Every finding on record at Friends Nursing Home

Based on observations and staff interviews it was determined that the facility failed to maintain a comfortable and homelike environment for Residents. This finding was found to be evident in 7 Resident rooms (rooms 201, 204, 210, 215, 218, 219 and 222) out of 22 Resident rooms reviewed for a safe, clean, comfortable, homelike environment during the annual recertification survey.The findings include:During tour of [NAME] Hall Nursing Unit on 5/19/2026 at 10:25 AM several of the Resident rooms were observed in need of repair and did not appear in good condition. The following Resident rooms were observed: room [ROOM NUMBER] - marred wall with black marks directly across from the bed; room [ROOM NUMBER] - marred wall behind the headboard of the bed with cracked, chipped, peeled paint and the cove base was loose from the wall; room [ROOM NUMBER] - marred wall with black marks to the left of the bathroom entrance, cracked/loose/peeling floor tile at the right of the bathroom entrance, marred bathroom door frame with black marks; room [ROOM NUMBER] - marred wall with black marks to the left near the bathroom entrance, missing floor tile under closet; room [ROOM NUMBER] - marred wall with black marks next to bathroom entrance on the left; room [ROOM NUMBER] - privacy curtain attached to a curtain rod at the entrance of the bathroom was not long enough to provide privacy; room [ROOM NUMBER] - marred wall behind head of bed with cracked/peeled paint, dresser drawer with chipped wood.TELS Platform is a computerized maintenance management system designed specifically for healthcare facilities. TELS helps facility managers handle work orders, preventative maintenance, compliance tracking, and capital planning in one hub. In an interview with the Maintenance Director (employee #16) at 8:55 AM on 5/26/2026 the surveyor conveyed the concerns of the Resident rooms on the [NAME] Nursing Unit that were not in good condition and in need of repair. The surveyor and Maintenance Director (employee #16) toured the [NAME] Nursing Unit and observed several of these Resident rooms (201, 210, 215, 218, 219 and 222) that were not in good repair, neat and attractive. Additionally, when the surveyor and the Maintenance Director (employee #16) were in room [ROOM NUMBER] at 9:05 AM, a black bug was observed crawling in the cracked/peeling bathroom floor tile. Maintenance Director (employee #16) acknowledged the surveyor and stated that he would enter the areas of repair needed in the TELS Maintenance System and enter the bug sighting on the Pest Control Log. Further stated by the Maintenance Director (employee #16) was that the pest control service company was scheduled at the facility 2 times a month, and preventative maintenance for the facility was performed on a schedule.At 10:30 AM on 5/26/2026 the surveyor with the Maintenance Assistant (employee #13) and Health Services Coordinator (employee #10) in attendance observed the marred wall and loose cove base behind the head of the bed in Resident room [ROOM NUMBER]. Maintenance Assistant (employee #13) stated that he would take care of this concern. No additional information was provided by the facility at the time of survey exit.

Based on observations, staff interviews and surveyor record reviews it was determined that the facility failed to maintain sanitary conditions for food in accordance with professional standards for food service safety. This finding was found to be evident during the review of the kitchen and the nourishment refrigerator on the nursing unit during the annual recertification survey.The findings include:During tour of the kitchen at 8:15 AM on 5/19/2026 with the Director of Culinary Services (DCS) employee #1 in attendance the walk-in refrigerator was observed with a container of beef base and a container of shrimp base that were opened and not labeled with dates sitting on the middle shelf of the metal rack to the right of the walk-in refrigerator. In the walk-in freezer there was an opened bag of French fries that was approximately 1/2 full on the top shelf of the center metal rack not labeled with dates. The DCS removed both containers of base and the bag of French fries and stated that the containers of base and bag of French fries should have been labeled with dates.At 8:38 AM on 5/19/2026 the surveyor observed several cardboard boxes of frozen food items sitting directly on the floor outside of the walk-in freezer. Additionally, there were several cardboard boxes sitting directly on the floor in the dry storage room, one of these cardboard boxes was an opened box of disposable plates.The Director of Culinary Services (DCS) employee #1 stated that US Food Delivery truck had just delivered these food items that were in cardboard boxes in the dry storage room and on the floor outside of the walk-in freezer and that kitchen staff had 2 hours to put away these food items. The surveyor stated that the food delivery truck was observed in the facility parking lot at 6:25 AM this morning delivering the food items to the kitchen and that it was now 8:38 AM. The morning cook employee #6 confirmed the time of the US Food Delivery truck and the DCS employee #1 stated that the kitchen staff needed to get these food items put away.At 10:15 AM on 5/19/2026 the DCS employee #1 provided the surveyor with an email confirmation of an order that he had placed with [NAME] Industrial Supply for shelving/dunnage rack for temporary storage of food items that were delivered.On 5/21/2026 at 8:45 AM the surveyor observed the nourishment refrigerator on the [NAME] Nursing Unit. Observed in the refrigerator was a plastic white bag from [NAME] Grocery Store. Inside the [NAME] Grocery Store bag were several individual baggies of nuts. The [NAME] Grocery bag and the individual plastic baggies of nuts were not labeled and dated. The surveyor conveyed this to the Health Services Coordinator employee #10 and she observed the nourishment refrigerator with the surveyor. Employee #10 removed the [NAME] Grocery bag and the individual baggies of nuts and stated that this bag was not in the refrigerator when she checked it earlier this morning. The surveyor asked what the expectation was for the usage of the nourishment refrigerator and employee #10 stated that the refrigerator was only for Residents' food items.The surveyor on 5/21/2026 at 11:15 AM reviewed the facility's policy Food Brought By Family/Visitors dated/revised 5/2026. The policy indicated that food items in the nourishment refrigerator were to be labeled with Resident's name, the items, and the use by date.On 5/26/2026 at 6:25 AM the surveyor observed the US Food Delivery truck in the parking lot delivering food items to the facility's kitchen.No additional information was provided by the facility at the time of survey exit.

Based on record reviews, and staff interviews, it was determined that the facility failed to ensure that residents on psychotropic medications have behavior monitoring interventions in place. This was evident for 3 (#31 , #70, #73) of 5 residents reviewed for unnecessary medication during the annual survey. The findings include. 1. On 5/20/26 at 11:30 AM, review of Resident #31's medications revealed that resident was on an anti-depressant, a psychotropic medication that affects brain activities. The order was written as: Paxil Oral Tablet 10 MG (Paroxetine HCl) Give 1 tablet by mouth at bedtime for Depression. Further review did not indicate that this resident had an order for psychotropic behavioral monitoring for this medication. On 5/21/26 at 3:25 AM the Director of Nursing (DON) was asked If residents on psychotropics such as anti-depressants should have behavior monitoring interventions. She acknowledged that it is part of the process to be initiated for residents on such medications. She was asked to provide their policy for psychotropic medications. On 5/22/26 at 8:06 AM a review of the policy indicated that behavioral monitoring should be implemented with residents on psychotropics such as anti-anxiety, anti-depressants and Hypnotics. The DON further indicated that the behavior monitoring has just been initiated for Resident #31. Review of the physician's order revealed that it was implemented on 5/22/26, after surveyor's intervention. She was made aware that this was a concern. She agreed and stated that all residents on antidepressant are being reviewed to make sure they have behavior monitoring in place. 2. On 5/21/2026 at 9:00 AM review of Resident #70's Medication Administration Record (MAR) for December 2025 and January 2026 revealed they were taking Prozac 40mg capsule by mouth for depression and Remeron 15mg tablet by mouth at bedtime for depression. Further review of the MAR revealed no documentation for behavioral monitoring for either psychotropic medication. On 5/21/2026 at 3:25 PM the Director of Nursing (DON) was interviewed and asked if she could provide documentation for behavioral monitoring for Resident #70's Prozac and Remeron. The DON stated she would look for documentation and get back to me. On 5/22/2025 at 7:30AM the DON stated they did not have documentation showing behavioral monitoring for Resident #70's psychotropic medications. 3. On 5/21/2026 at 1:07 PM review of Resident #73's MAR for October and November 2025 revealed they were taking Prozac 10mg give 3 tablets by mouth in the morning for depression, Trazodone 100mg tablet at bedtime for depression and Buspirone 7.5 mg tablet 3 times a day for mood. Further review of the MAR revealed no behavioral monitoring documentation for the psychotropic medications. On 5/21/2026 at 3:35 PM the DON was interviewed and asked if she could provide documentation for Resident #73's behavioral monitoring for his psychotropic medications. The DON looked at the MAR for October and November 2025 and stated they did not have documentation showing behavioral monitoring for Resident #73's psychotropic medications.

Based on staff interviews and record reviews it was determined that the facility failed to monitor a Resident for adverse side effects of usage of a high-risk medication. This finding was found to be evident in 1 (Resident #59) out of 3 Residents reviewed for falls and accidents. The findings include:Care Plan is a structured, formal document that outlines a Resident's specific health needs, individual goals, and the nursing interventions required to facilitate recovery. It serves as a continuous roadmap to ensure consistent, high quality, and evidence based patient care across all shifts. Care plans follow a clinical, five step framework which includes assessment, diagnoses, outcomes/goals, implementation, and evaluation. MDS (Minimum Data Set) assessment is a federally mandated clinical tool used in the United States to evaluate the health status and the functional capabilities of all Residents in Medicare and Medicaid certified nursing homes and skilled nursing facilities. MDS assessments are conducted on admission and discharge, quarterly, annually, and whenever a Resident experiences a significant change in health status. The MDS data heavily dictates a facility's Medicare and Medicaid funding. Anticoagulant medication is a blood thinner and high-risk drug. High-risk drug is a medication with a heightened risk of causing significant or fatal patient harm if an error occurs. Medications are classified as high-risk due to narrow therapeutic index, the dose required for a beneficial effect is very close to the dose that causes toxicity. Anticoagulant is a medication that prevents blood from clotting to easily or stop existing clots from growing, but they require careful management due to increased bleeding risks. The surveyor conducted a record review of Resident #59's medical record on 5/21/2026 at 2:15 PM. Review of the medical record revealed that Resident #59 had an active physician order for anticoagulant medication, Pradaxa 150 mg by mouth 2 times a day for atrial fibrillation as of 3/16/2026. Further review of the medical record revealed that there was no physician order for monitoring Resident for adverse side effects for usage of the anticoagulant medication, Pradaxa. However, there was a care plan for anticoagulant medication usage and the MDS assessment was coded for usage of a high-risk drug, anticoagulant medication.In an interview with the Director of Nursing (DON) at 3:20 PM on 5/21/2026 the surveyor conveyed that Resident #59 had a physician order for Pradaxa which was a high-risk drug but there was no physician order for monitoring Resident #59 for adverse effects of anticoagulant medication usage. The surveyor asked what the expectation was for monitoring a Resident for adverse side effects of anticoagulant medication usage and the DON stated that there should be a physician order for monitoring Resident for adverse side effects of anticoagulant medication usage and that this would be documented on the Residents' medication/treatment administration records. DON confirmed that there was no physician order and no documentation of monitoring for adverse side effects of anticoagulant medication usage for Resident #59. The surveyor conducted a follow-up record review of Resident #59's physician orders at 7:15 AM on 5/26/2026. Record review revealed that there was now an active order dated 5/21/2026 at 23:00 PM for ANTICOAGULANT MEDICATION - MONITOR FOR DISCOLORED URINE, BLACK TARRY STOOLS, SUDDEN SEVERE HEADACHE, NAUSEA & VOMITING, DIARRHEA, MUSCLE JOINT PAIN, LETHARGY, BRUISING, SUDDEN CHANGES IN MENTAL STATUS AND/OR VITAL SIGNS, SHORTNESS OF BREATH, NOSE BLEEDS. Document: 'Y' if monitored and none of the above observed. 'N' if monitored and any of the above was observed, select chart code 'Other/ See Nurses Notes' and progress note findings, every shift for monitor. On 5/26/2026 at 8:30 AM the DON stated that the facility was in the process of updating Residents' medical records with orders of monitoring for side effects of high-risk medication usage.No additional information was provided by the facility staff at the time of survey exit.

Based on observations and staff interviews it was determined that the facility staff failed to maintain infection prevention and control practices. This finding was found to be evident on the [NAME] Nursing Unit reviewed for infection control practices during the annual recertification survey.The findings include:On the initial tour of the [NAME] Nursing Unit on 5/19/2026 at 10:45 AM the surveyor observed a bag of linen sitting on the floor in Resident room [ROOM NUMBER] next to the trash can.At 6:45 AM on 5/21/2026 on the [NAME] Nursing Unit the surveyor observed 2 blue bags of soiled linen/trash in the hallway sitting on the floor outside of Resident rooms [ROOM NUMBERS]. Additionally, a clean linen cart was observed outside of room [ROOM NUMBER] without a cover on the clean linen that was stored on the cart.The surveyor interviewed 2 Geriatric Nursing Assistants (GNAs) employees #7 and #8 that were handling the linen and trash in the hall and asked the GNAs what the expectation was for covering the clean linen cart. The GNAs stated that the clean linen cart should be covered. Additionally, the GNAs stated that they did not have a cart/barrel for the soiled linen and trash. At 6:50 AM on 5/21/2026 the surveyor interviewed the Licensed Practical Nurse (LPN) employee #9, who observed the soiled linen and trash bags on the floor in the hallway, and the uncovered clean linen cart. LPN employee #9 stated that the clean linen cart should be covered. Additionally, she stated that the soiled linen and trash bags should not be on the floor, and the bags of linen and trash should be disposed of in the soiled utility room on the unit.At 6:55 AM on 5/21/2026 the surveyor reviewed the infection control observations with the Assistant Director of Nursing (ADON). ADON acknowledged the surveyor and also observed the nursing staff transporting the soiled linen and trash bags in the hallway by dragging the bags on the floor. Additionally, ADON observed the clean linen cart uncovered with clean linen on the cart. ADON stated that the clean linen cart should be covered, and the GNAs should take the soiled linen and trash bags to the soiled utility room and not store the bags on the floor in the hallways and in the Resident rooms.The Director of Nursing (DON) at 9:15 AM on 5/21/2026 was notified of the concerns with infection prevention and control practices of the nursing staff that were observed earlier on the [NAME] Nursing Unit. DON stated that she was aware of the concerns and it was being addressed.No additional information was provided by the facility at the time of exit.

Based on observations, staff interviews and surveyor record review it was determined that the facility failed to label and store medications in a locked, secure area and inaccessible to unauthorized staff, visitors and Residents. This finding was found to be evident in 1 (Resident #11) out of 12 Residents reviewed for medication storage during the annual recertification survey.The findings include:The surveyor on 5/19/2026 at 12:15 PM observed Resident #11 asleep in bed in Resident room. Observed on Resident #11's overbed table was a paper medicine cup with 9 tablets in the medicine cup which was sitting on top of the Resident's laptop computer. There were 2 capsules, 6 tablets and 1/2 of a tablet in the medicine cup. Medication Administration Record (MAR) is the official legal document or chart used by healthcare professionals to track all medications given to a Resident. It serves as a vital safety tool, ensuring the right patient receives the correct medication, dosage, route, and time. MAR is essential for error prevention, accountability and tracking, and legal protection. Standard documentation codes will often be indicated on the MAR when a medication dose was not administered, H Held (the medication was temporarily stopped); R Refused (the patients declined the medication); A Absent (the patient was away from the facility or unavailable); and L Late (administered outside the standard time window). A nurse's initials are documented on the MAR indicating that the medications were administered to Residents.Resident #11's nurse, Licensed Practical Nurse (LPN) #2 was asked to come into Resident's room at 12:18 PM on 5/19/2026 and observed the medications in the medicine cup sitting on the Resident's laptop computer on the overbed table. LPN #2 was interviewed by the surveyor and asked if Resident #11 was administered his/her medications today. LPN #2 stated yes that she gave the Resident morning medications with applesauce (as she always does), and administered eye drops and an inhaler to Resident. Also, LPN #2 stated that she stayed with the Resident while he/she took his/her medications. LPN #2 and the surveyor reviewed Resident #11's medication administration record (MAR) in the electronic medical record, and the Resident's morning medications were signed off by LPN #2 as being administered. Additionally, LPN #2 stated that she did not observe the medicine cup and medications on Resident #11's bedside table when she was in Resident's room earlier. LPN #2 took the 9 medications and the medicine cup to the Director of Nursing (DON).In an interview on 5/20/2026 at 8:30 AM the Director of Nursing (DON) stated to the surveyor that she was investigating the concern with medications found at the bedside for Resident #11 yesterday but was unsure how this happened. DON indicated that Resident stated that he/she took his/her medications and that LPN #2 stated that she stayed with the Resident during medication administration.The surveyor conducted a record review of Resident #11's medical record at 11:00 AM on 5/20/2026. Review of the medical record revealed that Resident had the following medications ordered to be administered in the mornings, Amlodipine for high blood pressure, Citalopram for depression, Eliquis for atrial fibrillation, Fluticasone Aerosol (inhaler) for wheezing, Glycolax for constipation, Ketotifen ophthalmic for eye allergies, Metoprolol for high blood pressure, Multiple Vitamin for supplement, Omega 3 for supplement, Pantoprazole for GERD, Polyethyl Glycol Gel for eye dryness, Rivastigmine for dementia, Sodium Zirconium for elevated potassium level, Vitamin D3 for supplement, and Vitron C for supplement. Further review of the medical record did not reveal a physician order, an assessment and a care plan for Resident #11 to self-administer his/her own medications.No additional information was provided by the facility staff at the time of survey exit.

Based on the main kitchen tour and staff interviews, it was determined that the facility failed to store, monitor, and serve food in accordance with professional standards for food service safety. This deficient practice has the potential to affect all residents in the facility. The findings include the following: During the initial kitchen tour with the Culinary Director (Staff #06) on 05/08/25 at 08:00 AM, the following was observed: 1. The temperature logs for 7 out of 7 refrigerators observed were incomplete for 05/07/25 Evening and 05/08/25 Morning. 2. In the walk-in freezer, nine 3-gallon size Hershey's Ice Cream Premium tubs were observed sitting on the floor. 3. In the walk-in refrigerator, 1 gallon container each of [NAME] Thousand Island salad dressing and Ken's Asian Sesame dressing had a handwritten date on the lid. There was no expiration or used by date on either container. During the follow-up kitchen visit on 05/13/25 at 08:45 AM the Surveyor conducted temperature reviews with the Culinary Director #06 utilized the facility thermometer and performed the cold foods temperature testing at the Deli Holding Station and refrigerator below the Deli Holding station which revealed temperatures above 41°F for the following: 1. The deli holding station refrigerator thermometer read to be at 41.7 °F 2. A package of yellow cheese read to be at 43.1 °F 3. A bag of hard-boiled eggs read to be at 42.6 °F. 4. A package of turkey read to be at 44.0 °F. 5. A package of hot dogs from within the refrigerator read to be at 42.6 °F. These findings were discussed with the administrator prior to and during the exit conference.

Based on observations and interviews, it was determined that the facility failed to ensure a homelike environment. This was evident for 13 out of 13 resident rooms reviewed during the survey. The findings include the following: During observation rounds on 05/08/25 at 08:35 AM the following was observed: 1. Resident rooms 217, 218, 219, 220, 221, 222, 223, 224, 225, 226, 227, 228, and 229, bathrooms were observed to have a missing Cove Base around the complete perimeter of the bathroom along with an ½ inch opening between the wall and the floor tiles. 2. The bathroom of room [ROOM NUMBER] black patches of growth appeared at the at the rear base of the toilet extending up from the missing cove base area to about 2 inches up the wall with exposed and peeling paint areas. 3. The floor tiles were stained brown and rust in color near the head of the bed in resident room [ROOM NUMBER]A. 4. There were missing floor tiles with exposed cement flooring observed near the head of the bed in residents' room [ROOM NUMBER]A, 222, and 224A. 5. There was no enclosed space for hanging clothing located in room for resident use in resident room [ROOM NUMBER]A. During a staff interview on 05/08/25 at 10:52 AM the Nursing Home Administrator #02 stated the cove base has been on back order for about a year for several rooms that have been damaged by the flood that occurred about a year ago.

Based on observations, record review and interviews, it was determined that the facility failed to: 1) maintain Infection Prevention & Control based on when and how isolation should be used for a resident. This was evident for 1 resident (#54) out of 20 residents reviewed during survey; 2) conduct an annual review of its Infection Prevention and Control Program (IPCP) and update their program, as necessary. This was evident during a review of the facility's Antibiotic Stewardship Program policy and procedures for infection control. The findings include: The findings include the following: 1. Enhanced Barrier Precautions are used as an infection control intervention that uses targeted gown and glove use during high-contact resident care activities in nursing homes to reduce the transmission of multidrug-resistant organisms (MDROs). During observation rounds on 05/08/25 at 08:44 AM there was a Enhanced Barrier Precautions sign posted on the door of resident room [ROOM NUMBER]. There was no indication to which resident within the room that the precautions applied to. During a staff interview on 05/08/25 at 08:47 AM with GNA, staff #09 stated that she did not know which resident within the room that the enhance barrier precautions were for. During resident medical record review on 05/08/25 at 10:00 AM revealed resident (#54) had diagnosis of a facility-acquired stage IV pressure ulcer requiring enhanced barrier precautions. 2. On 5/13/25 at 10 AM, surveyor asked Administrator #2 for a copy of their Antibiotic Stewardship policy which the Administrator returned immediately with a copy. Review of the policy revealed that it was last revised on August 2018 and should be reviewed in August 2019. The Admin #2 was asked if she had any documentation that the policy has been reviewed annually. Admin #2 stated that that's one of the things that I need to work on is updating PolicyStat where all the policies are. She then stated that she would get back to the surveyor with any information she could find. Admin #2 returned at 2:18 PM with an updated copy of the policy for review. Admin #2 stated that she did not have any documentation that the policy was updated since August 2018, but she was able to update the policy in PolicyStat. The new revised date is May 2025 and the next review date is May 2026.

Based on observations and interviews, it was determined that the facility failed to ensure that essential equipment to be in safe operating condition. This was evident for 2 out of 13 resident rooms reviewed during the survey. The findings include the following: During observation rounds on 05/08/25 at 08:35 AM the Surveyor observed the call bell box hanging from wall with blue wires exposed in resident rooms [ROOM NUMBERS]. During an observation round and staff interview on 05/08/25 at 10:50 AM the Nursing Home Administrator #02 stated the maintenance team provides repairs to the call boxes when they are dislodged, and I will have maintenance look at it right away.

2. On 5/14/25 at 8:28 AM, record review revealed that the incident took place on 1/14/25 during breakfast. Incident report revealed that Resident #12 experienced second degree burns with 3 clustered blisters to the Left thigh where Resident #12 spilled hot coffee onto themselves. On 1/16/25 the facility started their investigation with staff interviews and with Resident #12 being evaluated for their injuries by wound services. The facility reported the incident to the State Survey Agency on 1/21/25 at 10:32 AM. Further review of the incident showed that the report was not complete within the 5 days as required. Closing of the investigation by the facility was not reported to the State Survey Agency until 1/29/25. On 5/9/25 at 9:30 AM An interview with Administrator #2 and DON was conducted. Administrator #2 confirmed that resident did spill the coffee onto themselves and that corrective action was conducted for the staff member that was responsible for reporting the incident to leadership and education was also given for reporting incidents. Admin #2 was asked for a copy of the facility's investigation report for Resident #12. These deficiencies were discussed with the administrator of the facility prior to and during the exit interview. Based on record review and interviews, it was determined that the facility failed to report an allegation involving serious bodily injury within 2 hours and to complete the facility's investigation within 5 days. This was evident for 2 (Residents #12, #29) out of 3 Facility Incident Reports(FRI) reviewed during the survey. The findings include: 1. On 05/12/25 at 12:55 PM, the facility's investigation report was reviewed. The investigation report revealed that on 2/10/25, Resident #29 was noted to have bruising over his/her right clavicle, shoulder and upper arm. X-rays were obtained at the facility which revealed a displaced fracture of the distal, right, third clavicle and multiple right rib fractures. Resident #29 was interviewed and Resident #29 denied that he/she had a recent fall as well as denied that anyone abused and mishandled him/her. Facility staff assessed, stabilized and transferred Resident #29 to the hospital. The hospital diagnosed Resident #29 with having an acute fracture of the distal, third, right clavicle and fractures of the 5th, 6th, and 7th ribs. The facility's reports also revealed that staff were interviewed, and the staff stated that they observed bruising on the right humerus, ribs and breast. Staff also mentioned that there were no reports about Resident #29 falling or being found on the floor. Also, staff stated that Resident #29 had been observed sleeping on his/her right side, and Resident #29 had been observed walking to the bathroom without calling for assistance. The investigation report also revealed that the facility submitted the initial Facility Reported Incident (FRI) to the Office of Health Care Quality (OHCQ) on 2/11/25 at 11:00 AM and the follow-up Facility Reported Incident was submitted to OHCQ on 2/14/25. On 05/13/25 at 09:44 AM, the Nursing Home Administrator staff #02 was interviewed. The surveyor mentioned to staff #02 that according to the facility's records, the facility became aware of Resident #29's fractures on 2/10/25; however, the facility did not submit the initial FRI to OHCQ until 2/11/25 at 11:00 AM. Staff #02 stated that the facility staff, who speak Bengali, interviewed Resident #29, and Resident #29 denied falling and being abused. Staff #02 also mentioned that since the injury was of unknown origin and is not abuse, the facility would not have to report the incident to OHCQ within the required two-hour window. On 05/13/25 at 10:22 AM, Resident #29's records were reviewed. The record review revealed that Resident #29 has a Brief Interview for Mental Status (BIMS) Score of a 9/15, which indicates moderate cognitive impairment. Also, the record review revealed that Resident #29 spoke Bengali.

Based on observations, family and staff interviews, and record review, it was determined that the facility failed to manage pain for residents who require such services consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. This was evident for 1 (Resident #56) out of 28 residents observed during the survey. The findings include: On 5/08/25 at 2:00 PM Resident #56 was observed lying on their left side in bed complaining that it is burning. Surveyor spoke with resident's son who stated that when s/he urinates s/he says it burns and s/he doesn't like to be wet. Resident's son continued to state that s/he complains of pain all the time but I called for the GNA already. She's coming to change him/her. On 5/13/25 at 9:10 AM Resident #56 was observed lying on left side in bed screaming of pain. Resident was encouraged to use the call bell. Resident did hit the button but stated that s/he was scared no one would come. RN #18 came into the room within 3 minutes and asked the resident how could she help him/her. Resident #56 continued to scream in pain. RN #18 stated that she will bring pain medication. RN #18 was asked what the resident was getting for pain. She stated that Resident #56 is on scheduled Tylenol and Tramadol 25 mg as needed. Nurse #18 was then asked when was the last time that the resident received the Tramadol. RN #18 reviewed the chart and stated that the last time the resident received Tramadol was on 5/10/25. Resident #56 continued with screams that could be heard in the hallway. RN #18 was asked if this typical behavior for the resident to be calling out in pain. RN #18 stated that he/she only works one day a week but she has been the nurse before and noted that the resident is always in pain unless his/her family is visiting. RN #18 was asked, what did she think she should do for the pain as the resident's nurse. RN #18 replied that she was going to speak with the doctor about what they can do to better manage the resident's pain, maybe change the resident's Tramadol order from PRN to a standing order. On 5/13/25 at 12:15 PM Review of the Care Plan for Resident #56 revealed: Resident #56 is at risk for pain related to limited physical mobility and presence of sacral wound. Resident #56 will verbalize pain relief 0/10 scale through the review date. Administer pain medication as per ordered. Give 1/2 hour before treatments or care. Evaluate the effectiveness of pain interventions. Monitor/document for side effects of pain medication. Observe for constipation; new onset or increased agitation, restlessness, confusion, hallucinations, dysphoria; nausea; vomiting; dizziness and falls. Report occurrences to the physician. Monitor/record/report to Nurse resident complaints of pain or requests for pain treatment. Offer pain medication prior to wound care. On 5/13/25 at 12:50 PM, observation was made again of the resident. Resident #56 was sleeping comfortably in bed with wedges under his/her knees and pillows on both sides. Resident's family member was sitting with the resident at the bedside and stated that they were very satisfied with this nursing home, and that they take very good care of Resident #56. Surveyor asked the family member about resident's pain and if they thought that they were managing the pain for the resident. The family member replied that the resident has pain but it comes and goes; stated that they could manage the pain a little better and that the doctor had called today in reference to the resident's Tramadol order being changed to every 8 hours instead of PRN for better management of the pain.

Based on medical record review, interviews, and observations it was determined that the facility failed to revise and update the resident's care plan in a timely fashion. This was evident for 1 (#48) of 4 resident care plans reviewed during the survey. The findings include: A care plan is used to summarize a person's health conditions, specific care needs, and current treatments and outlines what needs to be done to plan, assess, and manage care. Care plans are developed, reviewed, and/or revised by the IDT after the completion of a comprehensive MDS assessment (Admission, Annual, Quarterly, Significant Change) to help to evaluate the effectiveness of the resident's care while in the facility. A comprehensive care plan is developed and revised by the interdisciplinary team to address a resident's individualized physical functioning for example. The Minimum Data Set (MDS) is a standardized, comprehensive assessment of a resident's functional, medical, psychosocial, and cognitive status to develop a plan of care based on the resident's individualized needs. On 05.08.25 at 08:30 AM the surveyor observed Resident #48 in bed with white knit tube stockings extending from the bilateral contracted hands up to the upper arms. The resident was non-verbal with surveyor at the time of the observation. During an interview with the DON it was determined that this resident required maximum assistance with eating meals and drinking fluids and was not wearing hand splints. On 05.09.25 at 12:30 PM the surveyor reviewed the electronic medical record and determined that there was no care plan present that addressed the use of hand splints for Resident #48 or occupational therapy (OT) interventions related to Resident #48's limited range of motion. On 05/12/25 at 01:24 PM during an interview with DON while observing Resident #48 in bed with white stretch cloth sock dressing from hand to elbows the surveyor asked if the resident should have hand and/or wrist splints on during certain times of the day and had occupational therapy made any recommendation. The surveyor also inquired whether the nursing staff ensured that the resident had the bilateral hand and wrist splints in place as recommended by the occupational therapy. The DON stated that the nursing department was responsible for applying the splints to the resident's bilateral hand and wrist. Resident #48's bilateral hand/wrist splints were located by the DON in the bedside table. On 05.13.25 at 08:20 AM the surveyor interviewed the DON regarding the status of the resident's hand splint. The DON stated that the OT staff had just started working with the resident. Also, the DON stated that the nursing staff had been using rolled washcloths in the resident's hands. The surveyor and the DON reviewed the electronic medical records with the surveyor to verify that the care plan did not include information regarding the resident's hand/wrist splints. The DON agreed that any interventions related to treating the resident's hand contractures should have been included in a care plan for Resident #48 and updated as the occupational therapist interventions changed. The DON was not able to show the surveyor a care plan related to the resident's use of hand/wrist splints since the OT interventions were initiated on 03.05.25 and continued through 05.14.25. On 05.13.25 at 08:50 AM the surveyor interviewed the Director of Rehabilitation, staff #14. The surveyor asked if the OT staff had participated in any care plan meetings with the interdisciplinary team since March 26, 2025. Staff # 14 stated that no, the rehabilitation staff had not participated in care plan meetings. Staff #14 stated that the current air pump style splint is new and experimental for the resident and therefore there was no order for this specific type of splint. Additionally, staff #14 stated that she had not participated in creating a care plan with nursing staff regarding the hand splints. On 05.13.25 at 11:28 AM a further review of the electronic medical record reveal the annual MDS, including section GG0115, functional limitation in ROM, bilateral hand, arm was completed and signed on 05.07.25. The facility failed to update and revise the care plan to address the resident's individual needs for the potential/actual use of bilateral hand/wrist splints/orthotics. This deficient practice was reviewed with the administrative staff during the exit conference on 05.14.25.

Based on medical record review, interviews, and observations it was determined that the facility failed to create, revise and update the resident's care plan in a timely fashion. This was evident for 1 (#48) of 4 resident care plans reviewed during the survey. The findings include: A care plan is used to summarize a person's health conditions, specific care needs, and current treatments and outlines what needs to be done to plan, assess, and manage care. Care plans are developed, reviewed, and/or revised by the interdisciplinary team (IDT) after the completion of a comprehensive MDS assessment (Admission, Annual, Quarterly, Significant Change) to help to evaluate the effectiveness of the resident's care while in the facility. A comprehensive care plan is developed and revised by the interdisciplinary team to address a resident's individualized physical functioning for example. On 05.08.25 at 08:30 AM the surveyor observed Resident # 48 in bed with white knit tube stockings extending from the bilateral contracted hands up to the upper arms. The resident was non-verbal with surveyor at the time of the observation. During an interview with the DON, it was determined that this resident required maximum assistance with eating meals and drinking fluids and was not wearing hand splints. On 05.09.25 at 12:30 PM the surveyor reviewed the electronic medical record and determined that there was no care plan present that addressed the use of hand splints for Resident #48 or occupational therapy (OT) interventions related to Resident #48's limited range of motion. On 05.13.25 at 08:50 AM the surveyor interviewed the Director of Rehabilitation, staff #14. The surveyor asked if the occupational (OT) staff had participated in any care plan meetings with the interdisciplinary team since March 26, 2025. Staff # 14 stated that there were no OT rehab. Staff #14 had participated in the creation of a care plan for Resident #48 that referenced the bilateral hand orthotics/splints. Staff #14 stated that the current air pump style splint is new and experimental for the resident and therefore there was no order for this specific type of splint. Additionally, staff #14 stated that she had not participated in creating a care plan with nursing staff regarding the hand splints. On 05.13.25 at 13:45 the surveyor reviewed the hard copy occupational therapy (OT) evaluation and plan of treatment notes for Resident #48. The document indicated that Resident #48 was certified for occupational therapy services from 03.25.25 through 05.19.25. One of the diagnoses described was contractures of bilateral hands and wrists. The OT notes documented a short-term goal of patient will tolerate bilateral hand orthotics without skin changes for four hours to maintain joint alignment and to prevent skin breakdown. As of 05.14.25 at 12:15 PM the facility failed to provide evidence that the interdisciplinary team which included nursing had created a care plan reflecting the occupational therapy goals for Resident #48 related to the use of bilateral hand and wrist orthotic splints.

Based on record review, facility document review, interview, and facility policy review, the facility failed to report an allegation of abuse to the state survey agency within two hours for 1 (Resident #6) of 3 residents reviewed for abuse. Findings included: A facility policy titled, Abuse Policy, revised 07/2024, revealed, [The facility name] follow the 7 components of abuse prevention, to include 7. Reporting and Response: Any suspicion of abuse MUST be reported to administrative staff immediately. (If you do not report and it is discovered you were aware; you are considered as guilty as the person committing the abuse). According to the Elder Justice Act: abuse that does not result in serious bodily injury needs to be reported within 24 hours. Any abuse that results in serious bodily (broken bones, severe wounds, death) and sexual abuse must be reported within 2 hours of knowledge. Reports may be made to the state and local law enforcement. The facility has 5 days to complete an investigation and report findings to the state. The policy revealed, [The state survey agency] shall be notified immediately by fax or email on the appropriate state form as to the nature of the allegation and the names of the resident(s) and individual(s) involved. (Within 24 hours) Within 2 hours where if [sic] the suspected crime/injury results in serious bodily injury. Resident #6's Admission Record indicated the facility admitted the resident on 01/04/2024. According to the Admission Record, the resident had a medical history that included diagnoses of dissection of the carotid artery, nontraumatic subarachnoid hemorrhage, hypertension, and anxiety disorder. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/09/2024, revealed Resident #6 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS revealed the resident required partial/moderate assistance from staff with toileting hygiene, showers/bathing, and lower body dressing. Per the MDS, the resident required partial/moderate assistance from staff with going from sitting on the side of the bed to lying, from lying to sitting on the side of the bed, from sitting to standing, with chair/bed-to-chair transfers, and with toilet transfers. Resident #6's care plan revealed a focus area, initiated 01/05/2024, that indicated the resident was at risk for skin breakdown related to immobility. Interventions directed staff to turn and reposition the resident routinely (initiated 01/05/2024). Resident #6's Progress Notes revealed an Incident Note, dated 01/05/2024 at 11:51 AM and electronically signed by Staff Identifier (SI) #18 (the previous Assistant Director of Nursing), that revealed Resident #6 reported physical abuse to a physical therapist. The note indicated that the resident provided descriptions of a male and female who were, in my room last night, I was sitting on my bed and the [description of female] hit me on my right arm four times very hard and told me to scoot, scoot up in bed. The note indicated that the resident's family member was in the room and stated that Resident #6 called them the previous night and told them that a female hit the resident on the arm. The note indicated that SI #27 (the Nurse Practitioner) was made aware of the allegation. A Facility Reported Incidents Initial Report Form, dated 01/05/2024, indicated that Resident #6 reported to a therapist during an occupational therapy session on 01/05/2024 that they were struck four times by a staff member the previous night. The document indicated that staff became aware of the incident on 01/05/2024 at approximately 6:00 PM and SI #1 (the Administrator) was notified of the allegation at 6:00 PM. The document indicated that the state survey agency was notified of the abuse allegation on 01/05/2024 at 8:00 PM, over eight hours after SI #18 documented the Incident Note. During an interview on 11/07/2024 at 2:45 PM, SI #1 stated she was notified of the allegation of abuse on 01/05/2024 after 6:00 PM, after she had left the facility. She stated that she filed the initial report by 8:00 PM. She stated that if the resident reported the allegation at around noon, the staff should have notified her at that time and the initial report filed within two hours.

Based on interview, record review, and facility policy review, the facility failed to ensure a physician's order for medicated eye drops was followed and the eye drops not administered until after surgery for 1 (Resident #3) of 3 residents reviewed for medications. Resident #3 had eye drops ordered to be administered three times daily for seven days after surgery, and the eye drops were administrated prior to the surgery. Findings included: A facility policy titled, Administering Medications, revised January 2024, indicated, Medications are administered in accordance with prescriber orders, including any required time frame. An Admission Record indicated the facility admitted Resident #3 on 03/24/2018. According to the Admission Record, the resident had a medical history that included diagnoses of dementia and cataracts. An annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/02/2024, revealed Resident #3 had a Brief Interview for Mental Status (BIMS) score of 7, which indicated the resident had severe cognitive impairment. Resident #3's care plan included a focus area, revised 05/14/2024, that indicated the resident had a history of cataracts. Interventions directed staff to arrange consultations with eye care practitioners as required (revised 10/15/2024) and to monitor, document, and report any acute eye problems (created 02/05/2024). A physician's order, dated 07/07/2023, indicated Resident #3 was to be administered prednisolone (a corticosteroid)/Moxifloxacin (an antibiotic) ophthalmic 1-0.5% solution, one drop into the right eye three times a day for seven days after surgery. The order start date was 07/13/2023, and the order end date was 07/20/2023. Resident #3's July 2023 Medication Administration Record (MAR) contained the transcription of an order, started 07/13/2023, for prednisolone/Moxifloxacin ophthalmic solution 1-0.5% one drop in the right eye three times a day for one week after surgery. The MAR indicated Resident #3 was administered the eye drops three times a day from 07/13/2023 through 07/19/2023 by staff including Staff Indicator (SI) #5 (the Assistant Director of Nursing) and SI #19 (a licensed practical nurse). A Current Summary Medication/Fluid Error Event, record for Resident #3, dated as entered 07/23/2023, indicated that Resident #3 received eye drops (prednisolone/Moxifloxacin 1- 0.5% ophthalmic solution) due to an order placed on 07/12/2023 that should have been discontinued when Resident #3 did not have surgery. The record indicated eye drops were given in error from 07/12/2023 through 07/19/2023. During an interview on 11/07/2024 at 12:12 PM, SI #19 stated Resident #3 had orders for eye drops prior to their surgery and after the surgery occurred. SI #19 stated Resident #3 did not have the surgery, and the order was never discontinued or changed. SI #19 stated she had administered the eye drops, as the order was on the MAR. SI #19 stated she did not know the surgery had never occurred until the previous director of nursing called her and brought it to her attention. SI #19 stated she should not have administered the eyes drops when she did because the surgery never happened. During an interview on 11/07/2024 at 1:39 PM, SI #5 stated she had been off work, and Resident #3 was scheduled for cataract surgery and had orders for eye drops after the surgery was completed. SI #5 stated when she returned to work, she did not know that Resident #3 had never had the surgery, and she administered the eye drops thinking the surgery had occurred. SI #5 stated the eye drops were administered even though Resident #3 did not have the surgery. SI #5 stated she only found out about the error when the previous director of nursing told her after the eye drops had been administered. During an interview on 11/08/2024 at 10:20 AM, SI #2 (the Director of Nursing) stated she started employment after the medication error, but was made aware of the issue. SI #2 stated Resident #3's orders were not followed but should have been. SI #2 stated the expectations were for all nurses to follow the orders as they were written. During an interview, on 11/08/2024 at 10:49 AM, SI #1 (the Administrator) stated staff should not have administered the eye drops.

Based on record review and staff interview it was determined that facility staff failed to develop a base line care plan for respiratory care for Resident #200. This finding was evident in 1 of 16 residents reviewed during the survey. On 05-17-21 Resident #200 observed lying in bed with oxygen on at two liters per minute (LPM) via nasal cannula. The resident was experiencing shortness of breath while speaking. On 05-17-21 review of the clinical record revealed a hospital discharge summary dated 4-28-21 that noted Resident #200 had been admitted to the hospital for shortness of breath and reported being constantly SOB but the resident was not hypoxic. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 5-18-21 further review of the clinical record revealed a nurse practitioner note written on 5-12-21 that documented that Resident #200 was constantly short of breath. However, there was no evidence that a baseline care plan was developed to address the respiratory status and care for Resident #200. On 5-20-21 interview with the ADON provided no additional information.

Based on surveyor review of the clinical record, surveyor observation of medication pass and interview with facility staff, it was determined that the facility failed to ensure nursing standards of practice in the timely medication administration for residents. This finding was evident for 2 of 11 residents observed during the medication observation of facility residents (Residents #8 and #17). The findings include: 1. On 05-19-2021 surveyor review of the clinical record for Resident #8 revealed the attending physician ordered an eyelid medication in the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The medication was scheduled for administration at 8:00 AM and 8:00 PM. Further review of the May 2021 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . However, surveyor observation of the medication pass to Resident #8 on 05-19-2021 at 9:58 AM revealed LPN #1 had administered the 8:00 AM eyelid medication to the resident at 9:58 AM on 05-19-2021. On 05-19-2021 at 12 PM surveyor interview with the Assistant Director of Nursing revealed no additional information. According to the Institute for Safe Medication Practices, January 12, 2011, Guidelines for Timely Administration of Scheduled Medications, medications administered more frequently than daily, (i.e. BID (twice a day), TID (three times a day), q4h (every 4 hours), q6h (every 6 hours)) require the administration of these medications are to be done within one (1) hour before or after the scheduled medication time. 2. On 05-19-2021 surveyor review of the clinical record for Resident #17 revealed the attending physician ordered an eyelid medication in the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The medication was scheduled for administration at 8:00 AM and 5:00 PM. Further review of the May 2021 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . However, surveyor observation of the medication pass to Resident #17 on 05-19-2021 at 10:05 AM revealed LPN #1 administered the 8:00 AM eyelid medication to the resident at 10:05 AM on 05-19-2021. On 05-19-2021 at 12:00 PM surveyor interview with the Assistant Director of Nursing revealed no additional information. According to the Institute for Safe Medication Practices, January 12, 2011, Guidelines for Timely Administration of Scheduled Medications, medications administered more frequently than daily, (i.e. BID (twice a day), TID (three times a day), q4h (every 4 hours), q6h (every 6 hours)) require the administration of these medications are to be done within one (1) hour before or after the scheduled medication time.

Based on review of employee records and facility staff interview, it was determined that the facility failed to complete annual performance reviews. This finding was evident for 3 of 3 Geriatric Nursing Assistan (GNA) records reviewed (GNA #2, #3, and #4). 1. On 05-20-21 survey review of employee file for GNA #2 revealed no evidence of an annual performance review for 2020. On 05-20-21 at 3:000 PM surveyor interview with the administrator provided no additional information. 2. On 05-20-21 survey review of employee file for GNA #3 revealed no evidence of an annual performance review for 2020. On 05-20-21 at 3:00 PM surveyor interview with the administrator provided no additional information. 3. On 05-20-21 survey review of employee file for GNA #4 revealed no evidence of an annual performance review for 2020. On 05-20-21 at 3:00 PM surveyor interview with the administrator provided no additional information.

Based on the review, on 1/31/20, of the residents' personal funds records, including individual resident's account statements, closed account summaries, transaction reports, and transaction receipts, this facility failed to maintain a system that ensures a full and complete accounting of the residents' personal monies entrusted to this facility. Findings include: 1. This facility closed the individual personal fund accounts for residents 1A, 2A, 3A, 4A, 5A, 6A, and 7A, without appropriate authorization. 2. This facility closed the individual, interest bearing, personal fund account for resident 2A on 4/26/19, for resident 3A on 5/22/19, for resident 4A on 8/7/19, for resident 5A on 8/21/19, for resident 6A on 8/27/19, and for resident 7A on 1/24/20. Each resident's closing balance was in excess of $50.00. Each resident's personal funds were transferred by the facility to a non-interest bearing, pooled, petty cash checking account. As of 1/30/20, each resident's personal funds remained in the non-interest bearing account. 3. All withdrawals of residents' personal funds were not appropriately authorized and/or witnessed.