Every finding on record at Davidson Health & Rehab Center

Based on record review and staff and Nurse Practitioner interview, the facility failed to immediately notify the Responsible Party (RP) and the physician of Resident #1 experiencing a fall with reported pain immediately after the fall and throughout the day. This failure to immediately notify the physician resulted in a delay in diagnostics and necessary medical treatment for a fractured hip. The result of the x-ray that followed was the diagnosis of a fractured hip that resulted in the resident being sent out for medical treatment. This deficient practice affected 1 of 3 residents reviewed for notification of change (Resident #1). The findings included:Resident #1 was admitted to the facility on [DATE] with diagnoses including traumatic subdural hemorrhage (bleeding near the brain) without loss of consciousness, fractured ribs, type II diabetes, muscle weakness, and unsteadiness on her feet.A review of the 5-day Minimum Data Set (MDS) assessment dated [DATE] indicated the resident was cognitively intact. She was assessed as requiring supervision with toilet transfers and toileting hygiene. Resident #1 was coded as having a fall with a fracture prior to admission.A phone interview was conducted with Resident #1 on 2/26/26 at 1:45 PM who stated on 1/28/26 she had turned her call light on sometime during the night, she was unsure of the time, to request help to go to the bathroom. She stated nobody answered her call light, so she tried to get up by herself. Resident #1 explained she lost her balance and fell to the floor. According to the resident, a while later, time unknown, two ladies picked her up off the floor and put her in a wheelchair then assisted her into bed. She stated neither lady completed an exam on her because she would have remembered that. Resident #1 stated her right leg hurt after the fall, and she rated the pain level a 10/10 (0 meaning no pain and 10 meaning the worst pain the resident experienced). A phone interview was conducted with Nurse #1 on 2/25/26 at 9:24 AM who was assigned the 7:00 PM shift to the 7:00 AM shift on 1/27/26 through the morning of 1/28/26. Nurse #1 stated she was notified by Nurse Aide (NA) #1 that Resident #1 had fallen in her room on the morning of 1/28/26. She stated she was completing her medication pass around 5:30 AM when the NA informed her. Nurse #1 stated she and NA #1 got the resident off the floor and up into her wheelchair. She stated she asked the resident what happened but said she did not complete an assessment on the resident. Nurse #1 stated Resident #1 winced and said Oh my leg when she and NA #1 got her up, but she didn't think the resident was hurt because she looked like she had full range of motion of her leg. Nurse #1 stated she had NA #1 take the resident to the bathroom then put her back to bed. She indicated she looked in at Resident #1 a while later, time unknown, and the resident looked fine, so she went down the hall. Nurse #1 further indicated she did not report the fall to the Doctor or the Nurse Practitioner and stated, I used bad judgement.An interview was conducted with NA #2 on 2/23/26 at 1:57 PM who stated she checked on Resident #1 before breakfast on 1/28/26, she estimated the time to be around 8:00 AM, to get the resident ready for the day. NA #2 indicated she was changing the resident's brief, and Resident #1 kept saying ouch as she moved her in the process. NA #2 stated the resident informed her she had fallen during the night. The NA stated she had not been informed the resident had fallen so she reported what the resident said to the Medication Aide. NA #2 indicated the Medication Aide informed her she was not aware Resident #1 had fallen. The NA stated she reported the resident's statement to the Unit Manager after she discussed the reported fall with the Medication Aide, and the UM replied she would get right on it.A phone interview was conducted with Medication Aide (MA) #1 on 2/24/26 at 12:12 PM who stated on 1/28/26 she was standing beside Resident #1's room at the medication cart passing medications between 8:00 AM and 9:00 AM when NA #2 came out of the room and told her the resident reported she fell during the night. According to MA #1 she did not receive notice of Resident #1 having a fall during shift change report. MA #1 indicated she immediately went to the resident and could tell Resident #1 did not look the same as she had when she worked with her on 1/27/26. She stated the resident had a look of agony on her face and reported her pain level was 10/10. MA #1stated she looked up and noted the Unit Manager was headed down the hall towards her to Resident #1's room to assess her. A phone interview was conducted with Nurse #2 who was assigned to Resident #1 on the morning of 1/28/26 for the shift of 7:00 AM to 7:00 PM. Nurse #2 stated she received a report from the previous shift nurse (Nurse #1) that Resident #1 had an unwitnessed fall during her shift. According to Nurse #2, she did not know if Nurse #1 reported the fall to the provider or the Unit Manager, and she did not know where to look in Resident #1's medical record to determine if the fall was reported.A review of the vital signs documented in the electronic medical record for Resident #1 revealed on 1/28/26 at 8:58 AM the resident reported a pain level of 8/10. The acceptable pain range for Resident #1 was documented to be between 0-4/10. Acetaminophen was administered at 8:59 AM. At 12:20 PM another vital signs documented in Resident #1's chart indicated the resident reported a pain level of 5/10, no interventions were listed.At 1:02 PM another vital signs indicated Resident #1 reported a pain level of 5/10, no interventions were listed.At 2:12 PM a vital sign documented in Resident #1's chart indicated the resident reported a 10/10 pain level and had acetaminophen administered at 2:13 PM.A final vital sign documented at 3:00 PM indicated Resident #1 reported a pain level of 10/10, and there were no interventions listed.A nursing progress note dated 1/28/26 written by the Unit Manager at 2:28 PM indicated Resident #1 informed the staff she attempted to walk to the bathroom without assistance that morning and slipped and fell to the floor. According to the progress note, Resident #1 stated two females assisted her off the floor and back to bed. Upon assessment, the resident complained of hip pain and was unable to bear weight on the right lower extremity. The right leg was noted to have limited range of motion and increased pain with movement. The resident was kept in bed for safety and Tylenol was given. The physician and family were notified of the fall and change in condition. Orders were received and a right hip fracture was noted. The provider was updated. A new order was received to send Resident #1 to the emergency department for further evaluation. The family was notified.An interview was conducted with the Unit Manager (UM) on 2/23/26 at 1:39 PM. The UM stated when she arrived at work on 1/28/26, sometime between 8:00 and 8:30 AM, the Medication Aide reported that Resident #1 had fallen earlier that morning and was complaining of pain. According to the UM, she assessed Resident #1 immediately. She stated the resident was alert and oriented, and very emotional during her assessment as she complained of right leg pain. The resident informed her during the night two females got her off the floor and helped her get into bed. The UM stated she instructed the Medication Aide to give the resident Tylenol for pain as she assessed Resident #1's leg. She stated she then called the Nurse Practitioner and got an order to obtain an x-ray of the resident's right hip. The Unit Manager stated she questioned both the Medication Aide and Nurse #2 if the night shift nurse had reported Resident #1 had a fall, and both denied they had received a report. The UM stated she called Nurse #1, the previous night shift nurse, to ask if the resident had a fall during the previous shift, and Nurse #1 denied it. She indicated she investigated and reviewed the camera footage for the previous shift and noted Nurse #1 and Nurse Aide #1 had entered the resident's room together at 5:45 AM on 1/28/26. The UM stated she called Nurse #1 back and informed her she was observed entering Resident #1's room at 5:45 AM with Nurse Aide #1 (NA), and Nurse #1 admitted the resident had a fall and she had messed up by not reporting it.A review of the electronic medical record revealed orders for post-fall monitoring and a stat (immediate) x-ray of the right hip were ordered by the physician on 1/28/26 at 11:50 AM.On 2/26/26 at 1:05 PM a phone interview was conducted with Customer Service Representative #1 with the facility's mobile imaging provider. She stated Resident #1's mobile imaging record revealed they received an order to perform a hip x-ray for the resident on 1/28/26 at 11:57 AM. The record further indicated that the service was dispatched to the facility at 12:54 PM.A phone interview was conducted with the Responsible Party (RP) on 2/25/26 at 12:50 PM who stated on the afternoon of 1/28/26 he was notified Resident #1 had fallen and was injured. He stated he arrived at the facility sometime between 2:45 and 2:50 PM and saw that his mother's right leg appeared injured. He stated the Unit Manager told him the facility was unsure when the fall had happened, but they were reviewing tapes to see if they could determine a time. According to the RP, he had believed the injury happened just before he arrived at the facility, but he found out instead he had not been notified that Resident #1 had fallen hours earlier in the day. The RP indicated the ambulance arrived to take the resident to the local hospital while he was at the facility.A further review of Resident #1's facility electronic medical record revealed an order from the physician dated 1/28/26 at 2:34 PM to send Resident #1 to the local hospital for evaluation and treatment, stat (immediately).A review of the local hospital treatment record dated 1/28/26 at 3:54 PM indicated Resident #1 presented to the emergency room (ER) with deformity and tenderness to the right hip. An x-ray of the right hip completed 1/28/26 revealed a comminuted, displaced, and impacted right hip fracture (a severe injury where the bone shatters into three or more pieces, the fragments are out of alignment, and the broken ends are driven into each other). The hospital record indicated the resident denied hitting her head when she fell, but due to the history of an existing subdural hematoma (bleeding near the brain) with CT (computed tomography) evidence of recent bleeding, the resident was admitted to the trauma intensive care unit for monitoring and neurological checks. Resident #1 was then transferred to a secondary hospital for surgical repair of the right hip fracture.The Director of Nursing (DON) was interviewed on 2/24/26 at 2:30 PM who stated Nurse #1 failed to report Resident #1 had fallen during her shift on 1/28/26. The DON stated she reviewed the 24-hour shift report and noted the time 5:45 was written and underlined next to Resident #1's name on the report, but there was no documentation in the medical record to indicate what had happened. She further stated that Nurse #1 did not report the fall to the oncoming shift. According to the DON, the staff should have done what was right for the resident and completed an assessment of the resident and notified the provider the resident had a fall. The Nurse Practitioner (NP) was interviewed on 2/23/26 at 4:41 PM and stated she was notified by the Unit Manager during the morning of 1/28/26 that Resident #1 had fallen but was unsure of the time she received the call. She stated she gave orders to obtain an x-ray of the resident's right hip due to reports of pain. The NP indicated if she had known the severity of the resident's pain level, she would have possibly given different treatment orders.

Based on record review and interviews with the resident, staff, mobile imaging provider Representative, and the Nurse Practitioner, the facility failed to identify the seriousness of a resident's unwitnessed fall and immediate reports of pain and complete and document comprehensive assessments following the fall to determine the need for transfer to a higher level of care. The Nurse did not complete a thorough assessment of Resident #1 before the resident was transferred from the floor to the bed. In addition, there were no comprehensive nursing assessments of the resident's condition documented in the medical record. The Unit Manager called the order for the stat (immediately) x-ray of the right hip to the mobile imaging provider instead of the computerized ordering system which further delayed transfer to the hospital for evaluation and treatment. An x-ray of the right hip completed at the hospital on 1/28/26 confirmed a comminuted, displaced, and impacted right hip fracture (a severe injury where the bone shatters into three or more pieces, the fragments are out of alignment, and the broken ends are driven into each other). Resident #1 was transferred to a secondary hospital for surgical repair of the right hip fracture on 1/28/26. This deficient practice was identified for 1 of 3 residents sampled for supervision to prevent accidents (Resident #1). The findings included:Resident #1 was admitted to the facility on [DATE] with diagnoses including traumatic subdural hemorrhage (bleeding near the brain) without loss of consciousness, fractured ribs, type II diabetes, muscle weakness, and unsteadiness on her feet.A review of the 5-day Minimum Data Set (MDS) assessment dated [DATE] indicated the resident was cognitively intact. She was assessed as requiring supervision with toilet transfers and toileting hygiene. Resident #1 was coded as having a fall with a fracture prior to admission.A phone interview was conducted with Resident #1 on 2/26/26 at 1:45 PM who stated on 1/28/26 she had turned her call light on sometime during the night, she was unsure of the time, to request help to go to the bathroom. She stated nobody answered her call light, so she tried to get up by herself. Resident #1 explained she lost her balance and fell to the floor. According to the resident, a while later, time unknown, two ladies picked her up off the floor and put her in a wheelchair then assisted her into bed. Resident #1 stated she was not assessed by a nurse after she fell, and she would have remembered if the nurse did assess her because her right hip was in pain at a level 10 out of 10 (0 meaning no pain and 10 meaning the worst pain the resident experienced).A phone interview with NA #1 was conducted on 2/26/26 at 9:46 AM who confirmed she was assigned to Resident #1 from 7:00 PM on 1/27/26 through 7:00 AM on 1/28/26. NA #1 reported that on 1/28/26 at approximately 5:30 AM, while completing final rounds on her assigned hall, she heard Resident #1 make a noise. She looked into the resident's room and observed the resident lying on the floor. NA #1 stated that when she asked what happened, the resident reported she had attempted to go to the bathroom and fell. NA #1 stated she asked the resident if she was injured, and Resident #1 replied she was not certain. NA #1 then notified Nurse #1. Upon returning with Nurse #1, NA #1 stated they assisted the resident from the floor into a wheelchair so they could transfer the resident more easily into bed. NA #1 did not indicate she checked on Resident #1 any further that shift.A phone interview with Nurse #1 was conducted on 2/25/26 at 9:24 AM. Nurse #1 confirmed she was assigned to Resident #1 from 7:00 PM on 1/27/26 through 7:00 AM on 1/28/26. Nurse #1 reported that around 5:30 AM on 1/28/26, NA #1 informed her that Resident #1 had fallen in her room. Nurse #1 stated she and NA #1 assisted the resident from the floor to her wheelchair. She asked the resident what occurred, and Resident #1 reported she attempted to get out of bed to use the bathroom and fell. Nurse #1 stated the resident winced and said, Oh my leg, during the transfer; however, she did not complete a full assessment, because Resident #1 appeared to have intact range of motion. She reported she instructed NA #1 to assist the resident to the bathroom and back to bed. Nurse #1 stated she looked in on the Resident #1 later (time unknown), observed her to appear fine, although she did not complete an assessment on Resident #1 at the time and continued down the hall. Review of Resident #1's nursing progress notes for 1/27/26 through 1/28/26 revealed no documentation by Nurse #1 about Resident #1's fall or any assessments.A phone interview was conducted with Nurse #2, who was assigned to Resident #1 on 1/28/26 for the 7:00 AM to 7:00 PM shift. Nurse #2 stated she received report from Nurse #1 that Resident #1 had an unwitnessed fall during the previous shift. Nurse #2 reported she did not complete an assessment of Resident #1 on 1/28/26 because her day was so busy. She stated that at an unspecified time during her rounds, she visually checked on Resident #1 and observed the resident to appear OK and not in discomfort. Nurse #2 stated that the Physical Therapist later informed her that during his visit Resident #1 reported pain rated 10/10. Nurse #2 acknowledged she did not immediately assess the resident after receiving this information. She stated she was preparing to text the Unit Manager for guidance when she observed the Unit Manager and another staff member already proceeding to Resident #1's room.A review of the vital signs documented in the electronic medical record for Resident #1 revealed on 1/28/26 at 8:58 AM Resident #1 reported a pain level of 8/10. The acceptable pain range for Resident #1 was documented to be between 0-4/10. According to the Medication Administration Record (MAR) acetaminophen was administered at 8:59 AM by Nurse #2. An interview was conducted with NA #2 on 2/23/26 at 1:57 PM who stated she checked on Resident #1 before breakfast on 1/28/26, she estimated the time to be around 8:00 AM, to get the resident ready for the day. NA #2 indicated she was changing the resident's brief, and Resident #1 kept saying ouch as she moved her in the process. NA #2 stated the resident informed her she had fallen during the night. The NA stated she had not been informed the resident had fallen so she reported what the resident said to the Medication Aide. NA #2 indicated the Medication Aide informed her she was not aware Resident #1 had fallen. The NA stated she reported the resident's statement to the Unit Manager after she discussed the reported fall with the Medication Aide, and the UM replied she would get right on it.A phone interview was conducted with Medication Aide (MA) #1 on 2/24/26 at 12:12 PM who stated on 1/28/26 she was standing beside Resident #1's room at the medication cart passing medications between 8:00 AM and 9:00 AM when NA #2 came out of the room and told her the resident reported she fell during the night. According to MA #1 she did not receive notice of Resident #1 having a fall during shift change report. MA #1 indicated she immediately went to the resident and could tell Resident #1 did not look the same as she had when she worked with her on 1/27/26. She stated the resident had a look of agony on her face and reported her pain level was 10/10. MA #1 stated she looked up and noted the Unit Manager was headed down the hall towards her to Resident #1's room to assess her after NA #2 reported the fall to her.A nursing progress note dated 1/28/26 written by the Unit Manager at 2:28 PM indicated Resident #1 informed the staff she attempted to walk to the bathroom without assistance that morning and slipped and fell to the floor. According to the progress note, Resident #1 stated two females assisted her off the floor and back to bed. Upon assessment, the resident complained of hip pain and was unable to bear weight on the right lower extremity. The right leg was noted to have limited range of motion and increased pain with movement. The resident was kept in bed for safety and acetaminophen was given. The physician and family were notified of the fall and change in condition. Orders were received and a right hip fracture was noted and the provider was updated. A new order was received to send Resident #1 to the emergency department (ED) for further evaluation and the family was notified. The progress note did not include pain scale, vital signs or details about the presence of redness, swelling, bruising or external rotation of the right leg. An interview was conducted with the Unit Manager (UM) on 2/23/26 at 1:39 PM. The UM stated when she arrived at work on 1/28/26, sometime between 8:00 and 8:30 AM, the Medication Aide reported that Resident #1 had fallen earlier that morning and was complaining of pain. According to the UM, she assessed Resident #1 immediately after she was notified. She stated the resident was alert and oriented, and very emotional during her assessment as she complained of a pain scale of 8/10 of her right leg. The resident informed her during the night two females got her off the floor and helped her get into bed. The UM stated she instructed the Medication Aide to give the resident acetaminophen for pain as she assessed Resident #1's leg. According to the UM, she did not observe any obvious signs of injury to the resident's leg. However, she did not explain how she determined the resident did not have an injury. The UM stated she then called the Nurse Practitioner and got an order to obtain an x-ray of the resident's right hip. The UM stated she called the mobile x-ray provider sometime around 9:00 AM to inform them of the stat (immediately) order for a hip x-ray and was told later that morning (time unknown) by a caller from the mobile imaging provider that they did not accept verbal orders and the order would need to be entered into the electronic chart. The Unit Manager indicated she was unaware the mobile x-ray provider did not accept a verbal order for imaging. According to the UM, the mobile x-ray unit arrived at the facility around 2:00 PM and she said the Director of Therapy saw the preliminary image when the x-ray tech obtained the x-ray, and the Director of Therapy, who is a Certified Occupational Therapy Assistant (COTA), told her it looked like a fracture. The UM explained she reported this to the NP and got the order to send the resident out.A review of the therapy progress note written by the Director of Therapy on 1/28/26 indicated he assessed Resident #1 between 8:50 AM and 9:10 AM. The note indicated upon arrival Resident #1 stated she was in extreme pain in her right hip and rated her pain to be 10/10. The note indicated that the therapist notified the nurse and management and that x-rays had been ordered.An interview was conducted with the Director of Therapy on 2/23/26 at 3:30 PM who stated he assessed Resident #1 for a routine visit on 1/28/26 between 8:50 AM and 9:10 AM, and the resident reported extreme pain in her right hip. The Director of Therapy, who is a Certified Occupational Therapy Assistant (COTA), stated this was reported to the Unit Manager, and he was told the UM had ordered a hip x-ray. According to the Director of Therapy, he did not see any bruising, rotation, or deformity of Resident #1's right leg during his assessment. He did say he thought Resident #1 had a fracture when he saw the imaging taken when the mobile imaging company was at the facility, but he was not trained to read x-rays.A review of a Physical Therapist (PT) note written by PT #1 on 1/28/26 indicated he assessed Resident #1 between 11:01 AM and 12:10 PM. The note indicated the resident complained of pain in her right hip rated 7/10, and the resident reported she had a fall earlier that morning. The PT documented the resident was tender to palpation (touch) and had significant pain with passive range of motion. The note indicated the PT reported the concerns to the nurse.An interview was conducted with PT #1 on 2/24/26 at 11:41 AM who stated he saw Resident #1 for an initial evaluation on 1/28/26 around 11:00 AM. He stated the resident informed him she had fallen the night before when she was trying to go to the bathroom. He stated Resident #1 did not initially report pain in her hip, but after attempting passive range of motion with Resident #1 she winced and complained of hip pain 10/10. According to PT #1, he did not see a deformity of Resident #1's leg, but he stopped the range of motion and reported the pain level to Nurse #2.A review of the electronic medical record revealed orders for post-fall monitoring and a stat (immediate) x-ray of the right hip were written by the Unit Manager as a verbal order from the Medical Director on 1/28/26 at 11:50 AM.At 12:20 PM vital signs completed by Nurse #2 indicated Resident #1 reported a pain level of 5/10, no interventions were documented.At 1:02 PM vital signs completed by Nurse #2 indicated Resident #1 reported a pain level of 5/10, no interventions were documented.At 2:12 PM vital signs completed by Nurse #2 indicated Resident #1 reported a 10/10 pain level. A review of the MAR indicated Nurse #2 administered acetaminophen at 2:13 PM.Vital signs completed by Nurse #2 at 3:00 PM indicated Resident #1 reported a pain level of 10/10, and there were no interventions documented. A review of Resident #1's nursing progress notes did not reveal any documentation of a post-fall assessment completed by Nurse #2.On 2/26/26 at 1:05 PM a phone interview was conducted with Customer Service Representative #1 with the facility's mobile imaging provider. She stated Resident #1's mobile imaging record revealed they received an order to perform a hip x-ray for the resident on 1/28/26 at 11:57 AM. The mobile x-ray provider stated the record further indicated that the service was dispatched to the facility at 12:54 PM. A review of the x-ray findings revealed the results were not signed by the radiologist until 1/28/26 at 9:42 PM. A further review of Resident #1's facility electronic medical record revealed an order from the Physician dated 1/28/26 at 2:34 PM to send Resident #1 to the local hospital for evaluation and treatment, stat. A review of the emergency medical services (EMS) transport record indicated EMS arrived at the facility on 1/28/26 at 2:48 PM. According to the report, when EMS personnel assessed Resident #1, she complained of right hip pain rated 5/10. The personnel did not find obvious injuries, contusions (bruises), or deformities to the hip area but pain when the area was palpated (touched). No treatment options were noted in the EMS report, and Resident #1's care was transferred to the local emergency department at 3:09 PM.A review of the local hospital treatment record dated 1/28/26 at 3:54 PM indicated Resident #1 presented to the ED with deformity and tenderness to the right hip. Resident #1's pain was not quantified using a pain scale assessment, and the medical record indicated Resident #1 refused analgesics (pain relievers) upon arrival at the ED. An x-ray of the right hip completed 1/28/26 revealed a comminuted, displaced, and impacted right hip fracture. The hospital record indicated the resident denied hitting her head when she fell, but due to the history of an existing subdural hematoma (bleeding near the brain) with CT (computed tomography) evidence of recent bleeding, the resident was admitted to the trauma intensive care unit for monitoring and neurological checks. Resident #1 was then transferred to a secondary hospital for surgical repair of the right hip fracture on 1/28/26.The resident did not return to the facility after the surgical repair of the right hip fracture.The Director of Nursing (DON) was interviewed on 2/24/26 at 2:30 PM who stated she was not working the morning of 1/28/26 but received a call from the Unit Manager that Nurse #1 failed to report to the physician that Resident #1 had fallen during her shift on 1/28/26. She further stated that Nurse #1 did not report the fall to the oncoming shift. The DON indicated she and the Unit Manager interviewed the nurses and nurse aides on the hall where Resident #1 resided to piece together the events that led to her injury. The DON stated later in the day of 1/28/26 it was discovered Nurse #1 and Nurse Aide #1 had entered Resident #1's room earlier that morning for a brief time. According to the DON, Nurse #1 was not in Resident #1's room long enough to have completed a post fall assessment. The DON stated Nurse #2 who was assigned to Resident #1 for the 7:00 AM to 7:00 PM on 1/28/26 was a new nurse, and she failed to document Resident #1's condition that day. The DON indicated she assumed Nurse #2 assessed the resident, but she did not find any documentation in the chart of a completed assessment. The DON stated the nurses should have completed a full post fall assessment on Resident #1 and notified the provider of the resident's level of pain to avoid delaying the level of care she required. According to the DON, the order for the mobile x-ray should have been entered into the computerized ordering system to avoid delay in diagnosing Resident #1's hip fracture.The Nurse Practitioner (NP) was interviewed on 2/23/26 at 4:41 PM and stated she was notified by the Unit Manager during the morning of 1/28/26 that Resident #1 had fallen but was unsure of the time she received the call. She stated she gave orders to obtain an x-ray of the resident's right hip due to reports of pain. The NP indicated if she had known the severity of the resident's pain level, she would have possibly given different treatment orders for the resident to receive the correct level of care to treat her injury.The facility provided a plan of correction for past non-compliance, however upon review, the plan of correction was found to have been lacking the necessary information and was found to be incomplete.

Based on record review and resident, staff, Responsible Party, and Nurse Practitioner interviews, the facility failed to provide effective pain management for a resident who reported acute severe pain rated a 10 out of 10 (0 meaning no pain and 10 meaning the worst pain the resident experienced) of the right hip after experiencing an unwitnessed fall. Despite receiving 2 doses of 1,000 milligrams (mg) of acetaminophen, the pain and discomfort the resident experienced caused the resident to cry out and wince in pain with movement. Resident #1 stated she told everyone she was in a lot of pain that day and she was not offered anything additional for pain relief. Resident #1 was transferred via Emergency Medical Services (EMS) to the hospital where an x-ray indicated the resident had a right hip fracture. This deficient practice affected 1 of 3 residents reviewed for effective pain management (Resident #1).The findings included:Resident #1 was admitted to the facility on [DATE] with diagnoses including traumatic subdural hemorrhage (bleeding near the brain) without loss of consciousness secondary to a prior fall at home, fractured ribs, diabetes, muscle weakness, and unsteadiness on her feet.A review of the 5-day Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #1 was cognitively intact. She was assessed as requiring supervision with toilet transfers and toileting hygiene. She was coded as having received pain medication within the past 5 days of the assessment period.Resident #1 had an active medication order with a start date of 1/23/26 for acetaminophen 500 milligrams (mg) 2 tablets by mouth for pain every six hours as needed.A phone interview was conducted with Resident #1 on 2/26/26 at 1:45 PM who stated on 1/28/26 she had turned her call light on sometime during the night (early morning), she was unsure of the time, to request help to go to the bathroom. She stated nobody answered her call light, so she tried to get up by herself. Resident #1 explained she lost her balance and fell to the floor. According to the resident, a while later, time unknown, two ladies (Nurse #1 and Nursing Assistant (NA) #1) picked her up off of the floor and put her in a wheelchair then assisted her into bed. She stated neither lady completed an exam on her because she would have remembered that. Resident #1 stated her right leg hurt after the fall, and she rated the pain level a 10 out of 10. Resident #1 indicated she told the ladies she was in pain, but she was not given anything for pain control at that time. Resident #1 stated she was given a dose of acetaminophen by someone later in the morning, but she was not offered any additional pain relief measures (ice, positioning) even though she told everyone she talked to that day (1/28/26) she was having a lot of pain.Review of Resident #1's nurses' notes for 1/27/26 through 1/28/26 revealed no documentation of a fall during the shift from 7:00 PM to 7:00 AM.A phone interview with NA #1, who worked the evening of 1/27/26 until the morning of 1/28/26, was conducted on 2/26/26 at 9:46 AM. NA #1 reported that on 1/28/26 at approximately 5:30 AM, while completing final rounds on her assigned hall, she heard Resident #1 make a noise. She looked into the resident's room and observed the resident lying on the floor. NA #1 stated that when she asked what happened, the resident reported she had attempted to go to the bathroom and fell. NA #1 stated she asked the resident if she was injured, and Resident #1 replied she was not certain. NA #1 then notified Nurse #1. Upon returning with Nurse #1, NA #1 stated they assisted the resident from the floor into a wheelchair so they could transfer the resident more easily into bed. NA #1 did not indicate she checked on Resident #1 any further that shift. A phone interview was conducted with Nurse #1 on 2/25/26 at 9:24 AM. Nurse #1 explained she was assigned to Resident #1 from 7:00 PM on 1/27/26 to 7:00 AM on 1/28/26. Nurse #1 stated she was notified by NA #1 that Resident #1 had fallen in her room on the morning of 1/28/26. She stated she was completing her medication pass around 5:30 AM when the NA informed her. Nurse #1 stated she and NA #1 got the resident off of the floor and up into her wheelchair. Nurse #1 stated Resident #1 winced and said, Oh my leg, when she and NA #1 got her up, but she didn't think the resident was hurt because she looked like she had full range of motion of her leg. Nurse #1 stated she had NA #1 take the resident to the bathroom then put her back to bed. She indicated she looked in at Resident #1 a while later, time unknown, and the resident looked fine, so Nurse #1 said she went down the hall. Nurse #1 stated she did not complete a pain assessment on Resident #1.A review of the Medication Administration Record (MAR) revealed Nurse #1 did not administer any pain medication after Resident #1's unwitnessed fall.An interview was conducted with NA #2 on 2/23/26 at 1:57 PM who stated she was assigned to Resident #1 on 1/28/26 during the 7:00 AM to 7:00 PM shift. The NA explained she checked on Resident #1 before breakfast on 1/28/26, she estimated the time to be around 8:00 AM, to get the resident ready for the day. NA #2 indicated as she was changing the resident's brief before breakfast, Resident #1 kept saying ouch as she repositioned her in the process. NA #2 stated the resident informed her she had fallen during the night and her right leg hurt. NA #2 stated she reported the resident reporting she had fallen to the Unit Manager (UM) after her discussion with the MA, and the UM replied she would, Get right on it, (check on Resident #1).A phone interview with Medication Aide (MA) #1 was conducted on 2/24/26 at 12:12 PM. MA #1 reported she was assigned to Resident #1 on 1/28/26. She stated between 8:00 AM and 9:00 AM on 1/28/26, while administering medications near Resident #1's room, Nursing Assistant (NA) #2 informed her Resident #1 reported experiencing a fall during the night. MA #1 indicated that no fall had been communicated to her during shift change report. According to MA #1, upon entering the resident's room, she observed that Resident #1's appearance had significantly changed from the prior day. The resident displayed an expression consistent with severe discomfort and reported a pain level of 10 out of 10.A nursing progress note dated 1/28/26 written by the Unit Manager at 2:28 PM indicated Resident #1 informed the staff she attempted to walk to the bathroom without assistance that morning and slipped and fell to the floor. According to the progress note, Resident #1 stated two females assisted her off the floor and back to bed. Upon assessment, the resident complained of hip pain and was unable to bear weight on the right lower extremity. However, the progress note did not include notation of a pain scale assessment. The right leg was noted to have limited range of motion and increased pain with movement. The resident was kept in bed for safety and acetaminophen was administered for pain. The physician and family were notified of the fall and change in condition. Orders were received and a right hip fracture was noted. The provider was updated. A new order was received to send Resident #1 to the emergency department for further evaluation. The family was notified.An interview was conducted with the Unit Manager (UM) on 2/23/26 at 1:39 PM. The UM stated when she arrived at work on 1/28/26, sometime between 8:00 and 8:30 AM, the Medication Aide reported Resident #1 had fallen earlier that morning and was complaining of pain. According to the UM, she went to Resident #1's room and assessed the resident immediately. The UM stated the resident was alert and oriented, and very emotional during the assessment as she complained of right leg pain. The UM stated she instructed the Medication Aide to give the resident acetaminophen for pain as she assessed Resident #1's leg. The Unit Manager stated she then called the Nurse Practitioner and got an order to obtain an x-ray of Resident #1's right hip. The UM did not disclose if she had followed up with Resident #1 to see if the acetaminophen was effective for the resident's complaints of pain.A review of the therapy progress note written by the Director of Therapy on 1/28/26 indicated he assessed Resident #1 between 8:50 AM and 9:10 AM. The note indicated upon arrival Resident #1 stated she was in extreme pain in her right hip and rated her pain to be 10 out of 10. The note indicated the therapist notified the nurse and management and x-rays had been ordered.An interview was conducted with the Director of Therapy on 2/23/26 at 3:30 PM. He stated he assessed Resident #1 for a routine visit on 1/28/26 between 8:50 AM and 9:10 AM, and the resident reported she had extreme pain in her right hip. He stated he reported this to the Unit Manager and was told she had ordered a hip x-ray.A review of the vital signs documented in the electronic medical record for Resident #1 revealed on 1/28/26 at 8:58 AM the resident reported a pain level of 8 out of 10 as documented by Nurse #2. The acceptable pain range for Resident #1 was documented to be between 0-4 out of 10.A review of the medication administration record (MAR) indicated Nurse #2 administered acetaminophen at 8:59 AM on 1/28/26. The MAR revealed Nurse #1 did not follow up after administering the medication until 12:20 PM when Resident #1 rated her pain 5/10 which was outside of the resident's documented acceptable range of pain. There was no follow-up intervention documented.A review of a physical therapist (PT) note written by PT #1 on 1/28/26 indicated he assessed Resident #1 between 11:01 AM and 12:10 PM. The note indicated the resident complained of pain in her right hip rated 7 out of 10, and the resident reported she had a fall earlier that morning. The PT documented the resident was tender to palpation (touch) and had significant pain with passive range of motion. The note indicated the PT reported the concerns to the nurse.An interview was conducted with PT #1 on 2/24/26 at 11:41 AM who stated he saw Resident #1 for an initial evaluation on 1/28/26 around 11:00 AM. He stated the resident informed him she had fallen the night before when she was trying to go to the bathroom. He stated Resident #1 did not initially report pain in her hip, but after attempting passive range of motion with Resident #1 she winced and complained of hip pain 10 out of 10. According to PT #1, he did not see a deformity of Resident #1's leg, but he stopped the range of motion and reported the pain level to the nurse. A review of the electronic medical record revealed orders for post-fall monitoring and a stat (immediate) x-ray of the right hip were ordered by verbal order from the Medical Director to the Unit Manager on 1/28/26 at 11:50 AM. After 1/28/26 at 8:58 AM the next pain assessment documented in vital signs was completed at 12:20 PM by Nurse #2 who noted Resident #1 reported a pain level of 5 out of 10, no interventions were listed.On 1/28/26 at 1:02 PM vital signs completed by Nurse #2 indicated Resident #1 reported a pain level of 5 out of 10, no interventions were listed. On 1/28/26 at 2:12 PM vital signs completed by Nurse #2 indicated the resident reported a 10 out of 10 pain level. Further review of the MAR revealed Nurse #2 had administered acetaminophen at 2:13 PM on 1/28/26.A phone interview was conducted with Nurse #2 who was assigned to Resident #1 on the morning of 1/28/26 for the shift of 7:00 AM to 7:00 PM. Nurse #2 reported she had a busy day on 1/28/26 but sometime during her rounds, time unknown, she checked on Resident #1 who looked OK and not in discomfort. Nurse #2 stated the resident informed her she had pain in her leg and rated the pain an 8 out of 10, but she did not assess the resident for the cause of pain. According to Nurse #2, she offered Resident #1 acetaminophen, and according to the medication administration record Nurse #2 administered acetaminophen at 8:59 AM. Nurse #2 stated she knew she should have rechecked Resident #1 an hour after her pain medication administration, but she was very busy that day and the time of her following up with the resident regarding her pain was probably longer than an hour. Nurse #2 stated the resident still looked fine, but she asked the resident about her pain. Nurse #2 stated the resident told her she had pain at 5 out of 10 and told her it was tolerable. However, when the physical therapist saw the resident at 11:00 AM, the resident told him her pain was 10 out of 10. Nurse #2 stated she did not go check on Resident #1 right away because she was busy that day. Nurse #2 Indicated she was about to text the Unit Manager to ask what she was supposed to do, but when she looked up, she saw the Unit Manager and another person were already headed to Resident #1's room.A phone interview was conducted with the Responsible Party (RP) on 2/25/26 at 12:50 PM who stated on the afternoon of 1/28/26 he was notified Resident #1 had fallen and was injured. He stated he arrived at the facility sometime between 2:45 and 2:50 PM and saw that Resident #1's right leg appeared injured because she could not straighten her leg, and the right knee was rotated outward as if it aligned with her underarm area. According to the RP, Resident #1 informed him she had asked several people for pain medication throughout the day, and someone had eventually given the resident acetaminophen. The RP stated Resident #1 informed him she told the physical therapist she was in significant pain, but the resident did not receive help, or pain medication.A further review of Resident #1's facility electronic medical record revealed a verbal order from the Medical Director given to the Unit Manager dated 1/28/26 at 2:34 PM to send Resident #1 to the local hospital for evaluation and treatment, stat (immediately).A final pain assessment at 3:00 PM on 1/28/26 completed by Nurse #2 indicated Resident #1 reported a pain level of 10 out of 10, and there were no interventions listed.The mobile x-ray report signed by the radiologist on 1/28/26 at 9:45 PM was reviewed and revealed Resident #1 had a right hip fracture with slight displacement. A review of the emergency medical services (EMS) report indicated EMS arrived at the facility at 2:48 PM. The report indicated Resident #1 complained of right hip pain with tenderness to touch. The EMS report did not note a numerical value for the reported pain. Per the EMS report, Resident #1 did not have an obvious injury, contusions (bruises), or deformities to the hip area, but the resident did have pain when the area was touched. The EMS report did not indicate any pain relief measures were administered for Resident #1. The resident was received at the local hospital at 3:09 PM. A review of the local hospital treatment record dated 1/28/26 at 3:54 PM indicated Resident #1 presented to the emergency department (ED) with deformity and tenderness to the right hip. According to the ED note, Resident #1 was alert and oriented, and she declined analgesics (pain relieving medications) upon arrival. An x-ray of the right hip completed at the hospital 1/28/26 revealed a comminuted, displaced, and impacted right hip fracture (a severe injury where the bone shatters into three or more pieces, the fragments are out of alignment, and the broken ends are driven into each other). Resident #1 was then transferred to a secondary hospital for surgical repair of the right hip fracture. The Director of Nursing (DON) was interviewed on 2/24/26 at 2:30 PM who stated Nurse #1 failed to report Resident #1 had fallen during her shift on 1/28/26. The DON stated there was no documentation in the medical record to indicate what had happened to Resident #1. The DON stated Nurse #2, who was assigned to Resident #1 from 7:00 AM to 7:00 PM on 1/28/26, was a new nurse, and she failed to document Resident #1's condition that day. The DON indicated she assumed Nurse #2 assessed the resident. The DON stated the physical therapist reported Resident #1 only reported pain when he touched the resident and if she was not being touched then Resident #1 did not complain of pain. According to the DON, the staff should have completed an assessment of the resident and notified the provider the resident had a fall and was in pain.The Nurse Practitioner (NP) was interviewed on 2/23/26 at 4:41 PM and stated she was not at the facility on the morning of 1/28/26 and she was notified by the Unit Manager that morning Resident #1 had fallen but was unsure of the time she received the call. She stated she gave orders to obtain an x-ray of the resident's right hip due to reports of pain. The NP indicated if she had known the severity of the resident's pain level, she would have possibly given different treatment orders.The facility provided a plan of correction for past non-compliance, however upon review, the plan of correction was found to have been lacking the necessary information and was found to be incomplete.

Based on observations, record review, and staff interviews, the facility failed to mark medications with opened-on or discard-by dates and failed to maintain medication refrigerator temperatures within the recommended range. This was for 5 of 6 areas reviewed for medication storage (Medication Carts #1, #4 and #5, and medication storage room refrigerators for Granny's Place and Lillian's).Findings included:1. On [DATE] at 11:40 AM Medication Cart #1 was reviewed with Nurse #5. Four dropper bottles of ophthalmic solution were discovered with no opened-on or discard-by dates:2 bottles- dorzolamide-timolol 2%/0.5% ophthalmic solution 10 milliliters (ml).1 bottle- netarsudil ophthalmic solution 0.02% % 2.5 ml.1 bottle- latanoprost 0.005% ophthalmic solution 2.5 ml.On [DATE] at 11:45 AM during the medication cart review, Nurse #5 stated that two of the eye drop bottles had been sent with the resident from the hospital and they all should have had opened-on dates.On [DATE] at 12:20 PM during an interview with the Assistant Director of Nursing (ADON) she stated the eye drops should have been marked when they were opened. 2. On [DATE] at 12:30 PM Medication Cart #4 was reviewed with Nurse #6. One dropper bottle of latanoprost 0.005% ophthalmic solution 2.5 ml was discovered with no opened-on or discard-by date.On [DATE] at 12:35 PM during the medication cart review, Nurse #6 verified the dropper bottle had been opened. During an interview with Nurse #6 she stated the bottle should have an opened-on date. 3. The Medication Room for Granny's Place was reviewed [DATE] at 12:40 PM with Nurse #7. The current temperature of the refrigerator was observed at 40 F (degrees Fahrenheit).The Temperature Log for Refrigerator- Fahrenheit instructions (version 8/21) included: Take action if temp is out of range -too warm (above 46 F) or too cold (below 36 F).1. Label exposed vaccine do not use, and store it under proper conditions as quickly as possible. Do not discard vaccines unless directed to by your state/local health department and/or the manufacturer(s).2. Record the out-of-range temps and the room temp in the Action area on the bottom of the log. 3. Notify your vaccine coordinator or call the immunization program at your state or local health department for guidance. 4. Document the action taken on the attached Vaccine Storage Troubleshooting Record. The refrigerator temperature logs were reviewed and revealed the following low temperatures documented and initialed by staff on the [DATE] log:[DATE]: 7 PM 35 [DATE]: 7 AM 32 [DATE]: 7 AM 32 [DATE]: 7 AM 34 There was no documentation of the action taken on the temperature log. Medications were observed in the refrigerator in the refrigerator in the medication room for Granny's Place on [DATE]. On [DATE] at 12:50 PM an interview with Nurse #7 was conducted during the observation. She stated this morning she had checked and adjusted the refrigerator temperature and notified the Infection Control nurse about the concern. She explained she was going to check the temperature again later and if it was still low, she was going to contact maintenance. An interview with the Infection Control Nurse was conducted on [DATE] at 1:23 PM. She explained she had spoken with Nurse #7 about the refrigerator temperature this morning and Nurse #7 had turned the temperature up. She stated she had not told maintenance about the refrigerator temperatures yet. 4. On [DATE] at 1:43 PM Medication Cart #5 was reviewed with Nurse #2. Five items were discovered without opened-on or discard-by dates:1 bottle- 20 ml sterile water for injection was without an opened-on date.1 vial- Lidocaine hydrochloride 1% 10mg/ml (milligram/ml) 5 ml without an opened-on date.3 bottles- Latanoprost 0.005% 2.5 ml ophthalmic solution; 1 noted as filled on [DATE] with no opened-on date, 1 noted as opened on 4/26, and 1 noted as opened 4/23. Manufacturer instructions to discard 6 weeks after opening.On [DATE] at 1:45 PM during the medication cart review, Nurse #2 stated items should be marked when opened and the eye drops should have been discarded when they expired.5. The Medication Room for Lillian's was reviewed on [DATE] at 1:50 PM with Nurse #2. The current temperature of the refrigerator was observed at 38 F.The Temperature Log for Refrigerator- Fahrenheit instructions (version 8/13) included: Take action if temp is out of range -too warm (above 46 F) (degrees Fahrenheit) or too cold (below 35 F).1. Label exposed vaccine do not use, and store it under proper conditions as quickly as possible. Do not discard vaccines unless directed to by your state/local health department and/or the manufacturer(s).2. Record the out-of-range temps and the room temp in the Action area on the bottom of the log. 3. Notify your vaccine coordinator, or all the immunization program at your state or local health department for guidance. 4. Document the action taken on the attached Vaccine Storage Troubleshooting Record. The refrigerator temperature logs were reviewed and revealed the following low temperatures documented and initialed by staff on the [DATE] log:[DATE]: 8 AM 34 [DATE]: 7 AM 33 / 7PM 34 [DATE]: 7:20 AM 31 / 3:50 PM 30 [DATE]: 8 AM 32 /5 PM 33 [DATE]: 8 AM 34 /5 PM 32 [DATE]: 9 AM 34 /6 PM 33 [DATE]: 8 AM 33 /5 PM 34 [DATE]: 7 AM 34 / 7 PM 33 [DATE]: 7 AM 32 / 7 PM 33 [DATE]: 7:50 AM 34 / 4:15 PM 32 [DATE]: 7 PM 34 [DATE]: 7 AM 32 / 7PM 33 [DATE]: 7 AM 34 / 7 PM 33 [DATE]: 7 AM 34 / 7 PM 34 [DATE]: 7 AM 32 / 7 PM 31 [DATE]: 7:20 AM 33 /6:50 PM 32 [DATE]: 7:05 AM 34 / 6:00 PM 34 [DATE]: 9 AM 34 / 5 PM 33 [DATE]: 9 AM 32 / 5 PM 32 [DATE]: 76:55 AM 33 / 5:20 PM 32 [DATE]: 7 AM 32 / 7 PM 31 [DATE]: 7 AM 33 / 7 PM 34 [DATE]: 7 AM 32 / 6:30 PM 34 There was no documentation of the action taken on the temperature log. Medications were observed in the refrigerator in the refrigerator in the medication room for Lillian's on [DATE]. On [DATE] at 2:00 PM an interview with Nurse #2 was conducted during the medication room observation. She stated she had checked the refrigerator temperature at the beginning of the shift and adjusted it and would check the temperature again later and make sure it was in range. An interview was conducted on [DATE] at 2:46 PM with the Director of Nursing (DON). She stated she expected the nurses to mark medications when they're opened and discard them when they expired. She stated she would expect the nurse to adjust the temperature of the refrigerator if it were out of range and then notify the nurse manager of the concern.

Based on observations and staff interviews, the facility failed to label, date, and seal food items left open to air and stored for use in 1 of 1 walk-in refrigerator and failed to label and remove expired food items stored for use 1 of 1 walk-in freezer. These practices had the potential to affect food served to residents.The findings included: Accompanied by the Dietary Manager, an observation was made of the walk-in refrigerator on 8/25/25 at 9:32 AM. The following items were stored in the refrigerator: -One undated box of turkey sausage that was open and partially used with the remaining contents unwrapped and exposed to air. -One undated package of Danishes open and partially used with the remaining contents unwrapped and exposed to air. An observation of the walk-in freezer revealed the following stored item:-One large plastic, zippered storage bag containing unlabeled and uncooked ground meat dated 7/7/25. The Dietary Manager was interviewed on 8/25/25 during the kitchen tour at 9:32 AM. He stated food should be wrapped once it's opened and labeled with the contents and date it was opened. He indicated food should be used or discarded within seven days after opening. The Dietary Manager stated he did not work over the past weekend, and he did not have an opportunity to check the refrigerator and freezer Monday morning due to printing meal tickets for the breakfast service. On 8/25/25 at 12:35 PM the Administrator was interviewed and stated foods should be labeled with their contents and opened dates and stored in the refrigerator and freezer correctly.

Based on observations, record review, and resident and staff interviews, the facility failed to provide cueing assistance during a meal as specified in the resident's plan of care. Resident #90 was seated at a table in the main dining room with her meal tray in front of her not eating while other residents at other tables were eating their lunch. This deficient practice affected 1 of 8 residents reviewed for dignity.The findings included:Resident #90 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease, dementia, dysphagia (difficulty swallowing), and memory deficit following other cerebrovascular disease.Review of a quarterly Minimum Data Set (MDS) dated [DATE] assessed Resident #90 to be severely cognitively impaired without behaviors. She was assessed as requiring set-up or clean-up assistance with eating.According to the active care plan for Resident #90 dated 6/28/25, the resident had an ADL (activities of daily living) self-care performance deficit related to Alzheimer's. An approach read Resident #90 needed set-up and cueing assistance with meals.On 8/25/25 at 12:15 PM an observation was conducted in the main dining room during lunch. Resident #90 was noted to be sitting by herself in a wheelchair at a table in the main dining room while four other residents were seated at a table to her right eating their meal. Resident #90 had a tray of food set up sitting on the table in front of her that was untouched. The resident did not attempt to eat during the observation. Nurse Aide (NA) 6 and NA #7 were observed seated at a table at the back of the dining room. Each NA had one resident sitting beside each of them assisting those residents with eating. Neither NA was observed assisting Resident #90. NA #6 and NA #7 were interviewed on 8/25/25 at 12:38 PM. NA #6 stated there were usually only 2 staff members in the dining room at mealtimes. NA #6 and NA #7 stated Resident #90 only occasionally needed cueing and assistance with her meals. On 8/26/25 a continuous observation from 12:30 PM to 1:17 PM was conducted in the main dining room during lunch. Resident #90 was noted to be sitting by herself at a table in the dining room with a tray of food set up sitting on the table in front of her, and it was untouched. The resident did not attempt to feed herself during the observation. There were three residents eating lunch at a table to Resident #90's right side. NA #3 and NA #4 were observed sitting at a table in the back of the dining room assisting two residents with eating. Each NA was assisting one resident with an empty seat on the other side of the NA. At 12:33 PM on 8/26/25 an interview was conducted with NA #4 and NA #3. NA #4 stated if more than one resident needed assistance with eating then she could have one resident sit at her right side and one resident sit at her left side to assist both during mealtimes. She stated Resident #90 only occasionally needed assistance with meals and would sometimes feed herself if her tray was set up in front of her. NA #3 agreed that NA staff could assist two residents during mealtimes. NA #4 and #3 were not aware Resident #90's care plan specified she required cueing with her meals. At 1:17 PM NA #4 completed assisting the resident she had been helping and then approached Resident #90 and began assisting her with eating her meal. The Director of Nursing (DON) was interviewed on 8/28/25 at 11:20 AM and stated if a resident needed cues to eat, they should be placed closer to the NAs in the dining room who were there to assist residents with eating. She stated a resident should not have to wait to eat their meals while others were assisted.

Based on observation and staff interviews, the facility failed to protect residents' private healthcare information by leaving confidential medication information unattended, visible, and accessible to others on the computer screen for 1 of 5 medication carts observed (100 hall medication cart). Findings included: A continuous observation of the upper 100-hall medication cart occurred on 8/26/25 from 2:28 PM until 2:33 PM. The medication cart was in the hallway unattended and was observed to have the computer screen opened which showed multiple residents' personal identifying information such as resident name, diagnoses, medications, date of birth , and room number. The medication cart was observed for five minutes, and during that time one Nurse Aide and the Wound Nurse walked past the cart. Nurse #3 was interviewed on 8/26/25 at 2:33 PM. She confirmed she was responsible for the 100-hall medication cart. Nurse #3 stated she should have locked the computer screen before leaving the cart. The nurse further stated, I'm so far behind giving medications that I just ran down the hall to give the medications. Nurse #3 explained she did not normally leave a computer screen unlocked, and she should have locked it before walking away. The Director of Nursing (DON) was interviewed on 8/28/25 at 11:20 AM and stated all computer screens should remain locked to protect the residents' privacy when a medication cart is unattended. She stated Nurse #3 was educated regarding patient privacy and sent home on 8/25/25 after leaving the screen open. On 8/28/25 at 2:25 PM the Administrator was interviewed and indicated residents' private information should have been secured.

Based on observations and staff interviews, the facility failed to ensure a resident room was in good repair and failed to maintain a clean and sanitary conditions in a resident room. The deficient practice was evidenced for 2 of 8 residents (Resident #67 and Resident #83) observed for a safe, clean and homelike environment on 1 of 4 resident halls (200 hall). a. An initial observation was completed on 08/25/25 at 10:33 AM of Resident #67 and Resident #83's room. The observation revealed a hole in the wall at the corner of Resident #83's headboard that measured approximately 11.5-inch x 8 inches with sheetrock exposed. On the wall to the left side of Resident # 83's bed paint was peeling off the wall between the bottom of the window frame and the packaged terminal air conditioner (PTAC) unit. The area of peeling paint extended was the length of the PTAC unit. During subsequent observations on 08/25/25 at 12:35 PM and 08/25/25 at 3:00 PM the room was still in need of wall repairs. An interview and observation were conducted on 08/25/25 at 3:00 PM with the Maintenance Director. The Maintenance Director observed the peeling paint above the PTAC unit and the hole at the headboard and stated he had not been made aware of the damaged areas. He measured the area of peeling paint above the PTAC unit which measured 42 inches x 4 3/4 inches and the area behind the headboard which measured 11-inch x 9 inches. He stated the areas should have been reported to maintenance for repairs. He explained that when staff notice repairs need to be done on equipment, furniture, and/or walls they would fill out a maintenance slip and put it in the maintenance book so it can be addressed. Another observation was conducted on 08/26/25 at 10:21 AM of Resident #67 and Resident #83's room. The wall behind Resident #83's headboard and under his PTAC unit were repaired. b. An initial observation completed on 08/25/25 at 10:33 AM of Resident #67 and Resident #83's room revealed the strong odor of urine throughout the room, an empty urinal on the floor between the bathroom door and Resident #67's bed, a sock, pillowcase, and box of tissues were under Resident #67's bed. Resident # 67's bedside table had an empty cup lying over on its side with a sticky substance from the edge of the cup across the table measuring approximately 6 inches X 3 inches and food crumbs were scattered on the table. A spoon and fork were on top of Resident #67's mattress. There was also food crumbs scattered on the floor throughout the room.Another observation was conducted on 08/26/25 at 10:21 AM of Resident #67 and Resident #83's room. The strong odor of urine was still throughout the room, a sock, pillow case, and a box of tissues were still under Resident #67's bed. Resident # 67's bedside table still had a sticky substance from the edge of the cup across the table measuring approximately 6 inches X 3 inches and food crumbs were scattered on the table. A follow-up observation was conducted on 08/27/25 at 9:40 AM of Resident #67 and Resident #83's room. Room was now clean, no smell of urine was present, no trash, a box of tissues, clothes or food crumbs were on floor.An interview was conducted on 08/26/25 at 3:10 PM with Housekeeper #1. She stated she was the only one cleaning rooms on 08/25/25 and 08/26/25 and she was doing the best she could. She indicated she could not recall if she had cleaned Resident #67 and Resident 83's room. An interview and observation were conducted on 08/27/25 at 2:56 PM with the Environmental Services Director. He stated the housekeeper for Resident #67 and Resident #83's room called out on Monday (08/25/25), Tuesday (08/26/25), and Wednesday (08/27/25) and he had only one person available to clean resident rooms. He explained that he had hired one new housekeeper and a different housekeeper quit on 08/25/25, and another one quit on 08/26/25. He indicated he didn't know what to do but continue to try and hire more staff. He stated normally when he had a call out, he would pull his floor tech to assist where he was needed but with the number of staff that have quit, he needed him in laundry and on the floor cleaning rooms. Monday and Tuesday the floor tech helped with the laundry and with cleaning rooms. The Environmental Services Director then stated the staff that were available would work together and do the best they could. He indicated he did not notify management or corporate for assistance because he didn't think it would change anything. An interview was conducted on 08/28/25 at 2:45 PM with the Administrator. She stated she expected any room that needed repairs to be reported to the Maintenance Director so the repairs would be addressed and that resident rooms should be kept in good repair and clean. She indicated she was unaware some rooms had been missed during cleaning due to environmental service department call outs.

Based on record review, Resident Representative (RR) and staff interviews, the facility failed to provide a written grievance response summary for 3 of 3 residents reviewed for grievances (Residents #9, #70 and #91).The findings included: A review of the facility grievance policy, dated 8/2018, included, in part, The Grievance Official will meet with the resident and inform the resident of the results of the investigation and how the resident's grievance was resolved or will be resolved, if applicable. A copy of the written grievance decision will be provided to the resident, upon request. The policy did not address how grievance resolutions would be handled by anyone else that filed a grievance concern, such as the RR. 1. Resident #9 was originally admitted to the facility on [DATE]. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated she was cognitively intact. A review of the facility grievance logs from August 2024 to August 2025 revealed a concern form had been initiated on 7/15/25 by Resident #9's RR, regarding negative staff interaction with Resident #9. The concern form indicated a telephone notification was completed with the RR on 7/30/25 by the Social Worker. The form indicated a written response was not provided to the family member and was signed and dated by the Administrator on 7/30/25. On 8/27/25 at 10:24 AM, a phone interview was completed with Resident #9's RR who completed the grievance form on 7/15/25. She stated that she had never received nor been offered a written resolution of grievances from the facility, just that the Social Worker called her or would speak to her when she visited Resident #9. An interview occurred with the Social Worker on 8/27/25 at 1:04 PM, who stated that she maintained the facility grievance log. She stated when a grievance resolution was received, she normally provided the resolution either via a phone call or face to face to the RR or resident, if it had not already been provided by another member of management. She stated that she was unaware a written response was required for grievances. The Administrator was interviewed on 8/28/25 at 8:58 AM and stated that she was aware a written grievance response was required and was not aware this was not being offered and provided to RR's when a grievance concern had been resolved. The Administrator stated it was her expectation for the facility to adhere to the regulatory guidelines regarding written grievance response summaries. 2. Resident #70 was admitted to the facility on [DATE]. A quarterly MDS assessment dated [DATE] indicated she had moderately impaired cognition. A review of the facility grievance logs from August 2024 to August 2025 revealed six concern forms were initiated by Resident #70's RR:- On 12/30/24 a concern form was initiated regarding staff concerns. The form indicated the Administrator spoke one-to-one with Resident #70's RR on 12/30/24 and a written response was not provided. The form was signed and dated by the Administrator on 12/30/24.- On 4/1/25 a concern form was initiated regarding laundry. The form indicated the Unit Manager spoke one-to-one with Resident #70's RR on 4/1/25, a written response was not provided to the RR and was signed and dated by the Administrator on 4/1/25.- On 6/25/25 a concern form was initiated regarding laundry. The form indicated the Social Worker spoke via phone to the RR regarding the resolution on 6/25/25, a written response was not provided to the RR, and the form was signed and dated by the Administrator on 6/25/25.- On 6/25/25 another concern form was initiated regarding care concerns. The form indicated the Social Worker spoke one-to-one with the RR on 6/25/25, a written response was not provided to the RR, and the form was signed and dated by the Administrator on 6/25/25. - On 6/25/25 a third concern form was initiated regarding staff communication for the care of Resident #70. The form indicated the Social Worker spoke one-to-one with Resident #70's RR on 6/26/25, a written response was not provided to the RR and was signed and dated by the Administrator on 6/26/25. - On 6/26/25 a concern form was initiated regarding the cleanliness of Resident #70's bathroom. The form indicated the Social Worker spoke one-to-one with Resident #70's RR on 6/26/25, a written response was not provided to the RR and was signed and dated by the Administrator on 6/26/25. A phone interview was completed with Resident #70's RR on 8/28/25 at 9:47 AM. She stated that she had never been provided or offered a written summary of her grievance concerns from the facility, just that they would either call her or speak to her face to face regarding the grievance resolution. An interview occurred with the Social Worker on 8/27/25 at 1:04 PM, who stated that she maintained the facility grievance log. She stated when a grievance resolution was received, she normally provided the resolution either via a phone call or face to face to the RR or resident, if it had not already been provided by another member of management. She stated that she was unaware a written response was required for grievances. The Administrator was interviewed on 8/28/25 at 8:58 AM and stated that she was aware a written grievance response was required and was not aware this was not being offered and provided to RR's when a grievance concern had been resolved. The Administrator stated it was her expectation for the facility to adhere to the regulatory guidelines regarding written grievance response summaries. 3. Resident #91 was admitted to the facility on [DATE]. An annual MDS assessment dated [DATE] indicated she was cognitively intact. A review of the facility grievance logs from August 2024 to August 2025 revealed a concern form was initiated by Resident #91's RR on 5/14/25 regarding care concerns and the functionality of the call light. The form indicated the Administrator spoke one-to-one with Resident #91's RR on 5/14/25 and a written response was not provided to the RR. A phone interview was completed with Resident #91's RR on 8/28/25 at 9:51 AM. He stated that he had never been provided with or offered a written summary of grievance concerns from the facility, just that they would either call him or speak to him face to face regarding the grievance resolution. An interview occurred with the Social Worker on 8/27/25 at 1:04 PM, who stated that she maintained the facility grievance log. She stated when a grievance resolution was received, she normally provided the resolution either via a phone call or face to face to the RR or resident, if it had not already been provided by another member of management. She stated that she was unaware a written response was required for grievances. The Administrator was interviewed on 8/28/25 at 8:58 AM and stated that she was aware a written grievance response was required and was not aware this was not being offered and provided to RR's when a grievance concern had been resolved. The Administrator stated it was her expectation for the facility to adhere to the regulatory guidelines regarding written grievance response summaries.

Based on record review, and resident, family member and staff interviews, the facility failed to protect a resident's right to be free from staff to resident abuse when Nurse Aide (NA) #1 slapped Resident #74's hand when she became combative after removing her from another resident's room. This was for 1 of 1 resident reviewed for employee to resident abuse (Resident #74). The findings included: Resident #74 was admitted to the facility on [DATE] with diagnoses that included dementia with behavioral disturbances, osteoporosis, and major depressive disorder. Resident #74 resided on the Lillian's Way Hall. An annual Minimum Data Set (MDS) assessment dated [DATE] prior to the incident and the most recent on 8/7/2025 indicated that Resident #74 had severely impaired cognition with behavioral symptoms. She had limited range of motion to extremities and utilized a wheelchair for mobility. Resident #74 was coded as weighing 115 pounds and was 63 inches tall on 5/7/2025. Resident #74's care plans on 5/7/2025 prior to the incident and the last reviewed on 8/19/2025 included the following problem areas: Resident had impaired cognitive function and thought processes related to Alzheimer'sResident had physical behavioral symptoms towards others (physical aggression, verbal aggression, refusing medications, refusal of care, easily agitated, and may attempt to get up without assistance). The interventions included intervene as necessary to protect the rights and safety of others including approach and speak to resident in a calm manner, divert attention when appropriate, and remove from situation and take to alternate location as appropriate. The interventions also included if resident becomes combative with care, leave resident safely and reattempt care at a later time. A review of the facility initial allegation report, investigation and statements revealed on 6/29/25 Resident #74 was in a separate resident's room when Nurse Aide (NA) #1 went to wheel Resident #74 out of the room. Resident #74 became combative, and NA #1 smacked her right hand causing a reddened area to appear on the top of posterior right hand. The incident was witnessed by NA #2 who was sitting at the nurse's station. NA #1 was initially suspended and then her employment was terminated. All staff received education on abuse. On 08/28/2025 at 11:13 AM phone call was placed to NA #1. NA #1 was not reachable. Message was left with no response call back. On 8/26/25 at 5:22 PM, an interview occurred with NA #2 who witnessed the events on 6/29/25. She explained that she was sitting at the nurse's desk at Lillian's Way Hall and could see NA #1 wheeling Resident #74 out of another resident's room and up to the nursing station. NA #2 saw Resident #74 start to [NAME] her arms up in the air and hitting NA #1 in the process. NA #2 saw NA #1 smack Resident #74's hand down. NA #2 told NA #1 that she would need to report the incident to the Director of Nursing (DON). On 8/26/25 at 6:10 PM, an interview occurred with Nurse #1. She explained that she received a call on 6/29/25 from the DON about the incident and was asked to go over and start a reportable. Nurse #1 reported that NA #1 admitted the incident to her. Nurse #1 stated that NA #1 reported not smacking the resident out of malice but due to reflex because Resident #74 was swinging her arms around and hit NA #1. Nurse #1 reported that NA#1 was immediately terminated and not allowed to return into the building. Nurse #1 reported that she has not seen NA #1 back at the facility since the incident occurred. On 08/28/2025 at 1:44 PM, an interview occurred with Nurse #2. She stated that she was not present on the evening of the incident but did work with Resident #74 on the next day, 6/30/25. Nurse #2 stated that she did not recall any redness on Resident #74's hand. Nurse #2 reported that she also did a skin assessment for Resident #74 on 7/1/25 and no redness was seen on resident's skin on that date. Nurse #2 stated that she had no concerns on that day regarding Resident #74's skin. On 8/25/25 at 10:15 AM, Resident #74 was observed sitting up in her bed with cookies in front of her. She was unable to recall the events of 6/29/25. On 8/25/25 at 12:40 PM, an interview occurred with a family member who was called about the incident after it happened. The family member reported that she has had good communication and rapport with staff during Resident #74's stay at the facility and staff treat Resident #74 well and she was satisfied with the care that she received. The family member indicated she was made aware of the incident that happened between Resident #74 and NA #1 a couple of months ago right after it happened and she was satisfied with the facilities response to the incident. Family member reported no additional concerns. On 8/28/2025 at 1:59 PM, an additional interview occurred with a family member. Family member reported that initially she was concerned when they called but once facility staff explained in detail what happened then she felt better. The family member reported that she felt like the facility handled the situation appropriately by terminating the employee and making a report to the authorities. The family member stated she was not nervous about Resident #74's care at the facility and felt that staff provided good care to Resident #74. On 8/27/25 at 8:07 AM, an interview occurred with DON. The DON reported that the NA #1 called her crying and stated that she had to tell her something she had done. The DON indicated that per NA #1's statement, Resident #74 was going into another resident's room and NA #1 went to get her out. NA #1 reported that Resident #74 was fighting her, and she smacked her on the hand. DON reported that NA #1 was a good NA and had never done anything like that before. The DON stated she explained to NA #1 that it was not acceptable and that NA #1 was not to go back into the building. DON reported that she called Nurse #1 on duty and asked her to go and take NA #1's statement in person so that it could be reported and Nurse #1 also called the family to notify them regarding the incident. the interview further revealed Nurse #1 also did a head to toe of the resident and did a complete sweep of the unit to check the other residents. DON reported that there were no other concerns reported. On 8/28/2025 at 11:42 AM, an interview occurred with the Administrator. The Administrator reported she was notified by NA #2 who witnessed the situation regarding the allegation of abuse. The Administrator stated that this was reported immediately, and NA #1 was removed from the facility. The Administrator revealed that NA#1 was immediately suspended and then her employment was terminated. The Administrator reported that the police department was notified, and an investigation was initiated. The Administrator stated she was able to view video footage at the time that revealed that Resident #74 had just been taken to the nurse's station when she became combative towards NA #1 which is when NA #1 was then seen smacking the resident's hand down. The Administrator stated that NA #1 was a good employee, however, they do not tolerate any type of abuse towards a resident. The Administrator reported that there have been no further staff to resident abuse concerns since this incident on 6/29/25.

Based on record review and interviews with staff, the facility failed to notify the State Mental Health Authority after a resident diagnosed with a serious mental illness experienced a change in condition. This deficient practice affected 1 of 1 resident reviewed for (PASRR) Preadmission Screening and Resident Review (Resident #91).Findings included: Resident #91 was admitted to the facility on [DATE] with diagnoses that included bipolar disorder, in partial remission and generalized anxiety disorder. Resident #91had a level I PASRR dated 5/23/24, which stated no further screening was required unless a significant change occurred to suggest a diagnosis of mental illness or a change in treatment needs for those conditions.Record review of the psychiatric follow-up evaluation dated 12/10/24 revealed on 12/5/24 Resident #91's Depakote dose was increased to 500 milligrams by mouth three times a day for treatment of bipolar disorder to assist with mood. According to the psychiatric evaluation, the Lexapro Resident #91 was previously prescribed was also restarted at 5 milligrams by mouth at bedtime due to the resident's increasing anxiety. The evaluation further indicated Resident #91 had behaviors of refusing showers and yelling out.On 8/27/25 at 9:24 AM the Social Worker was interviewed and confirmed she was responsible for ensuring residents with a newly diagnosed mental illness or change in condition were referred for a level II PASRR evaluation. She stated a level II PASRR screening request should have been sent at the time Resident #91 had a change in treatment for her bipolar disorder, but she must have overlooked it.The Director of Nursing was interviewed on 8/28/25 at 11:20 AM and stated residents with mental illness needed their level II PASRR determinations completed on time.On 8/28/25 at 2:25 PM the Administrator was interviewed and stated the residents with a mental health disorder had to have their PASRRs done correctly and on time.

Based on record review and staff interviews, the facility failed to develop a comprehensive person-centered care plan for 1 of 26 residents reviewed for comprehensive care plans (Resident #55).Findings included:Resident #55 was admitted on [DATE] with diagnoses including multiple fractures of the pelvis, glaucoma, and anxiety. Resident #55's admission Minimum Data Set (MDS) dated [DATE] indicated she was cognitively intact. The Care Area Assessment (CAA) Summary indicated eight areas of concern which were triggered from the MDS and identified for care planning. These included: Visual Function, Activities of Daily Living Function, Urinary Incontinence, Falls, Dental Care, Pressure Ulcer, Psychotropic Drug Use, and Pain. Four Care Plans were observed in Resident #55's record and included Social Services discharge planning and Advanced Directives both dated 7/26/25, Activities dated 7/28/25, and Nutritional Status dated 8/2/25. On 8/28/25 at 8:48 AM an interview with MDS Nurse #2 was conducted. MDS nurse #2 explained she was responsible for the short-term care residents' assessments and care plans. MDS nurse #2 stated she became aware last evening she had forgotten to complete Resident #55's care plans. On 8/28/25 at 2:46 PM an interview was conducted with the Director of Nursing (DON). She stated comprehensive care plans should be completed on time.

Based on record review, resident, Medical Director and staff interviews, the facility failed to initiate physician orders on admission for the care of a surgical wound for 1 of 2 residents reviewed for quality of care (Resident #100).The findings included: Review of the hospital records dated 8/7/24 through 8/9/24 revealed Resident #100 had a total left knee replacement and was admitted to the orthopedic unit for continued care. The hospital Discharge summary dated [DATE], included the following wound management orders:- Leave the Aquacel dressing (a type of dressing used for wounds to include surgical wounds) in place for seven days after surgery. On postoperative day seven, remove the Aquacel dressing and apply a dry dressing daily if needed.- If you have a Zipline dressing (a non-invasive skin closure device designed for surgical incisions): the Zipline dressing is adhesive and may be peeled off 14 days after surgery. Once removed, dressings or steri-strips are not needed. Resident #100 was admitted to the facility on [DATE] Her diagnoses included aftercare following joint replacement surgery, diabetes type 2 and primary osteoarthritis of the left knee. The admission skin assessment completed by Nurse #9 and dated 8/9/24 indicated Resident #100 had bruising present to her bilateral upper extremities, left hand, left thigh and a surgical incision to the left knee with Aquacel dressing in place. The skin assessment did not indicate if Resident #100 had surgical clips or a Zipline dressing. A review of the August 2024 physician orders did not include the removal of the Aquacel dressing seven days postoperatively or the removal of the Zipline dressing/surgical clips 14 days postoperatively. A review of the August 2024 Medication Administration Record (MAR) and Treatment Administration Record (TAR) revealed no orders for the removal of the Aquacel dressing seven days postoperatively or the removal of the Zipline dressing/surgical clips 14 days postoperatively. A physician progress note dated 8/12/24 indicated that Resident #100 had recently underwent an elective left total knee replacement and on postoperative day seven the Aquacel dressing could be removed and replaced with a clean dry dressing. The physician's assessment indicated a surgical incision was covered with Aquacel dressing and scant bloody drainage to the left knee. There was no increased redness or warmth. The Medicare 5-day Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #100 was cognitively intact and was coded with a surgical wound. A review of Resident #100's medical record did not indicate that the Aquacel dressing or Zipline dressing was removed during her stay at the facility from 8/9/24 through 8/20/24. Resident #100 was discharged home on 8/20/24. A review of the discharge nursing note did not indicate if any type of surgical wound care was completed. The discharge instructions did not include any type of surgical wound care that would be needed at home. Attempts were made to reach Nurse #9 during the survey with no success. She was the nurse assigned to Resident #100 on 8/9/24, 8/19/24 and 8/20/24. A phone interview occurred with Resident #100 on 8/26/25 at 4:34 PM, who stated she had a Zipline dressing present after her left knee surgery. She recalled the area was covered with a waterproof dressing when she was admitted to the facility. She stated she was told by the surgeon and facility physician that the dressing would be removed seven days after her surgery and could be covered with a dry dressing if needed. Resident #100 stated the outer dressing was to be removed on postoperative day 7 and the Zipline dressing would have been removed on postoperative day 14. She stated she had constantly asked nursing staff about removing the dressing but received no response. Resident #100 added that someone (unable to recall who) removed the outer dressing on 8/19/24 at the facility but she never had the Zipline dressing removed until she got home. Resident #100 stated that her home health therapist removed the Zipline dressing a day or so after her return home. She stated it caused no harm but was uncomfortable. On 8/27/25 at 2:43 PM, an interview occurred with the Director of Nursing (DON). She stated she had been in that position since April 2025 and was unfamiliar with Resident #100 and was unable to speak to the protocol that was in place in August 2024 for ensuring all discharge orders were present for new admissions. She was able to review Resident #100's medical record and confirmed there were no orders to remove the Aquacel dressing on postoperative day seven or the Zipline dressing/surgical clips on day 14 postoperatively. She stated the admitting nurse should have either transcribed the surgical wound orders from the discharge summary or reached out to the orthopedic provider if there was a question. A phone interview was completed with the previous DON #1 on 8/28/25 at 11:13 AM. She was the DON during August 2024. At first, she stated she couldn't recall what the procedure was for new admissions with surgical wounds in order to ensure all the orders were captured. She later stated that the physician or his Nurse Practitioner would have approved the discharge summary prior to the resident's admission but was unable to recall if this did or did not occur for Resident #100 saying, I can't confirm what happened during that time. The previous DON #1 was unable to recall Resident #100. The Medical Director was interviewed on 8/28/25 at 12:07 PM. He reviewed Resident #100's medical record and stated that the hospital discharge summary indicated when to remove the Aquacel dressing and Zipline dressing/surgical clips. The Medical Director indicated that Resident #100 should have had the Aquacel dressing removed on 8/14/24 and the Zipline dressing would have been removed on 8/20/24. He added that the Aquacel dressing has a bactericidal (anti-infectant) property that would have posed no harm to Resident #100 if the dressing had stayed on longer than ordered, however the surgical wound management should have been transcribed on admission from the hospital discharge summary and indicated on the August 2024 MAR/TAR for nursing staff to have addressed. The Administrator was interviewed on 8/28/25 at 12:36 PM and stated that it was her expectation for admission orders to be transcribed completely and correctly.

Based on record reviews, observations, and staff interviews, the facility failed to ensure the enteral tube feed (a method of supplying nutrition through a feeding tube that goes directly into the stomach or small intestine) was infusing per the active physician's order for Resident #78. In addition, the facility failed to store a plastic enteral feeding syringe with the plunger separated from the barrel of the syringe which had the potential for bacterial growth and contamination. The deficient practice affected 1 of 1 resident reviewed for enteral feeding management (Resident #78).The findings included: A. Resident #78 was admitted to the facility on [DATE] with diagnoses including cerebral infarction, type 2 diabetes, and dysphagia (difficulty swallowing). A review of a quarterly Minimum Data Set, dated [DATE] indicated Resident #78 was severely cognitively impaired. She was coded as having a feeding tube. A review of Resident #3's physician orders included the following active order for August 25, 2025, that read: Enteral feeding: tube feeding continuous; Special Instructions: Tube feeding continuous: Formula Isosource 1.5 calorie at 50 ml/hr (milliliters per hour) x 20 hours to allow for ADL (activities of daily living) care. On at 2 PM, off at 10 AM. Record total amount every shift. During an observation of Resident #78 on 8/25/25 at 10:45 AM, her tube feeding was infusing at a rate of 50 ml/hr. A second observation of Resident #78 was conducted on 8/25/25 at 12:56 PM, and the tube feeding was again infusing at a rate of 50 ml/hr. On 8/25/25 at 1:15 PM Nurse #4 was interviewed and verified the tube feeding order for Resident #78 was to begin at 2:00 PM and turned off at 10:00 AM. She stated 8/25/25 was her first day working at the facility, and she was unaware the tube feeding should have been turned off at 10:00 AM. Nurse #4 indicated the Assistant Director of Nursing (ADON) hung the bag for her at 8:00 AM, and she didn't know why the tube feeding was still infusing. The Assistant Director of Nursing was interviewed on 8/25/25 at 3:13 PM and stated she had assisted Nurse #4 by hanging the tube feeding bag for Resident #78 around 8:00 AM that morning because the nurse was busy sending another resident out of the facility. The ADON indicated 8/25/25 was Nurse #4's first day working at the facility, and she had been educated how to look up orders in the facility's computer charting system that morning. She stated Nurse #4 had not worked with the facility's charting program before, and she may have missed seeing the order. B. On 8/28/25 at 10:38 AM a plastic syringe used to provide medications and flush the feeding tube for Resident #78 was observed in a plastic bag hanging from the feeding pump pole. The plunger was in the barrel of the syringe and droplets of a clear liquid were noted in the tip of the syringe. Nurse #5 was interviewed on 8/28/25 at 10:40 AM and explained that she had provided Resident #78 with her medications and water flush via the feeding tube that morning. She stated that she was aware the plunger should be removed from the barrel of the syringe and stored separately, and she was on her way to find a new syringe because she stored it incorrectly. The Director of Nursing was interviewed on 8/28/25 at 11:20 AM and stated the Medication Aide usually administered medications for the residents on the 100 hall, but they were not allowed to assess tube feedings. She stated the oncoming nurse for 8/25/25 was an agency nurse whose first day was Monday so she may not have known she was responsible for residents with feeding tubes even though the previous shift's nurse should have given her a verbal report and written report sheet about the resident. She further stated the plunger for the enteral feeding syringe should have been removed from the barrel and stored separately due to the potential for bacterial growth in the syringe tip.

Based on record review, observations, and staff and Medical Director interviews, the facility failed to have oxygen in use signage on the door (Resident #10) and failed to administer oxygen at the prescribed rate for 2 of 3 residents reviewed for respiratory care (Resident #56 and Resident #10). The findings included: 1. a. Resident #10 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD), chronic respiratory failure with hypoxia, and mucopurulent (thick sticky substance that is both mucus and pus) chronic bronchitis. A review of the active physician orders revealed an order dated 05/21/25 for oxygen (O2) via nasal cannula (NC) continuously at 2 liters per minute (L/min), special instructions; check concentrator to ensure functioning and appropriate setting every shift (day shift and night shift). An admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident # 10 was cognitively intact. She experienced shortness of breath or trouble breathing when lying flat, and she received oxygen therapy. A review of Resident #10's active care plan, last reviewed 08/27/25, included a focus area that read Resident #10 had altered respiratory status related to mucopurulent chronic bronchitis, chronic hypoxic respiratory failure, and history of pulmonary embolism. One of the interventions was for staff to administer oxygen at 2 L/min via nasal cannula. A review of the Medication Administration Record (MAR) revealed oxygen was signed off as being administered at 2 L/min and the staff had checked the oxygen settings to be correct on 08/25/25 and 08/26/25. On 08/25/25 at 10:46 AM an observation was made of Resident #10 while she was lying in bed. The oxygen regulator on the concentrator was set at 3.5 L/min when viewed horizontally, at eye level. On 08/26/25 at 11:26 AM an observation was made of Resident #10 while she was lying in bed. The oxygen regulator on the concentrator was set at 3.5 liters per minute when viewed horizontally, at eye level. An interview was conducted on 08/26/25 at 11:28 AM with Medication Aide #1 who stated she checked Resident #10's vital signs and oxygen level that morning during the medication pass. Medication Aide #1 then verified Resident #10's order was for oxygen at 2 L/min and that the concentrator read 3.5 L/min when viewed horizontally, at eye level. Medication Aide #1 stated, I didn't fully check her concentrator and wasn't aware it was on 3.5 L/min.” She further stated she should have checked the flow rate on the concentrator at eye level. An interview was conducted on 08/26/25 at 12:24 PM with Nurse #3. She stated she believed there was an order to change Resident #10's oxygen order from 2 L/min to 3.5 L/min, but she needed to confirm that with the provider. She further indicated she had not checked the oxygen concentrator during the morning shift. An interview was conducted on 08/26/25 at 12:30 PM with the Medical Director. He stated he had not ordered Resident #10's oxygen to be increased because her oxygen saturation level had remained above 90% during assessments. He then stated he expected the staff to follow Resident #10's oxygen order. b. On 08/25/25 at 10:46 AM an observation was made of Resident #10 with oxygen in use. There was no “oxygen in use” signage on her room door. On 08/26/25 at 11:26 AM an observation was made of Resident #10 with oxygen in use. There was no “oxygen in use” signage on her room door. On 08/28/25 at 10:44 AM an observation was made of Resident #10 with oxygen in use. There was no “oxygen in use” signage on her room door. An interview was conducted on 08/28/25 at 11:20 AM with the Director of Nursing (DON). She stated Medication Aides were not allowed to perform assessments, and the concentrator evaluation was supposed to have been done by the nurse. She further stated she was not aware the facility needed oxygen in use signs on the resident's doorways since the facility was a non-smoking facility. 2. Resident #56 was admitted to the facility on [DATE] with diagnoses that included shortness of breath and atherosclerotic heart disease of native coronary artery (a condition where the coronary arteries (the blood vessels that supply the heart with oxygen) become narrowed or blocked due to the buildup of plaque (fatty deposits), leading to chest pain and can cause shortness of breath. A review of the active physician orders for Resident #56 revealed an order dated 04/11/24, for oxygen (O2) at 2 liters per minute (2L/min) via nasal cannula (NC) to keep O2 Saturation at 92% or above. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #56's cognition was moderately impaired. She was coded as receiving oxygen therapy and shortness of breath or trouble breathing when lying flat. A review of Resident #56's active care plan, last revised on 07/16/25 included a focus area that read Resident #56 required oxygen therapy related to shortness of breath while lying flat. One of the approaches was to provide oxygen as ordered. Resident #56's Medication Administration Record (MAR) revealed oxygen was signed off as being administered at 2L/min from 08/25/25 and 08/26/25 by Nurse #8. On 08/25/25 at 11:52 AM an observation was made of Resident #56 while she was lying in bed with eyes closed. The oxygen regulator on the concentrator read 6L/min when viewed horizontally, at eye level. On 08/25/25 at 3:22 PM an observation was made of Resident #56 while she was lying in bed. The oxygen regulator on the concentrator continued to read 6L/min when viewed horizontally, at eye level. On 08/26/25 at 10:18 AM an observation was made of Resident #56's oxygen regulator on the concentrator continued to read 6 L/min when viewed horizontally, at eye level. An observation and interview were conducted on 08/26/25 at 11:16 AM with Nurse #8. She verified she was Resident #56's nurse yesterday (8/25/25) and today (8/26/25). She then observed and verified the oxygen level for Resident #56 read 6L/min when viewed horizontally, at eye level. Nurse #8 stated the current oxygen order was for 2L/min via NC. She indicated she did not look at the oxygen yesterday or today although she signed the medication administration record (MAR) as being done. An interview was conducted on 08/26/25 at 12:30 PM with the Medical Director. He explained that he would have expected Resident #56 to have been seen for an acute visit if someone had turned her oxygen up to 6L/min. He reviewed Resident #56's notes and did not see any respiratory concerns documented. He stated he was not aware of Resident #56's oxygen levels dropping and that he expected nurses to follow the active oxygen orders and monitor oxygen saturations every shift. An interview was conducted on 08/28/25 at 10:15 AM with the Director of Nursing (DON). She stated she was unaware that Resident #56's oxygen was turned up to 6L/min. She explained nurses are to follow orders for oxygen and to check oxygen concentrators every shift.

Based on record review, Medical Director and staff interviews, the facility failed to discontinue a scheduled acetaminophen (used to relieve mild to moderate pain) order when a new order for scheduled Hydrocodone-acetaminophen (used to relieve moderate to severe pain) was received. This was for 1 of 6 residents reviewed for unnecessary medications (Resident #70).The findings included: Resident #70 was admitted to the facility on [DATE] with diagnoses that included right hip pain, low back pain and compression fracture of the thoracic spine. A hospice note dated 6/5/25 indicated an order was provided to Nurse #2 to discontinue Resident #70's scheduled acetaminophen 500 milligrams (mg) and as needed Tramadol (25 mg- used to relieve moderate to severe pain) and begin Hydrocodone-acetaminophen 5-325 mg one tablet by mouth twice a day for pain. Another hospice note dated 6/9/25 read that Resident #70's family member was concerned that Resident #70 was still receiving scheduled acetaminophen along with the new order for Hydrocodone-acetaminophen. The hospice nurse stated that she went to the facility and reviewed the Medication Administration Record (MAR) which indicated Resident #70 had received both acetaminophen 500mg twice a day along with Hydrocodone-acetaminophen 5-325 mg twice a day from the 6/5/25 evening dose to the 6/9/25 morning dose. No ill effects were noted, and the resident did not receive the maximum dose of acetaminophen in 24 hours. The hospice nurse wrote that Nurse #2 discontinued the routine acetaminophen order, and the Medical Director was notified. The June 2025 physician orders were reviewed and revealed the following:- Tramadol 25 mg every eight hours as needed was discontinued on 6/5/25 as ordered.- A new order for Hydrocodone-acetaminophen 5-325 mg one tablet by mouth twice a day was ordered on 6/5/25.- The order for acetaminophen 500mg one tablet by mouth twice a day was not discontinued until 6/9/25. A review of the June 2025 MAR indicated that Resident #70 received acetaminophen 500mg twice a day and Hydrocodone-acetaminophen 5-325 mg twice a day as follows:- The evening dose on 6/5/25.- Both morning and evening doses on 6/6/25.- Both morning and evening doses on 6/7/25.- Both morning and evening doses on 6/8/25.The June 2025 MAR indicated that the morning dose of acetaminophen on 6/9/25 was not administered. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #70 had moderately impaired cognition. An interview occurred with Nurse #2 on 8/28/25 at 9:17 AM. She was the nurse assigned to Resident #70 on 6/5/25 and 6/9/25. She reviewed Resident #70's medical record and was unable to state why she failed to discontinue the routine acetaminophen order when she received the new order for Hydrocodone-acetaminophen, only to say it was an oversight. Nurse #2 stated when she spoke with the hospice nurse on 6/9/25, the error was identified, the routine acetaminophen order was discontinued, and the Director of Nursing (DON) and Medical Director were notified. The DON was interviewed on 8/28/25 at 9:25 AM and recalled being made aware of Resident #70 receiving both routine orders of acetaminophen and Hydrocodone-acetaminophen. She stated this error occurred because the routine order for acetaminophen was not discontinued as ordered on 6/5/25. The DON further added that the Medical Director was notified at the time the error was identified. She stated she expected physician orders to be correct and that orders to be followed when discontinuing medications. An interview occurred with the Medical Director on 8/28/25 at 12:07 PM. He reviewed Resident #70's medical record and stated that he would not consider Resident #70 receiving seven doses of acetaminophen 500 mg twice a day along with Hydrocodone-acetaminophen 5-325mg twice a day a significant medication error as the amount of acetaminophen did not reach the toxicity point of 3000 mg per day. He added that the nurse should have discontinued the routine order of acetaminophen on 6/5/25 as ordered. The Administrator was interviewed on 8/28/25 at 12:36 PM and stated that she would expect orders to be followed and the routine dose of acetaminophen twice a day should have been discontinued on 6/5/25.

Based on observation, record review and staff interviews, the facility failed to maintain an accurate Medication Administration Record (MAR) for the documentation of supplemental oxygen for 2 of 3 residents reviewed for medical record accuracy (Resident #10 and Resident #56). 1. A review of the active physician orders for Resident #56 revealed an order dated 04/11/24, for oxygen (O2) at 2 liters per minute (L/min) via nasal cannula (NC) to keep O2 Saturation at 92% or above, every shift, day shift 7:00 AM-7:00 PM, evening shift 7:00 PM-7:00 AM. Review of Resident #56's August 2025 Medication Administration Record (MAR) revealed oxygen was signed off as being administered on day shift at 2L/min on 08/25/25 and 08/26/25 by Nurse #8. Night shift was signed off as being administered by Med Aide #2. Phone interviews were attempted with Med Aide #2 however she was unable to be reached for interview. A review of the staff schedule indicated Nurse #8 was assigned to Resident #58 on during day shift on 08/25/25 and 08/26/25. An interview was conducted on 08/26/25 at 11:16 AM with Nurse #8. She verified she was Resident #56's nurse yesterday (8/25/25) and today (8/26/25). Nurse #8 stated the current oxygen order was for 2L/min via NC. She indicated she did not look at the oxygen concentrator to verify the amount being administered yesterday or today although she signed the medication administration record (MAR) as being done. An interview was conducted on 08/28/25 at 10:15 AM with the Director of Nursing (DON). She explained nurses were to follow orders for oxygen and sign the medication administration record after verifying the amount was correct. She indicated the oxygen flow records were to be complete and accurate. 2. A review of the active physician orders for Resident #10 revealed an order dated 5/21/25 for oxygen (O2) via nasal cannula (NC) continuously at 2 liters per minute (L/min), special instructions; check concentrator to ensure functioning and appropriate setting every shift (day shift and night shift). A review of the Medication Administration Record (MAR) revealed oxygen was signed off as being administered at 2 L/min and the staff had checked the oxygen settings to be correct on 8/25/25 by Nurse #4 and 8/26/25 by Medication Aide (MA) #4. On 8/25/25 at 10:46 AM an observation was made of Resident #10 while she was lying in bed. The oxygen regulator on the concentrator was set at 3.5 L/min when viewed horizontally, at eye level. On 8/28/25 at 11:26 AM an observation was made of Resident #10 while she was lying in bed. The oxygen regulator on the concentrator was set at 3.5 L/min when viewed horizontally, at eye level. An interview was conducted on 8/28/25 at 11:28 AM with Medication Aide #4 who stated she checked Resident #10's vital signs and oxygen level the morning of 8/28/25 during the medication pass. MA #1 then verified Resident #10's order was for oxygen at 2 L/min and the concentrator read 3.5 L/min when viewed horizontally, at eye level. MA #1 stated, I didn't fully check her concentrator and was not aware it was on 3.5 L/min. She further stated she should have checked the flow rate on the concentrator at eye level. An interview was conducted on 8/26/25 at 11:28 AM with Nurse #3 who indicated she had not checked Resident #10's oxygen concentrator that morning. Nurse #4 was unable to be reached by phone for an interview after multiple attempts. An interview was conducted on 08/28/25 at 10:15 AM with the Director of Nursing (DON) who stated Medication Aides were not allowed to perform assessments, and the concentrator evaluation was supposed to have been done by the nurse to ensure the oxygen rate was set correctly. She explained nurses were to follow orders for oxygen and sign the medication administration record after verifying the amount was correct. She indicated the oxygen flow records were to be complete and accurate.

Based on record review and staff interviews the facility failed to educate and offer the pneumococcal (pneumonia) and influenza (flu) immunizations on admission (Resident #83) and failed to maintain a resident's medical record of refusal for the pneumococcal (pneumonia) immunization as well as education regarding risk and benefits of refusing the immunization (Resident #63). This occurred for 2 of 5 residents reviewed for immunization (Resident #63 and Resident #83).a. Resident #83 was admitted to the facility on [DATE]. Resident #83's quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated his cognition was severely impaired and the pneumococcal and influenza immunizations were not offered. Resident #83's immunization record revealed no documentation that he had been offered, given, or refused the pneumococcal or influenza immunizations. An interview was conducted on 08/28/25 at 11:40 AM with the Assistant Director of Nursing (ADON). She stated handled the immunizations for residents and staff. She verified that Resident #83 did not have any immunizations listed in his electronic medical record (EMR) nor did he have a consent or refusal form signed and uploaded into his EMR. She stated she was not sure why or how this may have occurred. She indicated influenza immunizations would be coming up, but she was unsure of a date at this time. b. Resident #63 was admitted to the facility on [DATE]. Resident #63's admission Minimum Data Set (MDS) assessment dated [DATE] indicated his cognition was moderately impaired. Pneumococcal immunization was offered and declined. A review of Resident #63's medical record revealed that he or his responsible party had been offered and refused the pneumococcal immunization. Further review revealed no refusal form or nursing note revealing refusal was on file and there was no education noted regarding the risk and benefits of refusing the pneumococcal immunization present in Resident #63's medical record. An interview was conducted on 08/28/25 at 11:40 AM with the Assistant Director of Nursing (ADON). She stated handled the immunizations for residents and staff. She verified that Resident #63 refused the pneumonia immunization, but she did not see his signed refusal form. She indicated she was on vacation when Resident #63 was admitted , and she would look to see if another staff member had completed the refusal but had not uploaded it yet. The ADON did not provide any additional information during the survey period. An interview was conducted on 08/28/25 at 2:45 PM with the Administrator. She indicated that immunizations should be discussed and offered on admission to the facility. If the resident refused, consented to, and/or had some or all immunizations that information should be obtained and entered into the resident's medical record.

Based on record review and staff interviews the facility failed to educate and offer Resident #83 the COVID-19 vaccine on admission and failed to maintain a resident's record of refusal, acceptance, or if contraindicated for the COVID-19 vaccine for 1 of 5 residents reviewed for COVID-19 vaccination status (Resident #83).Resident #83 was admitted to the facility on [DATE].Resident #83's quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated his COVID-19 vaccination was not up to date.Review of Resident #83's medical records revealed no documentation that the COVID-19 vaccine was offered, contraindicated, administered, or refused. No documentation that the COVID-19 vaccine education was provided, and no documentation of previous COVID-19 vaccines received. An interview was conducted on 08/28/25 at 11:40 AM with the Assistant Director of Nursing (ADON). She stated she was the ADON and oversaw the immunizations for residents and staff. She indicated that vaccines should be discussed and offered on admission to the facility by the admitting nurse. If the resident has had some or all vaccines that information should be obtained and entered into the resident's medical record. She verified that Resident #83 did not have the Covid-19 vaccine noted in his electronic medical record (EMR) nor did he have the Covid-19 consult/refusal signed and uploaded.An interview was conducted on 08/28/25 at 2:45 PM with the Administrator. She indicated all residents should have a consent/refusal form, education, and administration details filled out and filed in the resident's chart.

Based on record reviews and interviews with staff, Medical Director, Nurse Practitioner (NP) and emergency room Physician, the facility failed to provide treatment and services to replace an old, discolored, and leaking gastric feeding tube after 5/04/25 when approximately 5 inches of the tube broke off during routine feeding tube care. In addition, the facility failed to schedule an appointment with a gastroenterologist to assess for a feeding tube replacement. On 6/18/25, the feeding tube site was found with approximately 25 maggots in the skin surrounding her feeding tube during care. Resident #1 was sent to the Emergency Department (ED), where approximately 5 more maggots were removed, and it was noted there was some induration (thickening and hardening of the skin) and erythema (abnormal redness of the skin or mucous membranes) concerning for cellulitis (bacterial infection of the skin and the tissue beneath the skin). The ED provider documented the feeding tube appeared aged and soiled and a new feeding tube was inserted. Resident #1 was admitted to the hospital for treatment of sepsis (a life-threatening response to infection) with acute hypoxia (low levels of oxygen in the tissue) due to abdominal wall cellulitis, a catheter-associated urinary tract infection (UTI), and bacteremia (presence of bacteria in the blood). She was treated with intravenous (IV) antibiotics and was discharged on 6/23/25 with orders to continue IV antibiotics for 2 additional weeks. A reasonable person has an expectation of receiving treatment and care to prevent an infestation of maggots and would have experienced feelings such as embarrassment, anger, and disgust. The deficient practice occurred for 1 of 3 residents reviewed for feeding tubes (Resident #1). The findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses including vascular dementia, cognitive communication deficit, neuromuscular dysfunction of the bladder, a gastrostomy (a surgical procedure for inserting a tube through the abdomen wall and into the stomach) tube and dysphagia (difficulty swallowing). Resident #1's current comprehensive care plan noted she had a feeding tube to maintain adequate nutrition and hydration. Interventions included for staff to monitor for abdominal pain, distension, tenderness, and nausea or vomiting. Resident #1's quarterly Minimum Data Set (MDS) dated [DATE] documented she had short- and long-term memory problems and severely impaired cognition for decision-making, inattention, disorganized thinking, and altered level of consciousness constantly present. The MDS noted she had limited range of motion in both upper extremities and was dependent on staff for completion of her activities of daily living (ADLs). The MDS indicated she had an indwelling catheter and a feeding tube, received 51% or more of her calories and 501 cc of fluid daily by the feeding tube. Resident #1's May 2025 and June 2025 Medication Administration Record (MAR) noted Resident #1 received Isosource (tube-feeding formula) 1.5 Cal formula at 55 milliliters an hour through her gastric tube starting at 5:00 AM and continuing until 3:00 AM the next morning. An additional entry noted for the nurse to provide 200 cubic centimeters (cc) of water every 4 hours and to flush the tube with 60 cc of water before administering medications and 30 cc of water between each medication administered. Resident #1's May 2025 through June 2025 nursing progress notes, MAR, and the Treatment Administration Record (TAR) did not document any abnormalities with Resident #1's feeding tube. The TAR noted for the nurse to cleanse Resident #1's skin surrounding the feeding tube site daily with normal saline, apply T-drain sponge, and secure with tape. The daily site care was signed as being completed daily on the MAR until 6/18/25 when she went to the hospital. Nurse #3 documented on 5/4/25 and 5/5/25 during the night shift for providing feeding tube care and flushes. Resident #1's nursing progress notes dated 5/04/25 at 9:46 PM written by Nurse #3 documented that when she was de-clogging and flushing the feeding tube, several inches of the tube broke off, but noted the feeding tube was still patent and functioning. In a phone interview on 6/27/25 at 10:09 AM, Nurse #3 said in May, while providing medications and flushes, approximately 5 inches of the end of Resident #1's feeding tube broke off into her hand. Nurse #3 stated at that time, the feeding tube tubing was thicker silicone, and it appeared old and was no longer transparent. Nurse #3 indicated the tubing was very long, and there was still more than an inch of tubing available to provide flushes and formula. She stated she wrote the incident to the provider in the communication log and reported the incident to the oncoming nurse (Nurse #2) for a referral to a gastroenterologist. Nurse #3 explained when she documented she was de-clogging the tubing, it was not due to an obstruction, it was due to a small amount of residual formula left in the tube that she needed emptied into the stomach. Nurse #3 said she had not observed any leaks or abnormalities, such as a sweet smell from the formula, prior to the tubing breaking or in the following days before she was hospitalized . The Provider Communication Book entry dated 5/4/25 written by Nurse #3 noted for Resident #1 that part of the tube feed broke off. Resident #1's nursing progress note on 5/05/25 at 3:42 PM written by Nurse #2 documented the feeding tube was still running fine even after tube was shortened. In a phone interview on 6/27/25 at 10:00 AM, Nurse #2 said she provided feeding tube site care for Resident #1. She stated it was reported to her that the end of the feeding tube had broken off in May 2025, but the tubing was still intact and Nurse #2 was able to provide the flushes and formula ordered. Nurse #2 indicated she did not notify the provider for a referral because she remembered hearing Nurse #3 say she had written the information in the provider communication book. She said she had observed the feeding tube was stained and appeared old at that time. Nurse #2 recalled a sweet smell from the formula around Resident #1 when caring for the resident at times but had not seen any cracks or leaking from the tubing, so she did not think it was a concern. In her interview on 6/25/25 at 4:12 PM, Nurse #1 said she had learned from Nurse #3 (date not recalled) that the end of Resident #1's feeding tube broke off. Nurse #1 said the tubing was old and brittle (not easily flexible) at the time. Nurse #1 recalled there were a few times (dates not recalled) when she would observe drops of formula on the bedding and stated it was due to the feeding tubing leaking. She stated she would also at times smell a sweet smell in the room and on the resident that smelled like the formula. In a phone interview on 7/15/25 at 3:31 PM, Nurse #4 stated she spoke with the NP about Resident #1's feeding tubing breaking off on 5/05/25 after Nurse #3 reported the incident to her and also about needing the feeding tube assessed for replacement on 5/12/25. She stated she remembered hearing about a referral for a gastroenterologist (GI) appointment, but stated the NP wrote her own orders and Nurse #4 did not remember seeing an order. She stated the normal process was for the NP or Physician to write their own orders into the medical record, and the nurse will print the order for a referral and give it to the Director of Nursing (DON). A Nurse Practitioner (NP) progress note dated 5/12/25 at 7:47 PM documented the nurses reported that there was crusting around Resident #1's feeding tube. The NP noted when she assessed the site, there was hypergranulation (granulation tissue naturally forms when a wound is healing, but too much of this tissue results in a condition known as hypergranulation. Hypergranulated tissue is usually swollen or bumpy, red, and painful) with evidence of a fungal infection. The NP also noted that nursing staff inquired about a routine change of the feeding tube. The NP noted that per her Electronic Medical Record review, Resident #1 had the feeding tube placed 10/18/23 under anesthesia performed by a general surgeon. The NP noted the (feeding tube replacement) procedure [would be] moderately difficult due to Resident #1's anatomy and previous feeding tube placement. The NP included in the note that per guideline review, these feeding tubes may not require routine changing if they are functioning well. Some guidelines recommend to change the tubing every 1-2 years. Nursing staff denied any issues with function or patency of the tube. The Nurse Practitioner placed a nonurgent GI (gastroenterologist) consult to further assess the tube and make evaluations for any future routine changes if needed. In an interview on 7/15/25 at 11:00 AM, the Nurse Practitioner stated she did not recall being notified that approximately 5 inches of Resident #1's feeding tube had broken off. She stated the nurse asked her on 5/12/25 about when to get the feeding tube replaced and reported there was crustiness around the feeding tube site. The NP said she assessed the feeding tube site and noted a mild fungal infection and hypergranulation around the feeding tube site. She said there was nothing abnormal that she observed about the feeding tube. The NP indicated there was no leaking, no sweet smell of the formula (but she stated she usually wore a mask when assessing the residents and so may not have smelled anything due to the mask), and the feeding tube was functioning normally. The NP stated she remembered writing the orders for a gastroenterology consultation and for the antifungal treatment. The NP explained if she had been told the feeding tube had broken off, she would have noted it in her progress note on 5/12/25. The NP stated she was at the facility two to three times a week and did rounds and spoke with charge nurses at each nurses' station. She stated she notified Resident #1's responsible party and spoke with the Unit Manager about the referral and antifungal order and sent a message through the medical practice's portal to the Medical Director, who replied he agreed with her plan for a GI consult. The NP stated she also emailed the Director of Nurses (DON) about the referral and the antifungal order. She stated the facility would write in the communication book or tell her verbally when she was making rounds if there were any concerns with a resident's condition. The NP said because changing the feeding tube wasn't an emergency, she would expect there would be about a month or two wait for an opening at the GI doctor. Resident #1's physician's orders dated 5/13/25 documented an order for nystatin-triamcinoloneOintment (an antifungal) 100,000-0.1 unit/gram-% topically around the feeding tube twice a day. The order instructed that prior to application, to cleanse around the feeding tube with antibacterial soap and water, gently pat dry, apply the ointment and cover site with split gauze. There was no order found documented in the clinical record for a referral to the gastroenterologist from 5/04/25 to 6/17/25. There was no documentation Resident #1 saw a gastroenterologist from 5/04/25 through 6/17/25.In a phone interview on 7/15/25 at 2:54 PM, the facility Transportation and Appointment Scheduler stated she did not receive an order for a referral to a gastroenterologist in May 2025. She stated she did not have access to the medical record, so the nurses would print an order for a referral and put it in her mailbox. She stated she did not receive an order from the nurse to schedule an appointment for Resident #1. She stated specialist appointments would be scheduled quickly when she received the order.In an interview on 7/15/25 at 2:42 PM, the Unit Manager stated she remembered speaking with the NP about Resident #1's fungal infection and about a referral to the gastroenterologist. She stated she did not handle referrals to outside physicians, so she was not aware of what happened with the referral. In a phone interview on 7/15/25 at 3:40 PM, the DON stated when the provider wrote an order for a referral, the nurse would print the order and give the order to her. The DON would then review the referral information in the facility Morning Meeting and the order was given to the Transportation and Appointment Scheduler. She stated she did not remember having an order for a gastroenterology referral for Resident #1. She stated the NP would enter her own orders into the medical record, but would verbally communicate with the charge nurse, the Unit Manager, and the DON about any new orders or concerns. The DON further stated the usual facility practice was for the NP notes to be uploaded to the chart and they were not reviewed for any additional information or missed orders and that the facility nurses and management relied on the verbal information from the NP. She stated she remembered the NP told her about the order for the antifungal treatment and discussed the referral to the gastroenterologist, but because there was not an order for the referral, the appointment was not made, and she did not remember having an order for a gastroenterology referral for Resident #1. In a phone interview on 6/27/25 at 10:00 AM, Nurse #2 said she provided feeding tube site care for Resident #1 on 6/16/25 and 6/17/25. Nurse #2 stated on both days, she lifted the disk to clean the site, and she did not see any maggots in the site. She stated Resident #1 did not appear to be in any pain or to have any acute concerns. Nurse #2 indicated she had not noted any flies in the room and stated the window in the room was closed. She stated when she performed the care, the feeding tube was not leaking and was not cracked. In a phone interview on 6/27/25 at 10:09 AM, Nurse #3 said she worked the night shift (7:00 PM to 7:00 AM) on 6/16/25 and 6/17/25. Nurse #3 indicated there was not an order to clean and care for the feeding tube site on the night shift, but she provided flushes and assessed the area when giving medications. Nurse #3 stated she did not lift the disk to look under it and she did not see any maggots. She stated Resident #1 did not show any signs of a change in condition on her shifts and Resident #1's vital signs were normal, and she didn't appear to be in any distress. She stated the window to the room was closed and she did not see any flies in the room during those shifts. Resident #1's Subjective, Objective, Assessment, and Plan (SOAP) assessment dated [DATE] and written by Nurse #1 documented that Resident #1 was found with maggots surrounding her feeding tube site. Her vital signs were within normal limits. Her blood pressure was 124/67, her pulse was 71, and her temperature was 97.6 degrees Fahrenheit. Nurse #1 documented she notified the Nurse Practitioner, who ordered Resident 1 to be sent to the hospital. An interview with Nurse #1 on 6/25/25 at 4:12 PM revealed she had been off on 6/16/25 and 6/17/25. When she returned to work on 6/18/25, she began to do the daily feeding tube site treatment for Resident #1 and as she removed the protective disk around the tubing, she found approximately 25 maggots surrounding Resident #1's feeding tube site. She said the tubing was old, brittle, leaked drops of formula at times, and that she could smell a sweet smell from the formula when entering Resident #1's side of the room. Nurse #1 indicated the maggots could not be seen until the protective disk was lifted up away from the tubing. She said she immediately notified the Unit Manager, the Assistant Director of Nursing (ADON), the provider, and Resident #1's responsible party. Nurse #1 stated the ADON cleaned the wound with normal saline and removed approximately 25 maggots from the site. In a phone interview on 6/27/25 at 4:26 PM, the Unit Manager said she and the ADON were in their afternoon meeting when Nurse #1 came into the room and reported Resident #1 had maggots in her feeding tube site. The Unit Manager stated she and the ADON went to Resident #1's room and when they arrived, there were no flies in the room, Resident #1's window was not open, and the room was clean. The Unit Manager further stated she was not able to see the maggots initially. She stated the surrounding skin was not red and the area was not swollen. The Unit Manager recalled there was no dressing covering the feeding tube site at that time, and the nurses would not have been able to see the maggots when flushing the tube or when giving Resident #1 her feeding tube formula. She stated when she lifted the disk protecting the feeding tube site, she saw approximately 20 maggots in the site. The Unit Manager indicated the ADON washed the area with normal saline and removed the maggots from the site. She said Resident #1's vital signs were within normal limits, and Resident #1 did not appear to be in any distress. In a phone interview on 6/27/25 at 4:42 PM, the ADON stated she and the Unit Manager were in their afternoon meeting when Nurse #1 came in and reported seeing maggots in Resident #1's feeding tube site. She stated when they arrived in the room, she did not see any flies in the room, the room had been cleaned. The ADON recalled she was not able to see the maggots until she moved the disk covering the site and the maggots were not visible unless the edge of the disk was folded to provide site care. She stated she flushed and cleaned the site with normal saline and removed approximately 20 maggots. The ADON did not remember seeing any more maggots in the site when Resident #1 left for the hospital. She indicated Resident #1's feeding tube was not leaking, was not cracked, and she was able to flush the tubing without difficulty. The ADON Resident #1 did not appear to be in any distress and her vital signs were normal. She stated when the managers spoke with other staff members who had worked, no one remembered seeing any signs of maggots. Resident #1's hospital records included an Emergency Department (ED) Physician Note dated 6/18/25 and written by the ED Physician noted Resident #1 was sent to the hospital due to a feeding tube malfunction. When she was examined in the ED Triage department, her blood pressure was 84/50 (normal blood pressure was approximately 120/80) and she was noted to be grimacing. The physician noted Resident #1 was sent from the facility when they found maggots in and around her feeding tube. The Physician noted her feeding tube was in place, had multiple visible maggots around the wound, and had surrounding skin excoriation (raw, irritated, and sometimes bleeding patches on the skin) or erythema (any abnormal redness of the skin caused by dilation and irritation of the superficial capillaries). The ED Physician also noted the feeding tube itself appeared old and soiled. Laboratory tests completed on 6/18/25 in the ED and reported to the provider on 6/20/25 noted two blood cultures were drawn and both were positive for the bacteria Staphylococcus aureus and proteus mirabillis. The hospital History and Physical dated 6/18/25 noted Resident #1's feeding tube was found to be derelict with maggots surrounding the stoma site in the ED. A computed tomography (CT) scan done 6/18/25 in the hospital noted there was soft tissue thickening along the cutaneous (skin) surface and the soft tissues on the left upper area of her abdominal wall immediately adjacent to the tubing indicated cellulitis of the surrounding tissue needed to be considered. Resident #1's hospital Discharge summary dated [DATE] noted she was diagnosed with sepsis, acute hypoxia due to abdominal wall cellulitis, a catheter-associated urinary tract infection (UTI), cellulitis of the abdominal wall, and bacteremia. She was treated with the antibiotics Vancomycin, Zosyn, and intravenous (IV) Ancef while in the hospital with orders to continue the Ancef upon return to the facility until 7/04/25. In a phone interview on 6/27/25 at 5:18 PM, the ED Physician stated she remembered Resident #1's skin surrounding the feeding tube was indurated (hardened) and excoriated. She said when she examined Resident #1, nurses had already removed 2 maggots from the site and there were approximately 3 more in the site remaining on the skin in the site. The ED Physician recalled the feeding tubing itself was discolored and non-transparent, which was an indicator that the tubing had not been replaced for a long time. In an interview on 6/27/25 at 5:15 PM, the Director of Nursing (DON) stated the facility immediately responded to Nurse #1 reporting the maggots in Resident #1's feeding tubing site. She stated all other residents with feeding tubes and/or with any wounds were examined and no other resident was found to have maggots. The DON further stated maggots can appear quickly, within 8-12 hours, and the nurses on the previous shifts had not observed any. She stated Resident #1's vital signs, pain assessments, and nursing observations did not indicate she had any acute concerns. The DON indicated the feeding tube breaking in May was not an emergency since the nurses could flush, infuse the formula, and care for the feeding tube site. In a phone interview on 6/27/25 at 1:01 PM, the Medical Director stated the NP told him about a gastroenterologist appointment to replace the feeding tube but because she was at the facility, she responded to the situation appropriately while she was there. The Medical Director stated he was made aware (date not recalled) that Resident #1 was found with maggots in her feeding tube site. He stated he had examined Resident #1 the week preceding 6/18/25 and her feeding tube appeared old but there were no signs of maggots or of any dying tissue in the feeding tube site, which was what maggots would feed on. He further stated he could not find a cause for the maggots. The Medical Director explained that the maggots could have infested the area quickly, within 8-12 hours, so the day shift the previous day would not have observed any maggots. He stated the normal life expectancy for the tubing was approximately 6 to 12 months depending on how long a resident had the feeding tube in place. The Medical Director stated he believed the tubing had been changed in October 2023, so approximately 18 months was longer than the normal life expectancy of the tubing, but if the tubing was functioning, it was not cracked, and was not leaking, not having the tubing replaced since 2023 was not a concern. He further stated the NP told him about a gastroenterology consultation and he agreed with her that it was appropriate for Resident #1. The Administrator was notified of Immediate Jeopardy on 7/11/25 at 2:53 PM. The facility provided the following corrective action plan with a compliance date of 6/20/25. 1. Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice. On 5/12/2025 Provider was notified by nurse that feeding tube site was noted to have crusting, missing several inches and may need to be changed. Per Providers note on 5/12/2025 feeding tube site was noted to have hyper granulation with some evidence of fungal infection and no erythema or purulent drainage. The provider ordered antifungal cream 2 times a day for 10 days and placed a non-emergent GI consultation to further assess the tube and make evaluations for any future routine changes if needed. The feeding tube was still patent and infusing well. On June 18, 2025, a resident was noted to have maggots in her g-tube during wound care and medication administration. Upon observations of the feeding site on 6/18/2025, it was noted to have leaking around the site; the feeding tube was noted to have broken off several inches and the feeding tube was discolored and brittle. The area was cleaned thoroughly using normal saline and a new peg tube split sponge was applied and secured. The resident also was being treated for a sacral wound, and the facility staff nurse turned her over and visualized and cleaned the sacral wound. No evidence of maggots was found in the sacral wound at that time. The nurse practitioner was notified of the findings, and an order was received to send the resident to the hospital for further evaluation. Facility maintenance assistant performed deep cleaning of the room and pest control service. The facility observed no flies in the facility and no flies were noted in this resident's room. The facility purchased fly swatters and Professional Pest Control Company performed pest control in facility on 6-19-2025. The kitchen door has a blower, which is functioning, and all other doors were observed to be closed securely. The resident was admitted to the hospital with sepsis, gastrostomy tube dysfunction, cellulitis of the abdominal wall, and bacteremia but has since returned to the facility. The hospital replaced the feeding tube and started resident on antibiotics for cellulitis of the abdominal wall and bacteremia. On 6-25-2025 after the resident readmitted from the hospital to the facility, an order was obtained to clean the feeding tube site and change the dressing two times per day. Nurses will inform the Provider of any signs and symptoms of infection, leaking, malfunctioning, or brittleness of the feeding tube. 2. Address how the facility will identify other residents having the potential to be affected by the same deficient practice.All residents have the potential to be affected by deficient practice. On 6/18/25, Assistant Director of nursing and Unit manager audited all residents that have peg tubes and wounds were evaluated to ensure no other residents had evidence of maggots in their wounds. No other residents had maggots or pests in their wounds or peg tubes. On 6/18/2025 the ADON/Designee audited all residents with feeding tubes to assess the integrity of the tube, any leaking, draining, or signs and symptoms of infection around the feeding tube site. No areas of concern were identified. The Assistant Director of Nursing audited all residents' rooms who have feeding tubes and Central Supply to ensure the formula is stored appropriately and no formula was on the floor. No areas of concern were identified. The ADON audited resident rooms who have feeding tubes to ensure the pole was clean and syringes were cleaned and stored appropriately. In addition, pest control services were notified to treat and evaluate any concerns with flies in the facility. They performed pest control services on 6/19/25. No pest issues were noted by the pest control contractor when services were performed. The maintenance assistant inspected 100% of the entire building to ensure there were no issues with pests. No negative findings. 3. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur. Director of nursing/designee performed competencies on G-Tube management and educated on skin care of feeding tube site to include assessing for erythema, edema, drainage, quantity, odor, patency and integrity of tube and or appearance and to inform Provider of any concerns for f/u related to with 100% licensed nursing staff to include changing assessing site and that tube is patent, dressing changes, monitoring for s/s of infection. Completed 06/18/25. The DON/Designee educated all current certified nursing assistants to notify the nurse of any drainage, odor or abnormality of the feeding tube or site observed during care and to keep open wounds and feeding tube sites covered during care. Completed 6/18/2025 The DON/Designee educated all nursing staff on ensuring any open wounds, surgical sites and feeding tube sites need to be always covered to prevent attracting flies. Completed 6/18/2025.The Administrator educated all staff on ensuring doors are securely closed and not to leave doors open for any reason. Completed 6/18/2025. The administrator educated the Maintenance Director on monitoring the blower over the kitchen door functioning properly weekly. This education was completed on 6/18/2025. Administrator/designee educated 100% of all other departments on how to report pest control concerns/issues. Training included how to report pest sightings and timeliness of reporting. Completed on 06/18/25. Administrator/designee educated all housekeeping employees to ensure feeding tube poles were clean and floors in resident's rooms with feedings were free from formula on the floor and to clean up any area identified immediately. Completed 6/18/2025. The facility purchased fly swatters for each unit in the facility on 6/18/2025. Administrator/designee educated all staff that fly swatters are available on each unit and they are expected to eliminate flies when they are observed and promptly notify maintenance for pest control follow up. Completed 6/18/2025. Director of nursing/designee educated all employees that were not scheduled to work via phone. Completed on 06/18/25. Director of nursing/designee educated 100% staff to keep entrance doors securely shut, to empty soiled linen and trash barrels promptly. Completed 06/18/25. Director of nursing/designee will complete education to employees that are on vacation prior to returning to work. Director of nursing/designee will educate all new hire employees during on boarding/orientation. 4. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained.Include dates when corrective action will be completed. The Administrator and Director of Nursing discussed the Resident #1 incident regarding feeding tube on 6/18/2025 and determined to have ADHOC Quality Assurance Process Improvement (QAPI) meeting. ADHOC QAPI was held on 6/19/2025 with the Interdisciplinary team to discuss the incident with Resident #1 and educate the team on the interventions that were put into place to prevent further incidents. The Medical Director Designee was notified by the Administrator via phone on 6/18/2025 regarding Resident #1's feeding tube incident and what interventions that were put in place for Resident #1 and the plan of correction to prevent abuse. The Director of Nursing implemented the plan of correction to prevent abuse on 6/19/2025. The Interdisciplinary team will review and provide recommendations on the audit results provided by the Director of Nursing and Designee during the QAPI meeting for the next 3 months to ensure sustained compliance. If noncompliance is identified during these three months, immediate correction, reeducation of staff members and an ADHOC QAPI meeting will be held to address the noncompliance and make recommendations for adjustments to the plan. The Administrator and Director of Nursing will ensure the corrective action plan is implemented. Director of Nursing/designee will complete audits of 5 resident rooms 5 times a week x12 weeks to ensure no pest sightings. This audit will include observations of wounds, surgical sites, lacerations and peg tubes to include ensuring the integrity of the tube is not compromised and the site has no signs/symptoms of infection, leakage, discoloration or brittleness and to ensure free of maggots. The Director of Nursing/Designee will audit rooms formula is stored and resident's rooms with feeding tubes to ensure formula is stored appropriately, poles and floor are clean, and syringes are cleaned and stored appropriately 5 times per week X 12 weeks. Director of nursing/designee will audit nursing units daily to ensure trash/linen barrels are emptied promptly 5 times a week x12 weeks. Administrator/designee will audit two common areas 3 times a week for 12 weeks to ensure doors are closed securely and no pest sightings. The results of the audit will be reported monthly in QAPI x 3 months by the Director of Nursing. Alleged date of IJ removal: 6/20/25 On 7/16/25, the facility's corrective action plan was validated. Resident #1 was observed to be in a semi-private room and was free of any maggots. During the tour of the facility residents were observed to be assisted in and out of the front door, and fly swatters were present throughout the facility. Staff interviews confirmed education was received and included information on G-tube care; including proper care and maintenance, verifying tube feedings are running as ordered, tubes are flushed and patent, and G-tube sites are cleaned with appropriate dressing applied per order. NAs should notify nurses of any abnormalities such as leakage, discoloration, and/or odor. Ensure proper skin care and assessment of feeding tube sites, including monitoring for redness, edema, drainage (quantity & odor),[TRUNCATED]

Based on record review, and staff and resident interviews, the facility failed to protect a resident's right to be free from abuse for 1 of 1 resident reviewed for abuse (Resident #2). Resident #2's cognitively intact roommate (Resident #3) stated on 10/3/24 he was in the room while the curtain was pulled and he heard Nurse Aide (NA) #1 and Resident #2 fussing back and forth. NA #1 told Resident #2 you're not going to keep hitting me followed by an audible smack. After the incident, Resident #2 was identified by staff with a bright red hand mark on her right hip/thigh, she appeared agitated, and stated to NA #3 she hurt me. Resident #2 did not have the cognitive capacity to express an adverse psychosocial outcome. A reasonable person would experience fear and intimidation from being abused in their home environment. The findings included: Resident #2 was admitted to the facility on [DATE] with a diagnosis of Alzheimer's dementia. Review of the care plan that was revised on 08/22/24 revealed Resident #2 had diagnoses of Alzheimer's, and she was alert with confusion and had behaviors. Behaviors included sadness, crying, resistance to redirection, physical aggression, verbal aggression, smacking lips, clicking tongue and jaws on occasion. The goal was to prevent injuries. The interventions in part, were to approach Resident #2 in a calm, unhurried manner, if able to remove her from a high stimulation area to reduce agitation. When agitated intervene before agitation escalated, guide away from source of distress, engage calmly in conversation, if response was aggressive, walk away calmly and approach later. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #2 was severely cognitively impaired and had no behavior during the assessment period. She required staff assistance with all activities of daily living (ADL). Record review of the progress note written by Nurse #1 on 10/4/24 at 10:00AM revealed Nurse Assistant (NA #1) removed Resident #2 to her room because she kept removing her clothes in the hallway. She placed her in bed. NA# 2 and #3 went in to change clothes and brief and within the minute reported to Nurse #2 to come and look at Resident #2. Resident #2 was lying in bed on her left side with her brief opened, there was a bright red handprint on her right buttock. NA #2 and NA #3 called Scheduler and reported the event. Nurse #1 was not available for interview. An interview with NA #1 via telephone on 10/15/24 at 3:15 PM indicated she was sitting at the desk doing charting and Resident #2 and Resident #4 were sitting in their wheelchairs beside one another in the hallway. Resident #4 stated that Resident #2 was taking her shirt off. NA #1 stated she came around the desk and put Resident #2's arms back in her shirt and went back to charting. A few minutes later Resident #4 said Resident #2 was taking off her shirt again. NA #1 indicated she told Resident #2, Ah honey, you can't sit out here without your shirt on. NA #1 reported she attempted to redress Resident #2 in the hall the second time, and then took her to her room and put her to bed. NA #1 indicated Resident #2 was fussing when NA #1 took her to her room and had never been physically aggressive towards her. Resident #2 was fussing and cussing a little bit and that was normal for her. Resident #2 was no longer fussing when we entered her room, and she was assisted to bed by standing and pivoting. NA #1 reported Resident #2 did not try to hit her and she left Resident #2 lying in her bed with her day clothes on and she returned to the desk and finished charting. NA#1 explained a few minutes later NA #3 was looking for Resident #2 and NA #1 told her that she was in bed. NA #3 came out of the room and went back into the room with NA #2. About 15 mins later Nurse #3 told her to go home, because there was a handprint on Resident #2 and there was an investigation. NA #1 stated she did not smack or abuse Resident #2. She stated she had put Resident #2 in her bed, and they were not fussing with one another. Review of quarterly MDS dated [DATE] revealed Resident #4 was cognitively intact. An interview was conducted with Resident #4 on 10/16/24 at 10:35 AM and he denied any abuse to him personally since his admission. He reported that on the evening of 10/3/24 he and Resident #2 were sitting next to one another in their wheelchairs on the hall. Resident #2 removed her arms from her shirt. He notified Nurse Aide (NA) 1, who was sitting at the desk charting. NA #1 came over and put Resident #2's shirt back on and told her, No one wants to see your sick puppies, leave your shirt on or you are going to have to go to your room. A few minutes later, Resident #2 began to remove her shirt again. He notified NA #1 and this time she came over and bent Resident #2's arm behind her back, trying to put her arm back in her shirt. Resident #2 was yelling, You're hurting me, stop it. NA #1 let Resident #2 go, grabbed her wheelchair, spun it around and pushed her down the hall to her room and shut the door. Review of the MDS dated [DATE] revealed Resident #3 (Resident #2's roommate) was cognitively intact. An interview was conducted on 10/16/24 at 10:37 AM. On the evening of 10/3/24 she stated she was in her bed and saw NA #1 enter the room with Resident #2. They were fussing back and forth. NA #1 pulled the curtain between the beds. NA#1 said, You're not going to keep hitting me and then she heard a smack and Resident #2 stopped fussing and NA #1 left the room. Resident #3 reported that a few minutes later, NA # 3 came into the room, but went back out very quickly. An interview with NA #3 on 10/16/24 at 09:30AM revealed she went into Resident #2's room on 10/3/24 around 9:00 PM and Resident #2 was in bed in her day clothes. NA #3 removed Resident #2's pants and NA #3 observed a red handprint on Resident #2's right hip/thigh area. Resident #2 was not able to tell NA #3 what happened. NA #3 reported Resident #2 was agitated and stated She hurt me but was not able to say who hurt her. NA #3 indicated she immediately left the room and reported the incident to Nurse #1. She then telephoned and reported the incident to the Scheduler and Nurse #2. NA#3 returned to Resident #2's room and finished providing care. Resident #2 was not crying or upset when NA #3 returned to the room. NA #3 had never observed NA #1 be aggressive towards Resident #2 or any other resident. NA #3 reported working with Resident #2 regularly and there was no change in Resident #2's behavior or demeanor. Resident #2 was back to her baseline within an hour of the incident and had remained since. NA #2 was not available for interview. Interview with Scheduler 10/16/24 at 9:34 AM indicated on 10/3/24 at 9:30 PM, NA #3 reported by telephone she saw a red handprint on Resident #2's right hip. NA #3 reported that she had told Nurse #1 and Nurse #2. The Scheduler stated she telephoned the facility and spoke to Nurse #2, and she asked her to assess the situation and to ask NA #1 to clock out and leave the premises. The Scheduler explained, she and the Unit Manager came to the facility, arriving around 10:00 PM. The Scheduler stated, Resident #2 was asleep in her bed and had reddened lines pointing downward, on the right hip at the brief line. The Scheduler called the police department to make the report of the abuse incident. The scheduler reported she had never seen any instances of abuse or suspected abuse from NA #1 or any of their current staff. Interview with Nurse #2 on 10/15/24 at 8:20PM revealed on 10/3/24 around 9:10 PM the Scheduler had called and asked her and Nurse #1 to escort NA #1 out of the building, immediately. Once NA #1 had left, Nurse #2 assessed Resident #2 for injury. Nurse #2 stated Resident #2 was lying in bed with her baby doll, she was calm and was not agitated. Resident #2 agreed for Nurse #2 to look at her legs and a red handprint was found on her right hip at the brief line. Resident #2 was unable to tell Nurse #2 what happened. Nurse #2 indicated Resident #3 was alert and oriented and stated she heard Resident #2 and the NA #1 fussing. Resident #3 was in the room, in her bed and the curtain was pulled between the resident's beds. NA #1 told Resident #1 she was not going to hit her (NA #1) and then Resident #3 heard what sounded like a smack. The Scheduler and the Unit Manager had already been made aware of the incident and they both came to the building the night of the incident. The Administrator was also made aware. Nurse #2 reported she has never witnessed or been made aware of NA #1 having abused any resident. Review of Administrators' note written on 10/04/24 at 10:00 AM indicated in part, on 10/03/24 Unit Manager (UM) was notified of the abuse of Resident #2. The Police and Adult Protective Services (APS) were notified. NA #1 was immediately escorted out of the building. The resident was not fearful and was sleeping when UM checked on her. Record review of UM note dated 10/04/24 indicated in part, an Interdisciplinary Team meeting was held, and Resident #2 was discussed, and skin evaluated. Resident #2 had no pain and no redness or bruise to skin. Resident #2 did not exhibit distress and was baseline alert with confusion. Record review of Social Worker note dated 10/07/24 indicated Resident #2 had no changes in mood or behavior. Interview with the Social Worker on 10/16/24 at 9:28 AM indicated she was made aware of the abuse incident involving Resident #2 on 10/03/24 around 9:30 PM by the Scheduler. She came to the facility the night of the incident and witnessed a red mark and what she thought looked like fingers pointing down on the right hip of Resident #2. NA #1 had already been removed from the building. She stated she called Adult Protective Services (APS) at 9:52 PM on 10/03/24 and left a message on voicemail system. APS returned her call at 9:58 PM, the same night. The Social Worker reported Resident #2 was asleep in her bed when she observed the red mark. The interview with the Unit Manager (UM) on 10/16/24 at 9:51 AM revealed Resident #2 had a history of being combative towards staff, mostly during ADL care and she did take her arms out of her shirt on occasion. On 10/03/24 around 9:30 PM, the Scheduler called to report a handprint that had been found on the right hip of Resident #2 and NA #1 was the last person to provide care before NA #3 discovered the handprint. The UM reported that the Scheduler had asked Nurse #2 to remove NA #1 from the building. The UM stated she assessed Resident #2 on 10/03/24 around 10:00 PM and observed a red mark, in the shape of a hand and fingers on her right hip. Resident and staff interviews were conducted that night, and it was concluded that NA #1 was the accused. The Unit Manager reported she had not seen any instances of abuse by NA#1 in the past. An interview on 10/16/24 at 3:00PM with the Administrator revealed she reviewed the camera footage, from the night of the incident. The footage revealed Resident #2 and Resident #4 were sitting in the hall in their wheelchairs near the nursing station. Resident #2 began to remove her shirt. NA #1 got up and came around the desk and put Resident #2's shirt back on. Resident #2 took her shirt back off a second time, at this time NA #1 took Resident #2 to her room. The footage did not show NA #1 acting in an aggressive manner toward Resident #2. The camera footage then showed NA #3 coming to the desk and speaking with NA #1, and then heading to Resident #2's room. Administrator reported she interviewed NA #1 on Monday 10/5/24 and NA #1 stated, Resident #2 didn't hit me and I didn't hit her. The Administrator stated that the video of the incident in the hall was no longer available but when she had viewed the video and observed NA #1's attempt to redress Resident # 2 it did not look aggressive and when NA #1 turned Resident #2 in the wheelchair to go to the room it was not aggressive. The Administrator reported that interviews with staff and residents and observation of Resident #2 did reveal abuse by NA #1. Observation of Resident #2 immediately after the incident and for three days following that showed the red mark on her hip had disappeared and she was at baseline. The facility provided the following corrective action plan with a compliance date of 10/07/24. This will serve as our plan of abatement for [NAME] Health and Rehab related to: allegation of Abuse Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice. On 10/03/2024 After notification from facility and CNA #1 immediate removal from facility, Director of Nursing/Designee initiated investigation. Resident #2 provided a safe and comfortable environment. No signs/symptoms of withdrawal. No change in baseline psychosocial wellbeing. Head to toe assessment completed with -no other areas identified. Resident #2 denied pain. Statements obtained from staff and resident's roommate (Resident #3) as she witnessed the event. The roommate was alert and oriented with a reliable history. Police and (Adult Protective Services) APS notified us of the event. 10/04/2024- NC- CNA registry notified of event. NA #1 remained suspended and taken off schedule for duration of investigation. NA #l 1terminated on 10/08/2024. On 10/03/2024-10/04/24- Director of Nursing/Designee provided incapable affected residents with skin assessments to identify any new skin areas and to assess for psychosocial well-being. No negative findings. On 10-03/2024-10/04/2024- Director/Designee provided capable residents interviews for any concerns with abuse or concerns with care provided. No negative finding Address how the facility will identify other residents having the potential to be affected by the same deficient practice. To identify other residents that have the potential to be affected the Director of Nursing/designee interviewed 100% capable residents to ensure there were no concerns with abuse or care provided by staff by using questionnaire related to feeling safe in the facility and any concerns with care. No negative findings. Completed on 10/04/2024 To identify other residents that have the potential to be affected the Don/designee completed skin assessments on 100% incapable residents and to ensure no concerns with care provided. No signs/symptoms of withdrawal or change in behavior noted. Completed 10/04/2024. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur. To prevent this from happening again the NHA/designee will educate 100% current staff on the abuse/neglect policy and procedure and providing quality of care and services to Dementia residents-to include combative residents and staff responsibilities when caring for these residents, completed 10/04/2024. New hires were educated during on-boarding and Agency staff will be educated before taking shift on Abuse Policy and Providing Care for Dementia Residents. An Ad Hoc was held on 10-07-2024 with the facility medical director to review the event and the QAPI plan. Completed 10/07/2024. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained. To monitor and maintain compliance with psychosocial well-being and/or concerns with care by using questionnaire with questions related to concerns with care, who to report concerns to, and do they feel safe in the facility and safe to voice such concerns. Any deficits will be immediately addressed. The complete date for audits will be 12/22/2024. Results will be taken to QAPI for review and revision as needed. To monitor and maintain ongoing compliance the Director of Nursing/Designee will audit five incapable resident's weekly x's 12 weeks to assess for any signs/symptoms of withdrawal or abrupt change in baseline behavior. The complete date for audits will be 12/22/2024. Results will be taken to QAPI for review and revision as needed. To monitor and maintain compliance the NHA/Designee will assign 100% resident rooms to the Interdisciplinary Team to observe residents assigned to those rooms for signs of withdrawal or change in baseline behavior 5x's a week x's 12 weeks. The completed date for audits will be 12/22/2204. Results will be taken to QAPI for review and revision as needed. To monitor and maintain ongoing compliance the NHA/designee will interview five staff members weekly x's twelve weeks on abuse/neglect using questionnaire on types of abuse, when and who to report abuse to, first step to take if suspected and/or actual abuse witnessed and caring for dementia/combative behavior. Any deficits will be immediately addressed. The completed date will be 12/22/24.Results will be taken to QAP for review and revision as needed. Alleged date of compliance 10-07-2024. The corrective action plan was validated on 10/16/2024 by reviewing the abuse investigation, and resident and staff statements. The residents' skin assessments and the evidence of education provided to the staff was reviewed. The resident psychosocial audits were reviewed. Adult Protective Services and the Police were contacted. Staff were interviewed and they confirmed that they received education on abuse and reporting. The facility had conducted an AD Hoc QA meeting on 10/7/24. The facility provided an ongoing monitoring tool. The correction date was 10/7/24.

Based on record review and staff interviews the facility failed to provide care in a safe manner which resulted in a resident (Resident #21) falling from the bed. One of two falls from bed resulted in Resident #21 being sent to the emergency department for a laceration to her forehead that required 5 stitches. This was for 1 of 5 residents reviewed for accidents. The findings include: 1. Resident #21 was originally admitted to the facility on [DATE] with diagnoses that included cellulitis of right and left lower limbs, morbid obesity, and anxiety. Record review revealed Resident #21 had a closed care plan initiated on 09/11/23, last reviewed 02/29/24, and closed on 03/11/24, that included a focus that Resident #21 was at risk for falls characterized by history of falls, injury and/or multiple risk factors. The interventions included for staff to implement preventative fall interventions/devices and to educate resident/family regarding preventative fall interventions/safety devices as appropriate. An intervention was added on 09/27/23 for staff to encourage and assist Resident #21 to toilet after meals. The care plan also included a focus that read that Resident #21 had activities of daily living (ADL)/selfcare deficit related to impaired mobility. The interventions included Resident #21 required assistance of 1 staff member for bed mobility and toileting. Review of the quarterly Minimum Data Set (MDS) dated [DATE] indicated Resident #21 was cognitively intact. She had range of motion (ROM) limitations to both sides of her lower extremities. She required set-up/clean-up assistance with personal hygiene, moderate assistance with bed mobility, and maximum assistance with toileting hygiene and transfers. She was frequently incontinent of bowel and bladder. a. Review of incident report completed by the Wound Care Nurse, dated 09/26/23, revealed Resident #21 fell from the bed when Nursing Assistant (NA) #2 rolled her to her side while providing incontinence care. Resident #21 rolled off the bed and was noted face down on her abdomen. A small laceration was noted to Resident #21's forehead and a cut on her bottom lip. Under the notes section it stated the fall was reviewed by the interdisciplinary team (IDT) and a new intervention was added to the care plan for staff to encourage Resident #21 to toilet after meals. Nursing notes revealed a note dated 09/26/23 written by the Wound Care Nurse indicating Resident #21's family/responsible party (RP) and the Physician were notified of the occurrence, and Resident #21 was sent to the emergency department for a laceration to her forehead. emergency room notes dated 09/26/23 revealed Resident #21 received 5 sutures to her forehead. A computerized tomography (CT) scan of the head and spine was negative for fracture or intracranial hemorrhage. No other treatments were rendered. An interview with Resident #21 was conducted on 07/21/24 at 2:43 PM. She stated she remembers the fall on 09/26/23. She then stated when Nursing Assistant (NA) #2 was going to provide incontinence care and she rolled her onto her side, she rolled her too far causing her to fall from the bed onto the floor. She explained she landed on her abdomen and that she hit her head and face on the floor. She further explained that she was sent to the emergency department and had to get 5 stitches to her forehead. She also explained that the bed she was utilizing at the time was a regular sized bed and she was a big woman. She stated she did not have room on the bed to lay her arms down beside her body. She stated she got a bigger bed on 07/15/24 and she's glad the staff talked her into it because she was hesitant about it before due to being embarrassed about her weight. Resident #21 could not recall if a larger bed had been offered to her or if one had been offered and she refused it. An interview with the Nurse Manager was conducted on 07/24/24 at 2:35 PM. She stated Resident #21 fell from the bed when Nursing Assistant #2 rolled her to her side. She verified that Resident #21 would have benefitted from a bariatric bed due to her weight and height, however she did not have one at the facility until last week. She also stated she could have ordered one, however she doesn't know why but she did not do so. She further stated Resident #21's bed was switched out to a bariatric bed last week. She indicated she added an intervention for staff to toilet her after meals it would decrease the number of times staff would have to change her in the bed. A phone interview with Nursing Assistant #2 was conducted on 07/24/24 at 6:38 PM. NA #2 verified she was assigned Resident #21 on 09/26/23. She stated she was getting ready to provide incontinence care and when she turned her onto her right side, she rolled off the bed onto the floor. She further stated Resident #21 was laying on her side, holding onto the side of the bed frame to prevent herself from rolling off the bed. Resident #21 could not hold herself up and rolled off the edge of the bed onto the floor. She immediately yelled for assistance and other staff members came in to assist. She had a laceration of her head and was sent to the emergency department (ER) for stitches and to be evaluated. She stated at the time she was in a regular sized bed however she needed to be in a bigger bed. She verified Resident #21 did not have much room on each side of her body and the edge of the bed. An interview with the Wound Care Nurse was conducted on 07/25/24 at 11:54 AM. She verified she was Resident #21's nurse on 09/26/23 when the fall from bed occurred. She indicated she fell due to not having enough room in her bed to safely turn her due to her height and weight. She stated she did notify the Nurse Manager and physician at the time of the fall. b. Review of incident report completed by Nurse #4, dated 12/18/23, revealed Nursing Assistant (NA) #3 was providing care to Resident #21. When NA #3 turned Resident #21 onto her side she fell out of the bed onto the floor on her stomach. Resident was alert and oriented and stated, I rolled out of the bed while I was being changed. Resident #21 was noted with an abrasion to the right knee and bruising to her right elbow. Under the notes section it stated the fall was reviewed by the interdisciplinary team (IDT) and a new intervention was added to the care plan for 2 staff members to assist with activities of daily living (ADLs) and transfers. An interview with Resident #21 was conducted on 07/21/24 at 2:43 PM. She verified she remembered the fall on 12/18/23. She stated the same thing happened as it did on 09/26/23 but explained that this time she was holding onto the frame of the side of the bed however she could not hold herself any longer and fell . She indicated she only had minor injuries and did not require to go to the emergency department. She only had an abrasion to her right knee and her right elbow was bruised. She stated she got a bigger bed last Monday and she's glad the staff talked her into it because she was hesitant about it before due to being embarrassed about her weight. An interview with the Nurse Manager was conducted on 07/24/24 at 2:35 PM. She stated Resident #21 fell from the bed when Nursing Assistant #3 rolled her to her side. She verified that Resident #21 would have benefitted from a bariatric bed due to her weight and height, however she did not have one at the facility until last week. She also stated she could have ordered one, however she doesn't know why but she did not do so. She further stated Resident #21's bed was switched out to a bariatric bed last week. She indicated she added an intervention that required assistance of 2 staff members for bed mobility and toileting. Multiple unsuccessful attempts were made to contact Nursing Assistant #3. An interview with the Medical Director was conducted on 07/25/24 at 9:15 AM. He stated he had suggested Resident #21 get a larger bed on several occasions including her original admitted [DATE], however she refused the larger bed. An interview with the Administrator was conducted on 07/25/24 at 9:30 AM. She indicated all residents should be assessed for equipment, devices, and/or interventions to safely provide care.