 p.m., during an end of day meeting, the facility's administration and corporate staff were made aware of the above findings. They were asked to provide any additional information to the survey team upon their return on 6/20/24. On 6/20/24 at 9:04 a.m., the facility's director of nursing (DON) provided the survey team with documentation of the specifications of the mattress that they had on R3's bed. The DON said, it is a pressure relieving mattress and he [R3] was being turned and repositioned, was getting up into recliner chair with a cushion and therapy was working with him. When asked if they had documentation/evidence of the turning and repositioning, the DON said they did not. On 6/20/24 at 9:44 a.m., an interview was conducted with LPN #3, who was the unit manager where R3 resided. LPN #3 explained that Braden scales are conducted on admission to identify if a resident is at risk for development of pressure ulcers. LPN #3 went on to say, At that time we can put stuff in place to prevent that, we would have them on an air mattress, on a turn and repositioning, and use barrier cream. LPN #3 confirmed that turning and repositioning and barrier cream are standard and routine care practices used for all residents who are incontinent. On 6/20/24, interviews were conducted with the treatment nurse and LPN #6. Both confirmed that all the mattresses in use at the facility are pressure reducing and are standard for all residents, as well as the use of barrier cream for incontinent residents. Each of them also confirmed that turning and repositioning is part of routine care. On 6/20/24 at 2:45 p.m., an interview was conducted with CNA #2. CNA #2 reported that R3 had peeling skin on his buttocks, and she was going to put cream [she clarified to be barrier cream] on the bleeding spot that had been there a couple of days. CNA #2 said, The peeling wasn't where the bleeding spot was. CNA #2 explained when she moved her hand, R3's skin stuck to her glove and came off. CNA #2 said that the area started to bleed and she notified the nurse immediately. CNA #2 reported that R3 would get up around 10:30 a.m. to 11 a.m., into a recliner chair daily, would be returned to bed for incontinence care around 3-3:30 p.m., would be gotten back up following the incontinence care until after supper, and would be put back to bed for the day around 6 p.m. CNA #3 said towards the end of his stay at the facility, R2 would want to stay in bed more and once in a while would say his bottom was hurting. When asked about R3's bed and if an air mattress was on the bed, CNA #3 reported that the air mattress was put on the bed sometime after the incident on 4/23/24, indicating maybe the following day but wasn't sure. On 6/20/24 at approximately 5:30 p.m., a phone interview was conducted with the wound specialist. The wound specialist stated that when she saw the wound .it was irregular shaped, the tissue loss was not the whole wound, but it was 20% and it was deep purple. The wound specialist was unable to say how long it would take for such a wound to develop but said that upon her assessment of R3, she would not have anticipated the wound to deteriorate rapidly and did not feel the resident was in organ failure or significantly compromised. On 6/20/24, a review was conducted of the facility's 24-hour nursing reports. R3 was not noted on any of the reports during his stay at the facility. When a resident with the same first initial and last name was noted with a right leg wound, a clinical record review confirmed it was not R3, which the Regional [NAME] President of Operations also confirmed that it was not R3. On 6/20/24, a review was conducted of the facility's at-risk meeting minutes for the time frame R3 was a resident of the facility. R3 was not noted on any of the documents. On 6/20/24 at approximately 4:30 p.m., a meeting was held with the Regional [NAME] President of Operations (RVPO). When asking if the survey team was going to accept past non-compliance, the RVPO asked if he had seen the evidence provided to the survey team, he said he had not. The RVPO then joined the surveyor in the conference room and was given the facility's Risk binder with regards to R3. Upon being handed the binder, the RVPO said, well, I'm used these binders being about this thick [and noted about an inch- inch and 1/2 thick, with a hand gesture] and said, I see what you mean. The RVPO began looking through the binder and identified that many of the facility staff had not signed the education. The RVPO was also notified that when asked what the deficient practice was that had been identified and put a plan in place to correct, the facility administrator told the survey team, no deficient practice was noted. The RVPO was then notified that past non-compliance had not been achieved. Review of the facility policy titled, Skin and Wound Care Best Practices, was conducted. This policy read in part, 1. Skin care and pressure injury prevention: provide pressure reduction/redistribution for those at risk: offload/suspend heels for at risk residents, reposition at a frequency determined by risk assessment to avoid pressure to bony prominences, provide pressure redistribution/relief devices according to interdisciplinary assessment and recommendation . The facility policy titled, Pressure Injury Prevention and Treatment Policy, was reviewed. This policy read in part, Residents admitted with existing pressure injuries will receive necessary treatment and services, consistent with professional standards of practice, to promote healing and prevent infection. New pressure injuries will not develop unless the individual's clinical condition demonstrates that they were unavoidable .Residents will be assessed for pressure injury risk on admission . using the Braden Scale for Predicting Pressure Ulcer Risk . The policy titled, Resident Review Meeting Best Practice, was reviewed. The policy read in part, The interdisciplinary team will meet on a weekly basis to conduct a review of all residents who have experienced a change in condition, weight loss, acute infections, skin conditions, falls during the week and/or ongoing behaviors. The team will conduct a comprehensive review of the resident's clinical record to ensure develop and implementation of the necessary interventions to address each resident's specific risk has taken place and is appropriate for the resident F. The residents risk assessments will be reviewed, and re-assessment will be completed as deemed necessary . On 6/20/24, during an end of day meeting, the facility's director of nursing and corporate staff was made aware of the above findings. No further information was provided.

Based on staff interviews, resident interviews, clinical record and facility documentation, the facility staff failed to provide pain management, resulting in numerous instances of untreated pain, which constituted harm for one resident (Resident #2 - R2), in a survey sample of five residents. The findings included: For R2, who had a right hip fracture of unknown origin, the facility staff failed to respond to and treat the resident's documented complaints of unrelieved pain on 12 occasions, which adversely affected her level of physical functioning in therapy and constituted harm. Resident #2 (R2) was admitted to the facility on [DATE]. Diagnoses for R2 included, but were not limited: to cerebral infarction unspecified, muscle weakness and unspecified fracture of the lower end of left radius. R2's quarterly Minimum Data Set (MDS), (an assessment protocol) with an Assessment Reference Date of 4/14/23 coded R2 with a BIMS (brief interview for mental status score) of 7, which indicated severely impaired cognition. R2's most recent MDS, with an ARD of 3/13/24, noted R2 had a BIMs of 0. According to the MDS completed in April 2023, R2 required extensive assistance of staff for activities of daily living (ADLs), to include walking, and R2 was noted to have no limitation in her range of motion in her lower extremities. On 6/17/24, during the surveyor's investigation of an injury of unknown origin, a clinical record review was being conducted. According to the physician orders, on 5/24/23, an order was made for an x-ray of the right hip that read, x-ray of right hip. Unable to walk with therapy . There was a nursing note entry dated 5/25/23, that read, Spoke with nurse [name redacted] at [hospital name redacted]. Resident admitted to 5 east with right hip fx [fracture]. Nurse stated ortho recommended surgical intervention. According to R2's nursing progress notes, there was no indication of pain or events leading to the fracture prior to the order for the x-ray. There was a progress note from the nurse practitioner dated 4/27/23, R2 was seen for CC: [chief complaint] Trouble with right foot bending back under wheelchair when husband was pushing her along in the hall. Assisted them back to room. According to the progress note from the NP, both R2 and her roommate, who is her spouse have cognitive impairments. According to the note, it read in part, ROS: [review of systems] UTO [unable to observe] due to confusion. The note indicated a physical exam was conducted which included: vital signs, general, eyes, ENT [ears, nose, and throat], Neck, Respiratory system, CV [cardiovascular], Abdomen, skin, neurological, psychological, and musculoskeletal systems. The musculoskeletal section read, no contractures, nml [normal] muscle tone, symmetrically reduced strength. There was no indication that the R2's range of motion was assessed for her right foot, nothing about pain, nor any orders or communication to nursing to monitor for changes or pain. On 6/17/24, the director of nursing (DON) was asked to provide any facility documentation with regards to incidents involving R2, prior to the hip fracture. The DON reported there were no incidents/events. On 6/18/24 at 1:50 p.m., an interview was conducted with the NP, who had witnessed R2's incident of having her right foot dragged under the wheelchair on 4/27/23. The NP said that she had a vague recollection of the incident. The NP stated, They [R2 & R5] were between the chapel and the front offices in the facility. The NP stated that she had been walking behind them and noticed that R2's right foot was bent backwards under the wheelchair. The NP stated that she stopped the couple in the hallway and fixed R2's foot and assisted the couple back to their room. When asked if she assessed R2, the NP said that she did not assess at that time because she did not think it was a serious incident, she just helped them back to the room. When asked if she reported the event to nursing, she stated the day the incident happened was her first day at the facility and that she hadn't known anyone and did not report it to anyone. On 5/20/23, the medical doctor (MD) saw R2 for chronic care management discussion. The physician's note documented that urinary retention was addressed, a urinary catheter was reinserted, and noted that a urology consult was pending. On 5/24/23, the NP's note documented that she saw R2 due to physical therapy's report that R2 had not been able to do therapy due to complaints of right hip pain, that an x-ray of the right hip was ordered, and that results showed right hip fracture, for which the NP ordered R2 be sent to the emergency department for evaluation. On 5/26/23 the NP saw R2 for re admission back to the facility after R2's hospital stay. The NP's note had that the family opted for conservative nonsurgical treatment and that R2's pain was being controlled with the current medications. On 6/17/24, an interview was conducted with R2. R2 was noted with cognitive impairments and when asked about the incident from April 2023, and the hip fracture from May 2023, R2 had no recall of either events. On 6/18/24, an interview was conducted with certified nursing assistant, (CNA3). CNA3 was asked about R2 and if she had noticed any changes in the resident prior to the discovery of the hip fracture. CNA3 reported that R2 was moving slow in the mornings and was having some discomfort. CNA3 went on to say that R2 was not putting her right foot down when pivoting/turning, and said, I could tell she was in pain. When asked, what she does when she notices this, CNA3 said that she tells the nurse. The facility had no documentation/evidence of what CNA's report to the nurses to provide to the survey team. On 6/18/24 at 10:00 a.m., an interview was conducted with license practical nurse #9 (LPN9). LPN9 said, If the patient had a decline or change in status, we notify the nurse practitioner, (NP) or the medical doctor, (MD). If the NP or MD is on the unit that we would tell them of the concerns. If the NP or the MD is not in the facility, a communication sheet was filled out or a phone call was made to the provider. LPN9 verbalized that no daily report is received from therapy and that .the therapy staff does not communicate much with nursing department . If therapy staff had a concern that the NP or MD needed to be made aware, then therapy would communicate that with nursing. On 6/18/24, the communication book for R2's providers (doctor and nurse practitioner) was reviewed. The communication book did not have any information dating back to April and May 2023. The Director of Nursing was asked to provide the communication sheets from April and May 2023, but stated that she was not able to find them. On 6/18/24 at 10:15 a.m., an interview was conducted with OS4, one of the therapy staff, who had worked with R2. OS4 verbalized that a combination of things happened to contribute to R2's decline in therapy, including that R2 verbally refusing and that R2 was having pain that proceeded over a period of days to weeks. When questioned further, OS4 stated that she would talk with aides and nursing about pain medication. OS4 verbalized that if a resident was having pain that after a period of days, would have them put on the short list, which is the MD sheet, to be seen. OS4 verbalized that if it was something she could physically see, I would report it to the nurse on the floor and to the unit manager so the resident can be seen. No documentation was found to evidence this was done. On 6/18/24, an interview was conducted with the DON and the acting administrator. The acting administrator verbalized that the expectation is for anyone to report incidents, assess the resident for injury, assess the resident for pain, and to report any instances of pain so follow up can be done by nursing. The DON said that the purpose of the incident forms was to be completed, so follow up and ongoing monitoring could be completed by nursing. On 6/20/24, a clinical record review of R2's occupational therapy (OT) notes was conducted, which revealed the following: 1. On 5/4/23, the OT note documented that R2 had pain at 5/10 static sitting and 10/10 [severe pain] with standing and weight bearing. The note had no intervention for the pain or that nursing or the provider was made aware of the pain. 2. On 5/8/23, the OT note read in part, .pt [patient] not tolerating tx [treatment] session well this date 2nd to pain and fatigue . patient experienced pain? yes to right hip. The note had no intervention for the pain or any indication that nursing or the provider was made aware of the pain. 3. On 5/11/23, the OT note documented that R2 was experiencing pain to right lower leg, had right lateral leaning present, and was needing maximum assistance. The note had no intervention for the pain or any indication that nursing or the provider was made aware of the pain. 4. On 5/16/23, the OT note documented that R2 refused to stand, was non-weight bearing to right lower extremity (leg), and that R2 had pain in the right hip. The note had no intervention for the pain or any indication that nursing or the provider was made aware of the pain. 5. On 5/17/23, the OT note documented R2 had increased pain with movement and extension and that R2 had pain to right hip. The note had no intervention for the pain or any indication that nursing or the provider was made aware of the pain. 6. On 5/18/23, the OT note documented that R2 had pain that was at 10/10 (severe) to right lower leg and indicated OT spoke with physical therapy about right lower extremity contracture. The note had no intervention for the pain or any indication that nursing or the provider was made aware of the pain. On 6/20/24, a clinical record review of R2's physical therapy (PT) notes was conducted, which revealed the following: 1. On 5/1/23 at 4:03pm, the PT note documented .patient refused to transfer to chair or to ambulate and that patient had experienced pain to right lower extremity [leg]. The note had no intervention for the pain or any indication that nursing or the provider was made aware of the pain. 2. On 5/2/23, the PT note documented patient refused to perform exercises due to all over pain. The note had no intervention for the pain or any indication that nursing or the provider was made aware of the pain. 3. On 5/4/23, the PT note documented that R2 required cues to place right foot on the floor to accept weight. The note also documented that R2 displayed limited standing, weight shift, and had pain to right lower extremity. 4. On 5/5/23 at 4:41 p.m., PT note documented that R2 displayed leaning to the left, refused to put weight on right lower extremity, and with each sit to stand, pain worsened in weight bearing to right lower extremity. The note had no intervention for the pain or any indication that nursing or the provider was made aware of the pain. (Tylenol was administered at 10:01 p.m., according to the MAR.) 5. On 5/9/23, PT note documented .patient requested to lay down due to pain and fatigue . The note had no intervention for the pain or any indication that nursing or the provider was made aware of the pain. 6. On 5/11/23, the PT note documented that R2 had pain to right lower extremity but had no intervention for the pain or any indication that nursing or the provider was made aware of the pain. 7. On 5/12/23, the PT note documented that R2 was leaning to the left, avoiding full weight on right lower extremity, required cues to weight bear, and was experiencing pain. The note had no intervention for the pain or any indication that nursing or the provider was made aware of the pain. 8. On 5/16/23, the PT note documented that R2 had patient experienced pain to right lower extremity and communicated with nursing symptoms that supported the need to check R2 for urinary tract infection. The note had no intervention for the pain or any indication that nursing or the provider was made aware of the pain. 9. On 5/17/23, the PT note documented that R2 was unable to stand, patient needing max assistance and was able to balance on left lower extremity only, as R2 was . not wanting to put weight through RLE [right lower extremity] due to pain. The note had no intervention for the pain or any indication that nursing or the provider was made aware of the pain. 10. On 5/18/23, the PT note documented that R2 had pain and tightness to right lower extremity. The note had no intervention for the pain or any indication that nursing or the provider was made aware of the pain. 11. On 5/19/23, the PT note documented that R2 was having right hip pain and was avoiding weight to right lower extremity. The note had no intervention for the pain or any indication that nursing or the provider was made aware of the pain. 12. On 5/22/23, the PT note documented that R2 required constant cues to place right lower extremity flat on floor, to accept weight to the right leg, and that R2 experienced pain to right lower extremity. The PT note documented that nursing was asked to look at patient's right hip due to pain and discharged R2 from physical therapy. On 6/20/23, a clinical record review was conducted on the medication administration record (MAR), which includes a routine pain assessment every shift. The MAR revealed that R2 was assessed as having pain for 16 days from 5/1/23 - 5/24/23 and was given pain medications on six of those days from the nursing pain assessments. Pain medication, which was Tylenol, was administered on 5/1/23, 5/5/23, 5/15/23, 5/19/23, 5/21/23, and 5/24/23, but did not align with the times that therapy documented R2 was having pain. Occupational therapy documented pain on 5/3/23, 5/4/23, 5/5/23, 5/8/23, 5/11/23, 5/15/23, 5/16/23, 5/17/23, and 5/18/23, while Physical therapy documented pain on 5/1/23, 5/2/23, 5/4/23, 5/5/23, 5/9/23, 5/11/23, 5/12/23, 5/16/23, 5/17/23, 5/18/23, 5/19/23 and 5/22/23. On 5/14/23 and 5/18/23, R2's pain was documented as 10/10 or severe in the therapy notes, but according to the MAR, R2 did not receive any pain medications on those days. On 5/5/23, when therapy documented that R2 refused to put weight on right leg and pain worsened with weight bearing, R2 did not receive any medication to relieve that pain, according to the MAR. On 5/12/23, when therapy documented that the resident was unable to bear weight on right lower leg and was experiencing pain, R2 received no pain medication that day, according to MAR. On 5/17/23, when therapy documented that R2 was unable to stand and was experiencing pain, R2 received no pain medications that day, according to the MAR. On 6/20/24 at 3:45, an end of day meeting was held with the DON, the regional director of clinical services (RDCS), and the regional vice president of operations. The concerns for potential harm were discussed regarding staff's failure to assess/monitor for pain/injury after observing R2's right foot being dragged on 4/27/24, as well as the numerous instances therapy documented pain but failed to ensure relief or interventions were provided. No new information was provided. On 6/20/24 at 6:33 p.m. an exit conference meeting was conducted. The DON, RDCS, and the regional vice president of operations was in the meeting and no other information was provided at this time.

Based on observation, staff interview, and facility documentation review, the facility staff failed to provide care to residents within the professional standards of practice and within the scope of practice of staff providing care for residents on 3 of 6 nursing units. The findings included: For residents on 3 of the 6 nursing units, the facility staff permitted nursing assistants to apply a zinc topical cream to residents, which was outside of their scope of practice and without a physician order. On 6/17/24-6/18/24, during the clinical record review of the residents sampled (Resident #1-Resident #5), it was not noted that any of the residents had physician orders for the application of barrier cream. On 6/20/24 at 9:44 a.m., an interview was conducted with LPN #4 (licensed practical nurse), who was a unit manager. When asked about the admission process of a resident, LPN #4 explained that when a resident is admitted assessments are conducted to identify resident's risks for skin breakdown by doing a Braden assessment, along with other assessments. When asked to describe the purpose of the Braden, LPN #4 said that it identifies the resident's risk for developing skin breakdown and said, at that time we can put stuff in place to prevent it, we would have them on an air mattress, on a turn and repositioning plan and use barrier cream. On 6/20/24 at 10:50 a.m., an interview was conducted with the facility's treatment nurse. The treatment nurse explained that when a resident is incontinent, they have a barrier cream that the CNA's (certified nursing assistant) applied to help protect the resident's skin from moisture. The treatment nurse explained that anything beyond the barrier cream required an order from the physician and that the nurse would apply it. On 6/20/24 at 2 p.m., an interview was conducted with LPN #5. When asked about the application of zinc, LPN #5 explained this is something that would have to be ordered by the physician, the nurses would have to apply it as a treatment, and sign it off on the TAR [treatment administration record]. LPN #5 further confirmed that the facility does not have any such standing orders, that have already been approved by the provider, that the nurse would automatically implement. On 6/20/24 at 2:15 p.m., an interview was conducted with LPN #7. LPN #7 stated that to apply zinc requires a physician's order and is applied by the nurses. On 6/20/24 at 2:30 p.m., an interview was conducted with LPN #8. LPN #8 explained that barrier cream is applied by the CNA's but anything stronger than that would have to be ordered by the physician and applied by the nurses. LPN #8 showed the surveyor a tube of the facility's barrier cream, which was a white tube with green writing containing 100 grams of Vera Septine, Multi-Purpose Moisture Barrier. When looking at the ingredient listing, the active ingredient was listed as Zinc Oxide 21%. On 6/20/24 at 2:40 p.m., an interview was conducted with CNA #2. CNA #2 said that the barrier cream is a white tube with green writing called Vera Septine. CNA #2 went on to explain that it is kept in the resident's bedside drawer, is applied with incontinence care, and described it as a thick paste that is whitish pink. During the above interview with CNA #2, LPN #6 approached the surveyor and showed a tube of the Vera Septine, and it was noted that it contained a very thick paste with a pink hue. On 6/20/24, at approximately 5:15 p.m., the facility's director of nursing (DON) explained that they have had issues with supplies being out of stock and have had to change to alternate items, which included the facility barrier cream. When asked if she was aware that the facility barrier cream currently being used contains the active ingredient of 21% zinc oxide and is being applied by the CNA's, the DON said that she was not aware and had not thought about that. On 6/20/24, the facility policy titled, 6.8 Medication Administered through Certain Routes of Administration, was reviewed. This policy read in part, . Topical Medications: Medications are applied to the skin for many reasons including hydration and protection of skin surfaces, treatment of topical irritation or infection, to crease local anesthesia, skin barrier in the peri area, and to administer certain systemic medications .1. Verify medication order on MAR [medication administration record]. Check against physician order. 2. Identify the resident. Explain procedure. Wash hands. Wear gloves, to prevent medication from being absorbed by nurse if accidentally touches patch or ointment . 4.2 apply topical agent to affected area . 9. Document medication administration and/or dressings according to facility policy . The facility's policy titled General dose Preparation and Medication Administration, was reviewed and did not address who is permitted to administer medications and/or topical creams. On 6/20/24 at approximately 6:30 p.m., the facility's director of nursing was made aware of the above findings. No additional information was provided.

Based on staff interviews, resident interviews, clinical record, and facility document review, it was determined the facility staff failed to provide a complete and accurate investigation for an injury of unknown origin that affected one resident, (Resident #2, R2) in a sample of five residents. The findings included: The facility staff failed to provide evidence of a thorough investigation to include staff and resident interviews conducted during their investigation and the correct information concerning the resident's pain that was in the clinical record during their investigation period. Resident #2 (R2) was admitted to the facility on [DATE]. Diagnoses for R2 included but are not limited to cerebral infarction unspecified, muscle weakness and unspecified fracture of the lower end of left radius. R2's a quarterly Minimum Data Set (MDS) (an assessment protocol) with an Assessment Reference Date of 3/13/24 coded R2 with severely impaired cognition. On 6/17124 a review of facility documentation was conducted. During a review of the facility's investigation documents, the facility's final summary had that on 5/17/24, R2 worked with therapy and had no pain. The occupational therapy notes on 5/17/24, stated increase in pain reported with movement and extension and had yes to pain in right hip. According to the facility's investigation summary, they noted that R2 worked with therapy on 5/18/24 and complained of some discomfort. However, the occupational therapy notes, within the investigation folder had yes to pain and R2 rated her pain 10/10 on that day. On 6/18/24 at 3:30 p.m. an interview was conducted with the director of nursing, (DON), and the acting administrator, which was the administrator at the time of the incident. During the interview, this surveyor, DON, and acting administrator went over the final summary of the facility's investigation. The final summary, which was prepared by the acting administrator, stated the investigation had included: all shifts were interviewed. The documents provided only included three staff interviews in the investigation folder and two interviews was from the same staff person. The final summary from the facility investigation stated that the facility conducted interviews facility wide with residents that reported pain. No resident interviews were in the folder. The administrator at the time of the incident, was asked about the interviews and stated, I assumed we did interviews at the time of the investigation but could not find the interviews, so I printed off the quarterly nursing assessments that were closest to the date of the investigations. and the acting administrator provided eight quarterly nursing assessments that included a question about pain in the assessment and the quarterly nursing assessments were reviewed. The eight quarterly assessments provided included two assessments, dated 5/16/23 and 5/20/23 and were completed prior to the start of the facility's investigation date of 5/24/23. The acting administrator and DON verbalized that they would review the investigation findings and present any other information they were able to find. On 6/20/24 at 9:35 a.m. an interview was conducted with Resident #5 (R5). R5 was R2's spouse and roommate at the facility. During the interview R5 remembered that R2 had pain in her RLE (right lower extremity). R5 verbalized that R2 hurt her leg last year and that R2 is not someone that complains. R5 verbalized that R2 had an X-ray on her right leg but cannot remember the exact date. R5 verbalized he was sure it was R2's right leg and that it caused her problems and pain. On 6/20/24 at 9:45 a.m. an interview was conducted with R2. R2 was observed in the restroom unassisted transferring from the commode to the wheelchair. R2 verbalized that she could not recall any incident with her right lower extremity or pain with her right hip. On 6/20/24 at 1:00 p.m. an interview was conducted with the DON, the regional nurse consultant, and the regional vice president of operations. During the interview the final summary of the facility's investigation of R2's fracture of unknown origin was discussed. The missing interviews from staff and residents were reviewed. The regional nurse consultant verbalized that a review of the investigation and R2's clinical record was conducted by her yesterday and no additional information was provided to the survey team. On 6/20/24 a review of the facility document was conducted. The facility policy titled, Virginia Resident Abuse Policy, was reviewed and on page 4 under the section 4 protect the resident read, .staff should report all incidents immediately to their direct supervisors. The assessment should generally include the following: range of motion (ROM); full body assessment for signs of injury; and vital signs. On 6/20/24 at 3:45 an end of day meeting was held with the DON, the regional of clinical services, (RDCS) and the regional vice president of operations. The concerns of the lack of assessment of pain, the lack of pain management and the lack of evidence in the facility's investigation of R2's fracture of unknown origin was discussed. On 6/20/24 at 6:10 p.m. the RDCS presented the surveyor with copies of, POC [point of care] History Report, for 4/15/2024 thru 5/31/24. RDCS verbalized that it was to show the incident and pain did not interfere with her activities. The incident of R2's fracture of unknown origin happened in 5/24/23, which was the prior year. On 6/20/24 at 6:33 p.m. an exit conference meeting was conducted. RDCS asked if this would be considered as past noncompliance and the surveyor responded that the facility's final investigation was not completed with accurate information or evidence to support the investigation, so it did not meet the requirements for past noncompliance. No additional information was provided.

Based on staff interview, clinical record review, and facility documentation review, the facility staff failed to complete a comprehensive assessment timely for 1 resident (Resident #3- R3), in a survey sample of 5 residents. The findings included: For R3, the facility staff failed to conduct a comprehensive admission minimum data set (MDS) assessment timely. On 6/17/24 and 6/18/24, a clinical record review was conducted of R3's chart. This review on the census tab and in the progress, notes indicated that R3 was admitted to the facility on [DATE]. Review of the assessments under the MDS tab of the EHR (electronic health record) revealed that R3's admission assessment with an assessment reference date (ARD) of 4/14/24, was not completed and signed in section Z0500 until 5/6/24, by RN #1 (registered nurse). On 6/18/24 at 10:25 a.m., an interview was conducted with RN #1 and RN #2, both of whom were MDS nurses. RN #1 explained that admission MDS assessments are to be completed by day 14 of the resident's stay and the CAA (Care area assessments) are to be completed by day 21. During the above interview, RN #1 accessed R3's clinical record and admission MDS assessment. RN #1 confirmed that the MDS should have been completed by 4/21/24 and was not completed until 5/6/24. When asked, if this was timely, RN #1 said, no. RN #1 explained that the facility had an unexpected and unanticipated change in staffing within the MDS department, which lead to the delay. RN #1 also explained that the change in the EHR software had caused some additional delays. On 6/18/24 at 10:25 a.m., during the interview, RN #1, and RN #2, confirmed that they do follow the RAI (resident assessment instrument) manual for guidelines on timing of assessments. On 6/18/24 at 4:05 p.m., during an end of day meeting, the facility's acting administrator, director of nursing, and corporate staff was made aware of the above findings. On 6/20/24, the facility administration was asked if they had a policy regarding the timeliness of assessments, and the RDCS (regional director of clinical services) stated they follow the RAI manual. No facility policy was provided. According to the Centers for Medicare & Medicaid Services' Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, dated October 2023, For Use Effective October 1, 2023, guidance is given with regards to the timing of MDS assessments. According to the table on page 2-17, titled, RAI OBRA- required Assessment Summary, for an admission/comprehensive assessment, the MDS Completion date and CAA completion date is to be No later than 14th calendar day of the resident's admission (admitted + 13 calendar days). On 6/20/24 at 3:17 p.m., a pre-decision-making meeting was held with the facility administration, and they were again made aware of the above findings. No further information was provided.

Based on staff interview, clinical record review, and facility documentation review, the facility staff failed to develop and implement a baseline care plan for one Resident (Resident #3- R3) in a survey sample of 5 Residents. The findings included: For R3, the facility staff failed to develop a baseline care plan timely and failed to include instructions needed to direct/provide patient centered care of the resident. On 6/17/24 and 6/18/24, a clinical record review was conducted of R3's chart. This revealed that R3 was admitted to the facility on [DATE]. The baseline care plan was developed on 4/11/24, which was outside of the 48 hours following admission as required. According to this 4/11/24 base line care plan, the problem area read, Baseline Care Plan: Resident admitted to facility for (skilled, LTC [long term]) care. This is the Baseline Care Plan identifying initial care needs, risks, strengths, and goals. The goal was stated as, Initial goal is to (discharge to community, remain in LTC, or other). Resident will have access to necessary services to promote adjustment to their new living environment and/or post discharge from facility. The approaches/interventions within the baseline care plan read as follows, activities of daily living: resident will receive necessary assistance for activities of daily living, ANTICOAGULATION THERAPY: Resident will be monitored for abnormal bleeding due to anticoagulation treatment. Will receive anticoagulant therapy as ordered; will be observed for any s/s of abnormal bleeding (bruising, tarry stools, nose bleeds, bleeding gums) and/or hemorrhage; will receive education on risks and benefits of anticoagulant therapy if needed; and be monitored as ordered for lab tests to monitor coagulation factors and will have any abnormal findings reported to provider (MD/NP/PA), Behavioral needs: Resident behavioral health needs will be evaluated and provider contacted as needed, Cultural preferences: Resident will have consideration for cultural needs (select from the following): language barrier, cultural/religious practices, food restrictions/preferences, traditions, beliefs in alternative medicines, unfamiliarity with health care services, other if needed, specify ________________, DIET: Resident will receive diet as ordered., FALLS: Minimize potential risk factors related to falls/injury, MEDICATIONS: Resident will be monitored for adverse reactions to high risk medications, PAIN: Resident pain needs will be evaluated/anticipated, SAFETY: Resident will be monitored to minimize risk of wandering and/or elopement, SKIN: Resident will be provided skin care to prevent skin breakdown, SOCIAL SERVICES: Resident will receive initial Social Services evaluation to ensure psychosocial needs will be met. * PASRR II level needs will be addressed if applicable, and THERAPY: Resident will receive therapy service(s) as indicated. The above noted base line care plan did not inform the facility staff of the resident's level of support needed and/or interventions being provided to R3 for daily care needs. On 6/18/24 at 10:25 a.m., an interview was conducted with RN #1 (registered nurse), who was the MDS (minimum data set - an assessment) nurse. RN #1 explained that the purpose of the care plan is to develop a plan of care for taking care of the resident and their needs. RN #1 said, It helps us to care for the individual. RN #1 and RN #2, who was also an MDS nurse, both explained that the admitting nurse and/or unit managers are responsible for completing the baseline care plan. The surveyor reviewed R3's baseline care plan with RN #1. RN's #1 and #2 both explained that the new electronic health system just skims the surface and doesn't give details on the needs of the resident. Review of the facility policy titled, Interim/Baseline Care Planning Policy. The policy read in part, Within 48 hours of admission, the facility will develop and implement an interim/baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident until a comprehensive assessment can be completed, leading to a comprehensive care plan On 6/18/24 at 4:05 p.m., during an end of day meeting, the facility's acting administrator, director of nursing, and corporate staff was made aware of the above findings. On 6/20/24 at 3:17 p.m., a pre-decision-making meeting was held with the facility administration, and they were again made aware of the above findings. No further information was provided.

Based on staff interview and clinical record review, the facility staff failed to maintain a complete and accurate clinical record review for 2 residents (Resident #2 - R2 and Resident #3 - R3), in a survey sample of 5 residents. The findings included: 1. For R2, the facility staff failed to maintain a complete clinical record by not having an x-ray result in the chart. On 6/17/24-6/18/24, and 6/20/24 a clinical record review was conducted of R2's chart. According to the physician progress notes, on 4/27/23 the nurse practitioner (NP) saw the R2 for trouble with right foot back under wheelchair when husband was pushing her along the hall and the NP assisted them back to room. No new orders were put in place. According to another progress note from the NP on 5/24/23, the NP saw R2 due to physical therapy had not been able to do therapy due to complained of right hip pain. The NP ordered an x-ray of the right hip. The results of the x-ray were not in R2's chart. Review of the facility's investigation file, a copy of the x-ray was noted, and the results showed a right femoral neck fracture. The NP ordered to send R2 to the emergency department for evaluation. On 5/26/24 the NP saw R2 for re admission back to the facility after R2's hospital stay. The note had that the family opted for conservative nonsurgical treatment and pain is being controlled with the current medications. 2. For R3, the facility staff failed to maintain an accurate clinical record with regards to skin assessments. A review of the closed clinical record was conducted 6/17/2024 -6/18/2024 and 6/20/2024. On 4/22/24, R3 was seen by the nurse practitioner. This note read in part, Chief complaint/Reason for this visit: . Has an abrasion on coccyx . Has a small abrasion on sacral area about 3 cm circular with superficial depth. Pink with granulation tissue in base. No drainage or erythema. Will change daily and refer to wound team . On 4/23/24, R3 had a weekly skin observation was conducted at 3:07 p.m., and it noted, no skin issues noted. On 04/27/2024 at 7:24 a.m., a late entry was made for 04/23/2024, a nursing note was entered into R3's chart that that read, CNA [certified nursing assistant] reported open area to sacrum. Nurse approximated edges 2cm x 1 cm no depth. Wound base red in color. Small amount of serous drainage noted. Area cleansed with wound cleanser; zinc-based cream applied. Speaking with CNA and looking through chart resident is eating less than 25% at meals. NP aware of findings. Air mattress and wedge for turning and repositioning in place. On 6/18/24, in the afternoon, interviews were conducted with the wound treatment nurse. The wound treatment nurse stated that on 4/23/24, R3 had skin impairment that was identified by the nursing assistant. On 6/20/24, during an end of day meeting, the facility's director of nursing and corporate staff was made aware of the above findings. No additional information was provided.

Based on observation, staff interview, and clinical record review, the facility staff failed to provide adequate devices and interventions to maintain a safe environment to prevent accidents, affecting two Residents (Resident #1 and #4) in a survey sample of 8 Residents. The findings included: 1. For Resident #4, the facility staff failed to ensure Dycem (a non-slip device) was in place, which was used as a fall intervention to reduce the risk of a repeat fall. On 11/27/23 at 2:05 PM, Resident #4 was observed being assisted to the bathroom by CNA B. CNA B was asked that once Resident #4 was in a standing position that the Surveyor be permitted to look at her wheelchair. There was a cushion in the wheelchair, CNA B lifted the cushion and confirmed that dycem was not in the wheelchair. On 11/27/23, a clinical record review revealed that Resident #4 had a care plan focus area that identified the resident as being at risk for falls. Interventions included, but were not limited to, Dycem in wheelchair by md orders. 2. For Resident #1, the facility staff failed to ensure that fall interventions identified on the care plan were being implemented to provide an environment free of accident hazards and the needed assistance devices to prevent accident/falls. On 11/27/23 at 11:47 AM, Resident #1 was observed in the dining room. Observations of the Resident #1's room revealed that a fall mat was at the bedside. On 11/27/23, just after lunch, the unit manager/LPN G was made aware that when Resident #1 was transferred out of the wheelchair, this surveyor needed to make observations. LPN G stated that they were in the process of getting ready to put Dycem in his wheelchair. LPN G went on to say, He [Resident #1] was changed into this wheelchair at the end of last week and they didn't transfer the Dycem. Review of facility documentation revealed that Resident #1 has a history of frequent falls, varying from 1-3 per month. Resident #1's fall care plan with a revision date of 11/26/23, included, but was not limited to, the following intervention, dycem to wheelchair. The fall mat observed in the room was not indicated on the care plan. On 11/27/23, during the end of day meeting, the facility Administrator was made aware of the above findings. On 11/28/23, it was noted that Resident #1's care plan had been revised to include, fall mat when in bed. No further information was provided.

Based on staff interview, record review, and facility documentation review, the facility staff failed to follow professional standards of nursing practice for 3 Residents (Resident #1, #2, and #3) in a survey sample of 8 Residents. For Resident #1, #2, and #3, the facility staff failed to administer medications in accordance with physician orders and failed to notify the physician that the ordered medications were not administered. The findings included: On 11/27/23 and 11/28/23, clinical record reviews were performed. This review revealed the following: 1. For Resident #1, the facility staff documented on 11/27/2023 at 6:21 PM, Medication Administration Note: Ativan Oral Tablet 0.5 MG, give 1 tablet by mouth every 6 hours related to anxiety disorder unspecified, not available from pharmacy. Review of the Medication Administration Record (MAR) revealed that the Ativan was not administered on 11/27/23. There was no indication that the physician was made aware of the missed dose. 2. Resident #2 had the following progress notes: 11/14/2023 06:50 Type: eMAR- Medication Administration Note: Levothyroxine Sodium Tablet 75 MCG, Give 1 tablet by mouth one time a day for hypothyroid related to Hypothyroidism unspecified, medication not on hand. Another note dated 11/14/2023 at 06:49 am, read, eMAR- Medication Administration Note: Lasix Oral Tablet 40 MG, give 1 tablet by mouth one time a day related to edema, medication not on hand. Review of the MAR revealed that the medications were not administered. There was no indication in the clinical record that the physician was made aware of the missed medication doses. 3. Resident #3 had progress notes entered into his record on 11/8/23 at 10:32 PM, 11/9/23 at 12:08 AM, 11/9/23 at 1 PM, and 11/17/23 at 3:51 PM, that the Neurontin Capsule, which was ordered to be given 100 mg by mouth two times a day related to other hereditary and idiopathic neuropathies was not given. Various reasons were noted, which included: pending delivery, medication not in Omnicell, medication pending delivery, not in Omnicell, and awaiting pharmacy delivery. There was no indication that the physician was made aware of the missed doses of medication. On 11/28/23, interviews were conducted with LPN B, LPN C and LPN E. Each of them said if medications were not available, they would check the Omnicell [an onsite medication delivery system, where a supply of medications is stored] to see if it was available in there. If so, they obtain the medication and administer it. If not, they call the pharmacy to see when they can deliver it and call the doctor to let them know the medication was not given and when it would be available. On 11/28/23, the contents of the Omnicell were obtained and reviewed. It was noted that each of the medications, Ativan, Lasix, Levothyroxine and Neurontin, were available in the Omnicell in the original form or generic equivalent. Each of the Resident's physician orders included an order that read, Generic equivalent may be substituted unless otherwise specified. On 11/28/23, an interview was conducted with the Director of Nursing (DON). The DON stated that the nursing standard of practice for the facility followed is [NAME]. When asked what is expected if a medication is not in the medication cart, the DON said the nurse is to see if it is in the Omnicell and pull it from there. The DON confirmed that all the nurses have access to the Omnicell but if they do not use it in 30 days, it will lock them out. The DON stated that she had told the nurses that if locked out, get another nurse to pull it for them, and let her know to reinstate their access. A review was conducted of the facility policy titled, 7.0 Medication Shortages/Unavailable Medications. The policy read, . 3.1 A facility nurse should obtain the ordered medication from the Emergency Medication Supply. According to the [NAME] Manual of Nursing Practice, Eighth Edition, Common Legal Claims for Departure from Standards of Care were listed on page 18. The list included, but was not limited to, failure to administer medications properly and in a timely fashion, or to report and administer omitted doses appropriately. On 11/28/23, during an end of day meeting, the facility Administrator and Director of Nursing were made aware of the above findings. No further information was provided.

Based on observation, staff interview, facility document review, clinical record review and complaint investigation, the facility staff failed to ensure a safe transfer for one of four residents in the survey sample (Resident #2) and failed to ensure safety devices were in use for one of four residents (Resident #4). Resident #2's right arm was fractured and shoulder dislocated after staff attempted to lift the resident with a stand up (sit-to-stand) lift when she required a total mechanical (Hoyer) lift for all transfers. Resident #4 was observed in bed without physician ordered floor mats and a bed alarm in use as required by her plan of care for fall/injury prevention. The findings include: 1. Resident #2 was admitted to the facility on [DATE] and was discharged on [DATE]. [DIAGNOSES REDACTED]. The minimum data set ((MDS) dated [DATE] assessed Resident #2 with short and long-term memory problems and moderately impaired cognitive skills. This MDS documented the resident had impaired range of motion of both upper and lower extremities and was totally dependent upon two staff members for bed mobility and transfers. Resident #2's closed clinical record documented the resident was sent to the emergency roiagnom on [DATE] at 10:10 p.m. for evaluation/treatment of [REDACTED]. A nursing note dated 3/8/19 at 12:45 a.m. documented, .ER (emergency room ) called .Stated resident had a R (right) arm fx (fracture) and dislocation and would be coming back (with) a R arm sling . The hospital emergency room (ER) record dated 3/7/19 documented the resident presented with pain localized over the right shoulder. The ER assessment stated, .There is pain noted over the right shoulder . The patient is bedridden and is essentially nonmobile .Patient complains of pain affecting right shoulder. Nature of the pain cannot be described due to the patient's condition. Pain is constant .Pts (patient's) daughter notes the nursing home called her and reported the pt was grimacing in pain and her right shoulder 'looked different' than her left . Resident #2's x-ray report dated 3/7/19 diagnosed a comminuted fracture and dislocation of the right humeral head due to trauma and/or injury. The resident returned to the facility on [DATE]. Treatments included a sling for immobilization, ice to the injured area, pain medication and referral to orthopedics. Resident #2's clinical record, including nursing notes, made no mention of any incident, accident or possible source of the fracture/dislocation. A skin condition report dated 3/7/19 documented a skin tear on the resident left lower forearm but documented no source of this injury. A facility reported incident form to the state agency dated 3/8/19 documented an investigation of Resident #2's fractured arm and dislocated shoulder. This report documented, .Daughter stated resident c/o (complained of) R arm pain. Sent to ER for evaluation. Fx of right Humerus (upper arm). The investigation report dated 3/8/19 documented, CNA (certified nurses' aide) attempted to transfer resident using inappropriate mechanical lift. CNA put resident in lift to stand her up to get her dressed and harness slid up resident's back causing her arms to extend abruptly over her head .Resident sent to ER .Returned with dx (diagnosis): R humerus fracture .CNA used a sit to stand lift and resident was not a canidate (candidate) for that lift. Resident was to be transferred (with) Hoyer lift only . This report documented the circumstances of the incident as, (CNA #3) and (CNA#2) used inappropriate lift to stand resident to get her dressed after bath. Lift harness slipped up resident's back causing her arms to suspend over her head. Another CNA was called in to help to keep resident from falling but incident was not reported to nurse . The facility's investigation documented staff interviews stating, (CNA #3 and CNA #2) both reported they were trying to figure out the best way to stand resident to get her dressed and the harness slipped (wasn't secure) up resident's back causing bilateral arms to be extended abruptly over resident's head . The interviews documented during the evening of 3/7/19, CNA #1 got the resident ready for bed and noted resident grimmacing (grimacing) when arm was moved and upon investigation noted bruising to the RUE (right upper extremity). Nurse made aware and resident was assessed .Sent to ER .and returned with dx R humerus fracture . This report documented, Investigation with dayshift staff confirmed incident with inappropiate (inappropriate) mechanical lift happened at approx. (approximately) 7:30 AM and was never reported to nurse on duty . (Sic) The facility's investigation documented statements from staff members including CNA's caring for Resident #2 at the time the resident's arms slipped in the sit-to-stand lift. A written statement by CNA #2 dated 3/8/19 documented, . (CNA #3) and I gave (Resident #2) a whirlpool. We did a 2 person transfer from her geri chair to the spa chair. We bathed her and dressed her in the spa chair except for her brief. We could not lift her to put her bref (brief) on so (CNA #3) said to get the standup (sit-to-stand) lift. She (Resident #2) started to slip from the lift so we grabbed her and put her back in the spa chair. I went and got (CNA #4) to help. (CNA #3 and CNA#4) lifted her from the spa chair while I put her brief on and then the three of us put her in the geri chair. (Sic) CNA #4's written statement dated 3/8/19 documented, .was ask to assist with a transfer. From the whirlpool chair .I then proceed to walk into the spa to assist (CNA #3 and CNA#2) to hold (Resident #2) as (CNA #2) put on the brief .(CNA #3) stated thank you cause we almost lost her when we (CNA #3 and CNA #2) were trying to transfer her (Resident #2) with the stand-up lift . (Sic) Resident #2's plan of care in place at the time of the incident (revised 1/17/19) documented the resident required total care by staff related to dementia and contractures of upper and lower extremities. This care plan documented the resident was at risk of falls/injury due to extremity contractures and listed the resident as unable to hold body in correct position . Interventions to prevent falls/injury and to meet activities of daily living needs included, mechanical lift all transfers .Mechanical lift as needed for all transfers as of 4-1-18 no longer able to use sit to stand lift . On 9/15/20 at 11:30 a.m., CNA #2 that was with Resident #2 at the time of the lift incident was interviewed. CNA #2 described Resident #2 as requiring total assistance with all activities of daily living that included dressing, bathing, eating and transfers/mobility. CNA #2 stated on 3/7/19 she and CNA #3 used the Hoyer lift to transfer Resident #2 from bed to a reclining geri-chair and then took her to the spa for a whirlpool bath. CNA #2 stated when the bath was finished, she and CNA #3 performed a two-person transfer of the resident to the bath chair. CNA #2 stated they dressed the resident and could not get her raised enough to get her incontinence brief back in place. CNA #2 stated CNA #3 suggested using the sit-to-stand lift to raise the resident in order to put on the brief. CNA #2 stated when they raised Resident #2 in the stand-up lift, the resident slipped with both of her arms going straight up through the harness. CNA #2 stated she and CNA #3 then lowered her back into the chair. CNA #2 stated they got CNA #4 to come help them lift the resident so they could get the brief applied. CNA #2 stated she was aware the resident required a Hoyer lift but she was still in orientation and was following the suggestion of CNA #3. When asked about the differences in the lifts, CNA #2 stated the sit-to-stand lift required a resident to hold and assist with standing and the Hoyer lift was a total lift. CNA #2 stated she did not report the incident when it happened because she did not think the resident was hurt. On 9/15/20 at 11:40 a.m., the licensed practical nurse unit manager (LPN #1) that cared for Resident #2 was interviewed. LPN #2 stated Resident #2 required a Hoyer lift for all transfers, as she was totally dependent upon staff for mobility. LPN #2 stated their investigation revealed CNA #2 and CNA #3 attempted to use the sit-to-stand lift on 3/7/19 to raise the resident from the bath chair to put on an incontinence brief. LPN #1 stated the CNA's reported as she was raised, the resident's arms suddenly went up through the harness because the resident was unable to hold and stand. LPN #1 stated later that evening, CNA #1 reported the resident had a discolored right shoulder and was grimacing when her right arm was moved. LPN #1 stated the resident was then sent to the emergency room and diagnosed with [REDACTED].#1 stated the resident should have been transferred from the whirlpool using the Hoyer lift to the geri-chair then returned to bed for dressing and application of the incontinence brief. LPN #1 stated a mesh Hoyer lift pad designed for use in the shower room was available but was not used by CNA #2 or #3 when transferring the resident on 3/7/19. LPN #1 described Resident #2 as non-verbal and totally dependent upon staff for all care needs. On 9/15/20 at 11:55 a.m., CNA #1 that routinely cared for Resident #2 was interviewed. CNA #1 stated Resident #2 required total care and was not able to move her arms. CNA #1 stated the resident could partially open one hand with the other hand and both arms contracted. CNA #1 stated she cared for Resident #2 on the evening of 3/7/19 and noticed the resident grimacing when she moved her right arm while dressing the resident for bed. CNA #1 stated she also saw that the right shoulder was bluish and had discoloration that was not there previously. CNA #1 stated when she attempted to raise the resident's right arm the resident hollered out and she immediately got the nurse. When asked about transfers for Resident #2, CNA #1 stated the resident was always a Hoyer lift. CNA #2 and CNA #4 with Resident #2 at the time of the lift incident on 3/7/19 were not working at the time of the survey and not available for interview. The facility's policy titled Mechanical Lift (revised 1/19/10) documented the stand up (sit-to-stand) lift was used with residents able to weight-bear and hold lift grips with both hands. This policy documented concerning use of a stand up lift, The stand up lift may be operated by one (1) healthcare professional for ALL lifting preparation, transferring from and transferring to procedures with a cooperative, weight-bearing individual able to support the majority of his/her own weight . Lifting procedures for the stand up lift included, .Instruct the resident to do the following .Hold onto the hand grips on both sides of the stand up lift .Lean back into the standing or transport sling .Before lifting the resident, make sure .the resident's arms are outside the transport sling . The administrator was out of the facility during the survey. These findings were reviewed with the director of nursing on 9/15/20 at 3:40 p.m. This was a complaint deficiency. 2. Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The minimum data set ((MDS) dated [DATE] assessed Resident #4 with short and long-term memory problems and moderately impaired cognitive skills. On 9/15/20 at 1:50 p.m., Resident #4 was observed in bed. There was one protective floor mat beside the bed near the center of the room. There was no floor mat on the opposite side of the bed near the door and no bed alarm in use. Resident #2 was observed again on 9/15/20 at 2:10 p.m. in bed with one floor mat in place and no bed alarm. Resident #4's clinical record documented the resident ambulated independently with use of a walker and had a history of [REDACTED]. Nursing notes documented the following recent falls/injuries. 6/2/20 - found in floor beside bed, no injuries 6/18/20 - fell in television room while ambulating with walker, fractured clavicle and left rib fracture 7/2/20 - found in floor at foot of bed, skin tear to left forehead 7/21/20 - resident sat herself in floor, no injuries 8/13/20 - found in floor in hallway, no injuries The clinical record documented a physician's orders [REDACTED]. Resident #4's plan of care (revised 9/1/20) documented the resident was at risk of complications from fracture due to falls and was at risk of further falls due to Alzheimer's dementia, medications, wandering with use of walker, impaired vision, history of falls/fracture, restlessness and agitation. Interventions to prevent falls/injuries included, Fall alarm to bed .Fall mats times two bedside each side . On 9/15/20 at 2:15 p.m., accompanied by licensed practical nurse (LPN #4), Resident #4 was observed in bed with only one floor mat by the bed and no bed alarm. LPN #4 was interviewed about this time about the mats and alarm. Concerning the mats, LPN #4 stated the resident was supposed to have two mats in use, one on each side of the bed. LPN #4 stated, She (Resident #4) had them (mats) the other day. Certified nurses' aide (CNA) #2 entered Resident #4's room and stated she did not know where the second floor mat was located and that two mats had been in the room earlier. CNA #2 stated the resident at times removed the bed alarm. LPN #4 stated she did not know if housekeeping removed the other floor mat. CNA #2 and LPN #4 searched the resident's room including around/under the bed, closets, dresser drawers and restroom and did not locate an alarm. CNA #2 located the second floor mat folded inside the resident's closet. LPN #4 stated she did not know where the alarm was located or if the resident had removed it from use. These findings were reviewed with the director of nursing on 9/15/20 at 3:45 p.m.

Based on observation, staff interview and clinical record review, the facility staff failed to apply a physician ordered safety device for one of 14 residents in the survey sample. Resident #108, with a history of injury from falls, was observed in bed without a physician ordered bed alarm. The findings include: Resident #108 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The minimum data set ((MDS) dated [DATE] assessed Resident #108 as having long-term memory loss and moderately impaired cognitive skills for daily decision-making. Resident #108 was observed in bed on 8/2/11 at 2:05 p.m., 3:10 p.m. and 3:55 p.m. No bed alarm was observed in use with Resident #108 on any of these observations. Resident #108's clinical record documented the resident had a history of [REDACTED]. The care plan documented the fall on 4/8/11 resulted in a fracture to the resident's left arm. Care plan interventions to prevent falls included, "pressure pad alarm to bed." Resident #108's clinical record documented a physician's orders [REDACTED]." The current physician orders [REDACTED]." On 8/2/11 at 3:55 p.m. the certified nurses' aide (CNA #1) caring for Resident #108 was interviewed about the resident's use of a bed pad alarm. Accompanied at this time by CNA #1, Resident #108 was observed in bed. CNA #1 looked under the bed covers and along the edge of the mattress and stated, "I don't see it (alarm). Let me get the nurse." CNA #1 returned to the resident's room and stated the nurse told her the resident "was supposed to have one (bed alarm)." On 8/2/11 at 4:05 p.m. accompanied by the licensed practical nurse (LPN #1) and CNA #1, Resident #108 was observed in bed. LPN #1 and CNA #1 pulled back the resident's bed covers and turned the resident to each side. LPN #1 and CNA #1 look under the fitted sheet and between the air mattress overlay and the mattress without finding a bed alarm. LPN #1 stated, "I don't see one. I don't' know if they changed the sheets and didn't put it back. It's supposed to be on here. She's had one." On 8/3/11 at 9:10 a.m. a certified nurses' aide (CNA #2) caring for Resident #108 was interviewed about the resident's use of a bed alarm. CNA #2 stated she was not working yesterday (8/2/11) but Resident #108 usually had a bed alarm. CNA #2 stated, "Every now and then she'll try to get up. She's been having one (bed alarm)." The administrator and director of nursing were made aware of these findings on 8/3/11 at 11:00 a.m.

Based on observation, staff interview, clinical record review and facility document review, the facility staff failed to provide supervision during bathing to prevent an accident resulting in a fractured hip for one of 24 residents in the survey sample, Resident #2. The findings include: Resident #2 was originally admitted to the facility on [DATE] and readmitted on [DATE] with, but not limited to, the following Diagnoses: [REDACTED]. The resident was assessed with [REDACTED]. For transfers, ambulation, dressing, and personal hygiene the resident was assessed as needing extensive assistance with the assistant of two people. For bathing the resident was assessed as being totally dependent with the assistance of one person. Under section G0300 "Balance During Transfers and Walking," the resident was assessed as "(2) Not steady, only able to stabilize with human assistance, for moving from seated to standing, walking, moving on and off toilet, and surface-to-surface transfers." The following individuals at the facility were interviewed regarding the fall with fracture: the administrator, the DON (director of nursing), the Certified Nursing Assistant (CNA #1) on the Primrose unit, who was caring for the resident during the fall, and CNA#2, who was familiar with the residents on the Primrose unit. On 6/8/11 at approximately 8:24 a.m., Resident #2 was observed on the Primrose unit sitting in the dining area in a wheelchair. The resident was observed being administered her medications via the medication / charge nurse on the unit. On 6/8/11 at approximately 9:30 a.m., the following nurse's notes were reviewed in the clinical record to include the following: ? "2/12/11 7:30 a.m. During AM care, CNA noted a 1 cm (centimeter) x 1cm blue bruise surrounded by pinpoint bruises on outer aspect R (right) leg. Also resident could not bear weight on that leg and winced when leg was moved. MD (doctor / physician) made aware. New order- send to hospital named for further eval (evaluation). RP (responsible party) aware..." ? "2/12/11 11:45 a.m., Called hospital named ER (emergency room ) spoke to nurse named say resident is admitted to hospital, Rt (right) hip broken, to have surgery tomorrow(sic)." ? ? On 6/8/11 at approximately 9:35 a.m., the "Operative Report" was reviewed to include the following: ? Preoperative Diagnosis: [REDACTED]." ? Operative Procedure: Depuy self-centering hip arthroplasty, right hip." ? Description of Procedure...A T-shaped incision was made in the hip capsule exposing the fractured femoral neck. The femoral neck was then osteotomized appropriate to receive a prosthesis...The hip capsule was repaired with #1 Vicryl. Hip abductors were repaired back to the greater trochanter through drill holes with the same suture. The tensor was repaired with figure- of- eight sutures of #1 Vicryl. Subcu was closed with #2 -0 Vicryl and skin was closed with staples..." ? ? On 6/8/11 at approximately 4:20 p.m. the administrator and the DON were interviewed regarding the above documented nursing notes and the investigation regarding the fracture. The administrator stated, "Did yall get a FRI (facility reported incident), that's our investigation (sic)." ? ? The FRI dated 2/11/11 was reviewed to include the following: ? "Incident type: Injury of unknown origin ? "Describe incident, including location, and action taken: On 2-12-11, CNA reported discoloration to R. hip and resident resisted standing." ? ? Another form "Resident Abuse Investigation Form," dated ? 2/11/11 (sic), was reviewed to include the following: ? "Resident injured (yes) Fractured Right Hip-" ? "Location & Description of Incident: possibly the spa during whirlpool bath session." ? "Circumstances surrounding the incident: Resident had a slip during whirlpool bathing session and it is thought that this is when fracture occurred. Res. (resident) does not like to bathe and is combative. Her feet slid under sink (sic)." ? "Summary of investigator's findings: On 2-11-11, resident changed position in spa at bathroom sink. Resident's feet started to slide under the sink and CNA stopped the fall by placing a chair behind her." ? ? A statement written by CNA #1, the CNA that was caring for the resident during the bath, was reviewed to include the following: ? "After giving Resident #2 a whirlpool, drying lotioning and dressing. I helped her to stand. While standing I had her to hold onto the sink that is located at the foot of the whirlpool. During the time she was holding on to the sink I finished her bottom and pulled her brife (sp) and PJ's up. I was attempting to pick up towels and pull the curtain back when I noticed Resident #2's feet were sliding under the sink. To break her fall I used the wicker chair which was located at the other sink..." ? ? On 6/9/11 at approximately 9:55 a.m. the spa room was observed, a sink (the sink where the CNA had the resident standing) was observed approximately 6 feet from the opening of the door, approximately 2 feet to bottom left of the whirlpool tub, and approximately 12 feet from the commode (which was located on the back wall, behind the sink, next to the wicker chair that was used to break the resident's fall). Another sink was observed approximately 3 feet from the opening of the door and approximately 8 feet from the the bottom of the whirlpool tub and 6 feet from the sink where the resident was holding on. ? ? On 6/9/11 at approximately 10:00 a.m., CNA #2 was interviewed regarding the use of the whirlpool for resident bathing. CNA # 2 stated, "If I'm using the whirlpool I put towels on the floor at the sink and beside the whirlpool chair. I dry the resident off as much as I can while they are sitting then I help them to stand up at the sink and finish drying them off and pulling up their clothes. I always hold on to them because these people back here are unsteady and the floor is slippery from the moisture." ? ? CNA #2 proceeded to state, "When I'm finished dressing them, I walk them back to their room or where ever they want to go and then I come back and clean the spa." ? ? On 6/9/11 at approximately 1:15 p.m. CNA #1 was interviewed via telephone regarding the above mentioned fall and fracture during bathing. CNA #1 stated that she was giving the resident a bath and that the resident was completely dressed and standing at the foot of the whirlpool holding onto the sink. CNA #1 stated that she was cleaning up the spa room and her back was to the resident at intervals. CNA # 1 stated that she turned from cleaning the spa when she noticed that the resident was sliding. ? ? CNA # 1 was interviewed regarding the resident standing and not sitting as she was cleaning the spa. CNA #1 stated, "I could have (let her sit) but the sink was closer so I had her hold on to the sink until I finished cleaning up the spa." CNA #1 further stated that when she noticed that the resident was "slipping" she ran and got the wicker chair, "I felt it better to get the chair than try to catch her." ? ? When interviewed regarding the condition of the floor, CNA #1 stated, "the floor might have been damp at the lower part from filling the whirlpool, water may have been on the floor." ? ? On 6/9/11 at 1:50 p.m., the administrator was made aware of the above interview with CNA #1 and Restorative Nursing Notes (RNN) were requested. ? ? On 6/9/11 at approximately 1:55 p.m. a recent RNN dated 2/5/11, prior to the fall on 2/11/11, was reviewed to include the following: ? "2/5/11 Resident receives verbal cues to begin her exercises and throughout the remainder of exercises for encouragement safety and directional purpose. She is extensive assist of two staff members for transfer. It takes a lot of assistance with pulling her up from chair making transfer difficult. She ambulates with a gait belt and contact guard assistance somedays walks well and others will need you to help guide her along(sic)..." ? ? A Care Plan (CP) dated 11/16/07 with updates on 10/21/10, 1/5/11, 2/5/11 and 5/29/11 for ADLs (Activities of Daily Living) was reviewed to include the following: ? Resident #2 needs assist with ADL care needs. 1. Dressing-limited to extensive assist, 2. Eating-extensive assist, 3. Toilet Use-extensive assist, 4. Personal -Hygiene-extensive assist 5. Bathing-dependent. Strengths: Amount of assist needed may vary, may need 1-2 person assist..." ? ? On 6/9/11 at approximately 2:00 p.m., the DON presented to this surveyor a "Fall Investigation Form," with the following: ? "Description of current fall: 2/11/11 at 5 p.m. S shower / central bath area ? "History-Has resident had a fall within the past" with "3 months" checked. ? "Conditions-Circle ALL current conditions that may have impacted THIS fall: Unsteady gait." ? "Environmental / Situational Conditions: Circle ALL current conditions that may have impacted THIS fall: Floor wet / slippery." ? Impact from fall: Wound injury (circled) requiring hospitalization , skin tear, bruise."