Every finding on record at Edenwald

Based on a review of facility investigative material, medical records, and interviews with facility staff, it was determined that the facility failed to thoroughly investigate an allegation of physical abuse. This was evidenced by 1 (Resident #1) of two residents reviewed during a complaint survey. The findings include: On 08/20/25 the Office of Health Care Quality received a facility reported incident regarding an allegation a resident was a victim of physical abuse. Resident #1 was admitted to the facility on [DATE] with diagnoses that include but are not limited to dementia with aggression. Resident #1 had a BIMS score of 5/15 which indicates severe cognitive impairment. The BIMS (Brief Interview for Mental Status) score is a 0-15 point tool used in healthcare, particularly long-term care, to assess cognitive function, with higher scores indicating better cognition. It evaluates immediate recall, temporal orientation, and short-term memory. A score of 13-15 indicates intact cognition, 8-12 moderate impairment, and 0-7 severe impairment. A review of the facility investigation on 03/30/26 revealed that the facility became aware of an allegation of staff to resident physical abuse on 08/20/25 at 2:30 pm. The facility received the allegation of physical abuse from one of the construction company foremen completing renovations on the skilled nursing unit. The foreman stated that one of the construction staff witnessed a staff member hitting Resident #1 in the head sometime during the previous week. On 08/22/25, during the facility investigation, the construction company foreman sent an email to the facility regarding the allegation of staff to resident physical abuse. In the email, the construction foreman indicated elaborated on the construction staff's original statement. In the email, the construction staff reported that they had heard crying and pleas for help coming from Resident #1's room. As they approached the area, they claimed to have witnessed what appeared to be the staff member striking an elderly wheelchaired patient. The construction foreman indicated that they made a note of the incident and decided to keep an eye and an ear on any cries coming from that corridor. On 08/20/25 at approximately 2:225 pm, the construction foreman wrote in the email that they heard crying and pleas for help accompanied by noises resembling slapping coming from Resident #1's room. The construction foreman indicated in the email they felt strongly that someone in Resident #1's room was being assaulted during the times they heard crying and pleas for help. At 2:50 pm on 08/20/25, the construction foreman indicated they informed one of the facility staff members in the parking lot of what they heard and what was reported to them days earlier. In an interview with the facility director of nurses (DON) on 03/30/26 at 11:40 am, the DON indicated the alleged perpetrator was a private duty assistant (Staff#1) hired by Resident #1's family. The DON stated that the facility did not have any type of human recourse records for Staff#1 including abuse training, background checks, or licensing information for Staff #1. In a follow-up interview with he facility DON on 03/30/26 at 2:10 pm, the facility DON stated the facility investigation did not have separate facility conducted interviews with each of the construction staff.

Based on reviews of a facility investigation and record review, and staff interview, it was determined that the facility failed to implement an intervention, determined to be necessary, for a resident who was identified as a fall risk. This was evident of 1 (Resident #2) of 2 residents reviewed during a complaint survey. The findings include: On 07/23/25 the Office of Health Care Quality received a facility reported incident, #2569932, regarding an allegation of possible mistreatment. Resident #2 was identified with a fractured right femur (an injury of unknown source). Resident #2 was admitted to the facility on [DATE] with diagnoses that include but not limited to vascular dementia (Vascular dementia is a decline in thinking skills caused by conditions that block or reduce blood flow to the brain, robbing brain cells of oxygen), glaucoma (poor vision), and a history of bilateral knee replacements (Bilateral knee replacements involves replacing both knee joints, either simultaneously or in stages, for patients with severe arthritis to improve mobility). Resident #2 was deemed incapable of being able to make medical decisions by two physicians in November of 2022. Resident #2 is non-ambulatory and requires the use of a mechanical lift for all transfers in and out of bed. Resident #2 is also dependent upon the nursing staff for all activities of daily living. A review Resident #2 medical record on 03/30/26 revealed a physician's order, dated 03/08/2024, instructing the nursing staff to use a Hoyer (mechanical lift) lift for all transfers. A review of Resident #2's fall prevention/ADL care plans on 03/30/26 revealed a nursing intervention, dated 07/31/24 indicating the nursing staff are to use a Hoyer (mechanical lift) lift for all transfers. A review of the facility investigation on 03/30/26 revealed that the facility became aware of an injury of unknown source on 07/11/25 at 9:27 pm when Resident #2 was identified with a fractured right distal femur. Resident #2 was unable to inform the facility staff with any information or details as to when or how the fractured femur may have occurred. A review of the facility investigation on 03/30/26 revealed that the facility administrative staff viewed surveillance camera footage of the nursing units and in particular Resident #2 hallway footage. A review of GNA #1's employee warning notice, dated 07/14/25, the DON and unit manager interviewed GNA #1 about using a Hoyer lift and a second staff member with Resident #2's transfer on 07/07/25 during the 3-11 pm shift. Initially, the employee warning notice indicated, GNA #1 stated that they used a Hoyer lift with a second staff member on 07/07/25 during the 3-11 pm shift when transferring Resident #2. Then later, the employee warning notice indicated GNA #1 admitted to using only themselves when transferring Resident #2 on 07/07/25 during the 3-11 pm shift. In an interview with the facility director of nurses (DON) on 03/30/26 at 2:30 PM, the DON indicated that during the investigation into Resident #2's fracture femur, the administrative staff reviewed facility camera footage covering the entrance to Resident #2 rooms. The DON stated that the administrative staff viewed GNA#1 enter Resident #2's room, alone, with a Hoyer lift (mechanical lift) and after a period of time observed GNA #1 exit the room, alone, with the Hoyer lift. The DON stated that at not time did the administrative staff witness a second staff member entering the room to assist GNA #1 with Resident #2's transfer.

Based on reviews of 2 facility reported incidents, all pertinent facility documentation and staff interview, it was determined that the facility failed to report allegations of staff to resident abuse to local law enforcement. This was found to be evident for 2 (Resident #1 and Resident #2) of 2 residents reviewed during a complaint survey. The findings include: 1) On 08/20/25 the Office of Health Care Quality received a facility reported incident regarding an allegation that a resident was a victim of physical abuse. A review of the facility investigation on 03/30/26 revealed that the facility became aware of an allegation of staff to resident physical abuse on 08/20/25 at 2:30 pm. The facility received the allegation of physical abuse from one of the construction company foremen who was completing renovations on the skilled nursing unit. The foreman stated that one of the construction staff witnessed a staff member hitting Resident #1 in the head sometime during the previous week. Further review of the facility investigation revealed that on 08/22/25 at approximately 11:45 am pm, the construction foreman wrote in the email that they heard crying and pleas for help accompanied by noises resembling slapping coming from Resident #1's room on 08/20/25 at 2:25 pm. The construction foreman indicated in the email they felt strongly that someone in Resident #1's room was being assaulted during the times they heard crying and pleas for help. At 2:50 pm on 08/20/25, the construction foreman indicated they informed one of the facility staff members in the parking lot of what they heard and what was reported to them days earlier. 2) On 07/23/25 the Office of Health Care Quality received a facility reported incident, #2569932, regarding an allegation of possible mistreatment. Resident #2 was identified with a fractured right femur (an injury of unknown source). Resident #2 was admitted to the facility on [DATE] with diagnoses that include but not limited to vascular dementia (Vascular dementia is a decline in thinking skills caused by conditions that block or reduce blood flow to the brain, robbing brain cells of oxygen), glaucoma (poor vision), and a history of bilateral knee replacements (Bilateral knee replacements involves replacing both knee joints, either simultaneously or in stages, for patients with severe arthritis to improve mobility). Resident #2 was deemed incapable of being able to make medical decisions by two physicians in November of 2022.A review of the facility investigation on 03/30/26 revealed that the facility became aware of an injury of unknown source on 07/11/25 at 9:27 pm when Resident #2 was identified with a fractured right distal femur. Resident #2 was unable to inform the facility staff with any information or details as to when or how the fractured femur may have occurred. Further review of the facility investigation revealed that the local police had not been notified of an allegation of possible mistreatment/injury of unknown source. In an interview with the facility DON on 03/30/26 at 2:10 pm, the facility DON stated the facility did not report the allegation of abuse/mistreatment in either of the facility reported incidents #2595992 and #2569932 to the local police.

Based on observation and interview it was determined that the facility 1) failed to store, prepare, distribute and serve food in accordance with professional standards for food service and 2) failed to maintain food service equipment in a manner that ensures sanitary food service operations. This was evident during the recertification/complaint survey and has the potential to affect all residents. The findings include: On 06/16/25 at 8:15 AM during the initial tour of the kitchen, an observation of the entrance of the kitchen revealed that there were no hair nets available at the entrance. When the surveyor asked for a hair net, Staff #14 had to go to the opposite side of the kitchen to obtain a hair net for the surveyor to wear. Upon entrance into the kitchen on 6/16/25 at 8:20 AM, Staff member #15 was observed handling lettuce by pouring it into a pan without any gloves on and was wearing a baseball cap with a long braid of hair not covered with a hair net. Staff member #16 was also observed wearing a baseball cap with hanging down braided hair to shoulders and not covered by a hair net. Staff member #14 was wearing a hat only with no hair net, and Staff member #12 entered the kitchen without applying a hair net. Observation of the refrigeration at 8:25 AM revealed a tuna salad in a steel 5x7 inch steel container dated 6/12 in a refrigerator. Approximately 50 mayonnaise, relish, and mustard in small 30 CC (Cubic Centimeter) containers with a clear lid with no dates of preparation were also observed. Further observations of a refrigerator labelled Grille and Desserts only revealed a 5x7 inch Steel containers of cherries dated 5/25, celery dated 6/10, lemons dated 6/11, and pudding dated 6/9. In the refrigerator for storage of food items was observed in steel containers, a crab cake mix dated 6/10, a large tray of grilled chicken dated 6/10, and 1 large tray of lettuce that had no date. The food items with dates were all expired. In a walk-in refrigerator there were 3 large trays of potatoes with no date and were not covered located on a 2-shelf pushcart. On a dry storage rack there were 45 large baking trays noted with black and brown substances on the edges. Hanging on the wall rack, there were 4 large/medium frying pans with visible rust like material inside the pans. In a large walk-in freezer the plastic flaps at the entrance were covered with frost material and broken ice at the left entrance of the freezer. Observation of the temperature reading above the freezer was noted to be -1 degrees. In the dry store area, 1 gallon of red-hot sauce and cattleman BBQ Sauce were observed with no date to indicate when opened. Further, in the dried food storage area there were 3 large bins labeled sugar, flour, and rice, no dates indicating when filled and various large cans of food items on rack with no expiration dates. On 6/16/25 at 2:02 PM review of the Temperature log dated 04/2025 of 31 days in the month of April revealed that on the 7th, 8th, 12th, 13th, 16th, 21st, 26th, and 30th were partially completed while the rest of the dates were incomplete. On 6/16/25 at 2:12 PM review of the dish machine and sanitizer log for April 2025 revealed that on 4/12, 4/13, 4/16, 4/21, 4/26, and 4/30 were completed while the rest of the days were not completed at all. A review of the March 2025 log had only 12 entries for the month and in May of 2025 there were 2 days on 5/1 and 5/12 that were not completed. On 6/16/2025 at 2:30 PM review of the walk-in Freezer temperature log for the month of April 2025 with a standard temperature range of 0-20 degrees documented temperatures for 4/4 to be -1, and 4/6 was -3. On 6/16/2025 at 9:10 AM in an interview with Staff #10 the Director of Culinary Services when asked regarding food storage and dating of food items he stated that food should be dated and is only good for three days. He was also made aware of the above findings, he stated that regarding the trays, the brown/black substance does not come off, he will have to get new trays, the frying pans need to be seasoned to remove the rusty material. He confirmed the temperature logs were not completed adequately; and verified staff should be wearing hair nets and gloves with handling of food items. On 6/17/2025 at 10:00 AM, the Director of Nursing (DON) was also made aware of the findings in the Kitchen.

Based on a review of beneficiary protection notification reviews, and staff interview, it was determined that the facility staff failed to ensure proper notification of discontinued Medicare coverage was provided to the resident or their responsible party (RP). This was evident for 2 (Residents #91 and #92) out of the 3 residents reviewed for Beneficiary Protection Notifications during the recertification/complaint survey. The findings include: A review of three Beneficiary Protection Notifications for Residents #90, #91, and #92 was conducted on 6/17/25 at 8:30 AM. The documents were handed to the Administrator. The Administrator returned the three documents on 6/17/25 at 1:42 PM. For Residents #91 and #92, facility staff reviewed part one of the review form that asked, Was an SNF ABN [Advance Beneficiary Notice], CMS-10055 provided to the resident and then checked the box that said, If NOT issued and should have been. The Administrator was interviewed on 6/17/25 at 1:44 PM. She said, the residents did not get an ABN because we were adjusting to the new regs.

Based on medical record review and interview with staff, it was determined that the facility failed to ensure the residents' medication regimen was free from unnecessary medication by increasing psychotropic medication dose without documentation in the record explaining the reason for an increased dose. This was evident for one (Resident # 29) of five residents selected for unnecessary medication regimen review during this recertification/complaint survey. The findings include: Psychotropic medications are drugs that influence brain activity related to mental processes and behavior. They are commonly used to treat conditions like depression, anxiety, psychosis, and bipolar disorder by altering the brain's chemical balance, thereby impacting mood, thinking, and behavior. During a review of Resident #29's medication regimen on 6/20/25, at 12:09 PM, it was revealed that the resident was prescribed Lorazepam (Ativan), which is used to treat anxiety disorders. A further review of the Lorazepam order history indicated the following: - Lorazepam 0.25 ml via sublingual route, twice daily (6 AM and 2 PM) for 14 days for anxiety: Started on 6/10/25, and discontinued on 6/13/25. - Lorazepam 0.25 ml via sublingual route, three times daily (6 AM, 2 PM, and 10 PM) for anxiety: Started on 6/13/25. - On 6/18/25, the Lorazepam sublingual order for anxiety was revised to 0.25 ml twice daily (6 AM and 2 PM), and the bedtime (HS) dose was increased from 0.25 ml to 0.5 ml. - Lorazepam 0.25 ml via sublingual route every 4 hours as needed for anxiety: Started on 6/06/25, and remains an active order. On 6/20/25, at 1:00 PM, the surveyor reviewed Resident #29's medical records for a Psychology evaluation. The review revealed that a CRNP-PMH (Certified Registered Nurse Practitioner in Psychiatric Mental Health) saw the resident on 6/10/25, suggesting a schedule for Lorazepam to manage anxiety/agitation. However, no further psychiatric evaluation documentation was found. Further review of Resident #29's progress notes revealed a nursing staff entry on 6/12/25, at 3:46 PM, documented as a late entry for 6/10. The note stated: [Attending physician's name] notified of psych CRNP recommendation to consider Lorazepam 0.25 ml solution three times a day (TID), but MD opted to have twice a day (BID) instead for now at 9 AM & 2 PM. Patient's daughter aware and in agreement. However, no additional documentation regarding the increase in dosage was recorded in the resident's medical records. During an interview with the Director of Nursing (DON) on 6/20/25, at 2:23 PM, she stated that Resident #29 was enrolled in hospice care on 6/06/25. She added, The Psychologist does not see hospice residents, but they evaluated this resident on 6/10/25 and recommended Lorazepam. On 6/10/25, the attending physician ordered Lorazepam twice a day. On 6/13/25, the Nurse Practitioner revised the order as three times a day, then the attending physician increased the bedtime dose. The surveyor requested any provider documentation regarding the increasing psychotropic medication. On 6/20/25, at 3:16 PM, the DON provided copies of provider visit notes dated 6/10/25, and 6/13/25. However, no further evaluation was documented regarding the psychotropic dose increase on 6/18/25. The surveyor informed the DON of this concern, which she validated.

Based on a review of facility investigative material, medical records, and interviews with facility staff, it was determined that the facility failed to thoroughly investigate an injury of unknown origin for a resident. This was evidenced by 1 (Resident #140) of two residents reviewed for injury of unknown origin during this recertification/complaint survey. The findings include: During an investigation of the facility's internal investigation for MD00189789, on 06/16/2025 at 12:31 PM, it was revealed that on 03/05/2023, a night shift (11 PM - 7 AM) Geriatric Nurse Aide (GNA) reported a reddened area on Resident #140's right side of the face. A review of Resident #140's medical records on 06/17/2025 at 8:05 AM, revealed a progress note written by nursing staff on 03/05/2023 at 7:41 AM stated, Resident was reported by caregiver to have some discoloration to his/her face. Resident noted to have some rash-like redness to the right half side of the face, resident has some blood on his/her ear. Resident also noted to have some purple discoloration to the corner of his/her right eye. Resident had a sitter with him/her in the room all night. No report of changes given, and the sitter did not report any changes to patient. AM nurse notified. Message sent to MD/RP. Further review of Resident #140's medical records revealed that the resident did not have a fall incident and/or change in condition prior to the discoloration noted on 03/05/2023. A review of the facility's investigation packet on 06/17/2025 at 8:10 AM, revealed that the facility obtained six written statements from nursing staff who cared for Resident #140 from 03/04/2023 to 03/05/2023, and two statements from Private Duty Aides (PDAs), including the one who worked the 03/04/2023 night shift (PDA #17). However, no statements were obtained from other residents. The review of statements revealed that the last care was provided to Resident #140 around midnight on 03/04/2023, by a GNA and PDA, with no facial markings noted at that time. Around 5:30 AM on 03/05/2023, a GNA assisted the PDA again with care and noted a reddened area/rash on the right side of Resident #140's face. The GNA reported the area to the nurse. PDA #17's statement, written on 03/05/2024 at 11:04 AM via email, read: My last night's shift with [Resident #140's name] went well, I haven't worked with him/her before and I don't know how he/she looks like, much less knowing if he/she has injuries. And [Resident #140's name] did not fall in my shift because my eyes were on him/her the whole time. However, a review of the facility's follow-up self-report, submitted on 03/10/2023, on 06/17/25 at 8:10 AM indicated that the resident's face initially presented as a reddened area, like a rash, but by the morning of 03/06/2023, the area had developed into more pronounced bruising and swelling. It was initially thought that due to the resident's history of skin cancer, the area might have been developing into cancerous lesions. The sitter reported no problems during the hours in question. Upon speaking to the agency owner, the sitter admitted to him that he (sitter) fell asleep on his shift. On 06/17/2025 at 8:26 AM, during an interview with the Director of Nursing (DON), Nursing Home Administrator (NHA), and unit manager (Staff #2), the surveyor inquired about the process for investigating injuries of unknown origin. They explained that they interview staff who worked the previous three days, nurses conduct assessments, and if the incident is related to staff, they also interview other residents. The surveyor requested clarification on when other resident interviews were performed. The DON and NHA clarified that if the facility found the injury was caused by residents' known reasons (e.g., a reported red eye where the resident had a history of rubbing their eye prior to the incident), other resident interviews were not required. Furthermore, during the interview, the surveyor asked about Resident #140's injury of unknown origin reported on 03/05/2023. The DON stated that the resident did not have any episodes like a fall or intentional hitting prior to the reported discoloration. She said, The resident had a PDA who was hired by their family, so it was considered as a witness. That's why we didn't do other residents' interviews. The surveyor requested an explanation of the PDA's role and responsibilities. The DON and NHA stated that since PDAs were hired by the agency and/or residents' families, they were not facility employees. They stayed with residents, helping with feeding and assisting with daily activities alongside facility staff. They also added that facility staff encouraged them not to close doors at night, but the facility could not control them. The surveyor asked how the facility investigated the reported case of Resident #140's discolored right eye area on 03/05/2023, involving PDA #17. The NHA answered that they interviewed PDA #17, who wrote a statement, and the agency owner was contacted. The surveyor brought to their attention the discrepancy between PDA #17's written statement (claiming his eyes were on Resident #140 all night) and the facility's follow-up self-report (showing PDA #17 fell asleep on duty). Staff #2 stated she communicated with the agency owner via phone and discovered the fact. The surveyor requested supportive documentation for this. On 06/18/2025 at 8:35 AM, the NHA provided copies of emails from the PDA's company. The email, concerning Resident #140's unknown injury on 03/05/2023, stated: It was reported that [Resident #140] had sustained some bruising overnight. The caregiver assigned to his overnight care admitted to falling asleep during the shift. As a result, we immediately removed this caregiver from the resident's care. The caregiver is also prohibited from providing overnight care to any of our clients moving forward. On 06/18/2025 at 1:38 PM, the DON confirmed that this printed email was written by the agency company today (06/18/2025). The facility had no documentation to support their further action and/or investigation regarding PDA #17. Additionally, the part of the email copy provided to the surveyor contained notes regarding PDA #17 falling asleep on the job and being prohibited from working any more overnights, dated 08/28/2023, which was more than five months after the incident was reported. During an interview with the NHA, DON, and the [NAME] President of the facility on 06/20/2025 around 3 PM, the surveyor shared concerns that Resident #140's reported discoloration around the right half of the face was not thoroughly investigated. They validated this concern.

Based on record review and staff interviews, it was determined that the facility failed to ensure a resident received medication according to the physician's order set parameters (a specific instruction given for administration of medication). This was evident for 1 (Resident #22) of 5 residents reviewed for unnecessary medications during the recertification/complaint survey. The findings include: On 06/17/2025 at 12:37 PM a review of resident #22's medical record revealed a physician's order dated 3/10/2025 for Midodrine 10 mg tablet three times a day (a medication used to treat orthostatic hypotension, caused by a sudden drop in blood pressure when standing up). The medication had parameters to hold if Systolic Blood Pressure (the top number in a blood pressure reading, representing the pressure in the arteries when the heart contracts and pumps blood out of the body) is above 130. Further review on 06/17/2025 at 2:02 PM of resident #22's Medication administration record (MAR) for the months of April, May, and June of 2025 revealed that Resident #22 received this medication on: 04/15/2025 at 5:00 PM, Blood Pressure (B/P) was documented as 133/58 04/16/2025 at 5:00 PM, B/P was documented as 136/61 04/18/2025 at 12:00 PM, B/P was documented as 143/57 04/19/2025 at 5:00 PM, B/P was documented as 131/69 05/08/2025 at 8:00 AM, B/P was documented as 149/69 05/13/2025 at 5:00 PM, B/P was documented as 132/62 05/21/2025 at 5:00 PM, B/P was documented as 144/65 06/05/2025 at 8:00 AM, B/P was documented as 140/70 06/07/2025 at 5:00 PM, B/P was documented as 136/86 In an interview on 6/18/2025 at 10:10 AM with Staff #11, a licensed practical nurse, she was asked the significance of the B/P parameters. She stated that, if the Systolic B/P was greater than 130, she would not give the medication because it might lead to a higher B/P which can cause a heart attack or stroke, a medical emergency that could lead to a lasting brain damage or injury. On 06/18/2025 at 1:38 PM the facility's Director of Nursing (DON) was made aware of the above concerns; she stated that she will look into it.

2. A review of Resident #27's clinical record revealed the resident was discharged twice to the hospital on 2/6/25 and 4/9/25. A review of the clinical record, including the electronic health record, failed to locate evidence that notification was sent to the ombudsman. The Administrator was asked to provide a list of residents whose discharge or transfer was forwarded to the ombudsman on 6/23/25. The list did not include Resident #27. The Administrator was interviewed on 6/23/25 at 1:34 PM. She was shown the provided list of transfers and discharges. This surveyor explained the need to inform the ombudsman when a resident is admitted to the hospital. She replied I understand. Those are the names I was provided as to who was discharged or transferred. Based on record review and interview, it was determined that the facility failed to notify the State Ombudsman in writing at least 30 days prior to the residents' discharge and failed to notify the State Ombudsman when a resident was admitted to the hospital. This is evident for 2 (Residents #39 and #27) of 23 residents records reviewed for appropriate discharge process during the recertification/complaint survey. Findings Included: 1. On 06/23/2025 at 09:39 AM a review of Resident #39's closed record revealed that the resident had a planned discharge on [DATE]; however, the documentation provided indicated that the written notification of Resident #39's discharge was sent via email on 06/17/2025. On 06/23/25 at 01:07 PM, in an interview with the Nursing Home Administrator (NHA), the NHA was notified that the ombudsman notification was not submitted in a timely manner. When asked, the NHA stated that they provide a written notification to the ombudsman monthly; however, the facility does not have a lot of discharges and therefore, the late notification was an oversight.

Based on medical record review and staff interview it was determined the facility staff failed to notify the resident/resident representative in writing of a transfer/discharge of a resident along with the reason for the transfer. This was evident for 3 (#155, #158, #2) of 3 residents reviewed for hospitalization . The findings include: 1) Review of the medical record for Resident #155 on 6/10/2022 at 10:50 AM revealed that the resident was transferred to the hospital on 4/7/2022 for [CONDITION(S)] (an absence of enough oxygen in the tissues to sustain bodily functions). There was no evidence in the record indicating that the facility staff notified the resident/resident's representative (RP) in writing of the reason for the transfer/discharge to the hospital On 6/16/22 at 9:42 AM in an interview with the Unit Manager, Licensed Practical Nurse (LPN # 20), she/he stated that Resident # 155 and family were notified on transfer about reason for the transfer to the hospital. However, there was no information on the chart indicating that the facility staff notified the resident and/or RP in writing of the reasons for the transfer/discharge to the hospital. 2) Review of the medical record for Resident #158 on 6/10/2022 at 11:30 AM revealed that on 5/20/2022 the resident was transferred to the hospital for respiratory issues / pneumonia. There was no evidence found in the medical record that written notification was made to the resident and /or the RP regarding the reason for the transfer and the location of the transfer. In an interview with the resident's representative on 6/13/2022 at 11:30 AM they stated that the facility staff notified them by phone when the resident was transferred to the hospital. In an interview on 6/16/2022 at 9:50 AM with the Unit Manager, Licensed Practical Nurse (LPN # 20), she/he stated that the Bed Hold notice was given on the phone and in writing to the RP. However, she/he could not say or provide any documentation to show that the facility notified the residents and/or the RP in writing of the reasons for the transfer/discharge to the hospital. 3) Review of Resident #2's electronic and paper medical record on 6/16/22 at 8:45 AM revealed the resident had a fall on 5/20/22 at approximately 2:30 PM. Review of the 5/20/22 10:25 PM nursing note revealed that a phone order was obtained to send the resident to the emergency room and the resident was sent to [NAME] hospital. Further review of Resident #2's medical record documentation revealed that the responsible party was called, however, there was no written documentation that the responsible party and/or resident was notified in writing of the hospital transfer. The unit manager (staff #20) was interviewed on 6/16/22 at 12:15 PM related to resident #2's facility-initiated transfer to the hospital on 5/20/22. She did not show, or voice credible evidence related to written notification to resident #2 of the resident's responsible party. At survey exit on 6/17/2022 at 2:45 PM, no further documentation had been provided to the surveyor. All findings were discussed with the Administrator, the DON, and the department heads during the survey exit conference.

Based on medical record review and staff interview it was determined that physician and Nurse Practitioner progress notes were not completed and placed in the medical record after each visit. This was evident for 2 (#151, #152) of 14 finalized sampled residents during the initial certification survey. The findings include: 1) Resident #151's electronic medical record was reviewed on 6/15/22 at 10:37 AM. Review of a nurse practitioner's (#13) medical visit notes revealed a progress encounter note dated 1/11/22 at 12:30. The note was completed and signed off on 1/29/22 and up-loaded to the EHR (electronic health record) on 2/8/22. An encounter progress note dated 2/11/22 at 2:30 PM was completed and signed-off on 3/5/22 and uploaded two months later 5/12/22 at 5:25 PM. An encounter progress not dated 4/22/22 3:30 PM was dated 4/22/22. This note was completed and signed-off by staff #13 on 4/25/22 at 8:20 PM. This note was uploaded to the EHR on 6/8/22. 2) Resident #152's electronic medical record was reviewed on 6/15/22 at 9:05 AM. Review of a note written by the resident #152's attending physician (#12) revealed that his note was dated for 12/1/21, electronically signed on 12/6/21, and faxed to the facility on [DATE]. Another note written by the resident's attending revealed the resident encounter note was dated for 2/16/22 8:30 AM, electronically signed on 2/16/22 at 6:15 PM, and faxed to the facility on e week later 2/23/22. An encounter notes for resident #152 written by a nurse practitioner (staff #11) was dated 4/5/22 3:30 PM. This note was electronically signed and faxed to the facility 6 weeks later 5/17/22. On 6/17/22 10:15 AM, an interview was conducted with the facility's medical record person (staff #14). She collaborated the findings of the late notes and indicated a few methods of how she receives the clinicians' notes. She confirmed one of the notes written for resident #152 was delayed by 6 weeks prior to being sent/faxed to her for upload into the resident's electronic medical record. 6/17/22 11:30 PM, The director of nursing was informed that the physicians and nurse practitioners were not always writing notes at the time of the visit with residents as she was asked to make copies of the late notes.

Based on observations, review of daily staffing records, and staff interview it was determined that the facility failed to post the total number and actual hours worked by categories of Registered Nurses (RN), Licensed Practical Nurses (LPN), and Certified Geriatric Nurse Aides (GNA) per shift. This was evident on 6 of 7 days of the survey. The findings include. Beginning on 6/9/22 daily observations of the [NAME] Hall shift staffing ratio/hours did not reveal all the Federal requirements for the posting of nursing staffing. The daily observations revealed that the facility identified the total number and actual hours worked of all the licensed nurses but did not identify the RNs and LPNs separately. Additionally, the facility added a category of staffing for the Certified medicine aides (CMAs). On 6/16/22 at 12:15 PM, an interview/discussion was held with the Unit Manager (#20) to review the state and federal staff posting requirements with indication of the non-compliance as the staffing sheet for day shift of 6/16/22 was reviewed. On 6/17/22, review of the [NAME] Hall shift staffing sheet revealed that the facility changed the form to include the total number and actual hours worked by categories of RNs, LPNs, and combined the GNAs and CMAs for the total number and actual hours worked for the Geriatric Nurse Aides.