Every finding on record at Fairfax Rehabilitation and Nursing Center

Based on staff interview, clinical record review and facility document review, the facility staff failed to ensure appropriate interventions were implemented for resident safety for (1) one of (4) four sampled residents, Resident #1, resulting in harm. Resident #1 sustained a fall during transfer resulting in a subarachnoid hemorrhage and subsequent death. The findings included:Resident #1's diagnosis list indicated diagnoses that included, but were not limited to, metabolic encephalopathy, type 2 diabetes mellitus with diabetic kidney disease, congestive heart failure, unspecified dementia, end stage renal disease, arteriovenous fistula, unspecified lack of coordination, and muscle weakness. The most recent quarterly minimum data set (MDS) with an assessment reference date (ARD) of 11/25/25, assigned the resident a brief interview for mental status (BIMS) summary score of 8 out of 15 for cognitive abilities, indicating the resident was moderately impaired in cognition. A review of Resident #1's clinical record disclosed the following documentation: A progress note dated 1/19/2026 read in part, . 08:50 (8:50 AM) .Resident fell during Transfer from bed to chair with CNA (certified nursing assistant) assistance while preparing to go for dialysis in Resident room. Resident assessed immediately and found lying in a supine position on the floor. Noted with skin tear to the right upper eye. [provider name omitted] notified and order given to send resident to the ER (emergency room) . A progress note dated 1/19/26 read in part, .01/19/2026 17:15 (5:15 PM) .Health Status Note.Phone call was made to.Hospital Trauma/ICU (intensive care unit) for follow up status on resident. Charge nurse on the unit [name omitted] mentioned resident has been admitted with a diagnosis of Brain Bleed. A review of Resident #1's comprehensive person-centered care plan disclosed a focus which read in part, .requires assistance with their activities of daily living due to chronic disease. Interventions related to the focus read in part, .2 person assist transfer. On 2/3/26 at 5:05 PM, the facility administrator stated the facility had completed a plan of correction (POC) for this incident, and he provided the POC and the facility synopsis of events files. On 2/4/26 at 12:27 PM, an interview was conducted with Registered Nurse (RN) #2 via phone conversation and RN#2 stated she was Resident #1's nurse on the day of the incident and that Resident #1 was on the dialysis schedule for that day (1/19/26) and the resident was a 2-person assist for transfers. RN#2 recalled instructing CNA#1 to get assistance to transfer Resident #1 and then a few minutes later CNA#1 came to her and said Resident #1 was on the floor. RN#2 stated she went to the resident's room and observed the resident lying on the floor and bleeding from a laceration to her right eyebrow. RN#2 stated she checked Resident #1's vital signs and the nursing supervisor entered the room and then went and called 911 immediately. A review of the facility synopsis of events dated 1/19/26, read in part, . (Resident #1) sustained a fall while staff were transferring her. (Resident #1) was transferred to the hospital. Per the hospital notes, (Resident #1) sustained a subarachnoid hemorrhage (a life-threatening type of stroke caused by bleeding into the space between the brain and the surrounding membrane (subarachnoid space). It is commonly characterized by a sudden, severe thunderclap headache, often caused by a ruptured aneurysm or trauma). (Resident #1) passed away at the hospital.Incident Type: Allegation of Neglect.Location of Incident: Resident's room.Employee Involved: [employee name omitted-for purposes of this survey the employee has been identified as CNA#1] .(CNA#1) has been placed on suspension pending investigation. CNA #1 was unavailable for interview as they were no longer employed by the facility at the time of the survey. A review of witness statement #3 dated 1/20/26, provided by CNA#1 via phone conversation with the administrator and director of nursing, read in part, .How was the patient when you first saw them? .She was normal for the shift, have not worked with her before.2. Do you know how to check the patient's transfer status? .Yes, in the cardex [sic] (Kardex-a concise, quick-reference system used primarily to summarize essential, real-time patient data like medications, treatments, allergies, and care plans, facilitating communication and continuity of care across shifts, separate from the full patient chart).Did you call for help? .No, I was told she was a 1-person assist and did not need further assistance.4. How did you transfer the patient.? .Was sitting at the edge of the bed. Placed left leg between her (Resident #1's) legs. Used left arm around her body under her right arm. Used right arm to grab pants. Transferred her to the wheelchair. When repositioning her in the chair she fell.5. What happened immediately following the fall, what did you do/tell? .Rushed to get the nurses. Who then began to assess the resident. A review of the ER report dated 1/19/26 read in part, .presenting to the emergency department with a fall prior to arrival. Per EMS, the patient lives at the nursing facility and they were moving her out of bed when she fell. They note that she fell from about 3 feet up and hit the right side of her head.They note the patient had episode of vomiting on route.Subdural hematoma.the patient was admitted and handed off to ICU (intensive care unit.CT (Computed Tomography scan, a noninvasive, painless medical imaging procedure that uses specialized X-ray equipment and computer algorithms to produce detailed, 3D, and cross-sectional slice images of bones, blood vessels, and soft tissues) of the head showed.1. Large, acute right-sided subdural hemorrhage with prominent mass effect, right to left midline shift, effacement of basilar cisterns and probable early uncal herniation (a critical radiological finding, indicating a life-threatening emergency caused by high pressure inside the skull that is forcing brain tissue to shift out of its normal position. This situation requires immediate neurosurgical intervention to prevent permanent brain damage or death). 2. Smaller, acute left-side subdural hematoma. 3. Scattered subarachnoid hemorrhage (a, often non-aneurysmal, bleeding event in the subarachnoid space - the area between the brain and its surrounding membrane (arachnoid mater) - that appears in multiple, disjointed areas on imaging).Patient will be admitted to the ICU. A review of hospital neurosurgery notes dated 1/19/26 read in part, .10:55 AM.p/w (presented with) larged {sic} R (right) holohemispheric subdural hematoma in the setting of fall from bed at SNF (skilled nursing facility), + head strike.The patient's [family member name omitted] was contacted to discuss goals of care and management options.Discussed w (with) [family member name omitted] regarding pt (patient) clinical picture.Pt [family member] understands pt significant head injury and is actively dying.[family member] confirmed she does not want any surgical interventions however she does want pt to be on life support until she arrives bedside.would like everything done until she arrives to hospital and confirmed she is currently 5 hours away. Pt full code and will update family if pt continues to decline for further end of life discussions. A review of the facility synopsis of events final report dated 1/27/26 read in part, .Per the hospital notes, (Resident #1) sustained a subarachnoid hemorrhage. (Resident #1 passed away at the hospital.Employee action initiated or taken: CNA#1 has been terminated.Upon investigation, we found the resident did fall.During the investigation, the CNA had access to the resident's transfer status and signed off on the KARDEX acknowledging that she knew what the transfer status was. (Resident #1) was listed as a 2-person assist, but the CNA transferred her by herself. Based on the facts within the investigation, we are substantiating this [facility synopsis of events]. The CNA involved has been terminated. This concern was discussed on 2/4/26 at 8:20 AM in a meeting with the administrator, vice president of operations, regional nurse consultant, interim director of nursing, and director of nursing in-training. The administrative team concluded that deficient practice was identified and had been corrected. The POC had a completion date of 1/23/26 and read as follows: Corrective Action: Immediate Response: Resident #1 was assessed for pain and a skin assessment was performed. Laceration noted to R (right) eyebrow. Provider was called and notified. RP (responsible party) was called multiple times and message left. Resident was sent to the hospital with EMS (emergency medical services). All residents requiring a two-person assist or mechanical lift have the potential to be affected. A 100% audit was done of all residents having a transfer status in the care plan and put into the Kardex. Root Cause Analysis: Failure to follow the resident's care plan requiring a two-person assist for transfers, resulting in a fall with a subsequent death. Identification of Deficient PracticeHow will corrective action be accomplished for those residents having potential to be affected by the same deficient practice: On 1/20/26 an audit of all residents having a transfer status in the care plan/Kardex was performed by the administrative nursing staff to ensure that the care plans and Kardex are accurate. Any issues identified were corrected. Systemic Changes: On 1/21/26 the DON/designee began education with all nursing staff on safe transfer techniques, use of gait belts and mechanical lifts and to stop and seek help. On 1/21/26 the DON/designee began educating all staff on abuse and neglect. On 1/21/26 the DON/designee began educating all nursing staff on following care plan/Kardex for all transfer levels, stop the transfer if adequate assistance is not available, and a two-person transfer may not be completed by one staff member under any circumstances. On 1/21/26 the DON/designee began educating all nursing staff to check Kardex for transfer status if someone is a 2 person assist they need to be always with 2 people. Provision of how the facility plans to monitor its performance to make sure that solutions are sustained: The DON/designee will audit CNAs on how to check and access the Kardex on 6 CNAs 5 times per week for 8 weeks. The DON/designee will conduct random audits of 15 resident transfers per week to ensure they were transferred according to their care plan for 4 weeks. The DON/designee will audit all falls related to transfer to ensure the care plan was followed related to transfer status for 4 weeks. The DON/designee will audit all new residents for accurate transfer status to ensure all care plans are updated accordingly 5 times a week for 8 weeks. Completion Date Projection: 3/18/26 Credible Evidence Review:A review of the credible evidence for the POC on 2/4/26 found the audits and education to be complete. The interim director of nursing provided evidence of care plans, Kardex demonstration, and transfer status education is provided during orientation for new hires prior to working with the residents independently. Ongoing monitoring was also confirmed. Observations: On 2/4/26 at 9:37 AM, CNA#2 and CNA#3 were observed conducting a two-person transfer with Resident #4. No issues were identified. On 2/4/26 at 9:40 AM, CNA #2 and CNA#3 were observed conducting a two-person mechanical lift transfer with Resident #5. No issues were identified. Interviews: On 2/4/26, an interview was conducted with registered nurse #1 (RN#1) and RN#1 stated that she is educating new hires during orientation and orients them on the care plan/Kardex and what to look for. She is also educating on utilization of gait belts and enforcement of not transferring a two-person transfer unless two people are present. RN#1 stated she is assisting with the weekly audits and denied any transfer-related falls since the incident occurred. On 2/4/26, an interview was conducted with certified nursing assistants #2, #3, #4, #5, and #6 and they all concurred they had received education on resident transfers, care plans, and Kardex review. All the CNAs verbalized the correct protocol implemented for safe transfers of the residents. On 2/4/26, registered nurses #1 and #2, and licensed practical nurses #1, #2, and #3 were interviewed and all the nurses concurred they had received education on resident transfers, care plan and Kardex review. All the nurses verbalized the correct protocol implemented for safe transfers of the residents and they all concurred they assist CNAs for two-person transfers when needed, identify transfer status of new residents, and observe CNAs for proper transfer assistance. No further information was provided prior to exit on 2/4/26. This is a past non-compliance deficiency.

Based on observation, staff interview, clinical record review, and facility document review, the facility staff failed to maintain an infection prevention and control program to provide a safe, sanitary, environment and help prevent the development and transmission of communicable disease and infection for 1 of 4 sampled residents, Resident #7. The findings included:For Resident #7 the facility staff failed to identify the need for gowns as part of the required PPE (personal protective equipment) prior to entering an EBP (enhanced barrier precaution) room. Resident #7's diagnosis list indicated diagnoses that included, but were not limited to, end stage renal disease, type 2 diabetes with chronic kidney disease, and dependence on renal dialysis. The most recent quarterly minimum data set (MDS) with an assessment reference date (ARD) of 10/21/25 assigned the resident a brief interview for mental status (BIMS) summary score of 15 out of 15 for cognitive abilities, indicating the resident was cognitively intact. On 2/4/26 at 11:00 AM, this surveyor observed an EBP sign on Resident #7's door, which read in part, .requires use of gown.during high-contact patient care activities as defined.transferring. Two certified nursing assistants (CNAs) were observed transferring Resident #7 from a geri-chair to the bed. Both of the CNAs were observed to be wearing gloves. Both CNAs were not observed to be wearing gowns. This surveyor spoke with certified nursing assistant #2 (CNA#2) and he informed this surveyor he usually wears a gown. This surveyor stepped out into the hallway to observe the EBP sign again and spoke with licensed practical nurse #4 (LPN#4) and asked her to clarify if the CNAs should be donning gowns. LPN #4 reviewed the EBP sign on the door and agreed that the two CNAs should be donning gowns when working with Resident #7. This surveyor inquired of certified nursing assistant #7 (CNA#7) why a gown was not donned and CNA#7 informed this surveyor she was just helping with the transfer. A review of Resident #7's clinical record disclosed the following documentation: A medical provider orders with a start date of 1/20/26 read in part, .Enhanced Barrier Precautions every shift for Enhanced Barrier Precautions HD (hemodialysis). A review of the person-centered comprehensive care plan disclosed a focus that read in part, .ENHANCED BARRIER PRECAUTIONS: the resident required Enhanced Barrier Precautions related to AV Fistula to Right forearm ((Arteriovenous Fistula in the right forearm is a surgically created abnormal connection between an artery and a vein, specifically designed to act as a reliable, long-term access point for hemodialysis in patients with kidney failure). The interventions related to the focus read in part, .appropriate PPE per policy.Isolation precautions per order. This concern was discussed with the regional vice president of operations (VPO) on 2/4/26 at approximately 11:30 AM. Surveyor requested and received a facility policy titled, Enhanced Barrier Precautions (EBPs) with an effective date of 3/26/24, which read in part, .Employees providing high-contact care activities will follow Enhanced Barrier Precautions for patients who meet the criteria.1. May be indicated for patients:.with indwelling medical devices.3. EBPs require the use of gown.by staff during high-contact patient care activities as defined below:.c. Transferring. No further information was provided to this surveyor prior to exit on 2/4/26.

Based on observation and staff interview, the facility staff failed to ensure that food was served at a safe and/or appetizing temperature. The findings include: On 6/26/25 at 5:26 PM, this surveyor observed dietary staff plating food for a test-tray. The menu consisted of chef salad, tomato soup, (3) three bean salad, and a snickerdoodle cookie. The test-tray was placed on the last food cart for service. Review of the daily food temperature log revealed the temperatures of the items were as follows at start of meal service: Chef Salad (ham)-38 degrees 3 Bean Salad-37 degrees Tomato Soup-199 degrees The food cart arrived on the unit at 5:35 PM. After the resident trays were removed from the cart, the dietary manager took food temperatures from the test-tray at 5:45 PM and the temperatures were as follows: Chef Salad-59 degrees 3 Bean Salad-71 degrees Tomato Soup-169 degrees This concern was discussed at the end of day meeting on 6/26/25 at 6:04 PM with vice president of operations, regional nurse consultant #1, regional nurse consultant #2, administrator, and director of nursing. On 6/27/25 at 8:53 AM, dietary manager informed surveyor the 3 bean salad is served from a can and they store it in the refrigerator until service. She staed it has been so hot in the kitchen and they had the 3 bean salad on ice yesterday prior to service. She agreed the 3 bean salad was not at a preferable temperature with the test-tray the evening before. No further information was provided to the survey team prior to exit.

Based on observations and staff interviews, the facility staff failed to store food in accordance with professional standards for food service safety in the facility kitchen. The findings included: The facility staff failed to discard out of date perishable food items, failed to store food preparation pans clean, failed to promptly discard unused food items, failed to utilize beard restraints for male dietary aides, and failed to ensure foods were stored at safe temperatures. On 6/24/25 at 9:39 AM, surveyor entered facility kitchen for an initial tour with dietary manager-other staff #9 (OS#9) and regional dietary manager-other staff #11 (OS#11). Surveyor observed three reach-in refrigerators in the kitchen food prep area. The thermometer on refrigerator #1 was 50 degrees, no food items were present in the refrigerator. Refrigerator #2 had a sign on the door which read, Out of Order and inside was one tray of peaches in individual bowls with no lids, one tray of pudding in individual bowls with lids, and one tray of a small salad containing cucumber slices in souffle cups with no lids. OS#9 informed surveyor the refrigerator had been out of order for the past month. Surveyor inquired if the food in the refrigerator had been in there for a month and OS#9 stated no, that was from dinner last night, staff did not throw it away. During the observation other staff #20 (OS#20) came to the refrigerator and took out the tray of peaches. Surveyor inquired what she was doing with the peaches and OS#20 informed surveyor she was going to put lids on them. Surveyor inquired why she was putting lids on them, and she stated to, serve. OS#9 then stated, No, she is throwing them away. OS#20 then proceeded to throw the bowls of fruit into the large trash can nearby. OS#20 then removed the tray of salads and tray of pudding from the refrigerator and discarded the salads and took the bowls of pudding to the dish washing area. Surveyor observed refrigerator #3 to be at 36 degrees and empty. Surveyor observed an ice cream standing freezer to be at 40 degrees, all of the ice cream was observed to be frozen. Surveyor observed an ice cream floor freezer with two sliding doors on the top of the unit. No thermometer could be located in the freezer. A box of clear strawberry ice cream cups was observed on top of the other boxes of ice creams. All the strawberry ice cream cups were observed to be soft, melted, and separated-with the strawberry syrup on the bottom of the cups and a foamy pink liquid on top within the cups. OS#9 stated it has been extremely hot in the kitchen, and they had no air. Surveyor observed fans throughout the kitchen space. OS#9 threw the case of strawberry ice cream cups away. The temperature logs on top of the freezer documented the freezer at 10 degrees that morning. The walk-in refrigerator was observed, and 3 bags of cilantro were observed in a box on a bottom shelf. The cilantro appeared wilted in each bag and each bag had a BB (best by) date of 6/20/25. OS#9 discarded the cilantro. The walk-in freezer was observed, and a large bag of diced chicken was found to be soft with crystalized ice inside the bag. It was not firm to the touch. OS#9 discarded the chicken. Surveyor observed 1 large food pan and 2 small food pans with visible, crusty, light-brown substances on them, stacked in the clean dish area. OS#11 removed the pans and gave them to a dietary aide to re-wash. Surveyor observed the dry storage area, and a bottle of sparkling cider was located on the 2nd shelf with a BB date of 5/5/24. OS#9 discarded the cider. These concerns were discussed at the end of day meeting on 6/24/25 at 5:48 PM with the administrator, regional vice president of operations, director of nursing, and regional nurse consultant #1. On 6/26/25 at 11:05 AM, surveyor entered the facility kitchen for additional observations and met with OS#9, OS#11, and other staff #13. Surveyor observed four male dietary aides and OS#13 without beard restraints. OS#9 provided all the men with beard restraints and informed surveyor it is her expectation for them to always wear beard restraints. No further information was provided to the survey team prior to exit on 6/27/25.

Based on staff observation, staff interview, and facility document review, the facility staff failed to maintain mechanical and electrical equipment in safe operating conditions. The findings include: On 6/24/25 at 9:39 AM, surveyor entered facility kitchen and met with dietary manager-other staff #9 (OS#9) and regional dietary manager-other staff #11(OS#11) for an initial observation/tour. During the observation this surveyor observed 3 large serving pans with water heating on the griddle area of the stove. OS#11 informed surveyor dietary staff use them to keep the food hot because the steam table is broken. One well of the steam table works, but the other wells do not. OS#11 stated the steam table has been broken for about a month and explained it is a process because the steam table has a gas line, and they have to replace the line and cut the steam table to get to the problem area. On 6/24/25 at 2:11 PM in an interview with the administrator (ADM) about the steam table not working, the ADM stated he was not aware the steam table was not working and stated the facility is responsible for repairing equipment in the kitchen. On 6/26/25 at 11:05 AM, surveyor and OS#9 observed the 4th floor unit panty and surveyor observed a large hole in the sink cabinet beneath the sink. The door(s) were missing and the divider between the bottom of the sink and the side where a door was on the unit had 2 pieces of loose particle board standing where the divider would have been stationed. The hole was approximately the size of a whole loaf of bread and a container was observed to be sitting in the hole. In another observation of the kitchen on 6/26/25 at 5:26 PM, this surveyor observed an area to the right of the dish washing area to have about 1 inch of standing water from the wall to almost half-way across the floor. OS#9 informed surveyor there is a leak in the sink and she stated maintenance ordered the part to fix it. OS#9 stated dietary staff must sweep the water over to the floor drain after each meal service. These concerns were discussed at the end of day meeting on 6/26/25 at 6:04 PM with regional vice president of operations, administrator, director of nursing, regional nurse consultant #1, and regional nurse consultant #2. On 6/27/25 at 8:09 AM, the survey team entered the facility kitchen with the ADM, regional vice president of operations (RVPO), regional nurse consultant #2 (RNC#2), and OS#9 to observe the water leak to the right side of the dish washing area. The area continued to contain some water and dietary food service carts were parked in the area. OS#9 agreed the sink was leaking and had been for some time. RVPO stated they would take the sink out of service and OS#9 informed surveyors dietary staff would do dishes in the three-compartment sink. A large area of missing tile was also observed near the entrance to the dishwasher area and when stepped on, water seeped from underneath the tiles. RVPO stated they would use a squeegee to get rid of the excess water beneath the floor tiles. On 6/27/25 at 10:20 AM, surveyor observed the dish washing area of the kitchen to be roped off with caution tape and other staff #13 informed surveyor he had been informed a plumber had been called to come in to repair the leaking sink. RVPO presented surveyor with a Maintenance Request dated 5/7/25 which read in part, .Water build-up in dish room . The form indicated the request had been closed on 5/16/25. RVPO informed surveyor there is a waiting process for getting quotes for the steam table, he had located an invoice where the steam table was temporarily repaired on 6/19/25. He also stated the steam table is electric, not gas. The invoice from the electrical contractor dated 6/19/25 read in part, .one of the pans was heating but none of the others .the pans are not functioning properly .they need to get the manufacturer or a technician that services steam tables to service it. The other option would be to get a new steam table . These concerns were discussed at the pre-exit meeting on 6/27/25 at 12:28 PM with regional vice president of operations, administrator, director of nursing, regional nurse consultant #1, and regional nurse consultant #2. No other information was provided to the survey team prior to exit on 6/27/25.

Based on observation, staff interview, resident interview, clinical record review, and facility document review, the facility staff failed to dispose of expired medications in 1 of 1 medication rooms and on 3 of 12 medication carts and failed to properly store medications and biological's for 1 of 41 current residents, Resident #122. The findings included: The facility staff failed to properly store dialysis medications and biological's Resident #122's dialysis supplies were left outside overnight in the rain and failed to dispose of expired medications in the medication storage room and on medication carts. Resident #122's diagnoses included diabetes, muscle weakness, and end stage renal disease. Section C (cognitive patterns) of Resident #122's quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of 04/15/25 included a brief interview for mental status (BIMS) score of 15 out of a possible 15 points. Indicating Resident #122 was cognitively intact. On 06/27/25 at 8:47 a.m., during an interview with Resident #122, this resident stated to the surveyor that their medical supplies were delivered last night, and they were left outside in the rain. Resident #122 stated to the surveyor they had about a week's worth of supplies in their room. On 06/27/25 at 8:54 a.m., the surveyor and Licensed Practical Nurse (LPN) #9 checked the area outside for any medical supplies. Next to a driveway the surveyor observed two large pallets of boxes that were soaked with water. These boxes were observed to have resident #122's name printed on shipping labels attached to the boxes. The surveyor attempted to open one box, and the box started to fall apart. These boxes were labeled as containing dialysis cassettes, extension sets, and IV bags for dialysis. LPN #9 contacted the Director of Nursing (DON) and asked her to come to the area. Upon observing the dialysis supplies the DON stated they would call the contact person from dialysis. The DON stated whoever delivered the supplies was supposed to bring them into the facility. On 06/27/25 at 9:22 a.m., the Administrator stated they were going to call the company and either the company or the facility would eat the cost of the supplies. The Administrator stated they would communicate this to Resident #122. On 06/27/25 at 9:25 a.m., the surveyor checked the South 400 hall medication cart with Registered Nurse (RN) #9 this medication cart was observed to contain 1 opened bottle of a liquid antacid with an expiration date of 05/2025. RN #9 stated they would dispose of the medication. The surveyor then checked the medication room on 400 hall with LPN # 12. This medication contained the following expired medications. 32 bottles of enteric coated Aspirin 325 mg expiration date 04/2025. 13 bottles of Aspirin 325 mg expiration date 02/2025. 1 bottle of Sentry Senior Vitamins expiration date 10/2024. 2 bottles of Multi Vite liquid expiration date 01/2025. 1 bottle of Antacid liquid expiration date 05/2025. 1 bottle of Fexofenadine allergy expiration date 05/2025. The medication refrigerator contained Acetaminophen suppositories 650 mg 1 opened box and 1 unopened box. The expiration date on both boxes was 12/2023. LPN #12 confirmed with the surveyor the medications were expired and stated she would remove them from the medication supply. On 06/27/25 at 9:56 a.m., the surveyor and LPN #14 checked the 300 hall East medication cart. This cart contained the following expired medications. 1 bottle of Sentry Senior expiration date 10/2024. 1 bottle of Fexofenadine expiration date 05/2025. LPN #14 confirmed the expiration dates with the surveyor and stated they would dispose of the medications. On 06/27/25 at 10:04 a.m., the surveyor and LPN #15 checked the middle medication cart on 300 hall. This cart contained the following expired medications. 1 bottle of Fexofenadine allergy tablets expired 05/2025 1 bottle of Senna syrup expired 01/2025. LPN #15 confirmed the medications were expired and stated they would dispose of the medications. On 06/27/25 at 11:00 a.m., the DON provided the surveyor with a copy of their policy titled, Storage of Medications. This policy read in part, .Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from inventory . On 06/27/25 at 12:27 p.m., during a meeting with the Administrator, DON, Nurse Consultant #1 and #2 and Regional Director of Social Services the issues with the dialysis supplies being left outside, overnight in the rain and the expired medications were reviewed. The DON stated the company that delivered the dialysis supplies had not informed anyone that they had been delivered and the resident would not be charged. No further information regarding these issues was provided to the survey team prior to the exit conference.

5. For Resident #71, the facility staff documented the resident was a full code in a discharge planning note. The resident had a Do Not Resuscitate (DNR) order in place. Resident #71's diagnoses included dementia and severe protein calorie malnutrition. Section C (cognitive patterns) of Resident #71's significant change minimum data set (MDS) assessment with an assessment reference date (ARD) of 05/15/25 was coded 1/1/3 to indicate this resident had problems with long- and short-term memory and was severely impaired in cognitive skills for daily decision making. Resident #71's comprehensive care plan included the focus area has an advance directive DNR order. Resident #71's clinical record included a provider order dated 07/05/24 indicating this resident was a DNR. The clinical record included a discharge planning note transcribed by the Social Worker dated 06/19/25 that read in part, .A copy of Advanced Directive and Resident's Rights were made available to the resident. Resident code status is Full Code . On 06/25/25 at 5:45 p.m., during an end of the day meeting with the Administrator, Director of Nursing, Nurse Consultant #1, and Regional [NAME] President of Operations the inaccurate clinical record was reviewed. No further information regarding this issue was provided to the survey team prior to the exit conference. 3. For Resident #108, the facility staff failed to remove and/or update a completed Virginia Department of Health Durable Do Not Resuscitate (DDNR) Order form when the order was revoked by the resident representative. Resident #108's diagnosis list indicated diagnoses, which included, but not limited to Vascular Dementia, Parkinsonism, and Atherosclerotic Heart Disease of Native Coronary Artery. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 6/13/25 coded the resident as being moderately impaired in cognitive skills for daily decision making with short-term and long-term memory problems. Surveyor reviewed Resident #108's medical record on 6/24/25 and noted a current medical provider order dated 5/16/24 for full code status. At this time, a completed Virginia Department of Health Durable Do Not Resuscitate (DDNR) Order form dated 10/23/23 was also present in the clinical record. A Care Conference Meeting note dated 4/15/25 read in part .Care level review: Full Resuscitation. A Discharge Planning Psychosocial Assessment dated 5/30/25 read in part .Resident code status is Full Code . On 6/26/25 at 10:39 AM, surveyor spoke with Social Services Staff Member (Other Staff Member/OSM) #3 who stated during the 4/15/25 care plan meeting with Resident #108's resident representative (RR) and their spouse, the resident's code status was discussed, and the RR confirmed the code status for Resident #108 was full code. On 6/26/25 at 6:05 PM, the survey team met with the Administrator, Director of Nursing, Regional Nurse Consultant #1 and #2, and the [NAME] President of Operations and discussed the concern of Resident #108 having a completed DDNR form present in the clinical record following decision to revoke and be a full code. No further information regarding this concern was presented to the survey team prior to the exit conference on 6/27/25. 4. For Resident #3, the facility staff failed to discontinue a provider order for a left-hand splint following the discontinuation of the splint by therapy. Resident #3's diagnosis list indicated diagnoses, which included, but not limited to Vascular Dementia, Primary Osteoarthritis Left Hand, and Hemiplegia and Hemiparesis. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 4/28/25 assigned the resident a brief interview for mental status (BIMS) summary score of 5 out of 15 indicating the resident was severely cognitively impaired. A review of Resident #3's clinical record revealed a current medical provider order dated 11/20/24 for a left resting hand splint to be worn 8 hours a day. On 6/25/25, surveyor observed Resident #3 during breakfast and at 2:25 PM and the resident was not wearing a left-hand splint on either occasion. On 6/25/25 at 2:27 PM, surveyor spoke with Certified Nursing Assistant (CNA) #1 who stated she was unaware of the resident having a splint and did not apply one today. On 6/25/25 at 2:33 PM, surveyor spoke with Licensed Practical Nurse (LPN) #3 who stated Resident #3's left-hand splint was discontinued by therapy. On 6/25/25 at 2:55 PM, surveyor spoke with the Director of Rehab who stated Resident #3's left-hand splint was discontinued at the end of January because the resident could not tolerate it due to pain. On 6/25/24 at 5:48 PM, the survey team met with the Administrator, Director of Nursing, Regional Nurse Consultant #1, and the [NAME] President of Operations and discussed the concern of staff failing to discontinue the order for Resident #3's left-hand splint when the splint was discontinued by therapy. No further information regarding this concern was presented to the survey team prior to the exit conference on 6/27/25. Based on staff interview, clinical record review and facility document review, the facility staff failed to maintain a complete and accurate medical record for 6 of 41 residents in the survey sample, residents #85, #229, #108, #3, #71, and #87. The findings include: 1. For resident #85 the facility staff failed to include a diagnosis of schizophrenia for which the resident was receiving medications, on the demographic sheet, the diagnosis list or the minimum data set (MDS) R85's MDS assessment with an assessment reference date of 5/10/25 was reviewed. Under Section I. Active Diagnoses, the document listed diabetes, heart failure, depression, PTSD (post traumatic stress disorder), atrial fibrillation, pain in the right knee, hypothyroidism, gastroesophageal reflux, vitamin D deficiency and insomnia. The demographic sheet for R85 was reviewed. There was no diagnosis of schizophrenia ( a disorder that affects a persons ability to think, feel and behave clearly, characterized by thoughts or experiences that seem out of touch with reality per the Mayo Clinic) listed. The Medication Administration Record (MAR) for R85 was reviewed. This surveyor noted an order for Risperidone (an antipsychotic medication approved for the treatment of various conditions including schizophrenia) 0.5 mg at HS (hour of sleep) for an indication of schizophrenia and an order for Risperidone 2 mg give one tab once daily for an indication of schizophrenia. This surveyor reviewed R85's psychiatric progress notes going back to 2022. Each psychiatric note included a diagnosis of schizophrenia. R85 has been seen by psych at least monthly, most months multiple times and each time schizophrenia, symptoms, medications are discussed at length with each month having a visit for a possible GDR as well. There is extensive documentation that a GDR is contraindicated. This surveyor reviewed a document labeled, Physician's Orders that was dated 4/29/22. The document was from the facility that R85 transferred from and included a section labeled, Active Diagnoses. Included in the active diagnoses was schizophrenia. The care plan for R85 was reviewed and included a focus that read, The resident has a mood problem r/t (related to) disease process post-traumatic stress disorder, unspecified; schizophrenia, unspecified; major depressive disorder, single episode, unspecified. The most recent psychiatric progress note dated May 16, 2025 was reviewed and read in part, Patient seen for GDR (gradual dose reduction) of psychotropic medication. Under the section Active Medical Problems the document read, Major depressive disorder, recurrent, moderate; insomnia; schizophrenia. Under the section, Assessment and Plan, the document read, Antidepressant medication helps the elderly patient to provide quality of life and also helps the patient to be interactive and be responsive to every day care. The patient is on antidepressant medications and therefore the behavior needs to be monitored. If the patient shows any signs of hyperactivity or rebound mania than the antidepressant needs to be tapered off or mood stabilizers started. After careful consideration' the benefits of antipsychotic medications in this patient outweigh the potential risks of tardive dyskinesia' hyperglycemia, stroke, and black boxed warning - (for which there is no established relationship between antipsychotics and premature death in dementia patients per clinical studies). Antipsychotic medication will help in modifying the behavior such that normal care is possible while the patient is in the nursing facility. Current treatment demonstrates effective results and good patient outcomes; maintains baseline function. Dose reduction is not indicated at this time due to benefits outweighing risks. A GDR is likely to cause psychiatric and medical instability while impairing the resident's overall functional status. The patient has been evaluated and the medications have been examined the patient will be continued on the current medications for now. The patient does not appear to require any immediate change in the medications, however, further adjustments in medications can take place as necessary. On 6/26/2025 at 6:03 PM the survey team met with the Administrator, Director of Nursing, Regional Director of Clinical Services, and the Regional [NAME] President of Operations. The above concern was discussed with them at that time. No further information was provided to the survey team prior to the exit conference. 2. For resident #229, the facility staff failed to include in the medical record why the resident was sent to the hospital, what the hospital had done for the resident and why the resident had called 911 twice in one day. Resident #229 (R229) minimum data set (MDS) with an assessment reference date of 6/16/24 assigned the resident a brief interview for mental status score of 15 out of 15 indicating intact cognition. There were no behaviors documented on the MDS. A progress note dated 6/13/24 at 7:32 AM read, Type of Behavior : resident anxious cursing all staff, saying he wants 2 staff with him in the room all the time. also resident called 911 2 times within one hour. without calling the nurse even though the call light was within reach. Non-pharmacological Intervention : 911 staff redirected the resident, resident repositioned, fluid offered and encouraged. resident agreed not to transfer hospital. A change in condition assessment dated [DATE] at 8:06 AM was noted in the progress notes but was mostly blank and did not include any information as to what change the resident had experienced. A progress noted dated 6/13/24 at 11:05 AM read, Attempts made to assess residents skin with wound team and wound NP were declined, upon knocking and entering the room resident began screaming what the fuck are you doing in here extremely loud and continued to verbally abuse and curse at wound team, resident was left in bed with call bell in reach and given time to redirect, unable to educate on risks VS benefits of refusals of skin care, unable to have productive conversation due to extremely loud cursing and verbal abuse, MD notified of behavior and refusals and gave no new orders, RP is self and he is aware. The next noted dated 6/13/24 at 3:53 PM read, Resident Returned from (Name omitted) Hospital with no new order. (Name omitted) Friend made aware. NP made aware. resident is in stable condition call light within reach. BP 148/94, P99,T97.1, 02sat 94% R/A. This surveyor could find no information in the clinical record as to why R229 called 911 or why they were sent to the Emergency Department. On 6/27/25 at 9:29 AM this surveyor interviewed Licensed Practical Nurse (LPN) #11 who documented R229's return from the Emergency Department on 6/13/24. LPN #11 stated they did not recall the resident or the circumstances of that day. 06/27/25 9:50 AM interviewed the Director Of Nursing DON) they stated they do not remember resident. DON looked to see if R229 had made any grievances but there were no records that they had. DON did provide a one page document from the Emergency Department labeled, After Visit Summary, and dated 6/13/24. The document read in part, Reason for visit: SW complaint Diagnosis: weakness Lab tests completed whole blood glucose POCT (point of care testing). The document stated to Talk with your provider about your medications and listed oxycodone 5 mg immediate release. The document also stated to follow up with primary care provider. This surveyor asked the DON if they would expect the nurse to include in their notes the reason a resident called 911 two times and the reason they sent a resident to the Emergency Department. They stated, yes, they should have done better. 06/27/25 9:55 AM interviewed Registered Nurse (RN) #7 they had no recollection of R229. 06/27/25 10:05 AM Interviewed RN #10 they stated they had no recollection of R229. 6/27/25 at 12:28 PM the survey team met with the Administrator, Director of Nursing, Regional Director of Clinical Services and the Regional [NAME] President of Operations. The above concern was discussed at that time. No further information was provided to the survey team prior to the exit conference. 6. The facility staff documented (4) four activity progress notes intended for another resident in Resident #87's clinical record. Resident #87's diagnosis list indicated diagnoses that included, but were not limited to, Depression, Dementia, Unspecified Psychosis, Cerebral Infarction, Adjustment Disorder with Mixed Anxiety and Depression Mood, Alzheimer's, Pseudobulbar Affect, Aphasia, and Chronic Kidney Disease-Stage 3. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 5/6/25 coded the resident as being rarely/never understood and rarely/never understands with severe impairment in cognitive skills for daily decision making with short and long-term memory problems. A review of Resident #87's clinical record disclosed 4 activity progress notes addressing another resident by name on 6/25/25. Each note disclosed the other resident attended scheduled smoking times. This concern was discussed at the pre-exit meeting on 6/27/25 at 12:28 PM with the administrator, director of nursing, vice president of operations, regional nurse consultant #1, and regional nurse consultant #2. Surveyor requested but did not receive a clinical record documentation policy. No further information was provided to the survey team prior to exit on 6/27/25. 7. For Resident #88, the facility staff failed to discontinue an order for monitoring/observing for side effects of antianxiety medication. Resident #88's diagnosis list indicated diagnoses that included, but were not limited to, Right Femur Fracture, Chronic Kidney Disease-Stage 3, History of Falls, Dementia, Depression, Atherosclerotic Heart Disease, Weakness, Irritable Bowel Syndrome, Seizures, Hypertension, and Dysphagia. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 4/3/25 assigned the resident a brief interview for mental status (BIMS) summary score of 9 out of 15 for cognitive abilities, indicating the resident was moderately impaired in cognition. A review of a medical provider orders included an order with a start date of 3/27/25 which read in part, .Antianxiety Meds (medications)-Observation and documentation of potential side effects . The orders also included an order with a start date of 3/27/25 which read in part, .Antianxiety Medication-Monitor for . A review of the medication administration records (MARs) for April/May/June 2025 disclosed that the resident was being monitored for potential side effects for antianxiety medications. A review of Resident #88's medication orders did not disclose the resident was prescribed antianxiety medication. On 6/25/25 at 3:55 PM this surveyor and the director of nursing (DON) reviewed the orders and MARs for the antianxiety medication monitoring. The DON agreed the resident was not receiving antianxiety medication. On 6/27/25 the DON provided surveyor with two new medical provider orders dated 6/27/25. The new orders indicated the antianxiety medication monitoring had been discontinued. This concern was discussed at the pre-exit meeting on 6/27/25 at 12:28 PM with the administrator, director of nursing, vice president of operations, regional nurse consultant #1, and regional nurse consultant #2. Surveyor requested but did not receive a clinical record documentation policy. No further information was provided to the survey team prior to exit on 6/27/25.

Based on observation, staff interview, clinical record review, and facility document review, the facility staff failed to follow the provider orders for medication administration for 1 of 41 current residents Resident #33 and failed to follow the providers orders for treatments for 2 of 41 current residents, Residents #99 and #390. The findings included: 1. For Resident #33, the facility staff failed to administer the provider ordered medication Gabapentin. Resident #33's diagnoses included polyneuropathy, osteoarthritis, and anxiety. Section C (cognitive patterns) of Resident #33's admission minimum data set (MDS) assessment with an assessment reference date (ARD) of 05/29/25 included a brief interview for mental status (BIMS) score of 15 out of a possible 15 points. Indicating this resident was cognitively intact. Resident #33's comprehensive care plan included the focus area at risk for complications related to the use of opioid secondary to neuropathy and arthritis. Interventions included administer medications as ordered. Resident #33's clinical record included a provider order for Gabapentin 100 mg give 2 capsules by mouth two times a day for neuropathy. On 06/26/25 at 7:30 a.m., during a medication pass and pour observation. Licensed Practical Nurse (LPN) #11 stated Resident #33's Gabapentin was not available. LPN #11 called the pharmacy and obtained the medication from the Omnicell for administration. LPN #11 stated the system was down yesterday and the resident did not receive her Gabapentin. A review of Resident #33's medication administration records (MARs) for 06/25/25 revealed that the nursing staff had documented a 5 for this medication at 8:00 a.m. and a 9 for this medication at 5:00 p.m. Per the preprinted code on the MAR a 5=Hold/See Nurse Notes and a 9=Other/See Progress Notes. On 06/25/25 at 8:06 p.m. the nursing staff documented this medication had not arrived from pharmacy. A review of the Omnicell list indicated this medication was available in the Omnicell for administration. The facility policy titled, Medication Unavailability read in part, A licensed nurse will notify the provider of the unavailability of medication and discuss an alternative order, if necessary .A licensed nurse will document notification to the provider of the unavailability in the medical record . On 06/26/25 at 6:05 p.m., during an end of the day meeting with the Administrator, Director of Nursing, Regional [NAME] President of Operations, and Nurse Consultant #1 and #2 the issue with Resident #33 not receiving her provider ordered Gabapentin on 06/25/25 and being available in the Omnicell was reviewed. No further information regarding this issue was provided to the survey team prior to the exit conference. 2. For Resident #99, the facility staff failed to follow the wound provider orders for the treatment of incontinence associated dermatitis to the sacrum and erythema intertrigo to the bilateral groin area. Resident #99's diagnosis list indicated diagnoses, which included, but not limited to Hemiplegia and Hemiparesis following Cerebral Infarction and Type 2 Diabetes Mellitus. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 3/25/25 coded the resident as being severely impaired in cognitive skills for daily decision making with short-term and long-term memory problems. Resident #99's comprehensive person-centered care plan included a focus area stating the resident had a skin impairment with an intervention dated 5/08/24 for treatment as ordered. Resident #99 was seen by the wound provider on 6/18/25, the progress note read in part that the resident had incontinence associated dermatitis (IAD) to the sacrum with a treatment order to cleanse with wound cleanser and apply Greers [NAME] twice a day and leave open to air x 14 days with the end of treatment on 6/25/25. The progress note also included assessment of erythema intertrigo to the bilateral groin area with treatment to cleanse with wound cleanser and apply Greers [NAME] twice a day and leave open to air x 14 days with the end of treatment on 6/25/25. Resident #99 was seen again by the wound provider on 6/25/25. The progress note indicated to continue treatment of wound cleanser and Greers [NAME] twice a day and leave open to air x 28 days with the end of treatment on 7/09/25 for the sacrum and bilateral groin area. A review of Resident #99's clinical record revealed the most recent treatment order for Greers [NAME] to the sacrum and bilateral groin area was dated 6/06/25 for 14 days and ended on 6/21/25. According to Resident #99's June 2025 Medication Administration Record (MAR), the last treatment to the sacrum and groin was administered on 6/20/25. On 6/26/25 at 11:53 AM, surveyor spoke with the Wound Nurse and discussed Resident #99 not receiving treatment to the sacrum and bilateral groin as ordered by the wound provider. The Wound Nurse returned at 12:05 PM and stated she had no additional information to offer but would correct the treatment orders. Surveyor requested and received the facility policy titled Wounds/Skin Impairments with an effective date of 7/17/24 which read in part .5. Provide treatments as ordered . On 6/26/25 at 6:05 PM, the survey team met with the Administrator, Director of Nursing, Regional Nurse Consultant #1 and #2, and the [NAME] President of Operations and discussed the concern regarding Resident #99's sacral and groin treatments. No further information regarding this concern was presented to the survey team prior to the exit conference on 6/27/25. 3. For Resident #390, the facility staff failed to follow the wound provider orders for the treatment of arterial ulcers to the left lower extremity. Resident #390's diagnosis list indicated diagnoses, which included, but not limited to Acute Osteomyelitis of Left Ankle and Foot, Cellulitis of Left Lower Limb, and Peripheral Vascular Disease. The 6/17/25 Admission/readmission Nursing Collection Tool V15-V1 documented Resident #390 was cognitively intact and oriented to person, place, and time. Resident #390's comprehensive person-centered care plan included a focus area stating the resident had a skin impairment with an intervention dated 6/18/25 for treatment as ordered. Resident #390 was seen by the wound provider on 6/18/25 and 6/23/25. Each progress note indicated treatment to the left medial malleolus and left dorsal foot arterial ulcers as cleanse the areas with wound cleanser, apply honey hydrogel sheet dressing and cover with rolled gauze three (3) times per week. According to the resident's June 2025 Treatment Administration Record (TAR), the actual treatment being administered to each area was honey hydrogel sheet then calcium alginate and cover with ADB pad and wrap with kerlix. On 6/26/25 at 11:53 AM, surveyor spoke with the Wound Nurse regarding the discrepancies with the current treatments being provided and the wound provider orders. The Wound Nurse returned at 12:05 PM and stated she had no further information to offer but would be correcting the treatment orders. Surveyor requested and received the facility policy titled Wounds/Skin Impairments with an effective date of 7/17/24 which read in part .5. Provide treatments as ordered . On 6/26/25 at 6:05 PM, the survey team met with the Administrator, Director of Nursing, Regional Nurse Consultant #1 and #2, and the [NAME] President of Operations and discussed the concern of staff failing to provide treatment for Resident #390 as ordered by the wound care provider. No further information regarding this concern was presented to the survey team prior to the exit conference on 6/27/25.

Based on staff interview, clinical record review, and facility document review, the facility staff failed to provide all residents with the right to formulate an advance directive for 1 of 41 current residents, Resident #154. The findings were: For Resident #154, the facility staff failed to provide evidence the resident was provided written information regarding the right to accept or refuse medical or surgical treatment and formulate an advance directive. Resident #154's minimum data set (MDS) with an assessment reference date of 04/15/25 assigned the resident a brief interview for mental status summary score of 8 out of 15 in Section C (cognitive patterns) indicating moderately impaired cognition. On 06/25/25 after review of Resident #154's clinical record, the social worker (Other Staff #2) provided a document titled, Discharge Planning Psychosocial Assessment, page 5 of 6 only. Under #6 on the document, facility staff had highlighted the sentences, Resident does not have an AD [Advance Directive]. Per the RP [responsible party], resident did not obtain an AD in the past. The document included the statement, Resident does not have capability to make her [sic] own decisions. Other Staff #2 denied there was any evidence that the resident had been deemed incompetent by a provider. On 06/26/25 at 9:28 a.m., regional nurse consultant (RNC #1) stated there was no policy related to providing moderately impaired residents advance directive information. The policy titled, Advance Directives policy number 906 with an effective date of 01/06/2020 read in part, Procedure: . 2. If requested, assist patient/responsible party with resources for obtaining Advance Directive forms. And 5. Provide a written summary note of initiatives and outcomes in Social Work and Discharge Planning Progress Notes and indicate status of Advance Directive throughout assessment process. On 06/26/26 at 4:04 p.m. during a meeting with the director of nursing, administrator, vice president of operations, regional MDS coordinator, and two regional nurse consultants (RNC #1 and #2), the concern with Resident #154's advance directive information was discussed. No further information was provided prior to the exit conference.

Based on staff interview and clinical record review, the facility staff failed to ensure an accurate minimum data set (MDS) assessment for 2 of 41 residents, Residents #44 and #85. The findings included: 1. For Resident #44, the facility staff failed to code an antiplatelet medication on an annual MDS assessment and coded the MDS assessment to indicate a gradual dose reduction (GDR) had been completed in May 2025 when a GDR had not been attempted. Resident #44's diagnoses included bipolar disorder and schizoaffective disorder. Section C (cognitive patterns) of Resident #44's annual MDS assessment with an assessment reference date (ARD) of 06/06/25 included a brief interview for mental status (BIMS) score of 14 out of a possible 15 points. Indicating Resident #44 was cognitively intact. Section N (medications) was coded to indicate this resident was currently taking an antipsychotic, antianxiety, antidepressant, and anticonvulsant medication. It was not coded to indicate that the resident was receiving an antiplatelet. Section N was coded to indicate a GDR was last attempted on 05/30/25. Resident #44's comprehensive care plan included the focus area antiplatelets. Interventions included administer medications as ordered. A review of Resident #44's medication summary revealed this resident was currently receiving Aspirin enteric coated 81 mg by mouth one time a day for coronary artery disease. On 06/26/25 at 7:45 a.m., during an interview with Licensed Practical Nurse (LPN) #13 this staff reviewed Resident #44's MDS and stated the Aspirin had not been coded as an antiplatelet. LPN #13 stated Resident #44 had a psych visit in May 2025 and that was why they had coded the MDS to indicate this resident had a GDR. On 06/26/25 at 8:40 a.m., LPN #13 approached the surveyor and stated the GDR had been coded incorrectly on the MDS and the Aspirin had not been coded as an antiplatelet. LPN #13 stated a correction was being completed. The issue with the inaccurate MDS assessment was reviewed with the Administrator, Director of Nursing, Nurse Consultant #1 and #2, and Regional [NAME] President of Operations at an end of the day meeting on 06/26/25 at 6:05 p.m. No further information regarding this issue was provided to the surveyor prior to the exit conference. 2. For resident #85 (R85), the facility staff failed to code a diagnosis of schizophrenia on the minimum data set (MDS) assessment. R85's MDS assessment with an assessment reference date of 5/10/25 was reviewed. Under Section I. Active Diagnoses, the document listed diabetes, heart failure, depression, PTSD (post traumatic stress disorder), atrial fibrillation, pain in the right knee, hypothyroidism, gastroesophageal reflux, vitamin D deficiency and insomnia. The demographic sheet for R85 was reviewed. There was no diagnosis of schizophrenia ( a disorder that affects a persons ability to think, feel and behave clearly, characterized by thoughts or experiences that seem out of touch with reality per the Mayo Clinic) listed. The Medication Administration Record (MAR) for R85 was reviewed. This surveyor noted an order for Risperidone (an antipsychotic medication approved for the treatment of various conditions including schizophrenia) 0.5 mg at HS (hour of sleep) for schizophrenia and an order for Risperidone 2 mg give one tab once daily for schizophrenia. This surveyor reviewed R85's psychiatric progress notes going back to 2022. Each psychiatric note included a diagnosis of schizophrenia. R85 has been seen by psych at least monthly, most months multiple times and each time schizophrenia, symptoms, medications are discussed at length with each month having a visit for a possible GDR as well. There is extensive documentation that a GDR is contraindicated. This surveyor reviewed a document labeled, Physician's Orders that was dated 4/29/22. The document was from the facility that R85 transferred from and included a section labeled, Active Diagnoses. Included in the active diagnoses was schizophrenia. The care plan for R85 was reviewed and included a focus that read, The resident has a mood problem r/t (related to) disease process post-traumatic stress disorder, unspecified; schizophrenia, unspecified; major depressive disorder, single episode, unspecified. The most recent psychiatric progress note dated May 16, 2025 was reviewed and read in part, Patient seen for GDR (gradual dose reduction) of psychotropic medication. Under the section Active Medical Problems the document read, Major depressive disorder, recurrent, moderate; insomnia; schizophrenia. Under the section, Assessment and Plan, the document read, Antidepressant medication helps the elderly patient to provide quality of life and also helps the patient to be interactive and be responsive to every day care. The patient is on antidepressant medications and therefore the behavior needs to be monitored. If the patient shows any signs of hyperactivity or rebound mania than the antidepressant needs to be tapered off or mood stabilizers started. After careful consideration' the benefits of antipsychotic medications in this patient outweigh the potential risks of tardive dyskinesia' hyperglycemia, stroke, and black boxed warning - (for which there is no established relationship between antipsychotics and premature death in dementia patients per clinical studies). Antipsychotic medication will help in modifying the behavior such that normal care is possible while the patient is in the nursing facility. Current treatment demonstrates effective results and good patient outcomes; maintains baseline function. Dose reduction is not indicated at this time due to benefits outweighing risks. A GDR is likely to cause psychiatric and medical instability while impairing the resident's overall functional status. The patient has been evaluated and the medications have been examined the patient will be continued on the current medications for now. The patient does not appear to require any immediate change in the medications, however, further adjustments in medications can take place as necessary. On 6/26/25 at 6:00 PM this surveyor interviewed the regional MDS Coordinator. When asked why the diagnosis of schizophrenia was not coded on the MDS they stated, CMS (Centers for Medicare/Medicaid Services) told us we could not use this diagnosis if we did not do a really deep investigation first. We don't know when the resident got this diagnosis. On 6/26/2025 at 6:03 PM the survey team met with the Administrator, Director of Nursing, Regional Director of Clinical Services, and the Regional [NAME] President of Operations. The above concern was discussed with them at that time. No further information was provided to the survey team prior to the exit conference.

Based on staff interview, clinical record review, and facility document review, the facility staff failed to notify the Ombudsman of transfer or discharge for 2 of 41 residents and failed to provide the receiving entity with proper documentation upon transfer for 1 of 41 residents. (Resident #155, #138, and #434) The findings were: 1. For Resident #155, the facility staff failed to notify the ombudsman of the resident's discharge on [DATE]. Resident #155's minimum data set (MDS) assessment with an assessment reference date of 05/19/25 was signed as completed on 05/23/25. Resident #155's brief interview for mental status summary score was documented as a 15 out of 15; this indicated intact cognition. Resident #155's clinical record was reviewed and indicated the resident was discharged home with home health services on 06/07/25. The Discharge Instructions/Post Discharge Plan of Care - V6 document read the resident's discharge status/facility was Home. The summary/discharge arrangements read in part, Resident will discharge on [DATE] due to an insurance cut. Medical equipment arrangements included a hospital bed with home health arrangements made for in-home physical therapy, occupational therapy, registered nurse and home health aide. Discharge instructions were given to the resident. The clinical record included documentation Resident #155 filed an appeal for discharge. Social services assistant (Other Staff #6) was interviewed on 06/26/25 at approximately 10:15 a.m. Other Staff #6 reported and provided written documentation the appeal was denied and Resident #155 discharged home on [DATE] rather than filing a second appeal. On 06/25/25 the director of nursing (DON) was asked for evidence the ombudsman was provided with notification of Resident #155's discharge. The DON responded the facility staff does not notify the ombudsman of planned discharges, only discharges that were against medical advice (AMA) and discharges to a hospital. On 06/26/26 at 4:04 p.m. during a meeting with the director of nursing, administrator, vice president of operations, regional MDS coordinator, and two regional nurse consultants (RNC #1 and #2), the concern with the ombudsman not being notified of Resident #155's discharge was discussed. No further information was provided prior to the exit conference. 3. For resident #434 (R434), the facility staff failed to provide the receiving entity with proper documentation upon transfer to the hospital and failed to provide the resident with bed hold information. On 6/24/2025 this surveyor interviewed R434 at bedside. They stated they were readmitted to the facility on [DATE] after a brief hospitalization. I had pneumonia and sepsis they said. I didn't know I was sick. The ambulance showed up to get me and took out. I guess it was a good thing though. R434's minimum data set (MDS) assessment with an assessment reference date of 3/28/25 was reviewed and assigned the resident a brief interview for mental status score (BIMS) of 12 out of possible 15, indicating the possibility of mild cognitive impairment. A progress note dated 6/14/25 by the on-call physician service read in part, per nurse patient reported chest pain and SOB (shortness of breath) around 720 am EST patient seen with nurse Per nurse patient points to anterior chest as location of chest pain. Per nurse lungs clear on exam and HR (heart rate) 123 with regular rhythm on palpation. Patient states she has been having chest pain for awhile. States the chest pain is constant, point to her left axilla where pain starts and moves to her mid chest. States the pain feels like a pressure. States SOB started last night and worse this morning. Admits to dizziness and nausea. States nausea present earlier and now gone. The document went on to read, Transfer to Emergency Department via 911 RE: chest pain/SOB/dizziness/nausea -Nitroglycerin 0.4mg PO 1tab q5min prn Chest pain x 3 doses, first dose now Disposition : Transfer to Emergency Department .' An einteract SBAR summary for providers dated 6/19/2025 at 7:35 AM read in part, Change in Condition Nursing observations, evaluation, and recommendations are:While on rounds, resident reported to writer I am experiencing chest pain 6/10, on assessment pain is non-radiating, crackles auscultated to base of R lung, respiration is labored at 27/min, heart rate 122bpm, SpO2 88% (baseline). Writer administered O2 2L/M nasal canula for SOB. Writer contacted thirdeye clinician (name omitted). Orders issued to transfer resident to ED via 911, administer Nitroglycerin 0.4mg PO 1 TAB Q5min PRN for chest pain X3 doses, first dose STAT. Primary Care Provider Feedback : Primary Care Provider responded with the following feedback: A. Recommendations: Transfer resident to Emergency Department via 911 for Chest Pain/SOB/dizziness/nausea. Administer Nitroglycerin 0.4 mg PO 1 TAB Q5min PRN for chest pain X3 doses, first dose STAT. This surveyor was unable to locate any documentation of what the facility provided to the hospital upon R434's transfer. On 6/25/2025 at 3:15 PM this surveyor asked the Regional Director of Clinical Services to provide any evidence that the hospital received the proper information and documentation when resident was sent out and for evidence of the resident being given information about the bed hold policy. On 6/26/2025 the Regional Director of Clinical Services stated they could find no evidence for R434 that the hospital was provided with the proper documentation or that the resident received the bed hold information prior to the discharge on [DATE]. The policy entitled, Bed Reserve Process, was provided and read in part, The Admissions Director will ensure the proper documentation is executed for any patient discharge desiring to voluntarily reserve a bed. 06/27/2025 12:28 PM the survey team met with the Administrator, Director of Nursing, Regional Director of Clinical Services and the Regional [NAME] President of Operations. This concern was discussed at that time. No further information was provided prior to the exit conference. 2. For Resident #138 the facility staff failed to notify the office of the local long-term care ombudsman of a transfer/discharge that occurred on 1/26/25. Resident #138's diagnosis list indicated diagnoses that included, but were not limited to, Chronic Obstructive Pulmonary Disease, Dementia, Anxiety Disorder, Traumatic Brain Injury, Other Specified Disorders of Brain, Anxiety Disorder, Epilepsy, Depression, and Weakness. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 6/1/25 assigned the resident a brief interview for mental status (BIMS) summary score of 14 out of 15 for cognitive abilities, indicating the resident was cognitively intact. A review of the clinical record indicated Resident #138 was transferred to the hospital on 1/26/25. Surveyor requested evidence of notification of the transfer/discharge to the local long-term care ombudsman. On 6/26/25 at 12:47 PM, this surveyor was provided with the ombudsman notifications for January 2025 and Resident #138 was not on the list. The vice president of operations and the social worker both agreed the ombudsman was not notified of Resident #138's transfer/discharge. This concern was discussed on 6/26/25 at 6:04 PM at the end of day meeting with the administrator, vice president of operations, director of nursing, regional nurse consultant #1, and regional nurse consultant #2. Surveyor requested and received a facility policy titled, Notice of Transfer/Discharge which read in part, .7. Provide designated copies of the completed .Notice of Transfer/Discharge form to each of those specified on the form, which includes the Ombudsman .9. Once the document has been scanned into .complete a Social Work and Discharge Planning Progress Note confirming the following .b. Date the notice was sent to the Ombudsman and the method by which it was sent . No further information was provided to the survey team prior to exit on 6/27/25.

Based on staff interview, resident interview, clinical record review and facility document review, the facility staff failed to prepare or orient residents for transfer to the hospital for 1 (one) of 41 current residents in the survey sample, resident #434. The findings include: For resident #434 (R434) the facility staff failed to provide evidence of preparing the resident for a transfer to the hospital on 6/19/2025. On 6/24/2025 this surveyor interviewed R434 at bedside. They stated they were readmitted to the facility on [DATE] after a brief hospitalization. I had pneumonia and sepsis they said. I didn't know I was sick. The ambulance showed up to get me and took out. I guess it was a good thing though. This surveyor asked resident if the staff had explained that they were calling 911 due to a change in condition. No, I didn't know what was happening. The clinical record was reviewed. According to the demographic sheet, R434 is their own responsible party (RP). R434's minimum data set (MDS) assessment with an assessment reference date of 3/28/25 was reviewed and assigned the resident a brief interview for mental status score (BIMS) of 12 out of possible 15, indicating the possibility of mild cognitive impairment. The comprehensive individualized care plan was reviewed. There was no focus for impaired cognition and this surveyor was unable to find a diagnosis for dementia or other diagnosis to support impaired cognition. A progress note dated 6/14/25 by the on-call physician service read in part, per nurse patient reported chest pain and SOB (shortness of breath) around 720 am EST patient seen with nurse Per nurse patient points to anterior chest as location of chest pain. Per nurse lungs clear on exam and HR (heart rate) 123 with regular rhythm on palpation. Patient states she has been having chest pain for awhile. States the chest pain is constant, point to her left axilla where pain starts and moves to her mid chest. States the pain feels like a pressure. States SOB started last night and worse this morning. Admits to dizziness and nausea. States nausea present earlier and now gone. The document went on to read, Transfer to Emergency Department via 911 RE: chest pain/SOB/dizziness/nausea -Nitroglycerin 0.4mg PO 1tab q5min prn Chest pain x 3 doses, first dose now Disposition : Transfer to Emergency Department .' An einteract SBAR summary for providers dated 6/19/2025 at 7:35 AM read in part, Change in Condition Nursing observations, evaluation, and recommendations are:While on rounds, resident reported to writer I am experiencing chest pain 6/10, on assessment pain is non-radiating, crackles auscultated to base of R lung, respiration is labored at 27/min, heart rate 122bpm, SpO2 88% (baseline). Writer administered O2 2L/M nasal canula for SOB. Writer contacted thirdeye clinician (name omitted). Orders issued to transfer resident to ED via 911, administer Nitroglycerin 0.4mg PO 1 TAB Q5min PRN for chest pain X3 doses, first dose STAT. Primary Care Provider Feedback : Primary Care Provider responded with the following feedback: A. Recommendations: Transfer resident to Emergency Department via 911 for Chest Pain/SOB/dizziness/nausea. Administer Nitroglycerin 0.4 mg PO 1 TAB Q5min PRN for chest pain X3 doses, first dose STAT. There was no note located in the clinical record that indicated the staff had attempted to prepare or orient R434 to the transfer to the hospital prior to going out. On 6/26/2025 at 6:03 PM the survey team met with the Administrator, Director of Nursing, Regional Director of Clinical Services, and the Regional [NAME] President of Operations. The above concern was discussed with them at that time. No further information was provided to the survey team prior to the exit conference.

Based on observation, staff interview, clinical record review, and facility document review, the facility staff failed to ensure residents were free of unnecessary psychotropic medications for 2 of 41 sampled residents (Resident #167 and Resident #138). The findings included: 1. For Resident #167, the facility staff failed to monitor behavioral symptoms indicating the continued need for psychotropic medications. Resident #167's diagnosis list indicated diagnoses, which included, but not limited to Severe Dementia with Behavioral Disturbance, Psychosis, Generalized Anxiety Disorder, Major Depressive Disorder, and Adult Failure to Thrive. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 6/04/25 coded the resident as being severely impaired in cognitive skills for daily decision making with short-term and long-term memory problems. Resident #167's comprehensive person-centered care plan included focus areas stating in part the resident was at risk for adverse reactions related to the use of antipsychotics and psychoactive medications with interventions each dated 5/28/25 to monitor for behaviors related to medication use. According to Resident #167's clinical record, they had been taking Quetiapine Fumarate 25 mg 1/2 tablet one time a day in the morning and 25 mg in the evening and Mirtazapine 7.5 mg daily at bedtime since admission on [DATE]. According to the provider orders, the morning dose of Quetiapine Fumarate was being administered for dementia and the evening dose was being given for major depressive disorder. Surveyor reviewed Resident #167's clinical record and was unable to locate documentation of behavior monitoring for the continued use of Quetiapine Fumarate and Mirtazapine. Throughout the course of the survey, surveyor observed Resident #167 lying quietly in bed on each occasion. Resident #167 would open her eyes and smile each time surveyor called her name. On one occasion the resident was observed rubbing the privacy curtain with her fingers, otherwise the resident was quiet and still in the bed. Surveyor reviewed Resident #167's clinical record and noted one episode of agitation on the day of admission. A 5/28/25 7:27 PM nursing progress note read in part .Resident very agitated, redirected, offered po [by mouth] fluid and toileting not effective. Prior to discharge from the acute care hospital, Resident #167 was seen by Psychiatry on 5/27/25, the consult note read in part .She continues to appear mildly somnolent on exam. Given that patient has not been consistently getting her Remeron in the hospital, recommend that it is tapered, and would discontinue it all together if somnolence still does not improve. If patient still appears somnolent, would discontinue morning dose of Seroquel . Remeron dose was reduced to 7.5 mg nightly prior to discharge from the hospital. Surveyor requested and received the facility policy titled Chemical Restraints with an effective date of 1/29/24 which read in part .3. Patients receiving any psychoactive medications, regardless of the reason for use, will be monitored for the occurrence of specific behavioral symptoms .5. The patient will be evaluated for possible dosage reductions . On 6/26/25 at 2:35 PM, surveyor spoke with Regional Nurse Consultant #2 who stated they had no evidence of behavioral monitoring to provide for Resident #167. On 6/26/25 at 6:05 PM, the survey team met with the Administrator, Director of Nursing, Regional Nurse Consultants #1 and #2, and the [NAME] President of Operations and discussed the concerns regarding Resident #167's psychotropic medications including the lack of behavioral monitoring. No further information regarding this concern was presented to the survey team prior to the exit conference on 6/27/25. 2. For Resident #138 the facility staff failed to ensure adequate clinical indication and necessity for the prescribed psychotropic medication, olanzapine. Resident #138's diagnosis list indicated diagnoses that included, but were not limited to, Chronic Obstructive Pulmonary Disease, Dementia, Anxiety Disorder, Traumatic Brain Injury, Other Specified Disorders of Brain, Anxiety Disorder, Epilepsy, Depression, and Weakness. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 6/1/25 assigned the resident a brief interview for mental status (BIMS) summary score of 14 out of 15 for cognitive abilities, indicating the resident was cognitively intact. Review of Section N (Medications) disclosed the resident was receiving antipsychotic medication on a routine basis and the indication for the medication was noted. A medical provider orders included an order for olanzapine 5 mg (milligrams) at bedtime for Dementia with other behavioral disturbance with a start date of 5/25/25. A review of May 2025 and June 2025 MARs (medication administration records) revealed Resident #138 was receiving the medication as ordered. On 6/26/25 at 3:55 PM, the director of nursing (DON) provided surveyor with a copy of the medication regimen review pharmacy recommendations dated 12/30/24 which read in part, .Resident continues to receive the antipsychotic agent Olanzapine .but lacks an allowable diagnosis to support its use .please select an approved diagnosis . The medical provider circled, Schizoaffective Disorder and marked, Agree and signed and dated the pharmacy review on 6/26/25. The DON agreed the recommendation for the appropriate diagnosis for the medication was missed and not addressed until 6/26/25. A review of a medical provider orders revealed an order dated 6/26/25 that read in part, .Olanzapine tablet 5 mg-give 1 tablet by mouth at bedtime for schizoaffective disorder . This concern was discussed on 6/26/25 at 6:04 PM at the end of day meeting with the administrator, vice president of operations, director of nursing, regional nurse consultant #1, and regional nurse consultant #2. Surveyor requested and received a facility policy titled, Medication Regimen Review which read in part, .The physician is to review and sign the patient's individual MRR (medication regimen review) and document that he/she has reviewed the pharmacist's identified irregularities within 30 days of receipt . No further information was provided to the survey team prior to exit on 6/27/25.

Based on observation, staff interview, clinical record review, and facility document review, the facility staff failed to ensure the resident's personal privacy and confidentiality for 1 of 41 sampled residents (Resident #166). The findings included: For Resident #166, a nurse aide discussed the resident's medical condition in the presence of another resident. Resident #166's diagnosis list indicated diagnoses, which included, but not limited to Acute Respiratory Failure with Hypoxia and Type 2 Diabetes Mellitus. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 5/07/25 assigned the resident a brief interview for mental status (BIMS) summary score of 15 out of 15 indicating the resident was cognitively intact. On 6/25/25 at 9:05 AM, surveyor was speaking with a resident in their room when Nurse Aide (NA) #1 entered the room and informed the surveyor that she had a concern about the resident in room (room number omitted) having a rash that was not being treated. Resident #166 resided in the room reported by NA #1. NA #1 made this statement to the surveyor in the presence of the other resident. The other resident immediately stated, see a rash, I'm going to get blamed for that. Surveyor requested and received training records for NA #1 which indicated she had received HIPAA training on 5/01/25. Surveyor requested and received the facility policy titled Confidentiality/Privacy and Social Media which read in part .1. Center Staff .are responsible (via the signing of agreements and/or acknowledgements) for protecting a patient's Protected Health Information (PHI) (which included but is not limited to the patient's identity, photo likeness and medical information) from unauthorized use or disclosure as well as protecting the patient's legal right to privacy, confidentiality, respect, dignity . On 6/25/25 at 5:48 PM, the survey team met with the Administrator, Director of Nursing, Regional Nurse Consultant #1, and the [NAME] President of Operations and discussed the concern of NA #1 discussing Resident #166's health condition in the presence of another resident. No further information regarding this concern was presented to the survey team prior to the exit conference on 6/27/25.

Based on observation, resident interview, staff interview, clinical record review, and facility document review, the facility staff failed to ensure 1 of 41 current residents Resident #122 had incontinent supplies. The findings included: Resident #122 did not have any incontinence supplies available for use. Resident #122's diagnoses included diabetes, muscle weakness, and end stage renal disease. Section C (cognitive patterns) of Resident #122's quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of 04/15/25 included a brief interview for mental status (BIMS) score of 15 out of a possible 15 points. Indicating Resident #122 was cognitively intact. Section H (bowel and bladder) had been coded with a 2 (frequently incontinent) of urine and a 3 (always incontinent) of bowel. Resident #122's comprehensive care plan included the focus area is incontinent of bladder and/or bowels. Interventions included check and change briefs frequently as needed. On 06/24/25 during the initial tour of the facility Resident #122 expressed a concern to the surveyor regarding not having briefs/incontinent supplies. On 06/24/25 at 1:15 p.m., the Central Supply Coordinator stated this resident did not use briefs. On 06/25/25 at 8:19 a.m., during an interview with Resident #122 this Resident stated they did not have any briefs in their room, and they had ordered some from Amazon. On 06/25/25 at 2:41 p.m., during an interview with Certified Nursing Assistant (C.N.A.) #4 this staff stated Resident #122 did use briefs, they had enough briefs, and sometimes they had to go to central supply and obtain the briefs. C.N.A. #4 stated they had several new staff, a lot of new aides and maybe they did not know they had briefs. On 06/25/25 at 5:45 p.m., during an end of the day meeting with the Director of Nursing, Administrator, Regional Nurse Consultant #1 and the Regional [NAME] President of Operations the issue with this resident not having any briefs, the Central Supply Staff not being aware they used briefs, and the Resident having to order their own briefs from Amazon was reviewed. On 06/27/25 at 8:47 a.m., Resident #122 stated their Amazon order had come in, they had briefs now, and the facility staff brought some this morning. Resident #122 stated the facility staff had told him he could send his order back, but he stated I'll just keep it for emergencies. Prior to the exit conference the facility staff provided the surveyor with a copy of an Individual Inservice Record. Education topic was the Central Supply Coordinator will familiarize themselves with the number of residents who require briefs on every floor and the sizes they require. The date on this form was documented as 06/25/25. No further information regarding this issue was provided to the survey team prior to the exit conference.

Based on observation, resident interview, staff interview, clinical record review, and facility document review, the facility staff failed to assess 2 of 41 current residents for self-administration of medications, Residents #22 and #96. The findings included: 1. For Resident #22, the facility staff failed to assess the resident for self-administration of medications. Resident #22 had a bottle of Senokot gummies at the bedside. Senokot is a laxative used to treat constipation. Resident #22's diagnoses included hypothyroidism, rectal prolapse, and adult failure to thrive. Section C (cognitive patterns) of Resident #22's quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of 03/10/25 included a brief interview for mental status (BIMS) score of 14 out of a possible 15 points. Per the MDS manual a score of 14=cognitively intact. Resident #22's comprehensive care plan included the focus area at risk for constipation. Interventions included bowel medication regimen as ordered by MD. On 06/24/25 at 1:10 p.m., the surveyor and Central Supply staff #1 entered Resident #22's room. The surveyor observed a bottle of Senokot gummies at Resident#22's bedside on top of a table. Resident #22 stated they kept them at their bedside and took them as needed. On 06/24/25 at 1:25 p.m., the Director of Nursing (DON) was made aware that Resident #22 had medication at their bedside. On 06/24/25 at 1:30 p.m., the DON stated the resident refused to allow her to remove the medication and they would complete a self-administration assessment of medication for this resident. Resident #22's clinical record included an order dated 09/23/24 for Senokot oral tablet 8.6 mg give 1 tablet by mouth in the morning for bowel regimen use. Patient preferred Senokot gummies per patient request. On 06/24/25 this order was updated to read Senokot give 2 tablets by mouth every 12 hours as needed for constipation unsupervised self-administration. Use patient preferred Senokot gummies at bedside patient request. The facility policy titled, Self-Administration of Medication at Bedside read in part, .patient may request to keep medications at bedside for self-administration in a lock box. 2. Complete Medication Self-Administration Safety Screen assessment. 3. The Interdisciplinary Team will review the assessment and together, use clinical judgement to determine if the patient is eligible. 4. If eligible, medications that are ordered by a provider to be self-administered will be identified in the medical record . The facility staff provided the surveyor with a document titled, MEDICATION SELF-ADMINISTRATION SAFETY SCREEN dated 06/24/25. This document indicated Resident #22 could self-administer medications unsupervised. On 06/25/25 at 5:45 p.m., during an end of the day meeting with the Administrator, Regional [NAME] President of Operations, Nurse Consultant #1, and DON the issue with Resident #22's medications being at the bedside was reviewed. No further information regarding this issue was provided to the survey team prior to the exit conference. 2. For Resident #96, the facility staff failed to evaluate the resident for self-administration of the inhaled medication, Ventolin. The Ventolin inhaler was unsecured and present on the resident's overbed table. Resident #96's diagnosis list indicated diagnoses, which included, but not limited to Chronic Obstructive Pulmonary Disease, Chronic Respiratory Failure with Hypercapnia, and Congestive Heart Failure. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 3/25/25 assigned the resident a brief interview for mental status (BIMS) summary score of 14 out of 15 indicating the resident was cognitively intact. On 6/24/25 at 12:43 PM, surveyor observed a Ventolin inhaler present on Resident #96's overbed table. Resident #96 stated they had a doctor's order to keep the inhaler in their room, and it was a security for them. Resident #96's medical provider orders included an order dated 5/29/25 for Ventolin HFA Aerosol Solution 108 (90 Base) MCG/ACT two (2) puffs every four (4) hours as needed for wheezing. Surveyor reviewed Resident #96's clinical record and was unable to locate evidence of the resident being assessed for self-administration of Ventolin and there was no order for self-administration or approval to keep the medication at the bedside. Surveyor requested and received the facility policy titled Self-Administration of Medication at Bedside with an effective date of 1/29/24 which read in part .1. The patient may request to keep medications at bedside for self-administration in a lock box. 2. Complete Medication Self-Administration Safety Screen assessment. 3. The Interdisciplinary Team will review the assessment and together, use clinical judgement to determine if the patient is eligible. 4. If eligible, medications that are ordered by a provider to be self-administered will be identified in the medical record . On 6/26/25 at 6:05 PM, the survey team met with the Administrator, Director of Nursing, Regional Nurse Consultant #1 and #2, and the [NAME] President of Operations and discussed the concern of Resident #96's Ventolin inhaler being present at the bedside without approval for self-administration. No further information regarding this concern was presented to the survey team prior to the exit conference on 6/27/25.

3. For Resident #167, the facility staff failed to provide evidence of the resident/resident representative being informed of and obtaining consent for the use of the psychotropic medications Quetiapine Fumarate (Seroquel) and Mirtazapine (Remeron). Quetiapine Fumarate is an atypical antipsychotic medication, and Mirtazapine is an antidepressant medication. Resident #167's diagnosis list indicated diagnoses, which included, but not limited to Severe Dementia with Behavioral Disturbance, Psychosis, Generalized Anxiety Disorder, Major Depressive Disorder, and Adult Failure to Thrive. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 6/04/25 coded the resident as being severely impaired in cognitive skills for daily decision making with short-term and long-term memory problems. According to Resident #167's clinical record, they had been taking Quetiapine Fumarate 25 mg 1/2 tablet one time a day at 8:00 AM and 25 mg each evening at 9:00 PM since 5/28/25. The resident had also been taking Mirtazapine 7.5 mg daily at bedtime since 5/28/25. Resident #167's clinical record included an Informed Consent for Psychotropic Medication form dated 6/03/25 which was incomplete. The form did not include Quetiapine Fumarate 25 mg each evening, did not include the targeted behaviors for the use of each medication, and did not include the name of the responsible party spoken to or providing consent. On 6/26/25 at 6:05 PM, the survey team met with the Administrator, Director of Nursing, Regional Nurse Consultants #1 and #2, and the [NAME] President of Operations and discussed the concern with Resident #167's informed consent form. No further information regarding this concern was presented to the survey team prior to the exit conference on 6/27/25. Based on staff interview, clinical record review, and facility document review, the facility staff failed to obtain informed consent from the resident and/or resident representative of the risks and benefits of proposed care, treatment alternatives and/or treatment options for (3) three of (41) forty-one current residents in the survey sample. (Resident #88, Resident #138, and Resident # 167). The findings included: 1.For Resident #88, the facility staff failed to obtain an informed consent to ensure the resident and/or resident representative were informed in advance of the treatment risks and benefits, options, and alternatives in the use of antidepressant medications, citalopram and trazadone. Resident #88's diagnosis list indicated diagnoses that included, but were not limited to, Right Femur Fracture, Chronic Kidney Disease-Stage 3, History of Falls, Dementia, Depression, Atherosclerotic Heart Disease, Weakness, Irritable Bowel Syndrome, Seizures, Hypertension, and Dysphagia. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 4/3/25 assigned the resident a brief interview for mental status (BIMS) summary score of 9 out of 15 for cognitive abilities, indicating the resident was moderately impaired in cognition. A medical provider active orders included an order for citalopram hydrobromide 20 mg (milligrams) one time a day for Depression with a start date of 3/28/25 and an order for trazadone 50 mg at bedtime for depression/sleep with a start date of 4/14/25. A review of the clinical record did not disclose an informed consent for the use of the above-mentioned medications. Surveyor requested evidence of informed consent. On 6/26/25 at 4:53 PM, administrative staff #4 (AS#4) informed surveyor that she could not locate any evidence that the resident and/or resident representative had been informed in advance of the risks and benefits of the medications, treatment alternatives for the medications, or other options. This concern was discussed at the pre-exit meeting on 6/27/25 at 12:28 PM with the administrator, director of nursing, vice president of operations, regional nurse consultant #1, and regional nurse consultant #2. No other information was provided to the survey team prior to exit on 6/27/25. 2. For Resident #138, the facility staff failed to obtain an informed consent to ensure the resident and/or resident representative were informed in advance of the treatment risks and benefits, options, and alternatives in the use of antipsychotic medication olanzapine. Resident #138's diagnosis list indicated diagnoses that included, but were not limited to, Chronic Obstructive Pulmonary Disease, Dementia, Anxiety Disorder, Traumatic Brain Injury, Other Specified Disorders of Brain, Anxiety Disorder, Epilepsy, Depression, and Weakness. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 6/1/25 assigned the resident a brief interview for mental status (BIMS) summary score of 14 out of 15 for cognitive abilities, indicating the resident was cognitively intact. A medical provider orders included an order for olanzapine 5 mg at bedtime for Dementia with other disturbance with a start date of 5/25/25. A review of the clinical record did not disclose an informed consent for the use of the above-mentioned medication. Surveyor requested evidence of an informed consent, but did not receive any. This concern was discussed at the pre-exit meeting on 6/27/25 at 12:28 PM with the administrator, director of nursing, vice president of operations, regional nurse consultant #1, and regional nurse consultant #2. No other information was provided to the survey team prior to exit on 6/27/25.

2. For Resident #167, the facility staff failed to provide assistance with the removal of facial hair. Resident #167's diagnosis list indicated diagnoses, which included, but not limited to Severe Dementia with Behavioral Disturbance, Aphasia, and Adult Failure to Thrive. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 6/04/25 coded the resident as being severely impaired in cognitive skills for daily decision making with short-term and long-term memory problems. Resident #167 was coded as requiring substantial/maximal assistance with personal hygiene. Resident #167's comprehensive person-centered care plan included a focus area stating the resident requires assistance with their activities of daily living. The resident's care plan did not address their desire regarding facial hair. Surveyor observed Resident #167 on 6/24/25 at 10:52 AM, 6/25/25 at 8:41 AM, and 6/25/25 at 2:30 PM and on each occasion the resident had a large amount of thick, white facial hair present on her chin. On 6/25/25 at 2:32 PM surveyor spoke with the Unit Manager (UM) regarding Resident #167's facial hair and the UM stated when staff see facial hair on a resident they take care of it. On 6/25/25 at 2:35 PM, surveyor spoke with Licensed Practical Nurse (LPN) #3 who stated Resident #167 had recently moved to the unit and they contacted the family today requesting permission to shave the resident and permission was obtained. Surveyor reviewed Resident #167's clinical record and noted the presence of facial hair present in the resident's admission profile picture. The resident was admitted to the facility approximately one month ago and had resided on the current unit for six (6) days. According to the clinical record, since admission Resident #167 had received eight (8) showers and the most recent bed bath was provided on 6/24/25. On 6/25/25 at 5:48 PM, the survey team met with the Administrator, Director of Nursing, Regional Nurse Consultant #1, and [NAME] President of Operations and discussed the concern regarding staff failing to assist Resident #167 with the removal of her facial hair. No further information regarding this concern was presented to the survey team prior to the exit conference on 6/27/25. Based on observation, resident interview and medical record review, the facility staff failed to provide activities of daily living care (ADLs) to two (2) of 41 current residents, resident #433, and #167. The findings include: 1. For resident #433 (R433) the facility staff failed to provide a shower or bed bath to the resident for 6 days and failed to provide assistance with incontinent care. R433 was a recent admission and did not have an minimum data set assessment completed yet. On 6/24/2025 at 10:30 AM this surveyor interviewed R433 during the initial tour of the facility. R433 stated he had admitted to the facility for wound care and intravenous (IV) antibiotic therapy for 6 weeks and had been there for 3 nights thus far. R433 was disheveled, had several days of beard growth their and clothing was stained with food particles. When asked if the staff had helped or offered shower or bath, the resident stated, They asked me what I prefer and I told them a bed bath because of my foot. I have a bad wound that doesn't need to get wet in the shower, but they haven't given me one yet. Maybe today is the day. On 6/24/2025 at 1:37 PM this surveyor checked on R433 again. The resident still had the same clothes on and stated no one has mentioned a bath yet. The resident also stated that no one had offered to get a wash cloth and towel, I could wash off if I had the supplies. A Certified Nursing Assistant was outside the room and this surveyor asked them to come in. R433 asked them to bring a wash cloth and towel. On 6/25/2025 at 9:44 AM this surveyor observed the wound care Nurse Practitioner (NP) and Registered Nurse (RN) #8 perform a skin assessment and wound care on R433. During the skin assessment RN #8 pulled R433's pants and adult brief down for the NP to check the skin on the residents bottom. This surveyor could see that R433 was soiled. RN #8 stated, You have some stool back here. Neither staff member made an effort to clean the stool. RN #8 pulled up the brief and pants, covered the resident up and left the room. This surveyor observed RN # 8 and the NP leave the area. Neither of them stopped to notify any other staff member that R433 required attention. This surveyor went back in the resident's room and asked if RN #8 had said anything about getting help for incontinent care. R433 stated, No, she didn't say anything but I can go in there and take care of it. R433 took the wash cloth and towel provided the day before and went into the bathroom. When R433 exited the bathroom they stated, I think maybe I got it all off. I hope I get a good bath today. The clinical record was reviewed. According to the ADL record, resident was due to be bathed on the evening shift of 6/25/2025. On 6/26/2025 at 8:20 AM resident observed lying in bed with eyes closed with the same clothes on as the two days prior. On 6/26/2025 at 10:00 AM resident was interviewed. When asked if the staff had offered a bath R433 stated, No, not yet. Resident had on the same clothes as the two days prior. On 6/26/2025 at 12:06 PM this surveyor interviewed RN # 8. When asked what they did about the stool on R433 the day before they stated, I told an aide. When surveyor informed RN #8 that I had observed them leave the unit without stopping to speak to any other employee they stated, Yeah, I told an aide though. RN # 8 stated they could not recall which aide they told, I don't remember. On 6/26/2025 at 1:00 PM this surveyor requested a print off of R433's bathing record. The record indicated that resident had a bed bath on 6/21/2025 on the night shift. This surveyor asked R433 if staff had bathed them on 6/21/2025 during the night shift. R433 stated, No, no one has bathed me. I didn't get one in the hospital either. This surveyor asked resident if anyone ever came and offer to help him change his brief yesterday, No, I went in there and cleaned myself as best as I could. On 6/25/2025 at 2:20 PM this surveyor interviewed the Director of Nursing. When asked what the expectation is for providing showers or bed baths they stated, Everyone gets one twice a week unless they refuse. They stated refusals would be documented on the ADL record. R433 had no refusals documented. On 6/26/2025 at 6:03 PM the survey team met with the Administrator, Director of Nursing, Regional Director of Clinical Services, and the Regional [NAME] President of Operations. The above concern was discussed with them at that time. No further information was provided to the survey team prior to the exit conference.

Based on observation, staff interview, clinical record review, and facility document review, the facility staff failed to review and revise the comprehensive person-centered care plan for 1 of 41 sampled residents (Resident #3). The findings included: For Resident #3, the facility staff failed to revise the comprehensive person-centered care plan (CPCCP) following the discontinuation of a left-hand splint. Resident #3's diagnosis list indicated diagnoses, which included, but not limited to Vascular Dementia, Hemiplegia and Hemiparesis, and Osteoarthritis of the Left Hand. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 4/28/25 assigned the resident a brief interview for mental status (BIMS) summary score of 5 out of 15 indicating the resident was severely cognitively impaired. Resident #3's current CPCCP included a focus area stating, Resident post CVA [cerebrovascular accident] with LUE [left upper extremity] hand and wrist Hemiplegia and Contracture with an intervention dated 5/29/18 stating in part .assess skin integrity around splint as needed daily. On 6/25/25, surveyor observed Resident #3 during breakfast and at 2:25 PM and the resident was not wearing a left-hand splint on either occasion. On 6/25/25 at 2:27 PM, surveyor spoke with Certified Nursing Assistant (CNA) #1 who stated she was unaware of the resident having a splint and did not apply one today. On 6/25/25 at 2:33 PM, surveyor spoke with Licensed Practical Nurse (LPN) #3 who stated Resident #3's left-hand splint was discontinued by therapy. On 6/25/25 at 2:55 PM, surveyor spoke with the Director of Rehab who stated Resident #3's left-hand splint was discontinued at the end of January because the resident could not tolerate it due to pain. Surveyor requested and received the facility policy titled Care Planning with an effective date of 11/01/19 which read in part .5. Care plans will be updated on an ongoing basis as changes in the patient occur and reviewed quarterly with the quarterly assessment. On 6/26/25 at 6:05 PM, the survey team met with the Administrator, Director of Nursing, Regional Nurse Consultants #1 and #2, and the [NAME] President of Operations and discussed the concern of staff failing to revise the CPCCP following the discontinuation of Resident #3's left-hand splint. No further information regarding this concern was presented to the survey team prior to the exit conference on 6/27/25.

Based on observation, resident and staff interview and clinical record review, the facility staff failed to flush the peripherally inserted central catheter (PICC line) per the provider orders for 1 of 41 current residents in the survey sample, resident #433. The findings include: For resident #433 (R433) failed to flush the resident's PICC line (a device inserted into a large vein in the upper arm that is used to draw blood and give treatments, including intravenous fluids, drugs, or blood transfusions), per the provider order dated 6/21/25. R433 was a recent admission and there was no minimum data set completed yet. R433 was alert and oriented to self, time and place. On 6/24/25 at 10:30 AM, this surveyor interviewed R433 at bedside. R433 stated they were newly admitted to the facility and was there due to a wound infection on their foot. I have to be here for 6 weeks for antibiotics. This surveyor observed a PICC line in the upper left arm and there was an empty bag of intravenous ertapenem on an IV pole at the bedside. This surveyor asked if the staff were flushing the line before and after the medication and resident stated, no, I don't think so. Sometimes they do. They did at the hospital. R433's orders were reviewed. An order entered 6/21/25 read, IV (intravenous) saline lock with 10 cc normal saline for injection flushes every 12 hours and before and after medication administration. A second order read, IV 10 ml normal saline injection before administration of IV medication PRN (as needed). The Medication Administration Record (MAR) for R433 was reviewed. There was no entry on the MAR for flushing the PICC line since admission. There was an entry that read, Assess PICC line site q (every) shift for redness, infiltration, and or swelling and document. Call MD, and one that read, Ertapenem sodium solution reconstituted 1 Gram IV q 24 hours for infection for 37 days. Each of these orders were signed off daily as done. On 6/26/25 at 9:52 AM this surveyor interviewed Registered Nurse (RN) #7. When asked to show surveyor on the MAR an order for the PICC line to be flushed for R433, they stated, There is the order, right here. RN #7 pointed to the order in the clinical record. This surveyor asked to see evidence that the order has been carried out each day as ordered. RN #7 was unable to show any evidence but stated, We are flushing it. According to the INS (infusion nurses society) and the Center's for Disease Control and Prevention, a PICC line should be flushed with 10 ml of 0.9% sodium chloride before and after each antibiotic dose as a standard of practice. On 6/26/25 at 10:15 AM this surveyor went to R433's room. This surveyor asked if anyone had recently flushed the PICC line. R433 stated, She's going to. She just came in and told me she was going to get the stuff to do it. This surveyor asked if this was the first time it was being done and R433 stated, I don't think so, I think they have a time or two. When asked if it had been done daily before and after the antibiotics R433 stated, No, not every time. On 6/26/26 at 6:03 PM the survey team met with the Administrator, Director of Nursing, Regional Director of Clinical Services and the Regional [NAME] President of Operations. The above concern was discussed at that time. This surveyor asked for evidence the PICC line had been flushed daily per provider order. No further information was provided to the survey team prior to the exit conference.