Every finding on record at Franklin County Rehab Center, LLC

Based on interview and record review, the facility failed to ensure that 2 of 2 licensed nurses, a Registered Nurse (RN) and a Licensed Practical Nurse (LPN) (RN #1 and LPN #1) and 4 of 5 Licensed Nursing Assistants (LNAs) in the sample ( LNAs #1, #2, #3, and #4) were assessed for appropriate competencies and skill sets needed to provide resident care based on resident assessment, individual plans of care, and identified in the facility assessment. This has the potential to impact all residents. Findings include:Review of the facility assessment last reviewed by the facility Quality Assessment and Assurance (QAA) committee on 1/22/2026 the facility assessment will be used to: - Inform staffing decisions to ensure that there are a sufficient number of staff with the appropriate competencies and skill sets necessary to care for its residents' needs as identified through resident assessment and plans of care; Under the heading INFORMATION ABOUT OUR STAFF TRAINING/EDUCATION AND COMPETENCIES it refers to a document titled Facility Education/Staff Competencies Necessary To Care For Resident Population that identifies four categories of competencies to include knowledge, assessment, pharmacological/treatment/care considerations, and technical/hands-on skills. This document includes competencies such as wound care, dressing changes, medication administration, activities of daily living, respiratory care, incontinence care, and oral care/grooming to be completed upon hire and annually. Per review of LNA #1's education and competency file she is a traveler and began working at the facility on 1/26/2026. There was no evidence that LNA #1 had been assessed for competency in the areas identified in the facility assessment. Review of LNA #2's education and competency file revealed that there was no evidence the LNA had been assessed for competency in the areas identified in the facility assessment. Review of LNA #3's education and competency file she is a Traveler and began working at the facility on 12/15/2025. There was no evidence in their file that they had been assessed for competency in the areas identified in the facility assessment. Per review of LNA #4's education and competency file she is a traveler who was hired on 10/6/2025. There was no evidence in the file that she had been assessed for competency in the areas identified in the facility assessment. Review of an RN #1 training and competency file revealed that she had not been assessed for competency in the areas identified in the facility assessment. Review of LPN #1 who is a traveler with a date of hire of 6/16/25 revealed that there was no evidence that the facility had assessed her for competency in the areas identified in the facility assessment. Per interview on 4/21/2026 at approximately 3:00 PM the Nurse Educator confirmed that RN #1 had not been assessed for competencies since she took a management position and no longer required competency evaluation. The Nurse Educator stated that travelers/agency staff meet with the Director of Nursing (DON) when they are hired and that she is not involved in the onboarding of agency/travelers. During an interview on 4/21/2026 at approximately 3:25 PM the DON stated that competencies are completed through the travel agency and observed by in-house staff to assess patient preferences, facility-specific preferences, and expectations. The DON confirmed that competencies are not documented for travelers by the facility as they are for in-house staff.

Based on observation and interview, the facility failed to store food in accordance with professional standards for food service safety. This has the potential to impact all residents. Findings include: A kitchen tour was conducted with the Dietary Manager on 4/20/26 at 10:45 AM. Per observation of the kitchen prep area, the following expired items were found: Cream of Tartar dated 6/8/17. Taco seasoning dated 11/7/23. Tarragon dated 5/3/24. Rotisserie seasoning dated 12/12/24. Allspice dated 6/11/19. Per observation of the walk-in refrigerator, the following items were found improperly stored: Pancakes sealed in plastic but not dated. (2) Ziploc bags of fruit that were not dated. Per observation of the walk-in freezer, the following items were found improperly stored: An open sleeve of frozen hamburgers which was not dated. Per interview with the Dietary Manager at the time of the tour, they stated that expired seasonings and spices should be thrown out. They stated that prepared and open food should be labeled with the date it was opened or made and the date that it should be discarded, and containers and packages should be sealed. They confirmed that the above items were either expired or improperly stored. Review of the facility policy dated, Date Marking for Food Safety, dated 9/10/20, states the following. Perishable food shall be clearly marked to indicate the date or day by which the food shall be consumer or discarded. The Head [NAME] or designee shall be responsible for checking the refrigerator daily for food items that are expiring and shall discard accordingly. The dietary manager shall spot check refrigerators weekly for compliance.

Based on observation, interview, and record review, the facility failed to ensure that infection control measures were followed related to preventing contamination of laundry by leaving wet clean laundry in the washer overnight, which has the potential to impact all residents, and failed to ensure that infection control measures regarding hand hygiene were followed during medication administration for 2 of 2 sampled residents (Resident #7 and Resident #40). Findings include: 1) Per interview on 4/22/2026 at 10:30 AM, a member of housekeeping confirmed the process for leaving wet laundry in the washers overnight every day. Per an interview with the Assistant Director of Nursing, who is also the Infection Preventionist, at 9:30 AM on 4/22/2026, she confirmed that laundry should not be left wet overnight in the washers. The facility policy Laundry, last reviewed/revised on 7/6/25, does not address leaving wet clean laundry in the washer overnight, per CDC infection control recommendations. Leaving wet, clean laundry in the washing machine overnight can lead to the growth of mildew (a fungus that grows in warm, damp environments). Some symptoms that exposure to mildew can cause are wheezing, coughing, skin rash, itchy eyes, and runny nose. People with asthma, respiratory illness, and immune disorders, as well as the elderly, are at an increased risk. Work cited: Cleveland Clinic https://health.clevelandclinic.org/mold-what-you-need-to-know-to-cut-your-risk Updated May 26, 2025, Retrieved February 20, 2026 Guidelines for Environmental Infection Control in Health-Care Facilities (2003), G.II. Laundry Facilities and Equipment Part II. Recommendations for Environmental Infection Control in Health-Care Facilities | Infection Control | CDC Last updated January 11, 2024, Retrieved April 23, 2026 2) During observation of medication administration on 4/21/2026 at 8:22 AM, an LPN (Licensed Practical Nurse) did not perform hand hygiene by either using hand sanitizer or soap and water as required when preparing and administering medications for Residents #7 and #40. Facility policy titled Medication Administration, review date 6/24/2025, states that hand hygiene will be performed before and after medication administration. using a hand sanitizer containing at least 60% alcohol or alternatively soap and water. Per interview on 4/21/2026 at 8:30 AM, the LPN confirmed that she did not perform hand hygiene before or after medication administration for Resident #7 and Resident #40 and should have.

Based on interview and record review, the facility failed to review and revise resident care plans for 2 out of 17 sampled residents related to falls (Residents #40, and #48). Findings include:1) Per record review, Resident #40 has diagnoses that include: Anxiety disorder, major depressive disorder, peripheral neuropathy, atherosclerotic heart disease, weakness, presence of artificial hip, peripheral neuropathy, atherosclerotic heart disease, weakness, and presence of artificial hip. Per review of nursing progress notes, Resident #40 was found on the floor of his/her bathroom on 3/25/2026 after experiencing an unwitnessed fall.Per record review of Resident #40's care plan, s/he is at risk for falls related to weakness and peripheral neuropathy. His/Her care plan was last updated on 3/18/2026 with no new interventions entered for the fall on 3/25/2026. Per interview with the Director of Nursing (DON) on 4/21/2026 at 1:00 PM, care plans are revised and updated after each fall. She confirms that Resident #40's care plan was not revised and updated after the fall on 3/25/2026 and should have been.2) Per record review, Resident #48 has diagnoses that include: Muscle weakness, unsteadiness on feet, other drug induced secondary Parkinsonism, hypertensive heart disease with heart failure, congestive heart failure (CHF), major depressive disorder, anxiety disorder, and difficulty walking.Nursing progress notes from 3/21/2026, describe a fall experienced by Resident #48 while s/he was attempting to self-transfer. Per record review of Resident #48's care plan, s/he is at risk for falls related to weakness.Per record review the interdisciplinary team (IDT) met on 3/25/2026 and Resident #48's most recent fall [3/21/2026] was discussed with a statement that care plan had been updated as needed. The care plan was last revised on 3/8/2026 and did not reflect any new fall prevention measures for the fall on 3/21/2026. Per interview with the Director of Nursing (DON) on 4/21/2026 at 1:00 PM, care plans are revised and updated after each fall. She confirms that Resident #48's care plan was not revised and updated after the fall on 3/21/2026 and should have been.

Based on observations and interviews, the facility failed to ensure medications were properly stored for 2 of 17 sampled residents (Resident #30s and Resident #14). This is a repeat deficiency for this facility, with the violation cited during the previous recertification survey dated 3/12/25. Findings include:Per observation on 4/20/2026 at approximately 1:07 PM, Resident # 30 had Biotene lozenges on their bedside table.Per observation on 4/21/2026 at approximately 9:54 AM, Resident #14 had a prescription topical ointment on their bedside table.Per interview on 4/21/2026 at approximately 10:31 AM, Resident #30 stated that the Biotene lozenges (medicated lozenges) are always left at their bedside and that they are allowed to self-administer as many as they need to. Per interview on 4/21/2026 at approximately 10:45 AM, the Assistant Director of Nursing (ADON) confirmed that all medications and medicated products ordered by the provider and received from the pharmacy should not be left at the bedside for residents to self-administer. The ADON confirmed that residents need an order for self-administration. The ADON confirmed that prescribed medicated ointment and the Biotene lozenges should not be at the bedside. Per facility policy titled Medicines, revised date 1/1/2016, it reads . 2) No medicines are allowed to be kept at the resident's bedside at any time unless so prescribed by the physician and determined to be safe by Nursing after completing a self-administration of medication assessment.

Based on observation, interview, and record review, the facility failed to ensure that a resident was provided with an appropriately sized bed for 1 of 17 residents in the sample, (Resident #33). Findings include: Per record review Resident #33 was admitted on [DATE]. A care plan focus dated 3/20/2026 states that Resident #33 is at risk for skin breakdown related to decreased mobility. Interventions include Turn and position every 2 hours and as needed, revised on 3/23/2026. During an interview on 4/20/2026 at 11:37 AM, Resident #33 was observed lying on their back in bed with their feet hanging off the end of the bed by at least 4 inches. Their feet were extended downward with the weight of the blankets. The Resident stated that their feet always hang off because the bed was too short. S/he stated that they are 6' 1 feet tall and did not understand why the bed was so short. The Resident explained that it was hard to reposition themselves because the bed was so small. The Resident also said that staff were aware that the length of the bed caused her/his feet to hang over the end and were trying to get her/him another bed, but it has been a while. Per interview on 4/21/2026 at 11:33 AM the interim Charge Nurse about the resident's bed, she stated that maintenance had been notified of the bed being too short, and they were working to find an adequate solution. Per interview on 4/22/2026 at 12:30 PM the Director of Nursing (DON) and Assistant Director of Nursing confirmed that the facility had been aware that Resident #33's bed was too short and that the Resident's feet hung over the end of the mattress. The DON stated that the facility does not have extra beds to switch out when one doesn't fit a Resident and they had needed to find one that would fit.

Based on interview and record review the facility failed to ensure interventions were implemented, evaluated, and modified after a significant weight loss for one of 17 sampled residents (Resident #5). Findings include: Record review shows that Resident #5 has diagnoses that include multiple sclerosis, dementia, chronic kidney disease, type 2 diabetes mellitus, and hypothyroidism. Resident #5's care plan has a dietary information focus initiated 6/5/24 with an intervention stating I want to maintain my current weight initiated on 6/5/2024. Her/his dietary information care plan has an intervention stating, I have the following dietary risks: Risk for weight fluctuation initiated on 6/5/2024. Resident #5's care plan focus for diabetes mellitus initiated 6/5/24 includes an intervention which states Update MD with health changes initiated on 06/05/2024. Record review shows that Resident #5 weighed 253 pounds on 3/17/2026. The weight documented for Resident #5 on 4/14/26 was 239.8 pounds. Resident #5 was re-weighed on 4/14/26 with a weight of 239.5 pounds. The weight loss of 13.5 pounds or 5.3% in a 27-day period between 3/17/26 and 4/14/26 is a significant weight loss, per MDS (Minimum Data Set) guidelines. Per record review, Resident #5's dietary care plan was not revised to reflect this significant weight loss. Resident #5's medical record did not contain documentation that her/his physician had noted or addressed this significant weight loss. It did not include documentation that the dietitian had noted or addressed the significant weight loss. It did not include documentation that nursing had noted or addressed the significant weight loss, given that two weights were taken on 4/14/26, both reflecting a greater than 5% weight loss in a 27-day period. Per interview with RN #1 (Registered Nurse) and RN #2 on 4/21/26 at 11:36 AM, RN #1 confirmed that that Resident #5's medical record did not contain documentation addressing her/his weight loss, stating as she reviewed the resident's medical record, There's nothing. RN #2 confirmed Resident #5's medical record did not contain documentation noting or addressing the significant weight loss.

Based on interview and record review, the facility failed to ensure 1 of 1 sampled residents (Resident #67) was free from significant medication errors related to staff not verifying that morphine concentration on the bottle matched the written order. Findings include:Per record review, Resident #67 was placed on comfort care on 2/12/2026. Diagnoses for Resident #67 include dementia, hypertensive heart disease, anxiety, depression, lymphedema (swelling caused by accumulation of fluid), and unspecified seizures.During an interview with the Director of Nursing (DON), Assistant Director of Nursing (ADON), and the Administrator on 4/21/2026 at 1:10 PM, they confirmed that a significant medication error involving Resident #67 occurred. The DON stated an order for Morphine 20 mg (milligrams)/5 ml (milliliters) was sent to Health Direct Pharmacy, and per review of the individual narcotic record, the medication was received on 2/25/2026. The DON, ADON, and the Administrator stated the prescribed concentration of (20 mg/5 ml) was printed on a label attached to the bag the medication came in. On 3/16/2026, it was discovered that the bottle of morphine prescribed to Resident #67 had a label stating Morphine 20 mg/1 ml on it (5 times the prescribed concentration). During the interview, the DON, ADON and Administrator confirmed that morphine concentration written on the bottle label was morphine 20 mg/1 ml. Per record review of medication orders, Resident #67 was prescribed Morphine 20mg/5 ml, 1ml [4mg] by mouth every 2 hrs. as needed for pain or shortness of breath (SOB) by primary physician. Per the individual narcotic record and the Medication Administration Record (MAR), Resident # 67 received 1ml doses of Morphine 20mg/ml [20 mg] on 3/1, 3/4, 3/7, 3/12, 3/15/2026, and 1ml doses twice on 3/16/26. Per record review, another order was written by the physician on 3/16/26 to increase morphine to 20mg/5ml, 2.5ml [10 mg] every 6 hrs. for pain or SOB. Per the individual narcotic record and MAR, Resident #67 received 2 doses of 2.5 ml (50 mg) out of the bottle labeled Morphine 20mg/1ml on 3/16/2026. Per interview with the DON and ADON on 4/21/2026 at 1:10 PM, they confirmed their policy for administering medications is to follow the 5 Rights of medication administration, a fundamental framework to protect patients from medication errors (Right medicine, right patient, right dose, right route, right time). This includes confirming that the medication concentration and dosage on the container matches the order written by the primary provider before administering it.

Based on observation, interview, and record review the facility failed to develop a person-centered care plan for 1 of 17 sampled residents (Resident #2) in regard to monitoring behaviors and depression. The findings include:Per record review Resident #2, was admitted to the facility with a diagnosis of depression. Per Resident #2's Minimum Data Set (MDS; a comprehensive assessment used as a care-planning tool) dated 2/11/26, s/he has feelings of depression nearly every day and has behaviors.Per interview on 4/20/2026 at approximately 1:27 PM, Resident #2 was pleasantly answering this surveyor's questions and was making jokes, and overall in good spirits during the interview. However, the resident started to mention with an agitated tone how s/he is always getting a bladder scan and felt that the staff had nothing better to do. Per record review, progress notes dated 4/17/26 and 4/18/26 indicate that Resident #2 has been having an increase in agitation and verbal aggression towards staff. Also, Resident #2 was found to have a diagnosis of depression. The resident has not been care planned for depression or behaviors. Per interview on 4/21/2026 at approximately 1:14 PM, a Registered Nurse (RN) verbalized that resident was having increasing frequency in agitation and behaviors. When offered Geri-psych in the past they have refused the service. The RN verbalized that the resident should be care planned for the behaviors but has not looked at their care plan in some time. Per interview on 4/21/2026 at approximately 2:33 PM, the Assistant Director of Nursing (ADON) verbalized that Resident #2 does exhibit some behaviors at times and that they should be care planned for their behaviors. The ADON was unable to locate behaviors in Resident #2's care plan and confirmed that the resident was not and that they should be care planned for the behaviors and depression. Per interview on 4/21/2026 at approximately 3:09 PM, the MDS Coordinator confirmed that Resident #2 was not care planned for depression and that they should be. Per Policy titled Behavioral Health Services .2. The facility utilizes the comprehensive assessment process for identifying and assessing a resident's mental and psychosocial status and providing person-centered care. This process includes.e. Care plan development and implementation, and evaluation. Per Policy titled: Comprehensive Care Plans Policy Explanation and Compliance Guidelines:.3. The comprehensive care plan will describe, at a minimum, the following:a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.b. Any services that would otherwise be furnished, but are not provided due to the resident's exercise of his or her right to refuse treatment.

Based on interview and record review, the facility failed to notify the resident's physician of a significant health change for 1 of 17 sampled residents (Resident #5), that experienced a significant weight loss. Findings include: Record review shows that Resident #5 has diagnoses that include multiple sclerosis, dementia, chronic kidney disease, type 2 diabetes mellitus, and hypothyroidism. Resident #5's care plan has a dietary information focus initiated 6/5/24 with an intervention stating I want to maintain my current weight initiated on 6/5/2024. Her/his dietary information care plan has an intervention stating, I have the following dietary risks: Risk for weight fluctuation initiated on 6/5/2024. Resident #5's care plan focus for diabetes mellitus initiated 6/5/24 includes an intervention which states Update MD with health changes initiated on 06/05/2024. Record review shows that Resident #5 weighed 253 pounds on 3/17/2026. The weight documented for Resident #5 on 4/14/26 was 239.8 pounds. Resident #5 was re-weighed on 4/14/26 with a weight of 239.5 pounds. The weight loss of 13.5 pounds or 5.3% in a 27-day period between 3/17/26 and 4/14/26 is a significant weight loss, per MDS (Minimum Data Set) guidelines. Review of the facility policy titled Resident Status, revised 1/1/2016, states that the Charge Nurse is responsible for calling the resident's physician in case of a sudden change in resident condition. Per interview with RN #1 (Registered Nurse) and RN #2 on 4/21/26 at 11:36 AM, RN #1 confirmed that nursing had not notified Resident #5's physician about this health change, stating as she reviewed the resident's medical record, There's nothing. RN #2 confirmed the physician had not been notified about this change.

Per observation, interview, and facility policy review, the facility failed to ensure medications were removed from the medication storage room use when expiration date has been reached. Findings include: Per observation on [DATE] at 12:50 PM during the inspection of the facility's one medication storage room, the following medications were found to have expired: 1 box Bisacodyl 5 mg laxatives exp: ,d+[DATE] 2 Glucagon Emergency Kits (used in emergencies to treat significantly low blood sugars) exp: ,d+[DATE] 6 Salonpas pain patches exp: ,d+[DATE] 1 Pink Bismuth 8 oz bottle exp: ,d+[DATE] 5 Bottles of Aspirin 325 mg tab count: 100 per bottle exp: ,d+[DATE] Per facility Medication Storage policy [last reviewed/revised [DATE]] states, Policy Explanation and Compliance Guidelines: 8. Unused Medications: The Pharmacy and all medication rooms are routinely inspected by the consultant pharmacist for discontinued, outdated, defective, or deteriorated medications with worn, illegible, or missing labels. Per interview on [DATE] at 12:55 PM, LPN #1 confirmed the above medications had not been removed from the medication room when they expired.

Based on observation, interview, and record review, the facility failed to follow professional standards related to assessing and monitoring a large bruise for 1 of 22 residents (Resident #33). Findings include: Per observation on 3/10/2025 at 1:42 PM Resident #33 was observed to have a large bruise on his/her left outer thigh, approximately seven-inches in diameter. Per review of the Lippincott Manual of Nursing [edition 11, 2018], The standards of care for professional nursing include assessment, diagnosis, implementation and evaluation. Departure from Standards of Care include Failure to adhere to facility policy or procedure guidelines. Failure to monitor or observe a patient's clinical status adequately, failure to make prompt, accurate entries in a patient's medical records. Per record review, there was no documented evidence that the bruise had been assessed or monitored. An interview was conducted with Licensed Practical Nurse (LPN) #1 and Registered Nurse (RN) #1 on 3/11/2025 at 2:30 PM. Per interview, LPN#1 and RN#1 confirmed there was no assessment of, or documentation related to the bruise on Resident #33's left outer thigh. The DON [Director of Nursing] was present during the interview. She confirmed that she was aware of the bruise, and stated Resident #33 did not know how it happened.

Based on observation, interview, and record review, the facility failed to ensure that 1 of 5 sampled resident's (Resident #45) was free from unnecessary psychotropic medications. Findings include: On 3/11/24 at 1:20 PM Resident #45 was observed sitting in the hallway sleeping in their wheelchair. After approximately 30 minutes an LNA (licensed nursing assistant) attempted to rouse resident #45. Resident #45 briefly woke up and indicated that they would like to go to their room. The LNA wheeled Resident #45 into their bedroom. At 3:00 PM on 3/11/25 Resident #45 was observed sitting in their wheelchair pointed directly at the corner of their room staring at the wall with no music, TV, or other stimuli present. When asked questions, Resident #45 did not respond. Per record review Resident #45 is prescribed 0.5 mg of Ativan every 6 hours as needed for anxiety for 30 days **reassess after 30 days**. This order was entered on 2/18/25. A facility policy titled Use of Psychotropic Medication, which was implemented by the facility on 12/20/2021, states If the attending physician or prescribing practitioner believes that it is appropriate for the PRN [as needed] order to be extended beyond 14 days, he or she shall document their rational in the resident's medical record and indicate the duration for the PRN order. There was no documented evidence that the attending physician documented a rational for extending Resident #45's Ativan for 30 days instead of 14 days as indicated in the facility's policy. In an interview on 3/12/25 at 9:50 AM the Unit Manager confirmed that the attending physician who extended Resident #45's Ativan order to 30 days and did not document a rational in Resident #45's medical record.

Based on observation, interview, and record review, the facility failed to promptly provide routine and emergency dental services to meet the residents' needs related to loose decaying teeth for 1 of 17 residents in the applicable sample (Resident #7). Findings include: A record review reveals Resident #7 has resided at the facility since 01/6/21; diagnoses include adult failure to thrive. An interview on 12/4/23 at approximately 1:30 PM, Resident # 7 is observed to have several missing teeth and obvious decay on most of her/his remaining teeth; there are pockets of black decay evident in and around the gaps with broken teeth visible. Resident #7 explains that it has become difficult to chew food, and some of the teeth are loose and uncomfortable. She/he had a bottom bridge, but it has been missing for quite some time. Her/his son is aware and wants to use a family friend who is a dentist to save money. She/he has asked about the appointment but does not know if it is scheduled. A record review reveals a nursing note dated 9/28/23 indicating, [Resident # 7] came to this nurse regarding her bottom teeth [S/he] has had increased difficulty chewing food and feels embarrassed by having little to no bottom teeth .Resident #7's son was called and is going to come in to speak with [Resident #7] today and to set up an appointment with a family dentist that she will feel comfortable at. An interview with the Unit Manager on 12/6/2023 at approximately 9:29 AM reveals no evidence of any scheduled dental care for Resident #7. On 12/6/2023 at approximately 10:30 AM, the Director of Nursing and the Assistant Director of Nursing confirmed no evidence of scheduled dental care, and the facility had failed to assist Resident #7 in obtaining routine and 24-hour emergency dental care.

Based upon interview and record review, the facility failed to review and revise Care Plans related to fall prevention for 3 residents [Res. #42, #22, and #40] of 21 sampled residents. Findings include: 1). Per record review, Res. #42 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Progress notes record the resident requires 'a maximum assist of two to three persons for turning, repositioning in bed and transfers with mechanical lift and three persons. admitted for worsening dementia with possible Long Term Care placement due to increased need for 24 hour a day care.' Progress notes also record 'Alert and oriented to self only .Lives in her own world. Fall risk'. On the day of h/her admission, Res. #42's Care Plan was initiated and identified the resident as 'at risk for falls related to a history of several recent falls at home, confusion and impulsivity. H/her fall risk score upon admission = 17, indicating a high risk for falls.' An interview was conducted with the Director of Nursing [DON] and the Long Term Care Unit Manager [LTC UM] on 12/01/21 at 1:00 PM. The DON and LTC UM stated that a fall risk assessment should be completed as soon as possible after each fall by a resident, and that a resident's Care Plan should be updated/revised with new interventions after each fall. Per review of Res. #42's medical record, on 11/4/21 at 4:30 PM Res. #42 'yelled for help from [h/her] room, upon entering room the resident was observed lying in prone position on floor at the foot of [h/her] bed. Resident was noted to have [h/her] head near the bed and feet towards the wall .Resident with prior history of falls, has poor safety awareness.' Per record review and confirmed during the interview with the Director of Nursing [DON] and the Long Term Care Unit Manager [LTC UM] on 12/01/21 at 1:00 PM, the DON and LTC UM stated that a fall risk assessment should have been completed after Res. #42 fell on [DATE] but was not. The DON and LTC UM further stated that Res. #42's Care Plan should have been reviewed and revised to include additional interventions after the fall on 11/4/21 in order to prevent future falls but was not. 2.) Res. #22 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Res. #22's Care Plan, dated 9/11/2020 identified the resident 'at risk for falls related to a history of recent falls, impaired cognition, incontinence, and seizures. [H/she] is a high fall risk.' An interview was conducted with the Director of Nursing [DON] and the Long Term Care Unit Manager [LTC UM] on 12/01/21 at 1:00 PM. The DON and LTC UM stated that a fall risk assessment should be completed as soon as possible after each fall by a resident, and that a resident's Care Plan should be updated/revised with new interventions after each fall. Per review of Res.#22's medical record, on 7/19/21, 'This RN was called down to [Res. #22's] room at 9:45 AM related to [Res. #22] falling in the bathroom. When this writer entered the bathroom [Res. #22] was sitting on the floor with h/her back against the wall. An LNA found [Res. #22] in h/her bathroom after h/her fall.' A Care Plan note, dated 10/12/21, approximately 3 months after the fall on 7/19/21, records Res. #22 'had a fall on 7/19/21 with no injuries noted. Fall assessments completed per protocol.' Per record review, there was no fall risk assessment completed after Res. #22's fall on 7/19/21. A fall risk assessment dated almost 2 months later, on 9/2/21, records 'History of falls: No falls=0'. Per record review and confirmed during the interview with the Director of Nursing [DON] and the Long Term Care Unit Manager [LTC UM] on 12/01/21 at 1:00 PM, the DON and LTC UM stated that a fall risk assessment should have been completed after Res. #22 fell on [DATE] but was not. The DON and LTC UM further stated that Res. #22's Care Plan should have been reviewed and revised to include additional interventions after the fall on 7/19/21 in order to prevent future falls but was not. 3.) Per review of Resident #40's record, Resident #40 sustained falls at the facility on 1/30/21, 4/13/21, 5/28/21, 6/8/21, 8/22/21, 10/12/21, 10/25/21, and 11/3/21. Per review of Resident #40's care plan, there is a care plan focus of [Resident #40] is at risk for falls related to history of falls, poor safety awareness, and rolling walker recommended for ambulation which [they] often do not use initiated on 5/27/19. All interventions under this care plan focus were added to the care plan on 5/27/19. There have been no updates to the care plan interventions since 5/27/19. Per review of the facility's policy Fall Prevention and Post-Fall Protocol, bullet #9 under the section Post fall assessment/instructions states, Interdisciplinary team will review and revise care plans as necessary after each fall. The team will determine if additional interventions/strategies can minimize or prevent additional [falls]. Per interview on 12/1/21 at approximately 12:00 PM, the Charge Nurse discussed many interventions that have been implemented following Resident #40's repeated falls to try and prevent further falls. These include removing tray tables from the room, 1:1 observation, keeping their bed in the lowest position, and others. The Charge Nurse confirmed that these interventions were not documented in Resident #40's care plan.

Based on observation, staff interview, and record review, the facility failed to store food and drink in accordance with professional standards for food service safety as evidenced by the presence of expired food items and opened perishable food items without proper storage. Findings include: 1. Per observation on [DATE] at approximately 10:00 AM, the front kitchen fridge contained an opened bottle of thickened orange juice. There was no open date written on the bottle. The manufacturer's instructions on the bottle instructs the user to discard the contents within 10 days of opening. Per interview with the Dietary Manager at the time of observation, the Dietary Manager confirmed that this bottle was not labeled with an open date. Per observation on [DATE] at approximately 12:30 PM, the long-term care unit nourishment kitchen fridge contained the following items: - An unopened single-serve container of yogurt with an expiration date of [DATE]. - An opened bottle of thickened orange juice without an open date written on the bottle and manufacturer's instructions on the bottle to discard the contents within 10 days of opening. - An opened bottle of thickened water without an open date written on the bottle and manufacturer's instructions on the bottle to discard the contents within 10 days of opening. - An opened bottle of a resident's personal vegetable juice without an open date written on the bottle and manufacturer's instructions on the bottle to discard the contents within 14 days of opening. Per observation on [DATE] at approximately 12:40 PM, the rehab unit nutrition fridge contained an opened bottle of apple juice without an open date on the bottle and manufacturer's instructions on the bottle to discard the contents within 14 days of opening. Per interview on [DATE] at approximately 12:45 PM, the Dietary Manager confirmed the presence and condition of these food items. Per review of the facility's policy Date Marking for Food Safety, the policy states, 2. The food shall be clearly marked to indicate the date or day by which the food shall be consumed or discarded. 3. The individual opening or preparing a food shall be responsible for date marking the food at the time the food is opened or prepared. Per interview on [DATE] at approximately 3:30 PM, the Dietary Manager confirmed that the observed expired/unlabeled food and drink items were not stored appropriately.

Based on staff interview and record review, the facility failed to ensure a resident's drug regimen is free from unnecessary [CONDITION(S)] drugs as evidenced by drugs used without adequate indications for use and PRN (as needed) drugs used without a defined duration for one of 5 sampled residents (Resident #40). Findings include: 1. Per review of Resident #40's MAR (medication administration record), Resident #40 was ordered PRN [MEDICATION(S)] (a medication for anxiety) and scheduled [MEDICATION(S)] (an antipsychotic). The [MEDICATION(S)] order placed on 11/15/21 reads, [MEDICATION(S)] 0.5 mg tablet - give one tablet by mouth every 6 hours as needed for anxiety/agitation. There is no designated end date or duration ordered for this medication. The [MEDICATION(S)] order placed on 6/10/21 reads, [MEDICATION(S)] 10mg tablet - give one tablet by mouth every morning. There is no indication in the order of what specific condition or diagnosis the [MEDICATION(S)] is ordered to treat. Per interview on 12/1/21 at approximately 2:00 PM, the Director of Nursing confirmed that the [MEDICATION(S)] and PRN [MEDICATION(S)] orders do not meet the regulatory requirements for [CONDITION(S)] medications.

Per staff interview and record review, the facility failed to ensure that the resident assessment accurately reflects the resident's status for two of 21 residents (Resident #7 and Resident #12). 1. Per review of the MDS (minimum data set) assessment from 6/9/21, Resident #7 was marked as having had a [CONDITION(S)] (urinary tract infection) in the last 3 months. Per review of the resident record, Resident #7 had a laboratory confirmed [CONDITION(S)] in April of 2021 and was prescribed antibiotics for treatment. Per review of the MDS assessment from 9/8/21, Resident #7 was again marked as having had a [CONDITION(S)] in the last 3 months. Review of the resident record did not show any indication of Resident #7 having had a [CONDITION(S)] during that time period. Per interview on 11/29/21 at approximately 3:00 PM, the MDS Coordinator confirmed that the documentation of a [CONDITION(S)] in the 9/8/21 MDS assessment for Resident #7 was done so in error. 2. Per review of Resident #12's record, Resident #12 has had a small stage 2 pressure ulcer on their right second toe since March of 2021. Weekly skin assessments in the record show that the pressure ulcer has been present since its discovery in March 2021. Per review of the MDS assessment from 6/9/21, Resident #12 was marked as not having any pressure ulcers in the last 3 months. Per interview on 12/1/21 at approximately 11:00 AM, the MDS Coordinator confirmed that the documentation of no pressure ulcers in the 6/9/21 MDS assessment for Resident #12 was done so in error.

Based on record review and staff interview, the facility failed meet professional standards of quality regarding nursing assessment by a registered nurse of a change in condition for 1 of 19 residents sampled (Resident #38). Findings include: Per record review, Resident #38 has dementia and is a fall risk. On the morning of 5/15/16 at 4:30 AM, the resident had a fall from bed and was discovered by a Licensed Nursing Assistant who heard a noise from the room. The LPN (Licensed Practical Nurse) who was on duty came into the room and checked the resident for injury. The resident denied having any pain. When the LPN checked the resident's eyes as part of a neurological assessment, they noted in their documentation that the left pupil was sluggish when shining light in the eye, and the right pupil was not reactive to light. This is an abnormal finding that could indicate a head injury. The LPN waited until a Unit Manager came in at 5:51 AM, and then had this RN also check the resident's pupils. The RN noted similar findings with the pupil check, but stated to the surveyor on 6/19/19 at 10:43 AM, that they did not complete a full nursing assessment of the resident at that time. Per interview on 6/19/19 at 3:10 PM, the LPN stated that the resident was not very cooperative with the pupil check, was at their baseline for responsiveness to questions, and reported having no pain. The RN also stated that the resident was not very cooperative by being still with the pupil check, but also saw that the left pupil was slow to react and the right one not reacting to light. Neither of the nurses notified the doctor (MD) at that time to see if they thought the resident needed to be evaluated at the emergency room . Per interview on 6/19/19 at 2:44 PM, the Director of Nursing confirmed that the LPN who first responded to the early morning fall did not notify the MD, or call for an RN to assess the resident until the Unit Manager came in almost an hour and a half later, and that the RN at that time had not fully assessed the resident for injury. The DNS also confirmed that unusual neurological signs should have been reported to the MD immediately after the fall. In the State Board of Nursing Scope of Practice & Decision Tree for RN, APRN, and LPN the following is stated: LPN role in assessment, planning, and implementation of a strategy of care: -LPNs may not independently assess the health status of an individual or group and may not independently develop or modify the plan of care. LPNs may contribute to the assessment and nursing care planning processes; however, patient assessment and care plan development or revision remain the responsibility of the RN/APRN/licensed physician/licensed dentist. -LPNs may not modify a patient care protocol. If the situation and/or data collected by the LPN are not clearly consistent with a protocol, the LPN must consult with the supervising professional or authorized provider before taking action or making a recommendation to a patient.

Based on record review and staff interview, the facility failed to notify the physician regarding a change in condition for 1 of 19 residents sampled (Resident #38). Findings include: Per record review, Resident #38 has dementia and is a fall risk. On the morning of 5/15/16 at 4:30 AM, the resident had a fall from bed and was discovered by a Licensed Nursing Assistant who heard a noise from the room. The LPN (Licensed Practical Nurse) who was on duty came into the room and checked the resident for injury. The resident denied having any pain. When the LPN checked the resident's eyes as part of a neurological assessment, they noted in their documentation that the left pupil was sluggish when shining light in the eye, and the right pupil was not reactive to light. This is an abnormal finding that could indicate a head injury. The LPN waited until a Unit Manager came in at 5:51 AM, and then had this RN (Registered Nurse) also check the resident's pupils. The RN noted similar findings with the pupil check, but stated in interview on 6/19/19 at 10:43 AM, that they did not complete a full nursing assessment of the resident at that time. Per interview with the LPN on 6/19/19 at 3:10 PM, the LPN stated that the resident was not very cooperative with the pupil check, was at their baseline for responsiveness to questions, and reported having no pain. The RN also stated that the resident was not very cooperative by being still with the pupil check, but also saw that the left pupil was slow to react and the right one not reacting to light. Neither of the nurses notified the doctor (MD) at that time to see if they thought the resident needed to be evaluated at the emergency room . Per interview on 6/19/19 at 2:44 PM, the Director of Nursing stated that the resident had behavior changes the day before this incident, and was upset and anxious after a family visit. The MD was notified of the fall and the behavior changes later that morning, and gave orders for a urinalysis and bloodwork to determine if there was a medical reason. The resident continued to have behavior changes, but according to the DNS did not show any signs of injury from the fall. Later that day on 5/15/19, the Unit Manager witnessed the resident attempting to stand from a wheelchair, fell backwards and struck their head on the floor. The resident was transferred to the hospital ED at that time, and diagnosed with [REDACTED]. Per interview on 6/19/19 at 2:44 PM, the Director of Nursing confirmed that the LPN who first responded to the early morning fall did not notify the MD, or call for an RN to assess the resident until the Unit Manager came in. The DNS also confirmed that unusual neurological signs should have been reported to the MD immediately after the fall.