Every finding on record at Frederick Crossing of Journey

Based on administrative record review and staff interviews, it was determined that the facility staff failed to immediately report an injury of unknown origin to the facility administration and failed to report the injury of unknown origin to the state agency immediately but not later than 2 hours after becoming aware of the injury. This was evident for 1 (#1) of 1 residents reviewed for a facility reported incident. The findings include: Per the Centers for Medicare & Medicaid Services for an injury of unknown origin, the nursing standard of practice dictates a systematic, four-step approach: immediate assessment of the patient, strict objective documentation, thorough internal investigation, and mandatory reporting to supervisors and regulatory authorities to rule out abuse or neglect. On 6/16/26 at 10:07 AM, a review of facility reported incident 3002787 alleged a staff member struck Resident #1 in the head during the night shift. Resident #1 reported the allegation to his/her representative, and the resident's representative then alerted the charge nurse. The resident alleged incident occurred on night shift, between 5/2/26 and 5/3/26 and Resident #1 was found to have redness to the left side of his/her forehead and an abrasion. Further review of the self-report revealed staff became aware of the incident on 5/3/26 at 12:20 PM, the Nursing Home Administrator (NHA) was notified of the incident on 5/3/26 at 12:30 PM, and the facility reported the incident to the state agency, the Office of Health Care Quality (OHCQ), on 5/3/26 at 1:10 PM. On 6/16/26 at 1:27 PM, the facility's follow-up investigation report form, which documented the steps taken by the facility to investigate the allegation, was reviewed. A summary of interviews with the alleged victim and/or responsible party documented a Geriatric Nursing Assistant (GNA) originally noted the discoloration to Resident #1's head when the GNA was passing trays, and the resident told the GNA that s/he had done it to him/herself. Resident #1's representative arrived at the facility around 12:30 PM and was told by the resident that someone had hit him/her in the head. The representative immediately notified the nurse. A summary of interviews with staff documented that the discoloration of Resident #1's left forehead was observed in the morning of 5/3/26 and Resident #1 told the GNA that s/he had done it to him/herself. Prior to the arrival of Resident #1's representative to the facility, The abuse allegation was not made by Resident #1 prior to the arrival of his/her representative's to the facility. The facility's investigation concluded that the allegation of abuse could not be verified or refuted due to insufficient information to determine whether or not the allegation had occurred. On 5/3/26, in a statement following the incident, GNA #3 stated s/he went into Resident #1's room on 5/3/26 at 9:15 AM to give the resident his/her breakfast tray and noticed a mark on the left side of Resident #1's face. GNA #3 asked Resident #1 if s/he had scratched it and the resident said no, that s/he had hit it. GNA #3 asked Resident #1 if the nurse knew about the bruise, and the resident said the nurse was aware. On 5/4/26, in a statement following the incident, Licensed Practical Nurse (LPN) #5 documented s/he was the nurse assigned to Resident #1 on the day of the incident (5/3/26) and around 8:30 AM, s/he went into the resident's room to administer medications. At that time, LPN #5 noticed a bruise on Resident #1's face and thought the bruise appeared old, and thought the resident may have scratched him/herself. LPN #5 did not ask the resident what happened because Resident #1 kept telling LPN #5 to get out and leave him/her alone. LPN #5 then left the room to continue with the medication pass. Resident #1's representative later passed LPN #5 in the hallway, entered the resident's room, then came out of the room and asked LPN #5 if s/he saw the bruise on Resident #1's face. LPN #5 told the representative s/he had seen the bruise and thought it looked old. The representative said it was not old and alleged someone from night shift punched Resident #1. LPN #5 then notified the supervisor. LPN #5, with the supervisor, went to Resident #1's room and were told by resident's representative that GNA #3 knew what happened to Resident #1's face. GNA #3, was contacted, came to the room and stated that when s/he asked Resident #1 what happened to his/her face, the resident said s/he hit it and the resident said that the nurse knew about it. GNA #3 stated s/he did not go to the nurse at that time because Resident #1 said the nurse was aware. The facility's investigation documented the bruise on Resident #1's forehead was observed by LPN #5 on 5/3/26 around 8:30 AM and GNA #3 observed the bruise on Resident #1's forehead in the morning of 5/3/26. The Administrator was not notified of the resident's left forehead bruise and abrasion, which was an injury of unknown origin, until 5/3/26 at 12:30 PM, when the facility staff were made aware of Resident #1's allegation of abuse which alleged the resident's forehead injuries were from from the abuse. The facility reported the abuse allegation to the state office on 5/3/26 at 1:10 PM, which was greater than 2 hours after the facility staff observed the injury of unknown origin on Resident #1's forehead. On 6/17/26 at 12:11 PM, during an interview, LPN #5 stated when s/he first saw the bruise on the resident's face, Resident #1 was asleep and s/he didn't want to wake him/her. LPN #5 state the bruise looked dark, and s/he assumed it was an old bruise. LPN #5 stated that because s/he works PRN (as needed), s/he wanted to look at his/her notes and investigate it as s/he had not seen the resident for days or weeks, and because of the color of it, assumed it was an old bruise. LPN #5 stated that s/he was going back to the resident's room for the 2nd time when s/he saw the resident's representative coming down the hall, found out about the resident's allegation and reported it to the supervisor. The concerns with the facility staff failing to immediately report an injury of unknown injury to the facility's administration was discussed with the Assistant Director of Nurses (ADON) and the Corporate Nurse on 6/17/26 at 2:49 PM. At that time, the Corporate Nurse acknowledged the concerns and stated that following the facility's investigation of the allegation of abuse, the facility had an Ad Hoc (impromptu) QAPI (Quality Assurance and Performance Improvement) meeting, however, late reporting had not been identified.

Based on record review and staff interviews it was determined the facility staff failed to promptly conduct a thorough assessment of a resident after an injury of unknown origin. This was evident for 1 (#1) of 1 resident reviewed for abuse.The findings include:Per the Centers for Medicare & Medicaid Services for an injury of unknown origin, the nursing standard of practice dictates a systematic, four-step approach: immediate assessment of the patient, strict objective documentation, thorough internal investigation, and mandatory reporting to supervisors and regulatory authorities to rule out abuse or neglect. Complaint #3002103 and facility reported incident (FRI) #3002787 were reviewed concurrently on 6/16/26 at 9:35 AM. The complaint indicated that Resident #1 was punched 2 times by a geriatric nursing assistant (GNA), resulting in a gash on the left temple with bruising. The FRI's investigation documentation included statements signed by staff which revealed:LPN #5 stated she went to Resident #1's room around 8:30 AM to administer medication. Resident #1 asked her to just give me my (medication) and get out. At that time, I noticed a bruise to (Resident #1's) face. The bruise appeared old, and I thought maybe s/he scratched him/herself because s/he's known for scratching at hitting staff. I didn't ask him/her what happened because s/he kept repeating, (LPN#5) get out, leave me alone. I left his/her room and continued my med pass. She indicated that a few minutes later the resident's family member came in to visit and reported the resident had been struck by a GNA. The statement from RN #6 a Unit Manager/Shift supervisor indicated that she was alerted by LPN #5 before lunch, around 12 that the family of Resident #1 was reporting that someone hit (the resident); At which time she and LPN #5 went to the room to assess the resident. This was 3 1/2 hours after LPN #5 initially observed the injury. Review of the Visitor's Log confirmed Resident#1's family members signed in at 12:08 PM on 5/3/26. During an interview on 6/17/26 at 12:08 PM, LPN #5 was asked what she did when she first observed the injury to Resident #1's head/face on 5/3/26 at 8:30 AM. She indicated that the resident was asleep and she didn't want to wake him/her. So, she continued to pass medications then came back later.This varied from her signed statement in which she indicated that the resident was yelling at her to get out and leave me alone. LPN #5 went on to say the injury looked dark. She thought it looked old and she wanted to look at notes. She indicated that she continued to pass medications and by the time she came back to the resident the family member was there. She confirmed she was not informed about an injury or bruise during morning report from the previous shift. She was asked where she documented the initial assessment of the resident and injury. She indicated she put a note in the record, and the supervisor said she was going to handle it. She was asked if anyone initiated neurochecks She indicated yes, the supervisor said she'd handle it, I didn't do any neurochecks. Neurological Assessments (neurochecks): include a full set of vital signs(blood pressure, pulse, respirations, and temperature), check pupils for size and reaction to light, weakness on one or both sides, level of consciousness. The purpose of neurochecks is to monitor the resident for symptoms that may indicate a brain injury following a head injury or fall in which the resident is known to have hit their head or if it is unknown.Neurochecks should be started as soon as a potential head injury is identified and follow a protocol with a typical frequency of every 15 minutes x4, every 30 minutes x 2, every hour x 3, every 4 hours x 4 then every 8 hours x 3. This is to facilitate early detection if changes in neurological status occur, indicating a potentially serious head injury. A review of Resident #1's medical record on 6/17/26 at 9:00 AM revealed:An eINTERACT Change in Condition Evaluation completed by LPN #5 dated 5/3/26 12:44 PM. It summarized that the resident's family member reported the resident had a wound/bruise to left face and the resident reported that a GNA hit him/her on night shift. VS were obtained 5/3/26 12:46 PM. This was approximately 4 1/4 hours after LPN#5 initially observed the injury. The sections for Behavioral, Respiratory, Cardiovascular, Abdominal/GI, Genitourinary, Pain and Neurological, all indicated Not clinically applicable to the change in condition being reported.Skin Status Evaluation indicated that a skin assessment relevant to the change in condition was reported: described as Skin tear and Wound; Not associated with significant pain or bleeding and described as apparently minor recent wound now developing redness, swelling or pain.Location and details: Site: Face, Description: left face. It did not identify the size, type, or color of the wound, if there was any bleeding or drainage, redness or swelling or the condition of the surrounding tissue. There was no assessment of the residents' pain level or changes in the residents' emotional wellbeing. There was no indication that neurochecks were started.On 6/17/26 at approximately 2:25 PM the acting Director of Nursing (DON) provided a Neurocheck Assessment log which indicated neurochecks were initiated at 1:45 PM by someone with the same initials as LPN#5. This was approximately 5 1/4 hours after LPN#5 initially observed Resident #1's injury. A Skin Evaluation note by the supervisor RN #6 on 5/3/26 at 2:46 PM, included only Left forehead bruise. There was no assessment of the wound. A Progress note by RN #6 at 8:55 PM described a discussion with the resident regarding the incident and included On his/her left temple there was 2 bruises areas, 1 was opened with no drainage noted. MD was notified She did not conduct a complete wound assessment. This was approximately 10 1/2 hours after LPN #5 first observed Resident #1's injury. The ADON and Corporate Nurse were made aware of these concerns on 6/17/26 at approximately 2:45 PM.

Based on observation, record review, and interview, it was determined that facility staff failed to ensure that residents were free of accidents and hazards. This was evident for 1 (#2) of 2 residents reviewed for falls.The findings include:Care plan - is a guide that addresses the unique needs of each resident. It is used to plan, assess, and evaluate the effectiveness of the resident's care. A review of the facility's Fall Prevention Program dated 2/1/24 revealed in section 6. High Risk Protocols, c. provide interventions that addressed unique risk factors measured by the risk assessment tool; d. provide additional interventions as directed by the resident's assessment, including but not limited to an increased frequency of rounds and sitter, if indicated.A medical record review for Resident #2 on 5/1/26 at 11:55 AM revealed on 4/7/26 the resident had a care plan initiated for an actual fall on admission and remains at risk for falls related to a new environment, history of falls, weakness, diminished safety awareness, and balance problems. The goal was that the resident will maintain highest level of independence with mobility and safety, reducing the frequency of falls and injuries through staff intervention. The interventions were to place the resident on the secured unit, refer for physical and occupation therapy as needed, appropriate footwear, and keep frequently used items close to the resident. On 4/9/26 the facility added the interventions to encourage the resident to stay in high visible areas and keep floors and pathways clear of clutter. On 4/11/26 they added intentional rounds to meet the resident's needs, however, they failed to include a frequency of these rounds. On 4/24/26 they added a fall mat on the left side of the bed. Then on 4/13/26 an additional care plan for being at risk for falls and had experienced multiple falls since admission related to falls prior to admission, encephalopathy, lung cancer with metastasis to brain, failure to thrive, incontinence, and bipolar disorder was initiated. The goal was that the resident would not experience any serious injuries from the falls. The interventions initiated on 4/13/26 were to encourage the resident to wear nonskid footwear when out of bed, to ensure that the resident's call light was within reach while in bed, keep, and to review the root cause and analysis of the fall to determine the cause and intervene, and educate the resident, family, and caregivers of the cause. After a fall on 4/14/26, there was one intervention added: to encourage the resident to participate in activities. A review of the progress notes revealed a note from a visit conducted by Nurse Practitioner (NP) #8, dated 4/24/26, confirmed the resident had the diagnoses listed on the care plan for falls. In addition, the resident had pancytopenia (a condition where the person has low levels of red blood cells, white blood cells, and platelets) which increased his/her risk of bleeding. She noted the resident was pleasantly confused. A review of the evaluation tab revealed that the resident had falls on 4/7/26, 4/9/26, 4/12/26, 4/14/26, and 4/24/26. A review of the progress notes revealed the resident had a progress note dated 4/11/26, documented the resident had 2 falls that day. Another progress note dated 4/12/26, documented the resident had 2 falls that day. Although the resident experienced 8 falls, staff failed to escalate the level of supervision to ensure the resident's safety.During an observation of Resident #2 on 5/1/26 at 11:07 AM, upon which the surveyor found the resident's room door cracked open and the resident was observed lying on the floor in his/her room, Licensed Practical Nurse (LPN) #2 stated that this resident had multiple falls which was why they had the resident in bed. She stated that the resident had cancer that metastasized the brain and it was affecting his/her vision, and s/he had been falling frequently. An interview with geriatric nursing assistant (GNA) #3 on 5/1/26 at 11:07 AM revealed she checked on the resident throughout her shift; however, she had not set times or frequency that she checked on the resident. The care plan had failed to include the frequency of the checking on the resident. In addition, with the residentThe concerns were reviewed with the Director of Nursing on 5/1/26 at 1:37 PM and she stated that staff should not keep a resident in bed to prevent them from falling. She acknowledged that there was no escalation of supervision to ensure the safety of this resident.

Based on observation, record review, and interview, it was determined that facility staff provided substandard quality of care for a resident following an unwitnessed fall. This was evident for 1 of 2 observations of residents. The findings include:Assessment after a fall should include: before a resident can be moved, the nurse must assess them for an injury to the spinal column, obvious fractures, significant bleeding, and their level of consciousness. Overall, this assessment includes taking the resident's vital signs, assessing location and intensity of pain, respiratory status, circulation, and for signs and symptoms that a post-fall injury has occurred. If there are signs of an injury to the spinal column, a fracture, significant bleeding, or the resident's level of consciousness has changed, do not move the resident. Call EMS and provide supportive care until EMS arrives. (AAPACN [American Association of Post-Acute Care Nursing] Post-Fall Assessments 2021)Neurological Assessments (neurochecks): include a full set of vital signs B/P, pulse, respirations, and temperature), check pupils for size and reaction to light, weakness on one or both sides, level of consciousness. The purpose of the neurochecks is to monitor the resident for symptoms to indicate a brain injury falling a fall in which the resident is known to have hit their head or if it is unknown.On 5/1/26 at 11:07 AM an observation of Resident #2 revealed the resident's room door was cracked open and when the surveyor knocked the resident could be heard talking. When the surveyor entered the room, the resident was lying on the floor on his/her left side with their feet facing the bathroom. The resident was talking, but s/he was not making sense and some words were unintelligible. The bed was in a low position with fall mats on each side. The call light was on the floor next to the bed. The resident's over-the-bed table was pushed against the wall about 3 feet from the bed and had a full glass of juice, water cup, and a bag of goldfish on it. Geriatric Nursing Assistant (GNA) #3 was in the hallway and was made aware that the resident was on the floor. GNA #3 and GNA #4 came to the room. The Licensed Practical Nurse (LPN) #2 was in the hallway and heard GNA #4 state the resident had fallen again. LPN #2 entered the room and with the assistance of GNA #3 sat the resident up and was assessing his/her head for injuries. She then with the help of GNA #3 lifted the resident into a chair in the room. She looked at the resident's eyes and then checked the resident extremities for injuries. However she failed to conduct a neurological assessment referred to as a neurocheck. Although there had been 2 staff she asked them to get the vital signs equipment 10 minutes after the fall. GNA #3, who went to get the equipment returned stating that it was in the med cart. The nurse went to retrieve the equipment. She obtained the vital signs at 11:17 AM, but she failed to count the resident's respirations. The resident was placed in a wheelchair and taken to the nurses' station.At 5/1/26 at 11:30 AM she obtained a second set of vital signs minus the respirations. She failed to conduct a neurocheck on the resident. She was documenting a neurocheck sheet.A medical record review for Resident #2 on 5/1/26 at 11:55 AM revealed in the progress notes a visit note by Nurse Practitioner (NP) #8, that documented the resident had a condition called pancytopenia (the person has low blood counts of red blood cells, white blood cells, and platelets). Platelets assist with the blood's ability to clot. This condition placed the resident at a greater risk of bleeding in the brain after a head injury and required close monitoring after an unwitnessed fall.An interview with LPN #2 revealed she was aware she had not taken the resident's respiration with either of the vital signs check. She stated that in the room the resident was shaking too much to get the respirations. When asked how she would count the respirations without a watch or a clock in the room, she stated she would use her phone and showed it to the surveyor. However, it was a digital clock with no seconds displayed (healthcare staff are taught to count the number of respirations for 15 - 60 seconds). She offered no rationale for failing to obtain respirations during the second neurocheck. When asked how she would conduct a neurocheck, she was able to verbalize the correct way, however she failed to do so. She stated she planned to do them later. An interview with the LPN Unit Manager (UM) #1 on 5/1/26 at 11:44 AM revealed that staff were expected to assess the resident for injuries before getting them up off the floor after a fall. This assessment should include: a head-to-toe assessment checking for injuries, obtaining a set of vital signs, and a neurological assessment. She stated respirations were a part of the vitals signs and a resident shaking should not interfere. She stated that the neurological assessment should include checking the resident's pupil reaction and having them grip your hands with their hands and push on your hands with their feet.The concerns were reviewed with the DON and she acknowledged the concerns. She stated that she provided one-on-one training with LPN #2 and that a head-to-toe assessment had been completed on Resident #2 to include respirations and a full neurocheck.Cross Reference: F689

Based on observations, staff interviews, and record reviews, it was determined that the facility failed to provide activities programs to meet residents' needs and preferences. This was evident for one (Resident#75) of one Resident reviewed for Activities.The findings include:The Minimum Data Set (MDS) is a federally mandated assessment tool used by nursing home staff to gather information about each Resident's strengths and needs. The information collected informs Resident care planning decisions.During a tour of the memory care unit on 2/17/26 at 9:11 AM, Resident #75 was observed sitting alone at a table in the dining area, with his/her head bent over and no activity going on. In a later observation on 2/17/26 at 10:33 AM, Resident #75 remained seated in the same spot. A Chronicle paper was noted on the table in front of the Resident, and s/he was observed sleeping in his/her wheelchair. In a subsequent observation on 2/17/26 at 1:52 PM, Resident #75 had finished eating lunch, remained seated in his/her wheelchair in the dining area, was sleeping in the wheelchair, and there was no activity program.During an interview on 2/18/26 at 7:50 AM, Staff #27, a geriatric nursing assistant, reported that watching television [NAME] up Resident #75.A record review on 2/20/26 at 12:10 PM for Resident #75 showed a diagnosis of Dementia and altered mental status. The continued review included an MDS assessment dated [DATE], which noted that Resident #75 had severely impaired cognition.Further review included a care plan for Resident #75 stating that the Resident preferred to participate in time-limited activities of interest, such as table activities, old sitcoms, bingo, and music programs. Continued review of Resident #75's activity logs from January 1 to February 20, 2026, revealed the following: In December, socializing/social events and news & views occurred 34 times, music occurred 5 times, and bingo occurred 1 time. In January, socializing/social events and news & views were 25 times; music was 5 times.In February, socializing/social events, news & views, and music occurred 8 and 2 times, respectively.However, the logs did not indicate that Resident #75 was involved in activities related to television shows or sitcoms, as previously documented in his/her care plan as preferences.During an interview on 2/20/26 at 1:41 PM, staff #32, the activity director, reported that News & Views and socializing meant staff visited residents for a morning greeting, provided a daily chronicle, informed them of the day's activities, and encouraged them to attend. However, an earlier review of Resident #75's MDS assessment showed that s/he had severe cognitive impairment and relied on others for decision-making and self-care.During an interview on 2/23/26 at 9:23 AM, staff #33, an activity assistant, was present with staff #32. Staff #33 reported that Resident #75 liked watching TV. However, the TV had been moved to a different room and had not been working for several months. Staff #32 acknowledged the concern about not providing activity programs for Resident #75 based on his/her needs and preferences, and stated that they would do things differently moving forward.

Based on observations, record reviews, and interviews, it was determined that the facility failed to conduct a comprehensive assessment of a resident's dietary dislikes and food preferences. This was evident in 1 (Resident #110) of 3 residents reviewed for food.The findings include:During an initial tour of the facility on 2/17/26 at 8:53 AM, Resident #110 was observed in bed eating breakfast. The Resident told the surveyor, Can you write on my ticket again that I don't like eggs? The Resident indicated that s/he had told the staff multiple times that s/he disliked eggs; however, s/he continued to receive eggs for breakfast. Resident #110's diet slip indicated a regular diet but did not list the Resident's preferences or dislikes.On another observation on 2/18/26 at 8:28 AM, Resident #110 was seated in a wheelchair at the bedside, eating breakfast. The Resident reported to the surveyor that s/he had again received scrambled eggs and added, I've told them several times that I don't like eggs, especially when they're not real eggs, and they keep bringing me eggs. I don't know why.A review of the record for Resident #110 showed that the Resident was readmitted to the facility in January 2026.Continued record review included a nutrition care plan initiated and revised on 1/20/26, which noted that the Resident had an alteration in nutrition r/t [related to] significant weight loss of 7.2% in 30 days with an associated decline in average intake. The care plan interventions included monitor intake, honor food preferences.Further review found a dietary profile for Resident #110, signed as completed on 1/27/26. The profile recorded the resident's diet order and the texture of food. However, the resident's food preferences and dislikes were left blank.During an interview on 2/18/26 at 2:51 PM, staff #29, a registered dietitian, stated that the dietary manager was primarily responsible for assessing residents' food preferences and dislikes and for entering that information into the meal ticket system. During an interview on 2/18/26 at 3:30 PM, staff #10, the dietary manager, reported that her process for assessing residents' food preferences and dislikes included meeting with residents, assessing and recording their food preferences and dislikes on the dietary profile, and then entering the data into their menu programming system. However, that process was missed for Resident #110.In a subsequent interview on 2/19/26 at 7:30 AM, staff #10 reported that she visited Resident #110 after the surveyor's intervention and assessed the Resident's food preferences, likes, and dislikes.

Based on record reviews and interviews, it was determined that the facility failed to conduct care plan meetings after the completion of the comprehensive assessments. This was evident for 2 (Resident #5, #41) of 2 residents reviewed for care planning. The findings include:1) Resident #5 had been residing in the facility since early 2024. The medical record indicated that the resident was cognitively intact. In an interview with the resident on 2/18/26 at 9:18 AM, s/he was asked about care plan meetings and stated, it's been a while, (social services director) Staff #20 had left and I don't know who took his place.A review of Resident #5's medical record was conducted on 2/18/26 at 2:30 PM. The review revealed the 2 most recent assessments were comprehensive assessments. A significant change assessment with an assessment reference date (ARD) of 1/8/26 and an annual assessment with an ARD of 10/30/25. A review of the resident's progress notes was also conducted and did not reveal any documentation regarding care plan meetings.The social services designee (Staff #19) was interviewed on 2/19/26 at 12:12 PM. During the interview, Staff #19 reported her process with care plan meetings and that she used to split the facility with Staff #20, based on room numbers. Care plan meetings were documented under the evaluation tab as IDT care plan conference summary. She confirmed that Staff #20 was no longer employed by the facility.A review of Resident #5's medical record was conducted with Staff #19 on 2/19/26 at 12:20 PM. Staff #19 reported that based on the resident's room number, s/he was assigned to Staff #20. She was also asked when the last care plan meeting was held for the resident and she reported 4/2/25. The concern was discussed with Staff #19 that the facility failed to hold a care plan meeting after the completion of the comprehensive assessments. She verbalized understanding and acknowledged the concern.2) Resident #41 Had been residing in the facility since 2024. The resident's medical record indicated that s/he was cognitively intact. During an interview with a resident on 2/18/26 at 8:49 AM, s/he stated, I can only remember the first meeting when asked if the facility conducts care plan meetings on a regular basis.A review of Resident #41's medical records was conducted on 2/18/26 at 2:50 PM. The review revealed the last 2 assessments conducted were an annual assessment with an ARD of 1/14/26 and a quarterly assessment with an ARD of 11/4/25. The resident's progress notes were also reviewed for care plan meetings and revealed a note from the social services designee (Staff #19) dated 1/27/26 that indicated a care plan meeting was scheduled for 1/29/26 at 2:30 PM. No other progress note was found to indicate that care plan meetings were held after the completion of the quarterly and the annual assessments.An interview regarding care plan meetings was conducted with Staff #19 on 2/19/26 at 12:12 PM. During the interview, Staff #19 explained her process and reported that care plan meetings are documented in the resident's evaluation as IDT care plan conference summary. A review of Resident #41's medical record was conducted with Staff #19 on 2/19/26 at 12:35 PM. She confirmed the progress note that she wrote indicating that a care plan meeting was scheduled for 1/29/26 however, the last documented IDT care plan conference summary was dated 11/7/25. Staff #19 reported that she did have the care plan meeting with the resident on 1/29/26 but failed to document it in the resident's medical record and stated, I'm responsible.

Based on observations, record reviews, and interviews, it was determined that the facility failed to develop and implement comprehensive, resident-centered care plans. This was evident in 1 (Resident #42) of 3 residents reviewed for Activities of Daily Living (ADL).The findings include:A care plan is a guide that addresses each Resident's unique needs. It is used to plan, assess, and evaluate the Resident's care. Staff use care plans to provide resident-centered care that includes support, services, and resources to meet Residents' needs.During a lunch observation on the memory care unit on 2/17/26 at 1:12 PM, Resident #42 was seated at the same table as two other residents. Resident #42 was observed taking food from the other residents' trays and eating it.A record review for Resident #42 included a psychiatry progress note dated 7/22/25, which stated that Resident #42 had a diagnosis of dementia with behavioral issues. The note also reported that staff observed Resident #42 yelling, being agitated, screaming at staff and other residents, and having difficulty with redirection. Staff requested a psychiatric evaluation.Continued record review included a social services progress note stating that Resident #42 was sometimes agitated, screamed at staff and other residents, and was difficult to redirect.During an interview on 2/19/26 at 11:15 AM, the unit manager (UM) for the memory care unit reported that Resident #42's usual behavior was to grab other residents' food.In an interview on 2/19/26 at 1:33 PM, staff #27, a geriatric nurse assistant (GNA), reported that Resident #42's usual behaviors included occasionally grabbing other residents' food, which upset some residents.However, an earlier record review failed to show that Resident #42's behaviors were addressed in his/her care plan, including the actions staff would take to address them.On 2/19/26 at 1:44 PM, the UM was notified that a comprehensive care plan addressing Resident #42's behaviors had not been developed or implemented, including staff interventions to address those behaviors. The UM reviewed Resident #42's care plans, confirmed the concern, and stated she would address it immediately.

Based on record review and interview, it was determined that the facility failed to ensure that a resident's Minimum Data Set (MDS) assessment was accurately recorded. This was evident in 1 (Resident #81) of 3 residents reviewed for PASSR.The findings include:The Minimum Data Set (MDS) is a federally mandated assessment tool used by nursing home staff to gather information about each resident's strengths and needs. The information collected drives resident care planning decisions. MDS assessments must be accurate to ensure each resident receives the care they need.Preadmission Screening and Resident Review (PASRR) is a federal requirement that helps ensure individuals are not inappropriately placed in nursing facilities for long-term care. Individuals who test positive at Level I are referred to the local health department (LHD), where they receive an in-depth Level II PASRR evaluation.A medical record review on 2/18/26 at 1:07 PM for Resident #81 included a PASSR Level II evaluation report indicating a positive result due to a history of developmental delay. A subsequent review showed a care plan initiated on 4/26/23 stating that Resident #81 had a Positive PASSR due to developmental delay.However, further review of an MDS assessment dated [DATE] for Resident #81 showed that it recorded a no in section A1500 to the question, Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition?During an interview on 2/20/26 at 12:19 PM, staff #3, a social service designee, reported that Resident #81 was evaluated as having a positive PASSR II due to a history of developmental delay. Staff #3 also confirmed that Resident #81's MDS assessment dated [DATE] was recorded in error and stated that she would correct it.

Based on observation and interview, it was determined that the facility failed to ensure safe and secure drug storage of resident medications. This was observed for 1 (North Hall) of 3 resident medication carts observed during the annual recertification survey. The findings include: On 2/19/26 at 7:25 AM, the medication administration observation was conducted on the 2 North unit with Staff #6, a Licensed Practical Nurse. When the surveyor approached the cart, Staff #6 was inside room [ROOM NUMBER] with the resident's room door shut. The resident medication cart was unlocked and unattended in front of room [ROOM NUMBER] and the surveyor was able to open and access the medication drawers. Staff #6 exited room [ROOM NUMBER] upon hearing the surveyor accessing the medication cart and acknowledged that it was unlocked and unattended. 2/19/26 at approximately at 1:30 PM, the findings were reviewed with the Nursing Home Administrator. He acknowledged the concern.

Based on observation, record reviews, and interviews, it was determined that the facility failed to implement appropriate interventions for a resident with an altered mental status and identified behaviors. This was evident in 1(Resident #42) of 2 residents reviewed for behaviors.The findings include:During a lunch observation on the memory care unit on 2/17/26 at 1:12 PM, Resident #42 was seated at the same table as two other residents, Resident #76 and Resident #72. Resident #42 was observed taking bread from Resident #72's lunch tray and eating it. After eating it, Resident #42 also took Resident #76's cake from Resident #76's tray. Resident #76 yelled and snatched the cake back from Resident #42's hand. After the surveyor's intervention, the staff moved Resident #42 to the TV room. Record review for Resident #42 included a psychiatry progress note dated 7/22/25, which stated that Resident #42 had a diagnosis of dementia with behavior.Continued record review included a social services progress note indicating that Resident #42 was sometimes agitated, screamed at staff and other residents, and was difficult to redirect.In an interview on 2/19/26 at 1:33 PM, staff #27, a geriatric nurse assistant (GNA), reported that Resident #42's usual behavior included occasionally grabbing other residents' food, which upset some residents.During an interview on 2/19/26 at 1:44 PM, the unit manager (UM) for the memory care unit reported that Resident #42's usual behavior was grabbing other residents' food. The UM reported that staff had tried a seating arrangement to prevent Resident #42 from taking other residents' food during mealtimes; however, it didn't work. The UM then added that staff would attempt the seating arrangement again at the meal tables to prevent Resident #42 from taking other residents' food. Later that same day, in an interview with the UM, she showed the surveyor a document outlining a new seating arrangement for residents, to be implemented after the surveyor's intervention to prevent Resident #42 from taking other residents' food during mealtimes.

Based on record reviews and interviews, it was determined that the facility failed to ensure pain management was provided to residents according to professional standards of practice. This was evident for 2 (Resident #9, #41) of 4 residents reviewed for pain management. The findings include:1) Resident #9 had been residing in the facility since 2024. Diagnosis included but was not limited to chronic pain. A review of Resident #9's medical orders was conducted on 2/19/26 at 2:22 PM. The review revealed an order for narcotic pain medication to be taken on an as needed (PRN) basis and non-pharmacological interventions (NPI) to alleviate pain with numbers 1 through 8 that corresponded to the different interventions. Special instruction indicated to document all NPI's as needed.On 2/20/26 at 11:12 AM, a review of Resident #9's administration record for January 2026 revealed the PRN narcotic pain medication was administered 8 times. 3 of the 8 times the medication was administered failed to show documentation of the pain location, and there was no documentation to indicate NPI's were administered/attempted prior to giving the PRN pain medication.In an interview with the [NAME] President for clinical services (Staff #8) on 2/20/26 at 1:55 PM, the findings were reviewed. During the interview, Resident #9's medical record was reviewed with Staff #8 and she confirmed the finding. The concern was discussed that the nursing staff failed to document pain location and provide NPI's for pain management. Staff #8 verbalized understanding and acknowledged the concern.2) Resident #41 was admitted into the facility in early 2024. Diagnosis included but was not limited to osteoarthritis and spondylosis.A review of Resident #41's medical orders was conducted on 2/20/26 at 9:26 AM. The review revealed an order for pain medication to be taken on an as needed (PRN basis) and non-pharmacological interventions (NPI) to alleviate pain with numbers 1 through 8 that corresponded to the different interventions. Special instruction indicated to document all NPI's as needed.On 2/20/26 at 10:06 AM, a review of Resident #41's administration record for January 2026 revealed the PRN pain medication was administered 16 times. 2 of the 16 times the medication was administered for a 0/10 pain score, and there was no documentation to indicate NPI's were administered/attempted prior to giving the PRN pain medication.In an interview with the [NAME] President for clinical services (Staff #8) on 2/20/26 at 1:41 PM, the findings were reviewed. During the interview, Resident #41's medical record was reviewed with Staff #8 and she confirmed the finding. The concern was discussed that the nursing staff administered pain medication when there was no indication of pain for 2 instances and document NPI's provided prior to administering the PRN pain medication. Staff #8 verbalized understanding and acknowledged the concern.

Based on record reviews and interviews, it was determined that the facility failed to complete Significant Change in Status Minimum Data Set (MDS) assessments within 14 days following a significant decline in the Residents' condition. This was evident in 2 (Resident #94 and #4) of 47 residents reviewed during the recertification survey. The findings include:The Minimum Data Set (MDS) is a federally mandated assessment tool used by nursing home staff to gather information on each Resident's strengths and needs. Information collected on the MDS drives Resident care planning decisions. The nursing home should complete a Significant Change in Status MDS assessment within 14 days of a major decline or improvement in a resident's status after the determination that a significant change has occurred.1) A record review on 2/17/26 at 3:12 PM for Resident #94 included a progress note dated 9/7/25 by staff #11, unit manager, indicating that the Resident was admitted to hospice care effective 9/6/25 due to overall general decline.Further review included a Significant Change in Status MDS assessment dated [DATE] for Resident #94. The MDS assessment was completed and signed in sections Z0500B and V0200B2 on 9/29/25, 23 days after admission to hospice care and 9 days late.In an interview on 2/23/26 at 1:40 PM with staff #30, an MDS coordinator stated that admission to hospice care required completion of a Significant Change in Status MDS for any resident, and that the determination date was the day of admission to hospice care. Staff #30 confirmed that the Significant Change in Status MDS assessment for Resident #94, dated 9/16/25, was completed late.2) A record review for Resident #4 on 2/23/26 at 1:03 PM noted that the Resident was admitted to hospice services for failure to thrive, effective 11/10/25.A continued review of Resident #4's record included a Significant Change in Status MDS assessment dated [DATE]. The MDS assessment was completed and signed in sections Z0500B and V0200B2 on 12/2/25. During an interview on 2/23/26 at 1:45 PM, Staff #30 stated that the determination date for Resident #4's Significant Change in Status was 11/10/25, the date of admission to hospice services. However, an earlier review showed that Resident #4's Significant Change in Status MDS assessment, dated 11/20/25, was completed and signed in sections Z0500B and V0200B2 on 12/2/25, 22 days after admission to hospice care and 8 days late.Staff #30 confirmed that Resident 4's Significant Change in Status MDS assessment was completed late.

Based on record review and interview it was determined that the facility failed to notify residents of their potential financial liability when they were discharged from skilled care. This was evident for one resident (Resident #119) of 3 residents reviewed for beneficiary notification during the recertification survey.The findings include:Resident #119 was admitted to the facility on [DATE] for skilled care.On 2/18/26 a request was made for a list of residents who were discharged from skilled care in the past 6 months, and to include their disposition (whether they returned home or remained in the facility). On 2/19/26 at 10:00 AM a review of the list of residents discharged from skilled care was conducted. Three residents were randomly selected from the list, and the Nursing Home Administrator (NHA) was asked to provide the Notice of Medicare Non-Coverage (NOMNC) and Advance Beneficiary Notice (ABN) forms that were provided to those residents.On 2/19/26 at 12:15 PM a review of the documents provided was conducted and revealed that Resident #119 was provided with a NOMNC that indicated that their last covered Part A day was 9/03/25, and that the facility initiated the discharge from Part A Services when benefit days were not exhausted. No ABN form was provided for Resident #119.On 2/19/26 at 12:58 PM Resident #119's documents were reviewed with the NHA and Business Office Manager, Staff #21. When they were asked if the resident should have had an ABN provided, Staff #21 said yes, and they both confirmed that there was no evidence that an ABN was provided and there should have been.On 2/23/26 at 12:41 PM, in an interview with the NHA, he again confirmed the deficiency and said there was no other evidence to provide.

Based on record reviews and interviews, it was determined that the facility failed to ensure information to formulate an advanced directive was provided to a resident. This was evident for 1 (Resident #39) of 1 resident reviewed for advanced directives. The findings include:Resident #39 was admitted into the facility in late 2025. A review of the resident's medical record on 2/18/26 at 12:16 PM revealed a certification from the attending physician dated 12/12/25 that indicated the resident was able to comprehend information and make decisions. A social services admission evaluation dated 12/15/25 by social services designee (Staff #3) indicated that a copy of the resident's advanced directive was requested.Further review of Resident #39's medical records failed to show a copy of the resident's advanced directives and there was no documentation to indicate that information was provided to the resident to formulate one. In an interview with Staff #3 on 2/19/26 at 11:43 AM, she explained the social services department's process with advanced directives. She noted that usually within 72 hours from admission, She or her colleague (Staff #19 who was also present during the interview) conducts an evaluation that includes discussion of the advanced directives, if they confirm that the resident has the capacity to comprehend information and make decisions.A review of Resident #39's medical record was conducted with Staff #3 on 2/19/26 at 11:53 AM. Staff #3 confirmed that she requested for a copy of the advanced directive on 12/15/25, however the resident still had not provided the facility a copy and there was no documentation to indicate that a follow-up had been made. Both social services designees (Staff #3 and Staff #19) indicated that the resident currently does not have the capacity to formulate a new advanced directive but that s/he had a power of attorney (POA) on file. However, after continued review of the resident's medical records, the POA on file was a financial POA and did not cover the resident's healthcare preferences.The concern was discussed with both staff that there was no documentation to indicate that a follow up was made to acquire a copy of the advanced directive and/or information was provided to the resident to formulate an advanced directive while s/he was deemed capable of understanding and making decisions. Both staff verbalized understanding and acknowledged the concern.

Based on observation, record review, and interview it was determined that the facility failed to ensure that residents were treated with respect and dignity. This was evident for one resident (Resident #81), and three residents (Resident #68, #48, #110) of 4 residents reviewed for dignity during the recertification survey.The findings include:The Minimum Data Set (MDS) is a federally mandated assessment tool used by nursing home staff to gather information on each Resident's strengths and needs. Information collected drives resident care planning decisions. 1) During an initial tour of the Memory Care Unit on 2/17/26 at 8:59 AM, Resident #81 was observed to have finished breakfast. The Resident's blouse and pants were soiled with food particles, and the Resident was pacing up and down the hallway. Continued observation of Resident #81 noted facial hair on the Resident's chin and upper lip. In another observation on 2/17/26 at 1:53 PM, Resident #81 had finished eating lunch. The Resident was lying in bed, resting. His/her blouse remained soiled with food particles, and his/her lips were covered with a brown substance. Facial hair remained on the resident's upper lip and chin. A record review for Resident #81 included an MDS assessment dated [DATE]. The MDS noted that Resident #81 had severely impaired cognition and was totally dependent on staff for most self-care needs, including personal hygiene. During an interview on 2/17/26 at approximately 1:58 PM, Staff #27, a geriatric nurse aid (GNA), was with the surveyor in Resident #81's room. Staff #27 confirmed that the Resident's pants and blouse were soiled with food and that food residue was present on the Resident's lips. Staff #27 stated that he would immediately shave the Resident, clean the Resident's lips, and change the Resident's clothes. During an interview on 2/18/26 at 7:56 AM, Staff #27 reported that he shaved, cleaned, and changed Resident #81's clothing after the surveyor's intervention. 2a.) Resident #68 was admitted to the facility for care due to physical decline caused in part, by Parkinson's disease. The resident had a limited range of motion and was dependent on others for all care, which included the need to be fed. On 2/17/26 at 1:26 PM an unidentified staff nurse accompanied the surveyor to Resident #68's room to check on the resident, who resided in the bed closest to the door. When the nurse opened the door, a Geriatric Nursing Assistant (Staff #10) was observed as he stood next to the resident's bed and fed the resident lunch. The resident was alert and made eye contact with the surveyor but did not speak. There was no chair near the resident's bed. Staff remained standing during the observation. No attempt was made to find a chair to sit on, and no chair was observed near the bed. On 2/19/26 at 12:03 PM an interview was conducted with the Nursing Home Administrator (NHA) to review the observation that Staff #10 was observed as he stood over Resident #68 and fed them. The NHA said that one of the staff had also made that observation and reported it to him before the surveyor mentioned it. The NHA confirmed and acknowledged the deficiency and said he was disappointed because it was his practice to educate and encourage staff frequently regarding providing care with dignity. 2b.) On 2/17/26 at 1:36 PM, during the surveyor's interview with Resident #48, Staff #5, a Geriatric Nursing Assistant, failed to knock or ask permission to enter the resident's room before he entered the resident's room where the surveyor was speaking with Resident #48. Staff #5 also failed to identify himself or announce his intended purpose. Staff #5 was observed wearing headphone ear pieces as they proceeded to enter the room and removed both Resident #48 and Resident #48's roommate's meal trays and exited the room. Resident #48 confirmed to the surveyor that this was a normal occurrence. 2.c.) An observation on 2/18/26 at 8:32 AM showed that while Resident #110 was eating breakfast in his/her room, staff #28, a phlebotomist, entered the Resident's room and said, I'm here to draw your blood. The resident asked, Who sent you? and staff #28 responded, Your attending provider. Staff #28 then took the Resident's left hand and began preparing it to draw blood. The observation failed to show that Staff #28 knocked on the Resident's door, requested permission to enter the room and draw the blood, and introduced herself before drawing the blood. During an interview on 2/18/26 at 8:34 AM, staff #28 verbalized understanding of the concern regarding not knocking on the Resident's door and asking for permission before entering, not introducing herself, and not asking the Resident for permission before providing services. Staff #28 said she should have slowed down, not rushed, knocked, and introduced herself before drawing Resident #110's blood.

Based on record review and interview, it was determined that an incompetent resident was documented as having consented to the arbitration process. This was evident for one resident (Resident #10) of 3 residents reviewed for arbitration agreements.The findings include:Resident #10 was admitted to the facility on [DATE]. A review of the resident's clinical record revealed that the resident lacked capacity to make decisions for themselves, which was documented by two providers on 11/16/25. Further review failed to reveal any evidence that the resident had a designated power of attorney (POA), guardian, or surrogate.On 2/19/26 at 9:30 AM the Nursing Home Administrator (NHA) was asked to provide a list of all residents who had arbitration agreements with the facility.On 2/19/26 at 11:07 AM a review of Resident #10's arbitration agreement was conducted and revealed that the document had an electronic signature that indicated the resident signed it on 12/03/25. On 2/19/26 at 11:08 AM an interview was conducted with the Director of Marketing and Admissions (Staff #9) to review the facility's process for arbitration agreements. When asked what she did if she wasn't sure whether a resident had capacity to sign legal documents, she explained that she checked the resident's records for any capacity/decision making forms and if the resident lacked capacity, then she would read through the document with the family. When asked about Resident #10's agreement and the process for how that agreement was obtained she said she was not sure if the resident or the family signed the agreement, but she might have written a note about it. She subsequently found her notes and provided a copy to the surveyor. A review of the note, which was dated 12/03/25, and written by Staff #9, revealed the statement Called [family member], discussed admission packet, signed [Resident #10] name to forms due to no POA assignment, also discussed with patient as much as possible so both were informed. Staff #9 confirmed her documentation.Resident #10's arbitration agreement was then reviewed with Staff #9, and she confirmed that she signed it on behalf of the resident.On 2/19/26 at 11:35 AM an interview was conducted with the NHA who acknowledged that Resident #10's arbitration agreement was completed incorrectly, and that Staff #9 should not have signed the resident's name on the document.

Based on observation, record review, and interview, it was determined that the facility failed to ensure appropriate pressure relieving device settings. This was evident for 3 (Resident #57,#93, and #118) of 3 residents observed with pressure injuries during the annual recertification survey. On 2/17/26 at 9:09 AM, the surveyor observed that Resident #93 had a pressure-relieving mattress on their bed. Resident#93 had a pressure injury and also had an order from the provider for the mattress with parameters for the settings to be within 10 pounds of the resident's current weight. The record revealed Resident #93's last documented weight on 02/03/2026 was 154 pounds. The pressure relieving mattress setting was inflated to 260 pounds. On 2/17/26 at 9:22 AM, the surveyor observed that Resident #57 had a pressure-relieving mattress on their bed. Resident #57 had a pressure injury and also had an order from the provider for the mattress with parameters for the settings to be within 10 pounds of the resident's current weight. The record revealed Resident #57's last documented weight on 02/03/2026 was 172 pounds. The pressure-relieving mattress setting was inflated to 220 pounds. On 2/17/26 at 9:35 AM, the surveyor observed that Resident #118 had a pressure-relieving mattress on their bed. Resident #118 had a pressure injury and also had an order from the provider for the mattress with parameters for the settings to be within 10 pounds of the resident's current weight. The record revealed Resident #118's last documented weight on 02/05/2026 was 163 pounds. The pressure relieving mattress setting was inflated to 220 pounds. On 2/19/26 at 11:53 AM, Staff #5 and Staff #17, both Geriatric Nursing Assistants (GNAs), completed a dual observation of the pressure relieving mattress for Resident #93 with the surveyor. Each was asked who was responsible for calibrating the mattress settings or checking the pressure settings, and Staff#5 and Staff #17 deferred to the licensed nursing staff being responsible for entering the resident's weight on the equipment. On 2/19/26 at 12:05 PM, Staff #18, a Licensed Practical Nurse (LPN) and the unit manager, was asked who sets up the pressure relieving mattress for a resident and how accurate weight settings are ensured. Staff #18 informed the surveyor that the facility's maintenance staff sets up the equipment in the room and deferred accuracy questions to the facility's wound nurse. On 2/19/26 at 12:13 PM, Staff #7, an LPN and the facility's wound care nurse, completed a dual observation of Resident #93,#57, #118's pressure relieving mattresses and was asked who ensured that resident weights are accurate, who trained staff on accuracy, and if audits were completed to ensure accuracy. Staff #7 explained that a resident's weight for the pressure relieving mattress is based on what is recorded in the resident's electronic medical record. Staff #7 explained that she can make adjustments as well as the unit manager, Staff #18. Staff #7 stated that when a provider enters an order, the facility used a durable medical equipment provider to deliver and service the equipment used by residents. Staff #7 explained that GNAs did not adjust or change the pressure relieving mattress settings, but are made aware of the appropriate setting. Staff #7 stated that they completed audits of pressure relieving mattresses throughout the facility, but they do not maintain documentation of those audits. During this observation and interview, Staff #7 confirmed that Resident #93, #57, and #118's pressure relieving mattress settings were not accurate. 2/19/26 at approximately at 1:30 PM, the findings were reviewed with the Nursing Home Administrator. He acknowledged the concern.

Based on observations, record reviews and interviews, it was determined that the facility failed to ensure residents with oxygen therapy received oxygen as prescribed. This was evident for 1 (Resident #41) of 3 resident reviewed for respiratory care. The findings include:Resident #41 was admitted into the facility in early 2024 with diagnosis that includes acute respiratory failure with hypoxia.Hypoxia is a critical condition where tissues are deprived of adequate oxygen, causing symptoms like confusion, rapid heart rate, shortness of breath, and cyanosis (bluish skin). It is caused by lung issues, low blood oxygen (hypoxemia), anemia, or poor circulation. Treatment involves immediate oxygen therapy, medication, or ventilation.During an interview with Resident #41 on 2/18/26 at 8:55 AM, it was observed that the resident was receiving oxygen via nasal cannula set at 3.5 liters/min.A review of Resident #41's medical records on 2/20/26 at 9:33 AM revealed oxygen order to be administered at a rate of 2 L/min. There was no other documentation found to indicate that the rate of oxygen administration can be titrated or changed.On 2/20/26 at 3:08 PM, Resident #41 was observed sitting in bed, receiving oxygen via nasal cannula at a rate of 7 L/min.The registered nurse (RN #23) assigned to care for Resident #41 was invited for an interview in the resident's room on 2/20/26 at 3:10 PM. RN #23 confirmed that the resident was currently receiving oxygen at a rate of 7 L/min and when asked about the resident's usual use of oxygen, she stated, it fluctuates. Usually between 4 - 5 L/min but could be up to 6 L/min. RN #23 reported that there was an order to titrate the oxygen as needed because the resident suffers from panic attacks and when experiencing such episodes, her/his oxygen saturation (O2 sat) drops. RN #23 further reported that the resident experienced an episode at 1:30 PM and had an O2 sat of 88%.However, when Resident #41's medical record was reviewed with RN #23 on 2/20/26 at 3:15 PM, she confirmed that there was no order to titrate the rate of oxygen administration and there was no documentation to indicate that the resident's O2 saturation was 88% at 1:30 PM.The findings above were discussed with the nurse unit manager (Staff #18) on 2/20/26 at 3:29 PM. The concern was discussed that Resident #41 oxygen administration was being titrated without orders and current observation of the resident receiving oxygen at a different rate than prescribed. Staff #18 stated, I will address it right now and reported that she would discuss the concern with the Nurse Educator so that she may address it with RN #23.

Based on interviews and record review, it was determined that the facility failed to ensure that residents who required assistance with Activities of Daily Living (ADLs) received showers. This was evident in one (Resident #110) of three Residents reviewed for ADL. The findings include:The Minimum Data Set (MDS) is a federally mandated assessment tool used by nursing home staff to collect information on each resident's strengths and needs. This information informs resident care planning decisions.During an interview on 2/18/26 at 8:54 AM, Resident #110 reported having received only one shower in the past 3 weeks. A review of Resident #110's admission MDS assessment dated [DATE] noted that the resident was totally dependent on staff for assistance with showers. A continued review of the shower schedule for the Unit where Resident #110 resided showed that s/he was to receive 2 showers per week, totaling 8 showers per month.Further review of the GNA (Geriatric Nurse Assistant) shower documentation for Resident #110 from 1/15/26 to 2/18/26 was completed. The review showed that Resident #110 received two showers in January and one in February. In an interview on 2/19/26 at 8:56 AM, staff #31, a geriatric nurse assistant, reported that Resident #110 was scheduled for 2 showers per week and a bed bath (washing a resident in bed using a basin of water, soap, and a washcloth without washing the hair) on non-shower days. However, an earlier review found that Resident #110 received only 3 showers between 1/15/26 and 2/18/26. During an interview on 2/19/26 at 1:57 PM with staff #11, a unit manager, she confirmed that Resident #110 received 3 showers between 1/15/26 and 2/18/26. Staff #11 added that she would ask her nursing assistants why Resident #110 was not offered showers on the days when s/he was scheduled to receive them. As of the survey exit on 2/23/26 at 4:15 PM, no additional documentation was provided showing that the resident received all scheduled showers during that period.

Based on record review and interview, it was determined that the facility failed to ensure that residents were free of abuse. The facility implemented effective and thorough corrective measures following this incident and prior to the start of this survey. The facilities plan and action were verified during this survey, therefore this deficiency was found to be past noncompliance with a compliance date of 12/13/23. This was evident for 1 resident (Resident #296) of 6 residents reviewed for abuse during the recertification survey. The findings include: On 10/23/24 at 3:15 PM a review of the facility reported incident #MD00200167 revealed that on 12/03/23 when Geriatric Nursing Assistant (GNA #14) attempted to place Resident #296 into a wheelchair, GNA #14 grabbed the resident ' s hands and pulled and wrestled with the resident which resulted in bruises and bloody skin tears on the resident ' s hands. On 10/23/24 at 3:20 PM a review of the initial report to the Office of Health Care Quality (OHCQ) dated 12/03/23 at 7:45 PM, revealed that the incident occurred in the resident ' s room and that Resident #296 had skin tears on the right and left thumbs, and a skin tear on the top of his/her left hand. It further stated that the alleged perpetrator was suspended, treatment was ordered for the resident ' s injuries, and the resident ' s physician and family were notified. A review of the facility's investigation file included a statement dated 12/04/23 written by the Interim Director of Nursing (Staff #19) who interviewed Resident #296. The resident stated that GNA #14 pulled on his/her hands and the GNA stated I ' m in charge today. Further review of the same document revealed another witness statement from Resident #296 ' s roommate who observed GNA #14 as she wrestled with Resident #296 and stated that GNA #14 pushed and pulled on Resident #296 and made the resident sit in a chair. The roommate observed that both of Resident #296 ' s hands were bloody. On the same statement, handwritten notes indicated that the police were notified and a case number was included. Another handwritten notation on the same document was dated 12/05/23 which stated 1-2 weeks before police report ready and was signed by Staff #19. Further review of the investigation file revealed a nursing progress note written on 12/03/23 at 8:57 PM by Licensed Practical Nurse (LPN #22) that stated that the resident was observed to have three skin tears and multiple scattered dark bruises on both hands. The note included Resident #296 ' s description of the incident, that GNA #14 grabbed the resident ' s hands. The nurse wrote that she provided Resident #296 treatment for the skin tears and pain medication. In a handwritten witness statement written by LPN #22 she said that when she questioned GNA #14 about what happened and asked the GNA to write a statement, GNA #14 cursed loudly at LPN #22 and refused to write a statement. A review of the facility ' s final report to the Office of Health Care Quality (OHCQ) revealed a statement in the Conclusion section of the document that stated The allegation was verified by evidence collected during the investigation and interview with the victim and the victim ' s roommate. In the Corrective Action portion of the final report to OHCQ Staff #19 wrote that Employee (GNA #14) has remained suspended and will be terminated today. The incident will be reported to the nurse aide registry. A police report present in the facility ' s investigation file stated that the facility concluded that abuse (an assault) did occur. On 10/25/24 at 2:37 PM - a review of GNA #14 ' s employee file revealed that she had an active GNA license, a clear background check when hired, and that she received abuse training in May 2023. On 10/25/24 at 3:55 PM the Senior [NAME] President of Clinical Services (Staff #7) was interviewed regarding the incident and she provided evidence of steps taken following the incident. She further stated that no other incidents of abuse have occurred at the facility. The surveyor reviewed the evidence provided by Staff #7 and it demonstrated that the facility took the following actions after the incident, 1) abuse education was provided to all employees, 2) resident skin assessments and resident interviews were done daily x 2 weeks, then 2 times per week for 2 weeks, then monthly x 2 months and 3) the employee was immediately terminated on the day of the incident, 4) the GNA was reported to the nursing registry. Based on the above evidence it was determined that the date of compliance was 12/13/23.

Based on medical record review and interviews, it was determined the facility: 1) failed to provide services to prevent the development of a sacral pressure ulcer; the infection of two heel ulcers; and a significant weight loss. The resident's height was incorrectly documented in the medical record which led to the dietitian's failure to identify that the resident was underweight. Once the error was identified and nutritional interventions were recommended, they were not implemented and the resident proceeded to develop a sacral pressure ulcer, which was not reported to the physician for a week, an infection of the heel ulcers and a continued significant weight loss, which was not reported or addressed prior to the resident's discharge from the facility. This was found to be evident for one out of seven residents (Resident #165) reviewed for pressure ulcers during the survey. This deficient practice resulted in actual harm to Resident #165. The findings include: 1) Review of Resident #165's medical record revealed the resident was admitted to the facility in (MONTH) 2019. Review of the initial Nursing Admission Data Collection documentation revealed the resident was admitted with open blisters to the left and right foot, but no documentation was found that the resident had any skin breakdown or pressure ulcers to either heel or the resident's sacrum (backside). This documentation also listed the resident's height as 5.8 (no indication of units i.e.: feet/inches) and weight of 118 (no indication of units, i.e. lbs. or kgs found on the documentation). The resident was noted to have swelling in both upper and lower extremities with limited range of motion. The resident was assessed as requiring moderate assistance for mobility such as moving from lying to sitting on the side of the bed. Review of the Baseline Care Plan and Summary effective 4/27/19 revealed the resident required one person physical assist for eating, personal hygiene, dressing and bed mobility. Review of the Geriatric Nursing Assistant (GNA) documentation failed to reveal any documentation that the resident received assistance with any activities of daily living, including bed mobility, during the night shift on Saturday 4/27 or Monday 4/29. There was also no documentation of assistance with toilet use during the day shift on Sunday 4/28/19. Review of staffing sheets revealed that on Sunday 4/28/19 the facility provided 2.55 hours of bedside care per resident. On Monday 4/29/19 the facility provided 2.72 hours of bedside care per resident. The current state regulations require staffing to be at a level where at least 3.0 hours of bedside care is provided to each resident. The resident was seen by the primary care physician on 4/29/19. On 9/3/19 review of this note, with the Director of Nursing, revealed the resident was emotionally dependent for everything since a repeat fall . On 5/2/19 the resident was seen by the wound physician. Review of the documentation from this visit revealed the identification of two pressure injuries: -unstageable deep tissue injury on the right heel measuring 2.5 by 2.5 cm with a notation that it was just starting to open; -and an unstageable deep tissue injury on the left heel measuring 3.5 x 3 cm. The note included the following: Recommend air mattress for prevention of breakdown given (resident) pain with turning, weakness and breakdown on heels. Use pillows to float heels. On 5/3/19 there was a nursing note that included, BLE (bilateral lower extremities) elevated on pillows for pressure relief. No further documentation was found that the lower extremities were elevated as recommended by the wound physician until 5/9/19 when there was an order to elevate heels off the bed every shift for pressure reduction. Review of the labs which were reported to the facility on [DATE] revealed a HCT of 33 which was low (reference range is 41-53). The resident's Iron level was low at 29 (reference range 50-212), Vit D was low at 10.1 (range was 30-100), and the [MEDICATION NAME] was low at 2.6 (reference 3.5 - 5.7) After the labs were reported the following orders were found: Vit D 50,000 unit every week for 6 weeks then recheck Vit D level; Vitron C 125/65 daily. Vitron C is a high potency iron supplement with Vit C to assist with absorption. On 5/3/19 there was also an order [REDACTED]. Review of the nursing documentation revealed staff documented as ordered from 5/3/19 until 6/6/19. On 9/10/19 interview with the Certified Dietary Manager (CDM) revealed that at present the meal tracker (computer system) would state what should be sent for a snack but that they also sent bulk snacks to the units in the evenings which included a variety of items, such as animal crackers, cookies, graham crackers, peanut crackers and half sandwiches, to name a few. The nursing staff documented the acceptance of 50 - 100 % of the bedtime snack every evening, except for 5/12/19 when they documented 0 acceptance. No documentation was found as to what the bedtime snack consisted of. According to the National Institutes of Health (NIH) a person is considered underweight if their Body Mass Index is less than 18.5. According to the NIH website the BMI for an individual who is 5 feet 8 inches tall is 17.9. Further review of the medical record revealed a Minimum Data Set assessment with an assessment reference date of 5/4/19 which documented a height of 58 inches. A person who is 58 inches tall is 4 foot 10 inches in height. On 9/6/19 at 9:46 AM RD#1 reported she usually does an initial assessment, called the data collection, within a week of the admission, and within 30 days completes a dietician assessment. Review of the Nutrition Data Collection documentation, completed by the Registered Dietician (RD#1) with an effective date of 5/4/19, revealed a height of 5.8 and a weight of 116.4 Of note further review of the medical record revealed the weight of 116.4 was obtained on 5/6/19nd this Nutrition Data Collection documentation was signed by the RD on 5/7/19, which is 3 days after the effective date of 5/4/19. The Body Mass Index (BMI) was documented as 24.3. This BMI reflected a height of 58 inches (4 ft 10 inches) and a weight of 116.4. On 5/12/19 there was documentation that the resident weighed 110.7. On 5/13/19 there was documentation that the resident weighed 110.8 These weights represent a significant weight loss of more than 5% since the resident's admission two weeks prior. No documentation was found that this significant weight loss was reported to the physician and was not addressed by the dietician until 5/16/19. Review of the 5/16/19 RD assessment revealed that the resident had lost 7.2 lbs since admission and that the BMI was currently 16.8, which is underweight. On physical assessment resident looks very thin with fat and muscle loss on facial features and extremities .Continue with current diet order and order Ensure BID (two times a day) at 10:00 am and 2:00 pm with assorted sandwich at 2:00 pm for additional protein/energy intake. This note also revealed that the resident reported not eating the HS (bedtime) snack. On 5/16/19, the wound physician saw the resident. Notes indicated an arterial doppler showed bilateral vascular disease with the [MEDICAL CONDITION] being worse on the left than the right. Further review of this note revealed the heel wounds were now classified as arterial wounds rather than pressure wounds. On 5/23/19, the wound physician saw the resident. Review of this note failed to reveal documentation regarding the sacral ulcer. The wound physician performed a surgical excisional debridement procedure on the left heel wound to remove necrotic (dead) tissue and establish margins of viable tissue. On 5/30/19, the wound physician saw the resident. The physician performed a surgical excisional debridement procedure on the left and right heel wounds to remove necrotic (dead) tissue and establish margins of viable tissue. There was a notation that the right heel wound had deteriorated with [DIAGNOSES REDACTED] (redness) in the skin surrounding the wound. The wound MD ordered two different antibiotics for 14 days to treat the wound infection. The 5/30/19 wound physician note also documented an assessment of the sacral pressure ulcer. The wound was 1.3 cm x 1.4 cm x 0.1 cm in depth and was assessed as a stage 3 pressure ulcer. Further review of the recorded weights revealed that, on 6/2/19, the resident weighed 100 lbs. No documentation was found of a re-weight. This represents an additional10 lbs weight loss since the 5/16/19 assessment. No documentation was found that the physician, nurse practitioner, or family was made aware of this significant weight loss. The resident was seen by the wound physician on 6/6/19. Review of this note revealed the right heel wound was 3 x 2.6 x 0.1 cm and the physician performed a surgical excisional debridement procedure to remove necrotic (dead) tissue and establish margins of viable tissue. The left heel wound was 3.8 x 4 x 0.3 cm and the physician performed a surgical excisional debridement procedure to remove necrotic (dead) tissue and establish margins of viable tissue, and to remove infected tissue. The sacral pressure wound measured 1 x 1 x 0.1 cm. Review of the progress notes revealed a WEIGHT WARNING note dated 6/7/19 with a notation that the resident discharged the facility on 6/7/19. On 9/5/19, review of the medical record revealed that, on 5/17/19, nursing staff completed a Skin - Head to Toe Skin Checks assessment. Review of this assessment revealed documentation of a New Pressure Ulcer and revealed a sacral pressure ulcer measuring 1.5 cm by 2.0 cm. Further review of the medical record failed to reveal any documentation that this newly identified sacral ulcer was reported to the physician, the nurse practitioner or the wound nurse. On 9/3/19 review of the care plans revealed a care plan, initiated on 5/16/19, addressing malnutrition and weight loss related to poor appetite and increase energy/protein needs. The interventions included: needs extra time to finish meals; and provide and serve supplements as ordered: Ensure BID at 10:00 and 14:00 (2:00 PM). On 9/3/19 at 12:37 PM RD#1 reported, after review of her 5/16/19 assessment, that she had consulted with the resident and her concern was that the resident was not eating enough to support wound healing and healthy weight. She confirmed that she had recommended the Ensure. She reported that the process for a recommendation was that she would write a paper order and either give it to the unit manager or just put it in the unit manager's mailbox and also in the DON's mailbox and typically would also update the care plan with the recommendation. She went on to report that typically she keeps the paper and checks the next day to make sure the order got put in the system. After discussing the process for implementation of a recommendation the RD then checked the electronic health record and confirmed there was no Ensure order. She also confirmed nursing staff would document the administration of the Ensure if ordered. On 9/4/19 at 1:16 PM the Administrator confirmed there was no documentation regarding the Ensure and the afternoon snack. She went on to report that they initiated assisted dining for the resident and that he/she was physically assisted to eat by staff, stating that I (the Administrator) went in to help him. When surveyor reviewed the GNA documentation indicating that Set up help only had been provided from 5/2 until the time of discharge in June, the Administrator responded: Can't explain. As of time of exit, no additional documentation had been provided about the resident's participation in an assisted dining program. On 9/5/19 at approximately 12:30 PM the wound nurse reported that the nurses complete a weekly head to toe skin assessment and if they find something new they need to let us know so we can address it. Surveyor then reviewed the 5/17/19 documentation of the sacral ulcer with the wound nurse. She reported, they didn't tell me and confirmed she had not known that the sacral ulcer had been identified prior to 5/23/19. On 9/6/19 at 9:46 AM, RD#1 confirmed the height of 58 inches used to compute the BMI of 24.3 was incorrect. She went on to report that she caught the error when she calculated the resident's needs when she completed the dietician assessment on 5/16/19. She went on to report that she had observed the resident, however, the resident was sitting in a chair with blankets on and the RD didn't catch how tall (resident) was. Surveyor reviewed the concern with the RD that, based on the BMI assessment using the incorrect height she had failed to identify that the resident was underweight at the time of the initial assessment. Further review of the medical record failed to reveal documentation that the Ensure BID was ordered. On 9/6/19 at 10:00 AM, the RD #1 provided a copy of the meal tracker that was in effect at the time of resident's discharge. The meal tracker included an assorted yogurt cup and banana at 10 am and a deli sandwich at 2:00 PM. RD #1 confirmed that there was no way to assess when these items were added to the meal tracker and that there was no documentation that they were administered. There was nothing in the meal tracker documentation regarding the evening snack that nursing staff documented as administered. On 9/10/19 at 10:30 AM the wound physician reported that she decided to treat with antibiotics due to odor, increased drainage and redness, and that by 6/6/19 the odor and drainage had improved. On 9/10/19 at 10:30 AM wound physician confirmed that the sacral pressure ulcer was a stage 3 ulcer. Surveyor reviewed the concerns regarding failure to accurately assess nutritional status when first assessed and also failure to implement dietary supplement as indicated in RD #1 note and care plan. When asked, the wound physician reported the sacral ulcer probably was preventable and stated that the resident should have been turned and repositioned and if resistant (to position change) it should have been documented. On 9/10/19 surveyor reviewed the concerns with the DON and the Administrator regarding the resident's development of a pressure ulcer, an infection of heel wounds and significant weight loss. Cross reference to F 580 notification F 641 assessments F 656 care plans F 686 pressure ulcers F 800 nutrition Resident #72 was interviewed on 8/22/19 at 10:36 AM and stated that he/she smoked. The resident stated that the nurse kept the cigarettes and lighter. When asked if the resident was ever burned while smoking the resident said yes, on the back of the hand. The surveyor asked the resident if it was reported to the nursing staff and the response was yes. The surveyor asked the resident when the burn occurred, and the resident stated he/she did not remember. Review of the medical record for Resident #72 failed to reveal that the resident had a burn from smoking. LPN #3 was interview on 9/4/19 at 10:30 AM and stated the resident had not reported a burn to the back of the hand. LPN #2 was interviewed on 9/4/19 at 10:32 AM and stated the resident never said anything to her about a burn mark. Further review of Resident #72's medical record revealed (MONTH) 2019 physician's orders [REDACTED]. Review of skin sheets for Resident #72 dated 7/22/19 documented resident has purpura and sun marks throughout his/her arms. The surveyor was unable to find any other skin sheets for Resident #72 in the medical record or in any binders at the nurse's station that would indicate the resident had a burn. Review of the Skin Management System Policy documented that if no skin concern or breakdown is identified on admission or re-admission then the resident should have weekly skin checks. If there is an identified resident with breakdown then there should be a weekly pressure ulcer or non-pressure ulcer recording on the record and then weekly skin checks. On 9/5/19 at 11:55 AM the surveyor requested to look at skin sheets from LPN #2 for Resident #72. LPN #2 could not find any weekly skin assessments. LPN #2 confirmed that weekly skin assessments should have been done and were not done. Further review of Resident #72's medical record revealed the resident was deemed an unsafe smoker on 8/14/18, 12/3/18 and 4/11/19. A smoking assessment had not been done since 4/11/19. Review of Resident #72's care plan, I am a smoker had the goal, I will abide by the safe smoking policy as set by facility. The care plan interventions documented that the resident was a supervised smoker and that all smoking materials were kept at the nurse's station. The care plan did not have an intervention regarding wearing a smoking apron while smoking per the facility smoking policy. Cross Reference F657 Review of the Facility Smoking Policy revealed the following: The Smoking Policy requires the Facility Interdisciplinary team (IDT) to assess each resident who smokes to determine if the resident is a safe or unsafe smoker. If the Resident is an unsafe smoker, he or she must wear a protective vest or apron while smoking and will be supervised at all times while smoking. Review of the Safe/Smoking/Tobacco Use Policy revealed under Safe Smoking/Tobacco Use Determination, the resident's care plan reflects: the degree of supervision that is necessary, if any; if the resident is to wear a protective smoking vest/apron. The smoking policy documented, smoking assessments will be Quarterly, annually, with significant change of condition, and/or an infraction of facility smoking policy: Intervention #4 stated, Residents who are determined to be unsafe while smoking are required to wear a protective smoking vest/apron (not required for e-cigarette use) and are supervised at all times while smoking. The Nursing Home Administrator (NHA) was interviewed on 9/4/19 at 11:06 AM regarding the smoking policy which stated, The degree of supervision is determined based on the Safe Smoking/Tobacco Use Evaluation UDA, the physical attributes of the smoking area, and other relevant factors. Residents who are determined to be unsafe while smoking are required to wear a protective smoking vest/apron (not required for e-cigarette use) and are supervised at all times while smoking. The NHA stated that if the resident is assessed to be unsafe but doesn't want to wear a smoking apron then she will have a conversation with the resident, and it would be noted in their progress notes. Review of progress notes for Resident #72 revealed there were no notes from the NH[NAME] On 9/4/19 at 11:50 AM the resident was interviewed again and was asked when the last time he/she smoked, and he/she said this morning. The surveyor again asked him/her if he/she got burned and the response was, yes, on my left hand. There was a red mark. When asked if he/she told anyone he/she said, yes, mama-sister and she wrote up a report and put tape on me. The resident was asked if he/she wore a smoking apron when smoking and the response was, No. When asked if the NHA had every spoken to him/her about wearing a smoking apron the response was, no one has ever talked to me about wearing a smoking apron. The MDS Coordinator was interviewed on 9/4/19 at 1:50 PM as she takes the resident out in the courtyard and supervises the resident smoking. She stated, I have never been called mama-sister and when I supervise the resident smoking the resident does not wear a smoking apron. When asked if the resident ever reported a burn the response was, no. If the resident would have burned his/her hand I would have reported it. A discussion was held with the Director of Nursing (DON) on 9/4/19 at 2:00 PM regarding the resident. The DON looked through all the incident reports and there was nothing about a burn. The DON stated he didn't know anything about a burn and asked the surveyor if it happened at the facility or at a consulting physician's office where the resident also smokes and gets cigarettes from their facility staff. The DON confirmed that a recent smoking assessment should have been done, especially after noted confusion with [MEDICAL CONDITION] treatments that the resident was receiving. The DON stated that if the resident refused to wear a smoking apron that it should have been care planned. Reviewed the smoking assessment of 4/11/9 with the DON and the question was not answered about being unsafe and having a smoking apron and the DON stated that should have been answered. Discussed with the DON that the smoking care plan was not updated regarding the smoking apron and the resident's increased confusion and that there was no evaluation of the smoking care plan.

Based on medical record review and interviews, it was determined that the facility failed to provide services to prevent the development of pressure ulcers and promote healing of existing pressure ulcers/injuries. This was evident for 2 (#165 and #5) of 7 residents (Resident #165) reviewed for pressure ulcer/injury. The findings include: 1) Review of Resident #165's medical record revealed that the resident was admitted to the facility in (MONTH) 2019 with open blisters to the top of the left and right foot, but no documentation was found that the resident had any skin breakdown or pressure ulcers to either heel or the resident's sacrum (backside). The resident was noted to have swelling in both upper and lower extremities with limited range of motion. The resident was assessed as requiring moderate assistance for mobility such as moving from lying to sitting on the side of the bed. Review of the Baseline Care Plan and Summary, effective 4/27/19, revealed that the resident required one person physical assist for eating, personal hygiene, dressing and bed mobility. Review of the GNA documentation for (MONTH) 2019 failed to reveal any documentation that Resident # 165 received assistance with bed mobility or was turned and repositioned during the 4/27/19 and 4/29/19 night shifts. For the shifts that assistance was documented, the GNAs noted that the resident either required extensive assistance or total dependency on staff. The resident was seen by the primary care physician on 4/29/19. On 9/3/19, a review of this note with the Director of Nursing, revealed the resident was emotionally dependent for everything since a repeat fall . Review of the care plans revealed that, on 4/29/19, a care plan addressing the potential for skin break down and skin issues was initiated, however, all of the interventions were documented as initiated on 5/5/19. One of the interventions was: follow facility protocols for treatment of [REDACTED]. Additional interventions included: Encourage good nutrition and hydration in order to promote healthier skin; Identify/document potential causative factors and eliminate/resolve where possible; Monitor dressing to ensure it is intact and adhering; Provide me with a LAL (low air loss) mattress to my bed and check for functioning q (every) shift; and Use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surface. No interventions were found in the potential for skin breakdown regarding assisting or encouraging the resident to change position on a regular basis. On 5/2/19, the wound physician documented that the resident had a venous wound on the left dorsal (top of) foot; the right dorsal foot, a wound on the left knee; an unstageable deep tissue injury on the right heel, and an unstageable deep tissue injury on the left heel. The wound physician documented the resident's Body Mass Index as 17.94, which is indicative of being underweight. The note also included the following: Recommend air mattress for prevention of breakdown given (resident) pain with turning, weakness and breakdown on heels. Use pillows to float heels. According to the National Institutes of Health (NIH) a person is considered underweight if their Body Mass Index is less than 18.5. Review of nursing notes revealed a LAL mattress was delivered on 5/3/19. A 5/3/19 nursing note revealed the following: resident feels more comfortable laying on the edge of the bed, education was provided that is not safe and she/he should attempt to lay in the middle, resident was in agreement with assisting to reposition no open areas or skin issues observed to sacral area, resident requires max assistance x 1 staff for all bed mobility and repositioning. Review of the labs, which were reported to the facility on [DATE], revealed a HCT of 33 which is low (reference range is 41-53). Iron level was low at 29 (reference range 50-212); Vit D was low at 10.1 ( range was 30-100), and the [MEDICATION NAME] was low at 2.6 (reference 3.5 - 5.7) After the labs were reported the following orders were found: Vit D 50,000 unit every week for 6 weeks then recheck Vit D level; vitron C 125/65 daily. Vitron C is a high potency iron supplement with Vit C to assist with absorption. A bedtime snack was also ordered on [DATE]. A low [MEDICATION NAME] level can be an indicator of malnutrition. Further review of the medical record failed to reveal what the bedtime snack consisted of. Interview with the Certified Dietary Manager on 9/10/19 revealed that, if no specific item is ordered, then the snack could consist of any number of items that are sent as bulk snacks to the unit in the evening. These bulk items included crackers, cookies and half sandwiches. Review of the Nutrition Data Collection documentation, completed by the Registered Dietician (RD#1) with an effective date of 5/4/19, revealed a Body Mass Index of 24.3 and that the resident's intake of 50 - 100% was adequate on a regular diet. After further review of the medical record and interview with the RD#1, it was determined that the BMI of 24.3 was incorrect based on an inaccurate height documentation. On 9/6/19, surveyor reviewed the concern with the RD#1 that, based on the BMI assessment using the incorrect height, she had failed to identify that the resident was underweight at the time of the initial assessment. Review of the care plan addressing the left and right heel wounds, initiated 5/5/19, revealed an intervention to assist me to reposition as often as I need and allow to prevent further skin issues. Further review of the care plans revealed a care plan addressing activities of daily living which included: I require max assistance of 1 person to assist me to reposition in bed as I tolerate and as necessary. Further review of the record revealed that a care plan was initiated on 5/8/19 which included the following intervention: I need you to move and position me to relieve pressure about every 2 hours and as needed. This intervention was canceled on 5/9/19. Review of a nursing note with an effective date of 5/9/19 at 4:57 PM revealed: This resident has generalized muscle weakness and requires extensive assistance for bed mobility and transfers education has been provided to attempt to keep feet elevated on pillow to keep pressure from heels, and encouragement to get out of bed more frequently Staff will continue to reposition as needed/tolerate and ensure BLE (bilateral lower extremities) are elevated for pressure relief. Further review of the nursing notes from 5/10 thru 5/16 failed to reveal documentation regarding positioning of resident or that the resident was refusing or resistant to changing position. Further review of the nursing notes from 5/16 thru 5/23 failed to reveal documentation that the resident refused care, except for one note on 5/17 in regard to refused to be shaved. Review of the Geriatric Nursing Assistant (GNA) documentation revealed documentation once every shift regarding bed mobility by answering How resident moves to and from lying position, turns side to side and positions body while in bed or alternate sleep furniture. Review of the (MONTH) 2019 documentation regarding bed mobility revealed the resident was totally dependent on staff for bed mobility during the night shift for 26 out of the 31 days in May. On 5/6/19 day shift, 5/14/19 night shift and 5/25/19 day shift the GNA documented an 8 indicating the activity did not occur or family and/or non facility staff provided care 100 % of the time for that activity. No documentation was found for bed mobility for the 5/10/19 day shift. Further review of the GNA documentation revealed a section for Monitor - Turn and Reposition. In response to the question Is the resident on a Turning and Positioning Program? some GNAs documented No, some documented Yes, and some documented Not Applicable. If the GNAs documented yes or not applicable, they would be prompted to respond to a second question: Did you turn and reposition? If the answer to the first question was No, there would be no prompt to answer the follow up question. Out of 93 shifts in May, the GNAs documented yes and that the resident was turned and repositioned on 9 occasions. The response was Not Applicable in regard to the Turning and Positioning program but revealed documentation that the resident was turned and positioned on 21 occasions. There were 62 shifts when the Turning and Positioning Program question was answered as No, and there was no documentation whether or not the resident was turned and repositioned. On 9/4/19 at 12:13 PM, GNA #5 reported that, in regard to the Is the resident on a Turning and Positioning Program? question the answer should never be yes, stating that everyone gets turned. On 9/4/19 at 12:16, the surveyor asked the unit nurse manager (LPN #1) how the GNAs would know if a resident was on a turning and repositioning program. The unit nurse manager reported that she was unable to answer this question at this time and would go and check. On 9/4/19 at 3:39 PM, surveyor asked the DON how the GNAs would know if a resident was on a turning and repositioning program. The DON first gave a response that, if the resident were on a program, it would populate in the ADL program for documentation. Surveyor then discussed GNA#5's response and the concern that review of the documentation for Resident #165 revealed GNA responses of yes/no/and not applicable. Review of the 5/16/19 RD assessment revealed that the resident had lost 7.2 lbs since admission and that the BMI was currently 16.8 which is underweight. On physical assessment, resident looks very thin with fat and muscle loss on facial features and extremities .Resident reports being overwhelmed by the variety of food served at lunch and dinner. Would rather eat more frequent smaller foods. Resident reports that (s/he) goes to bed right after dinner and does not eat HS (bedtime) snacks Protein needs with wounds = 76 gm protein/day. Caloric needs are 1800 -2400 kcal for wounds and weight gain. Continue with current diet order and order Ensure BID (two times a day) at 10:00 am and 2:00 pm with assorted sandwich at 2:00 pm for additional protein/energy intake . On 9/3/19, review of the record revealed a care plan, initiated on 5/16/19, addressing malnutrition and weight loss related to poor appetite and increased energy/protein needs. The interventions included: needs extra time to finish meals; and provide and serve supplements as ordered: Ensure BID at 10:00 and 14:00 (2:00 PM). The sandwich at 2:00 pm was not found in the care plan. Further review of the medical record failed to reveal documentation that the Ensure BID was ordered or administered. On 9/3/19 at 12:37 PM, RD#1 reported, after review of her 5/16 assessment, that she had consulted with the resident and her concern was that the resident was not eating enough to support wound healing and healthy weight. She confirmed that she had recommended the Ensure. She then checked the electronic health record and confirmed there was no Ensure order. She also confirmed that nursing staff would document the administration of the Ensure if ordered. On 9/6/19, the RD #1 provided a copy of the meal tracker that was in effect at the time of resident's discharge. The meal tracker included an assorted yogurt cup and banana at 10 am and a deli sandwich at 2:00 PM. RD #1 confirmed that there was no way to assess when these items were added to the meal tracker and that there was no documentation that they were administered. There was nothing in the meal tracker documentation regarding the evening snack that nursing staff documented as administered. On 5/16/19, the wound physician saw the resident. Notes indicate an arterial doppler showed bilateral vascular disease with the [MEDICAL CONDITION] being worse on the left than the right. Further review of this note revealed that the heel wounds were now classified as arterial wounds, rather than pressure wounds. On 9/5/19, review of the medical record revealed that, on 5/17/19, nursing staff completed a Skin - Head to Toe Skin Checks assessment. Review of this assessment revealed documentation of a New Pressure Ulcer and documented a sacral pressure ulcer measuring 1.5 cm by 2.0 cm. Further review of the medical record failed to reveal any documentation that this newly identified sacral ulcer was reported to the physician, the nurse practitioner or the wound nurse. On 9/5/19 at approximately 12:30 PM, the wound nurse reported that the nurses complete a weekly head to toe skin assessment and if they find something new they need to let us know so we can address it. Surveyor then reviewed the 5/17/19 documentation of the sacral ulcer with the wound nurse. She reported they didn't tell me and confirmed that she had not known that the sacral ulcer had been identified prior to 5/23/19. According to the facility's Weekly Pressure Ulcer Record, a stage 1 pressure ulcer is Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. On 5/23/19, the wound physician saw the resident. Review of this note failed to reveal documentation regarding the sacral ulcer, thus confirming that it had not yet been reported to the physician. Further review of the medical record revealed a SBAR nursing note, with an effective date of 5/23/19 at 10:01 PM, that stated: Resident was noted with a pressure sore (2x3cm) on the sacrum, no drainage, no odor. Wound bed is pink colored. This note also addressed the resident's 5/20/19 weight of 111.2 and identified weight loss as a concern. The note indicated that the family was notified on 5/23 at 10:15 PM and the primary care physician on 5/23 at 10:00 PM. This note was completed by LPN #5. According to the facility's Weekly Pressure Ulcer Record, a stage 2 pressure ulcer is Partial thickness loss of dermis (skin) presenting as a shallow open ulcer with a red pink wound bed, without slough. Further review of the medical record revealed a late entry nursing note with an effective date of 5/24/19 at 1:04 PM, which was written by the unit nurse manager (LPN #1). This note included the following: Late entry note from SBAR completed on 5/23/19 at 2000 (10:00 PM) 5/23/19 resident was noted with a wound to the sacral area during incontinence care, upon observation, (his/her) sacral area has bony prominence without fat or muscle observed,(s/he) is noted to not like laying on either side and (his/her) comfort is to lay on (his/her) back, (s/he) is underweight with a BMI between 15 and 16. Resident has been previously provided a LAL (low air loss) Air Mattress for this reason and education provided on the importance of off loading pressure and laying on side to prevent further skin breakdown, on physical assessment resident looks very thin with fat and muscle loss on facial features and extremities,(s/he) does report having a fair appetite that fluctuates with meals. Dietary services have been notified to assess regarding intake, increased protein, etc, treatment orders have been set in place for healing of this wound and resident will be assessed on weekly basis by (name of wound MD) (Wound MD) until wound is resolved. Staff will continue to encourage and offer assistance with turning and repositioning and offloading pressure of this wound. Further review of the medical record failed to reveal any follow up assessment by the Registered Dietician as indicated in the 5/24/19 nursing note. No orders were found to modify diet to increase protein or for supplement that would provide increased protein. Review of the resident's care plans revealed interventions, initiated 5/5/19: Assist me to reposition as often as I need and allow to prevent further skin issues; I require max assistance of 1 person to assist me to reposition in bed as I tolerate and as necessary. Further review of the care plans failed to reveal documentation that the resident does not like laying on either side and his comfort is to lay on his back; no interventions found regarding encouraging resident to lay on side as indicated in the 5/24 late entry nursing note. Further review of the nursing notes prior to 5/23 failed to reveal documentation regarding Resident #165's refusal to be repositioned. The 5/30/19 wound physician note documented an assessment of the sacral pressure ulcer. The wound was 1.3 cm x 1.4 cm x 0.1 cm in depth and was assessed as a stage 3 pressure ulcer. On 9/10/19 at 10:30 AM, the wound physician confirmed that the sacral pressure ulcer was a stage 3 ulcer. Surveyor reviewed the concerns regarding the registered dietitian's failure to accurately assess nutritional status when first assessed and also failure to implement dietary supplement as indicated in RD #1 note and care plan. When asked, the wound physician reported the sacral ulcer probably was preventable and stated that the resident should have been turned and repositioned and if resistant (to position change) it should have been documented. According to the facility's Weekly Pressure Ulcer Record, a stage 3 ulcer is Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. Once a pressure ulcer is classified at a stage it cannot be downgraded, i.e. a stage 3 can be a healing stage 3 but cannot be changed to a stage 2. The resident was seen by the wound physician on 6/6/19. This note revealed the sacral pressure wound measured 1 x 1 x 0.1 cm and was a stage 3 wound. The 6/6/19 Weekly Pressure Ulcer Record, signed by the wound nurse on 6/11/19, also documented the sacral pressure ulcer as a stage 3 pressure ulcer. Review of the nursing Discharge Plan and Summary, dated 6/7/19, revealed that the resident was receiving wound treatments to both heels and the sacrum at time of discharge. Review of the Discharge Summary with a date of service date of 6/7/19 and completed by the nurse practitioner failed to reveal documentation regarding the development and presence of the sacral ulcer or the two heal wounds; and failed to reveal documentation about the significant weight loss identified on 6/2/19. 2) Resident #5 was observed on 8/26/19 at 9:03 AM in the day room on North wing reclined in a geri-chair (a wheeled, high backed reclining, chair). The resident was wearing tan non-skid socks on both feet. Resident #5's medical record was reviewed on 8/26/19 at 8:19 AM. The resident was hospitalized from [DATE] - 2/10/19. A nursing note, dated 2/10/19 21:37, revealed that Resident #5 was admitted to Hospice care upon readmission to the facility due to declining health. A Braden Scale assessment for Predicting Pressure Sore Risk, dated 2/10/19, indicated that resident #5's score was 8 - Very High Risk. Braden Scale assessments, dated 2/21/19 and 5/20/19, resulted in scores of 10 - High risk. Resident #5 had an existing stage 2 pressure ulcer to the right buttocks upon re-admission. The documentation reflected that the area was resolved by 3/12/19. Another pressure ulcer was identified to the right buttocks on 6/11/19 and was documented as healing on 6/27/19. Intact skin was documented on the weekly head to toe skin checks, dated 7/4/19 - 8/21/19. A Weekly Non-Pressure Condition record, dated 8/23/19, revealed that Resident #5 had again developed an Open area left buttock 1 cm (centimeter) long, 0.2cm wide 0.1 cm deep and Right buttock 2.5 cm long 0.9 cm wide, 0.1 cm deep. A plan of care for Resident #5 was developed on 3/21/17 and updated on 2/21/19 with the focus: Potential/have skin issues related to incontinence of bowel, limited mobility and dementia the residents goal: My skin will remain intact without signs of breakdown by next review. The target date for the goal was 8/23/19. The care plan interventions included, but were not limited to: I have pressure reduction cushion to w/c (wheelchair) please make sure it's in place, and Please provide foam boots per Dr. (doctor) orders. Another plan of care was developed on 2/10/19, reviewed and revised on 4/16/19 for I have a risk for pressure ulcer development related to dementia, immobility, incontinence. The resident's goal was: I will be free from any ill effects related to skin related issues throughout review date. No plan of care was found to address Resident #5's risk for or actual skin injury to his/her ears from oxygen tubing. Resident #5 was observed in the dining room on 8/28/19 at 11:20 AM watching television. He/She was reclined in a geri-chair with a pillow beside each hip. He/She was wearing white socks on both feet. The resident was not wearing foam boots. No pressure relieving devices were observed on the geri-chair. Resident #5 was observed on 8/29/19 at 10:52 AM reclined in the geri-chair in the day hall on the North wing. He/She was wearing white crew socks. He/She was not wearing foam boots. The resident was observed the same day at 11:39 AM in the dining room. He/She was still wearing white crew socks on both feet. No foam boots were present. No Gel cushion was observed on the seat of the geri-chair. Further review of the resident's record revealed a physician's orders [REDACTED].#5's readmission from the hospital to discontinue the gel cushion. The Reason: admitted on Hospice/per order. No documentation was found to indicate that the resident's need for a pressure relieving device was considered, including rationale for discontinuing the gel cushion, when his/her Braden assessment scores indicated Very High to High risk for pressure ulcers. During an interview, on 8/29/19 at 12:16 PM, the resident's pressure ulcer history was reviewed with the DON (Director of Nursing). He was asked what preventative measures were put in place in an attempt to reduce Resident #5's risk of pressure ulcers. He indicated that either foam padding or gauze pads were used to prevent breakdown behind the resident's ears from his/her oxygen tubing, but was not sure what was in place because Hospice implemented a plan of care. He indicated when asked that the facility follows the interventions implemented by hospice. He was made aware of the above findings. The DON observed the resident at that time with the surveyor and confirmed that there was no pressure relieving device on the geri-chair and the resident was not wearing foam boots. The pressure wounds behind both of Resident #5's ears were not covered with a dressing and his/her oxygen tubing was lying against the open areas. Cross reference F 842 and F 849.

Based on medical record review, resident observation and resident and staff interview, it was determined that the facility failed to have an effective system to manage resident pain, when pain medications were ordered, but unavailable. Pain assessments were consistently not completed in accordance with standards of practice, as-needed pain medications were not always given when needed, and were given with insufficient assessment of effectiveness. Ongoing pain was not reported to the physician and the care plan for pain management was not followed. This was evident for 2 (#149 & #47) of 3 residents reviewed for pain during the Quality Indicator Survey and left Resident #149 in pain described as severe. The failure to provide necessary services to meet the individualized needs of Resident #149 resulted in a finding of actual harm. The findings include: Resident #149 was admitted to the facility on [DATE] at 15:45 PM from an acute care hospital by Registered Nurse (RN) #1 after a recent hospitalization for a left (L) hip Intertrochanteric (top of the femur) fracture. During this hospital stay, Resident #149 underwent nailing of the L hip on 12/12/16. In addition, just prior to this hospitalization , this resident underwent [REDACTED]. Review of the medical record found a hospital consultation report, dated 12/8/16, which noted that Resident #149 had other [DIAGNOSES REDACTED]., poor circulation to the lower extremities), [MEDICAL CONDITION] Disc Disease, Depression and Anxiety. Following the admission assessment, a note completed by RN #1 indicated that Resident needed to urinate and was in too much pain, even with 2 staff assist to be placed on bedpan. RN #1 also documented resident stated that he/she was in too much pain to be turned and placed on a bed pan for urination, due also to pain from metastatic [MEDICAL CONDITION] .At that time RN, #1 placed a call to Certified Registered Nurse Practitioner (CRNP) #1 to obtain an order for [REDACTED]. On 12/18/16, RN #1 established a care plan for Pain and Pain Symptoms Risk, with multiple areas listed under the Problem column related to pain. A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess and evaluate the effectiveness of the resident's care. According to this plan of care, Resident #149 had pain related to Bone, Hip pain, Incision pain and R foot amputation site of R great toe. The care plan goal was Resident will verbalize decrease in pain with pain relieving strategies. Interventions listed to achieve this goal were: 1) Assess and establish level of pain using numeric scale or PAIN AD tool. 2) Implement pain control strategies of: medication, positioning, elevation. 3) Monitor response on pain scale relative to:- Medications, -Treatments, -Procedures 4) Evaluate need to provide medications prior to treatment or therapy i.e. 20 min before therapy. 5) Evaluate need for routinely scheduled (q. 4 hrs. or q.i.d.) rather than As Needed (PRN) pain medication. 6) Don't wait for resident to request pain medication but offer it to the resident at frequencies indicated in the physician order. 7) Notify rehab for possible assessment. Resident interview, and observation on 12/19/16 at 11:50 AM, revealed Resident #149 with a distressed look on Resident #149 's face with tears streaming down the side of the face. Soon after the surveyor interview began, LPN # 3 came into the room to do Resident #149's finger stick for a glucose level, and asked Resident #149 if he/she was still having pain. Resident #149 confirmed that he/she was still in pain and that the [MEDICATION NAME] (Narcotic pain medication) had only helped a little. LPN #3 stated I'm sorry your [MEDICATION NAME] (Narcotic pain medication) hasn't arrived from the pharmacy yet When the surveyor asked about the location and severity of the pain, Resident #149 stated that It's about an 8 right now. It hurts everywhere but especially my left hip, the pain never really goes away, but the [MEDICATION NAME] helps a lot. Review of the Resident #149's current physician's orders [REDACTED]. [MEDICATION NAME] HCL Tablet 10 mg (milligrams) Give 2 tablets by mouth four times a day [MEDICAL CONDITION] pain, [MEDICATION NAME] Tablet 30 mg Give 30 mg by mouth every 3 hours as needed (PRN) for breakthrough pain related to Nondisplaced Intertrochanteric Fracture of Left Femur, For Closed Fracture; Complete Traumatic Amputation of Right Great Toe; Acute [DIAGNOSES REDACTED]. Not more than 5 tablets per day. [MEDICATION NAME] (medication used to treat nerve pain) Capsule 300 mg, give 300 mg by mouth at bedtime for pain. [MEDICATION NAME] Tablet 600 mg by mouth two times daily for pain. Review of the Automatic Dispensing Unit (ADU) with the on-site Formulary (medications available at all times in the facility) revealed [MEDICATION NAME] 15mg tablets and [MEDICATION NAME] 300 mg tablets were available. Review of the Resident #149's December 2016 Medication Administration Records (MAR) revealed that the resident did not receive any pain medication at all following arrival to the facility on [DATE]. On 12/19/16, RN #1 documented a missed [MEDICATION NAME] dose at 9:00 AM and documented Not available from pharmacy. On 12/19/16, [MEDICATION NAME] was administered as ordered at 9:00 AM, and [MEDICATION NAME] 30 mg PRN, was administered at 10:44 AM. Review of the MAR further revealed a pain level of 8 at 5:00 PM when the first scheduled dose of [MEDICATION NAME] was given, and a pain level of 9 at 9:00 PM when the second dose of [MEDICATION NAME] was given. Review of the medical record failed to reveal an evaluation of the effectiveness of the PRN pain medication, or that PRN pain medication was offered to provide adequate pain relief. On 12/20/16, [MEDICATION NAME] was administered at 9:00 AM with a pain level of 8. On 12/20/16 at 11:47 AM, Resident #149 was observed with tears running down his/her cheeks and looking very upset, stated his/her pain level was currently at an 8, he/she was feeling yucky today stated that he/she had been nauseated and vomited this morning. Resident #149 stated he/she was told by the nurse that CRNP would be in today to evaluate if there was anything else that can be done to manage his/her pain and nausea. On 12/20/16 at 12:14 PM, LPN #2 stated Resident #149 vomited at approximately 8:30 AM, I am waiting for him/her to be seen by CRNP for further evaluation. When asked if Resident #149 was medicated for nausea or offered PRN pain medication, LPN #2 stated no, she didn't have anything ordered for nausea, CRNP is going to see her soon. When asked if the doctor or CRNP were notified about the new onset of nausea and vomiting or the resident's pain status, LPN #2 said no. CRNP #2 on 12/20/16 at 12:20 PM, when interviewed, stated I have not received any calls regarding pain levels, medications or nausea and vomiting, I am here now to do the initial assessment. On 12/20/16 at 12:14 PM, during an interview with LPN #2, the surveyor asked when did the [MEDICATION NAME] become available for Resident #149, and what was done to manage Resident #149's pain until the [MEDICATION NAME] was available. LPN #2 stated that he/she would have to look into it because he/she wasn't the nurse caring for the resident at that time. Follow up interview, on 12/21/16 at 10:25 AM, with LPN #2 confirmed that the [MEDICATION NAME] was delivered from the pharmacy at 3:30 PM on 12/19/16. Record review revealed that medication orders were faxed by RN #1 to the pharmacy on 12/18/16 at 10:39 PM, and there was no request made at that time for STAT (Immediate) delivery of the pain medications. The packing slip that arrived with the [MEDICATION NAME] and signed by LPN #2, was marked delivered on 12/19/16 at 4:17 PM. As previously noted, the first dose of [MEDICATION NAME] was not given until 5:00 PM on 12/19/16, greater than 24 hours after admission. On 12/21/16 at 10:55 AM, interview of Resident #149, who appeared comfortable, sitting up in a wheelchair talking on the phone, when asked about current pain level he/she stated I'm feeling much better today. A phone interview, on 12/21/16 at 12:04 PM of RN #1, revealed that he/she completed the admission for Resident #149 on 12/18/16, and documented that the resident was in a lot of pain. RN #1 stated that he/she called the pharmacy regarding the [MEDICATION NAME] availability, and was told that it would not be available for the evening dose. When asked what he/she did to manage Resident #149's pain until the [MEDICATION NAME] would be available, he/she stated that he/she also asked the pharmacist about the [MEDICATION NAME] 30 mg dose which he/she said was not available in the ADU (automatic dispensing unit) and had to wait approximately 20 minutes on the phone to have the two 15 mg tablets made available to dispense for this resident. RN #1 also stated that he/she removed the [MEDICATION NAME] 30 mg (2 x 15 mg tablets) from the ADU but does not recall if I or the other nurse (the one on the medication cart) actually gave the medication to the resident. When asked if Resident #149 actually received pain medication on 12/18/16, RN #1 said he/she was unsure if the pain medication had been given. When asked the name of the other nurse, RN #1 said he/she did not know the name because he/she doesn't usually work on that unit. Review of the medications removed from the ADU for 12/18/16 revealed that no [MEDICATION NAME] had been removed for Resident #149 until 12/19/16 at 10:25 AM. On 12/21/16 at 3:28 PM, interview of the Administrator found that he/she and the Admissions coordinator would have received Resident #149's information from the acute care hospital on Thursday 12/15/16 or Friday 12/16/16. The Administrator confirmed that, at that time, they were aware of the pain medications [MEDICATION NAME] and [MEDICATION NAME] needed for this resident and were aware that [MEDICATION NAME] was not readily available in this facility. When asked about expectations for wait time for [MEDICATION NAME] to be delivered from the pharmacy, the Administrator stated it should be available within 8 hours if the pharmacy is called with a STAT order, it should be delivered by the local Walgreens Pharmacy When asked if RN #1 should be aware of this process, the Administrator said yes, absolutely. Interview of the Admissions coordinator, on 12/21/16 at 4:03 PM, confirmed that they became aware of Resident #149's admission on Friday 12/16/16. At this time, they received documentation from the acute care hospital, which included a complete medication list. They expected the resident to be admitted on Friday, but later found out that there was a delay in discharge from the acute care hospital, and Resident #149 instead arrived on Sunday 12/18/16. During an interview with the Clinical Pharmacist, on 12/21/16 at 4:16 PM, he/she stated if the [MEDICATION NAME] was ordered before the 8:00 PM cut off it should have been in the building by that night. The facility staff failed to use a consistent and effective tool to monitor Resident #47 for pain during a dressing change. 2) An observation was made of Resident #47'z dressing change on 12/20/16 at 11:40 AM. The Associate Director of Nursing (ADN) and Unit Manager (UM) #1 was present as well as another employee who was helping to hold Resident #47 in position during the dressing change. Resident #47 yelled out 2 times during the dressing change as the ADN removed bandages from the open area to his/her neck. At approximately 11:50 AM and just prior to the ADN packing the open area, the surveyor asked the ADN when was the last time the resident received pain medication. UM #1 stated, the resident received pain medication at 6:00 AM this morning and is due again at 12:00 PM (noon). The ADN turned to the surveyor and stated, I am not going to continue with the dressing change because the resident is in pain. Immediately after the ADN stated that he/she was not going to continue with the dressing change to Resident #47, he/she turned to the resident and asked him/her if he/she was in pain. The ADN stated that the resident responded no by nodding his/her head. The ADN continued with Resident #47's dressing change. After the dressing change was completed at 12:10 PM, an interview was conducted with the ADN and he/she was asked if the resident was assessed for pain and why pain medication was not administered prior to the dressing change. The ADN looked up the physician orders [REDACTED].>Review of the physician orders [REDACTED].#47 had an order for [REDACTED]. Review of resident #47's Medication Administration Record [REDACTED]. Review of Resident #47's pain care plan and skin integrity care plan included under interventions, to monitor resident for pain. Interventions include,evaluate and establish level of pain on the appropriate scale/evaluation tool. The pain care plan specifies to use the PAINAD (Assessment for Pain secondary to dementia) tool. An interview was conducted with the Director of Nursing (DON), on 12/20/16 at 1:50 PM, and he/she stated that he/she held a quick meeting and identified that there was a breakdown in the system. The DON stated that resident #47's order for Tylenol needed clarification by the physician and therefore, the resident did not receive pain medication that day. The DON further stated that UM #1 was incorrect when he/she stated to the surveyor during the dressing change, that the resident received a dose of pain medication at 6:00 AM on 12/20/16. The surveyor asked the DON how Resident #47's pain is assessed, and he/she responded that, due to severe cognitive impairment, a pain assessment in advanced dementia (PAINAD) tool was used by staff. The surveyor asked the DON if a pain scale for cognitively intact residents could be used, and he/she responded,no.

br>Based on a review of the electronic medical record, administrative records and interviews with the resident and the resident family and facility staff, it was determined the facility staff failed to ensure that residents were free of accident hazards when GNA #1 transferred resident #71, who was a known risk for falls, without the assistance of a second staff member, as was required in the resident care plan. With only one staff assisting during a transfer from the toilet, resident #71's knees buckled and he/she fell sustaining a fracture. This was evident for 1 (resident # 71) of 3 residents reviewed for accidents during the facility's annual Medicare/Medicaid survey. Findings include: An interview was conducted with resident # 71 and his/her daughter on 9/10/15 at 2:00 PM. The daughter stated that her mother's shoulder was broken approximately 9 weeks ago as GNA (Geriatric Nurse Assistant) # 1 was transferring her mother from the toilet to the wheelchair. The daughter stated that she was visiting with her mother on Thursday 7/2/15, and was present when the incident occurred. She stated that GNA# 1 assisted her mother into the bathroom. She indicated that the gait belt which is used by the GNA's to assist with transferring of residents, was lying on the dresser in her mother's bedroom. She stated that her mother knees buckled as the GNA transferred her mother from the toilet to her wheelchair. She stated, I attempted to assist the GNA, however, the GNA had already lowered my mother down to the floor. Review of Minimum Data Set (MDS) assessment data from the comprehensive assessment, with an assessment reference date of 6/23/15, revealed that the resident required extensive assistance from 2 persons for toileting, during the assessment window of 6/17/15 through 6/23/15. The same comprehensive MDS assessment revealed that the resident was at risk for falls, because he/she had 1 fall during the month before this admission. Review of resident # 71's care plan revealed that the resident had impaired mobility on admission, due to right hip fracture. The care plan indicated that Resident #71 used a wheelchair for locomotion and required extensive assistance from 2 staff for ADL's (Activities of Daily Living), and required mechanical lift for all transfers. (Toileting is an ADL.) In an interview with the Nursing Home Administrator (NHA) and the Director of Nursing (DON) on 9/15/15 at 2:00 PM, the NHA gave an account of the incident that occurred on 7/2/15. The NHA stated that GNA # 1 assisted the resident to the bathroom, and while in the bathroom GNA # 1 said the resident turned and pivoted while standing on her feet .The GNA stated that resident #71's knees buckled underneath her, and he lowered the resident to the floor. The NHA indicated that GNA # 1 told her that he grabbed the residents arms and lowered her to the floor when her knees buckled. The NHA stated that GNA # 1 did not follow the GNA assignment sheet for resident # 71, which indicated that the resident was a 2 person assist with transfers. The NHA stated that GNA # 1 had the GNA Assignment Sheet on him and chose not to adhere to it. As a result GNA # 1 was terminated, because he improperly transferred a resident which contributed to her injury. The incident report, reviewed on 9/15/15, corroborated that, on 7/2/15 at 11:00 AM, resident # 71 was transferred from wheelchair to the toilet. When finished, GNA # 1 transferred resident # 71 without a second staff to assist, while holding the resident under his/her arms as he did in prior transfers. Resident's knees gave way and GNA #1 tried to lower resident # 71 to the floor. Resident # 71 stated that she went to stand from the toilet, but her knees gave way and she could not bear the weight falling to the floor. Resident # 71 felt pain in her left upper arm. Resident # 71 was sent to the emergency room for evaluation. On 9/15/15 at 3:15 PM, a meeting was conducted with the Medical Director (MD) and she stated that she spoke with resident # 71's orthopedic physician because she was concerned about the resident and the multiple fractures that she had sustained. She offered that she was concerned and wanted to look at risk factors that could lead to spontaneous fractures. The MD offered that she is involved with Quality Assurance and that is why she was looking at resident # 71 risk factors. Resident was put on Calcium and Vitamin D as precaution. Review of the facility statement from GNA #1 corroborated that resident # 71 was wheeled to the bathroom on 7/2/15, and assisted onto the toilet. The call light was within reach and patient was safe. Approximately 30 minutes later, call light was on and GNA #1 entered the bathroom to assist patient. A walker was placed in front of patient and she was assisted to stand. The resident was initially stable upon standing from toilet, but then began pivoting towards the wheelchair positioned just outside the bathroom. During the process, resident #71 legs buckled and he/she lost his/her balance. He/she was then lowered to the floor, and LPN #1 was then called for evaluation. An interview was conducted with LPN #1 on 9/15/15 at 2:35 PM, and she stated that, on 7/2/15, she was passing medications, and GNA #1 called for assistance. She went into resident # 71's room and saw that Resident #71 was laying on the floor in his/her bathroom, and was partially outside of the bathroom door. LPN #1 stated that resident #71 was complaining of pain to his/her left arm, so she immediately called the Nurse Practitioner (NP) who was present on the unit. LPN # 1 further stated, the NP came into resident #71's room, assessed her, and ordered an x-ray. LPN #1 added that an order was given for the resident to go to the emergency room (ER) for evaluation. The x-ray obtained at the hospital revealed that Resident # 71 sustained an acute fracture involving the proximal humerous with mild displacement. During another interview with the NHA, on 9/16/15 at 9:45 AM, she stated that the NP no longer works at the facility. During this interview, the NHA was asked if she could provide documentation of education that was done with her staff. The education documentation that was submitted was on fall assessment/prevention, and was done on 7/19/15 thru 7/21/15, with a signature sheet of 13 staff. (In follow up on 9/18/15, the facility DON indicated that the facility employed 65 nursing staff including full-time, part-time, and PRN, including RNs, LPNs and GNAs.) Additionally, she provided documentation of a GNA meeting that was held on 8/7/15, which covered ADL training to include GNA assignment sheets, falls and gait belt use, with a signature sheet of 19 staff. She also indicated that stand-up audits were conducted. The NHA was unable to provide documentation that all staff on all shifts were educated.