Every finding on record at Future Care Irvington

Based on record review, observations, and interviews, it was determined that the facility failed to provide appropriate care with activities of daily living (ADLs) as evidence by facility staff not providing showers to a dependent resident. This was found to be evident in 1 (Resident #30) of 3 residents reviewed for ADLs during the recertification survey.The findings include:Activities of Daily Living (ADLs) describe fundamental self-care skills like eating, bathing, and mobility. A Kardex is a medical information system summarizing critical patient data. Nursing homes use it as a centralized reference for a resident's daily care needs, medical orders, and preferences. The BIMS (Brief Interview for Mental Status) score is a 0-to-15 point screening that objectively measures memory, orientation, and recall. A score of 0 is the lowest result, meaning the resident is completely non-responsive or has unmeasurable short-term cognitive function.On 8/25/2026 at 9:53 AM, complaint #3070064 was reviewed, alleging the facility failed to provide appropriate showers to Resident #30. On 8/25/2026 at 10:30 AM, Resident #30 was observed nonverbal in bed with a tracheostomy, unable to respond to questions. Resident #30's roommate (Resident #133) stated they observed facility staff performing daily bed baths for Resident #30 but was unaware of any showers. On 8/25/2026 at 11:02 AM, the complainant stated via telephone during an interview that they complained to staff about the lack of showers and only knew of 1 shower given to Resident #30.On 8/27/2026 at 11:33 AM, Resident #30's medical records were reviewed. admitted in August 2025, the resident had a BIMS score of 0 and was staff-dependent for all ADLs per the latest Minimum Data Set (MDS). The care plan noted the resident was dependent for bathing/showering and required two-staff assistance. Resident #30's Kardex scheduled showers every Monday and Thursday.On 8/28/2026 at 10:47 AM, documentation survey reports for April through August 2026 were reviewed. Documentation survey reports audit Electronic Health Record (EHR) data, pulling real-time logging of clinical tasks and care requirements. These reports showed only 1 shower documented on 5/8/2026, with all other bathing logged as bed baths. The EHR lacked documentation explaining why Resident #30 missed scheduled showers.On 8/28/2026 at 1:25 PM, Geriatric Nursing Aide (GNA) #30 demonstrated EHR bathing documentation. GNA #30 stated that the bathing type (shower or bed bath) is logged in the Bathing-GG section and reflects what the resident actually received. On 8/31/2026 at 7:40 AM, the Director of Nursing (DON) stated their expectation is that residents receive showers on scheduled days unless there is a documented reason why it was not given, and that documentation must accurately reflect the bathing type provided. The surveyor reviewed the reports with the DON, who was made aware of the lack of shower documentation.

Based on observation and facility staff interview, it was determined the facility failed to ensure residents had access to their call bell. This was evident for 7 Residents (#7, #18, #39, #133, #109, #112, #47) of 65 residents included during the surveyor's initial tour of the facility during the recertification survey. The findings include: On 08/28/25 at 8:45 AM the surveyor commenced to interview Resident #7 at the resident's bedside. The surveyor observed that Resident #7's call bell cord and it's activation pad (to operate the call bell) was wrapped around the bedframe at the head of the bed. On 08/28/25 9:02 AM the surveyor and the unit manager, Staff #9 entered Resident #7's room. The surveyor interviewed Resident #7 who said that he/she could not locate his call bell device (a flat pad attached to a cord) to use for when he/she needed help. Staff #9 attempted to locate the call bell device on the resident's person and within their bed sheets, however it was found hooked around the left side of the bedframe (near the head of the bed) which was out of the resident's reach. The surveyor observed Staff #9 untangle the call bell cord and place it under Resident #7's right hand. On 8/38/25 at 9:14 AM the surveyor interviewed Staff #9 who revealed that Resident #7 was given morning hygiene care by a geriatric nursing assistant, and they did not place the resident's call bell within his/her reach afterwards. On 08/28/25 at 8:37 am the surveyor observed Resident #18 in bed with their call bell on the floor on the right side of the bed. Resident #39 call bell was across the overbed light which was not in reach. At 8:48 am during observation rounds the surveyor observed Resident #133 in bed without their adaptive call bell within reach. The resident verbalized being unable to use their left hand and asked the surveyor to place the adaptive call bell near their right hand. At 9:06 am the surveyor observed Resident #109 call bell on the floor. At 9:12 am the surveyor observed Resident #112 call bell on the floor on the left side of the bed. At 9:29 am the surveyor observed Resident #47 call bell hanging on their overbed light. On 08/28/25 at 12:06 pm during an interview with Geriatric Nursing Assistant (GNA) #13 the surveyor asked them to describe how their morning is started. GNA #13 verbalized they go into the residents' room, greet the residents, get them cleaned up, change the sheets, and make sure they have their call bell. Before leaving the room the residents' bed is put into the lowest position. They surveyor verbalized observing multiple residents without their call bell during observation rounds. On 08/28/23 at 12:16 pm during an interview with Certified Medication Aide #14 the surveyor asked when they verify the residents have their call bell. CMA #14 verbalized they make sure the residents have their call bell and bed control when they enter the residents' room.

Number of residents sampled: Number of residents cited: Based on observations and interviews it was determined that the facility staff failed to report and complete maintenance concerns on Unit 1 South in a timely manner. This deficient practice was widespread on Unit 1 South and was discovered during the recertification survey. The findings include:On 08/28/25 at 8:24 AM during observation rounds on Unit 1 South the surveyor observed multiple maintenance concerns. At 8:37 AM the surveyor observed the lights exposed in the bathroom in room [ROOM NUMBER] bathroom; the light cover was on the floor beside the sink in the bathroom. At 8:42 AM the surveyor walked in Room#103 and observed a large hole in the wall behind the resident's bed on the left side. The surveyor walked to the right side of the bed and observed a large hole in the wall behind the bed. There were damaged tiles on the floor under the resident's bed. At 8:53 AM while in room [ROOM NUMBER] the surveyor observed marring on the wall behind the resident's bed, and an outlet had exposed wires. At 8:58 AM the surveyor observed a hole in the wall in the bathroom near the right side of the commode in room [ROOM NUMBER]. In room [ROOM NUMBER] the door to the clothing armoire was loose and hanging. At 9:12 am the surveyor observed the first and second drawers were broken to a resident's bedside table in room [ROOM NUMBER]. At 9:18 AM the surveyor observed a hole in the wall behind the right side of the bed in room [ROOM NUMBER]. At 9:49 AM the surveyor observed an electrical outlet with exposed wires in room [ROOM NUMBER].On 08/28/25 at 12:10 PM the surveyor asked Geriatric Nursing Assistant (GNA) #13 if the observed a maintenance concern on the unit, what would they do. GNA #13 verbalized they would let the nurse know about the problem. If the nurse were not available, they would let someone in the maintenance department know.On 08/28/25 at 12:13 PM the surveyor asked Certified Medication Aide #14 what the process was for reporting maintenance concerns. CMA #14 verbalized there is a maintenance log on the unit to report maintenance concerns. The maintenance log is kept behind the desk on the shelf. They document the location of the concern, the problem, and the date.On 08/28/25 at 12:20 PM during an interview with Maintenance Director #15 he/she verbalized they have a log to enter maintenance concerns, and the logs are checked one - two times a day. They have a preventative maintenance log in TELS. The system lets the maintenance staff know when something is scheduled. They attempted to start checking the residents' rooms monthly. Every Tuesday they do rounds on the units. The surveyor and Maintenance Director #15 walked the unit simultaneously to visualize all the surveyor's maintenance concerns.

Based on observation, facility staff interview and review of facility policy it was determined that the facility failed to maintain an effective infection prevention and control program. This was found to be evident for 7 of 7 residents reviewed for infection control practices and was widespread on Unit 1 South.The findings include: 1) During medication administration, the surveyor observed that Employee #20 failed to practice infection control by not washing their hands or using hand sanitizer between providing residents with medication. It was noted that Employee #20 used a glucometer on residents #20, # 25, 153, and #193 without washing their hands or using hand sanitizer and did not clean the glucometer between residents. 2) On September 2, 2025 at 9:30 PM spoke with the Director of Nursing (DON), The Regional Clinical Services Manager (#3) and the Administrator and asked them what their expectations for infection control during medication administration. The DON stated that they expected the nurse to wash and/or sanitize their hands between medication administration to residents and that all equipment used in resident care to be cleaned between usages. 3) On 08/27/2025 at 9:56 AM Resident #170's nasal cannula tubing, including the part that goes in the resident's nose, was observed on the floor. Resident #170's nebulizer mask was not covered but was lying on the bedside table next to open peri-care wipes, skin care cream, peri-spray, and an open container of Boost. On 08/27/2025 at 10:04 Staff #12, Licensed Practical Nurse (LPN) was interviewed and asked if Resident #170's nasal cannula should be on the floor. Staff #12 replied no, stating it should be in the resident's nose, and said he/she would get new oxygen tubing to replace the tubing on the floor. Staff #12 was then asked if the nebulizer mask on the bedside table was used daily for Resident #170's ordered nebulizer treatments, to which he/she replied yes. When asked if the nebulizer mask should be lying uncovered next to open peri-care products and an open container of Boost, Staff #12 replied no and stated he/she would remove and replace the mask and cover it. 4) During observation rounds on 08/28/25 at 8:28 AM the surveyor observed several infection control problems on Unit 1 South. In the shared bathroom in room [ROOM NUMBER] the surveyor observed an unlabeled basin on top of the paper towel dispenser, a bedpan on the floor beside the commode, and an unlabeled fracture bed pan on the metal bar beside the commode. At 8:33 AM the surveyor observed a yellow kidney basin inside of a bedpan on Resident #176 wheelchair cushion. The surveyor also observed grey slippers on top of the refrigerator. At 8:37 am the surveyor observed two unlabeled basins on the floor in room [ROOM NUMBER]. Certified Nursing Assistant #4 confirmed the surveyor's findings. At 8:53 AM while in room [ROOM NUMBER] the surveyor observed a bed pan on the floor near the left side of the commode in the bathroom. At 9:09 AM the surveyor observed a kidney basin on the floor under the sink in room [ROOM NUMBER]. At 9:18 AM the surveyor observed two unlabeled bedpans on the bathroom floor in room [ROOM NUMBER]. At 9:23 AM the surveyor observed two unlabeled urinals, a basin on the floor, and three unlabeled basins in room [ROOM NUMBER]. At 9:26 AM the surveyor observed Resident #49 oxygen tubing on the floor on the right side of the bed. On 08/28/25 at 12:36 PM the surveyor informed Infection Preventionist #5 the infection control concerns observed on the unit. Also, the surveyor shared pictures to verify the concerns were valid. Infection Preventionist #5 verbalized the nursing staff was instructed to write the room and bed number on the residents' personal care equipment. The staff were provided permanent markers to label the residents' personal care equipment. They are not sure why the equipment was on the floor. They will evaluate the staff and agency personnel because that was not the standard of practice. Rounds will continue to be done, and they will follow up with the Nurse Manager.

Number of residents sampled: Number of residents cited: Based on observation and an interview with facility staff, it was determined that the facility failed to maintain a resident's privacy by having their foley catheter bag uncovered. This was evident for 1 (Resident # 170) of 3 residents reviewed during the annual recertification survey.The findings include:GUIDANCE S483.10(h)Each resident has the right to privacy and confidentiality for all aspects of care and services. A nursing home resident has the right to personal privacy not only his or her own physical body, but of his or her personal space, including accommodation and personal care.On 08/27/2025 at 9:52 AM, during an observation of Resident #170, the foley catheter bag was seen hanging in the center of the bed upon entering the room. Amber-colored urine was visible in the foley catheter bag from the doorway.Staff # 12, Licensed Practical Nurse (LPN) was interviewed and asked about the policy/practice for covering foley catheter bags with a privacy bag. Staff #12 confirmed their policy was to keep foley bags covered with a privacy bag. Staff #12 acknowledged that Resident #170's catheter bag was not covered with a privacy bag and stated they would cover it.

Based on interviews and record review it was determined that the facility failed to develop and implement a comprehensive care plan to meet the need of a Resident. This was found evident of 1 (Resident #8) out of 65 residents reviewed during the survey. The findings include: On 9/2/25 at 7:56 AM, the surveyor reviewed Resident #8's medical record. The review revealed that Resident #8 had a past psychological history that included schizophrenia and depression. On 9/2/25 at 8:24 AM, the surveyor reviewed Resident #8's care plan. The review revealed a care plan created on 1/13/23 that stated Resident #8 had a mood disturbance related to changing in health status, depression and bipolar disorder. The surveyor was unable to find any documentation in the medical record that indicated Resident #8 had bipolar. On 9/2/25 at 10:54 AM, the surveyor conducted an interview with the Director of Nursing (DON). During the interview the DON stated that the care plan was created in error and that Resident #8 did not have bipolar disorder. She further stated that the Unit Manager that created the care plan no longer works at the facility and was unable to find out why the care plan was created.

Based on observation, record review and interview, it was determined that the facility failed to 1) reassess the effectiveness of the interventions and review/revise them (Resident #25) and 2) failed to invite a resident to attend and participate in their care plan meeting (Resident #186). This was found on review of 65 resident's care plans. The findings include: 1) Observation, on 08/28/2025 at 9:17 AM, Resident #25 with their feet ace-wrapped from toe to knee level and the resident was sitting in the chair with their feet down to the floor. During a record review on 08/29/2025, at 10:42 AM, it was noted that Resident #25 was admitted to this facility from the hospital on [DATE], due to hospitalization of septic leg wounds. The admission medical diagnoses included: non-pressure ulcers of the lower legs, ongoing hemodialysis, Type II diabetes mellitus, leg pain, and peripheral vascular disease. Peripheral Vascular Disease (PVD) is a systemic disorder that involves the narrowing of peripheral blood vessels (vessels situated away from the heart or the brain). This happens because of narrowing body arteries as arteriosclerosis, or a buildup of plaque, and can happen with veins or arteries. When plaque accumulates, it may result in blood clots and dangerously limit the amount of oxygen that circulates to the legs. Observation, on 08/29/2025 at 12:50 PM, Resident #25 remained in the same position and there was no staff available to assist with changing position or helping into bed. On the same day, at 01:05 PM the Unit Manager Staff #6 stated that wound care plans were initiated on 07/14/2025. However, it was noted that Resident #25 was not consistently adhering to the most interventions, specifically keeping feet elevated at all times or turning/repositioning at least every two hours. A record review conducted on August 29, 2025, at 2:01 PM, from the wound assessment documentation, revealed that Resident #25 had a total of 12 lower leg wounds (wound areas per staff- right heel; right dorsal foot; left shin; left heel; right shin; right lateral calf; right lateral foot) on admission. Only one wound was healed from wound documentation. Also found that all wound care plans were initiated on 07/14/25, to address Resident #25's impaired skin integrity related to vascular insufficiency, with the goal of decreasing wound areas. Staff documentation often indicated that the resident had been unable to keep his feet elevated or remained in bed all day, and had not been repositioned at least every two hours. It appears that interventions had not been revised since 07/14/2025, to reflect these challenges or to include this resident's input. Interview, on 09/02/2025 at 10:05 AM, reviewing above findings with the Administrators that revising of care plans' interventions was an on-going process, however, the facility staff failed to revise them as a deficiency concern. 2) On 8/29/25 at 9:28 AM, the surveyor conducted an interview with Resident #186. During the interview Resident #186 stated that he/she had not been involved in the care planning process. On 9/2/25 at 12:07 PM, the surveyor reviewed Resident #186's medical record. The review revealed that Resident #186 had been in and out of the facility multiple times in 2025. On 6/20/25 Resident #186 was admitted to the facility and on 6/27/25 Resident #186 had a Minimum Data Set (MDS) admission assessment completed. Next the surveyor requested care conference notes and attendance documentation for the care plan meeting following the 6/27/25 MDS admission assessment. On 9/2/25 at 1:37 PM, the surveyor reviewed the documentation with the Regional Clinical Services Manager Staff #3. Resident #186 was not on the attendance log, and the care plan meeting note written by Registered Nurses (RN) #29 for the meeting date of 7/8/25 only referenced that the care plan was reviewed by the interdisciplinary team. There was no mention of the Resident. Staff #3 stated she would follow-up with the Social Worker for clarification if the Resident was in attendance. On 9/2/25 at 1:54 PM, the surveyor conducted an interview with Social Service Assistant, SW #28. During the interview SW #28 stated that Residents are invited to their care plan meeting with a written invitation and if they attend then their name should be added to the attendance log. The surveyor reviewed the attendance log and care plan note with the Social Worker and asked if Resident #186 was in attendance and part of the care plan meeting on 7/8/25. SW#28 stated she believed the care plan meeting was done at the bedside but could not remember for certain. The surveyor asked if there was documentation that Resident #186 was invited to the meeting. SW #29 confirmed there was no documentation to show that Resident #186 was invited to the meeting or that he/she attended the care plan meeting.

Number of residents sampled: Number of residents cited: Based on observations and interviews it was determined that the facility staff failed to practice according to professional nursing standards as evidenced by a nurse removing a pain patch from a resident and placing it on the windowsill. This deficient practice was evidenced in 1 (#18) in 1 resident observed with a pain patch that was not properly discarded. This deficient practice occurred during the recertification survey. The findings include:On 08/28/25 at 8:37 AM while speaking with Resident #18 the survey observed a pain patch dated 08/26, 7:00 AM - 3:00 PM shift was on the windowsill. Geriatric Nursing Assistant (GNA) #4 confirmed the surveyor's findings.On 08/29/25 at 1:02 PM during an interview with the Director of Nursing (DON) the surveyor asked what the expectation of the nursing staff when removing a resident's pain patch. The DON verbalized the expectation was for the nurse to discard the pain patch.On 08/29/25 at 2:03 PM during an interview with Registered Nurse (RN) #17 the surveyor asked to explain the process of removing a resident's pain patch. RN#17 verbalized they would first check the resident's order before the patch was removed. They would wash their hands and apply gloves, then remove the patch. A clean washcloth would be used to clean the area where the patch was located. The patch would be discarded in the wastebasket. The nurse would document on the medication administration record that the patch was removed.

Based on record review and interview, it was determined that the facility failed to provide necessary services to maintain good personal hygiene for dependent Residents. This was found evident in 1(Resident #77) out of 3 Residents reviewed for Activity of Daily Living (ADL) cares. The findings include:On 9/2/25 at 9:25 AM, the surveyor reviewed Resident #77's medical record. The review revealed Resident #77 had a Minimum Data Set (MDS) assessment dated [DATE] that assessed Resident #77 as Dependent (helper does all the effort) for shower/bathe self category. Also dependent for upper and lower body dressing and toileting. Next the surveyor reviewed Resident #77's Task documentation for bathing/showering for the month of August 2025. The review revealed that on 8/5/25, 8/11/25 8/28/25 and 8/31/25 Resident #77 was documented as set up or clean up (helper sets up or cleans up; resident completes activity. Helper assists only prior to or following the activity) by two different staff members. One of the staff two members additionally documented that Resident #77 was dependent for bathing 15 other days in August 2025. On 9/2/25 at 10:32 AM, the surveyor conducted an interview with the Director of Nursing (DON). During the interview the surveyor reviewed the documentation with the DON and asked, if Resident #77 was dependent on staff for bathing, then how was a bath completed on the 4 days in August when it was documented that he/she was set up. The DON confirmed that the Resident was dependent on staff and that if a bath were completed it would have been completed completely by staff and not a set up. At the time of exit no additional information was given to indicate appropriate Activities of Daily Living (ADL)'s care were provided on 8/5/25, 8/11/25 8/28/25 and 8/31/25.

Number of residents sampled: Number of residents cited: Based on observations, record reviews, and staff interviews, it was determined that the facility failed to ensure oxygen therapy was set up in accordance with professional standards of practice. This was evident for 1 (Resident #122) out of 3 residents reviewed for respiratory care during the annual survey.The findings include:On 08/27/2025 at 9:51 AM, the surveyor observed that the oxygen tubing was not connected to the humidifier bottle, and the end of tubing was lying on the floor. There was no date label observed on the tubing or the humidifier bottle. LPN #1 was notified that the oxygen was disconnected and laying on the floor. Licensed Practical Nurse (LPN) #1 verified that she did not see labeling and stated she would provide Resident #122 with new tubing.On 08/27/2025 10:27 AM Assistant Director of Nursing was notified of the missing oxygen label and administration tubing lying on the floor disconnected. She stated she would investigate the concern.The Director of Nursing confirmed that she was aware of the oxygen tubing and labeling concern identified on 09/03/2025 at 01:20 PM.

Number of residents sampled: Number of residents cited: Based on review of narcotic counts, it was determined that the facility failed to ensure that narcotic medications were consistently accurate. This was evident for 2 of 6 medication carts reviewed for accuracy and completeness of controlled medication storage and documentation. The findings include: Controlled substance medications, due to their potential for abuse and addiction, are required to be thoroughly tracked and accounted for by the facility. This includes but is not limited to an accounting of controlled substance in storage whenever they are administered to a resident occurs. Any discrepancy in the count from what is expected to be found must be addressed immediately. 1. While performing the medication storage facility task, the surveyor while inspecting 6 medication carts discovered discrepancies in the controlled substance log. The following controlled substance were found to be in discrepancy: Resident #160's Oxycodone; Resident #27's Oxycodone and Lyrica; Resident #129's Diazepam and Resident#195's Tramadol. 2. On September 2. 2025 at 9:30 PM the surveyor spoke with the DON, the Administrator and the Regional Clinical Service Manager (#3) and requested their expectations for maintaining an accurate control substance count. They confirmed that they expected the nurse to sign out any control substance that they are administering.

Number of residents sampled: Number of residents cited: Based on observation and facility staff interview, it was determined that the facility failed to properly label bulk medications with the date that included month, day and year and to properly date multi-dose insulin injectable pens when they are opened. This was evident for 3 of 6 medication carts that were reviewed.The findings include:1. While conducting the Medication Storage and Labelling facility task, it was observed that in 3 of the 6 medication carts that the bulk medication had either an incomplete date indicating when the medication was opened or no date at all. It was also noted that an open insulin pen was not labelled with the date the medication was opened.2. On September 2, 2025, at 9:30 PM spoke with the Director of Nursing (DON), The Regional Clinical Services Manager (#3) and the Administrator and asked them what their expectations for the labelling of bulk medication and other medications when they are opened. The DON stated that they expected the nurse to date any medication with the date it was opened.

Number of residents sampled: Number of residents cited: Based on observation, interview, and record review, it was determined that the facility failed to provide sugar substitute as specified by the ordered diet. This was found to be evident for 1 (#86) out of 3 residents investigated for food preferences. The findings include:The primary purpose of a Consistent Carbohydrate diet is to manage blood sugar levels in individuals with diabetes or prediabetes. By maintaining a steady intake of carbohydrates, the body can better regulate insulin production and prevent blood sugar spikes or crashes.On 08/29/2025 at 12:29 PM, the surveyor observed Resident #86's lunch tray. Resident #86 stated that the facility served regular sugar instead of sugar substitute on the tray. He/She further stated, I am a diabetic and should not be served regular sugar. The surveyor observed the tray card provided with the meal. It read CCHO (Consistent Carbohydrate), Dysphagia 3, Thin 1350 fluid restriction/day and specified sugar substitute under condiments. At 12:37 PM on 8/29/2025, LPN #18 confirmed that the tray contained sugar, while the menu specified sugar substitute. LPN #18 offered to provide sugar substitute to Resident #86. During an interview on 09/02/2025 at 1:18 PM, Registered Dietician (RD) #25 stated that a typical CCHO diet would have sugar substitute. RD #25 provided the Dining Service Menu Guide titled CCHO Diet (LCS) (Consistent Carbohydrate Limited Concentrated Sweets) which stated, the CCHO diet utilized sugar substitute. On 09/03/2025 at 1:20 PM, the Director of Nursing confirmed that RD #25 informed her of the concern.

Based on medical record review and staff interview, facility staff failed to follow a resident's plan of care to prevent injury to resident while providing care. This resulted in harm to Resident #6. This was evident for 1 of 3 residents reviewed for falls during a complaint survey.After the incident, the facility developed, initiated and completed a plan of correction to prevent further injuries to residents while providing care. Therefore, this deficiency will be cited as past non-compliance. The date of correction was 8/18/23. The findings include:Review of complaint intake MD00195745 (Iqies: 297381) on 7/17/25 at 10:52 AM revealed that Resident #6's family alleged that the resident fell from his/her bed and sustained a laceration to the head due to facility staff failing to provide adequate supervision to the resident. Review of Resident #6's medical record on 7/17/25 revealed a care plan which stated that the resident required 2 person assistance for toileting and bed mobility as of 2/21/21. Review of Resident #6's medical record on 7/17/25 revealed a progress note which stated that the resident had a fall incident on 8/12/23. The resident was observed with a laceration to the right side of his/her forehead as a result of the fall. The resident's forehead laceration was wrapped with gauze and the resident was transferred to the local hospital for evaluation and treatment. Continued progress note review on 7/17/25 at 12:00pm revealed that the resident returned from the local hospital after treatment on 8/13/23. The resident returned with forehead stitches that were used to close the forehead laceration. Interview with the Director of Nursing (DON) on 7/17/25 at 12:30pm confirmed that the Resident #6 had a fall incident on 8/12/23. The resident sustained a forehead laceration from the fall which required the resident to be transferred to the local hospital for treatment. The DON confirmed that a fall investigation was conducted, and the fall investigation revealed that the assigned nursing staff, Geriatric Nursing Assistant (GNA) #9, failed to follow the resident's care plan when he/she provided toileting care for the resident on 8/12/23. The facility developed a place of correction which included re-education of all nursing staff on reviewing the resident's plan of care prior to providing care to the resident and bed mobility techniques. Review of the facility's fall investigation on 7/18/25 at 9:47 AM revealed that the fall incident occurred on 8/12/23 at approximately 12:15 PM. The facility investigation contained a witness statement from GNA #9 dated 8/14/23 which stated that GNA #9 failed to follow the resident's care plan for 2 person assistance when providing toileting care. GNA #9's statement revealed that the resident fell from his/her bed and hit his/her head on the floor when GNA #9 provided toileting care to the resident alone. The statement was taken by former Administrator #18 and the DON was the witness. The DON provided the surveyor with the GNA Kardex for Resident #6 on 7/18/25 at 10:30 AM. Review of the GNA Kardex revealed that the resident required 2 person assistance for toileting care and bed mobility. Interview with former Administrator#18 on 7/22/25 at 9:30 AM confirmed that he/she conducted the interview with GNA #9 after the fall incident with the DON as a witness. Former Administrator #18 also confirmed that GNA #9 admitted to providing toileting care to resident #6 alone when the resident's care plan required 2 person assistance for toileting care and bed mobility. The facility's Plan of Correction included the following immediate action taken related to the facility's staff failure to follow Resident #6's plan of care which was verified by the survey team: The DON completed re-education of GNA#6 and all other nursing staff on reviewing bed mobility requirements prior to resident care and bed mobility techniques. Unit Managers/DON/ADON reviewed current residents' GNA Kardexes and care plans to ensure the appropriate bed mobility/fall prevention needs were documented. Reviewed the last 30 days of falls (ending in 8/14/23) involving current residents to ensure that no other residents were impacted by nursing staff failing to follow bed mobility plans of care. Conduct observations of residents requiring 1-2 person assistance with bed mobility daily for 2 weeks. Conduct random observances of 10% of residents requiring 1-2 person assistance for bed mobility for 2 weeks. Review incident reports daily in clinical meetings to ensure nursing staff were following the resident's plan of care. Charge nurses/supervisors continue random audits of 10% of residents requiring 1-2 person assistance with bed mobility weekly for 10 weeks after initial 2 week evaluation. Report results of the bed mobility observations and audits to the QAPI committee.

Based on observation of dry goods in the kitchen on 5/30/23 at 9:15 AM, and foods stored in the freezer, the facility failed to label four food items in the freezer with the date. This was evident for 8 items in the freezer, pasta, and can goods in the dry storage areas. The findings include: On 5/30/23 at 9:15 AM a tour of the kitchen was conducted with Staff # 1 (kitchen supervisor). The freezer had a bag of cooked chicken that was not dated, opened and unopened french fries not dated, unopened hot dogs not dated and 4 large boxes of cheese cakes not dated. The items were pulled out of freezer and thrown away. In addition the dry storage area had pasta that was not dated and 1 large can of green beens that was dented and other cans of vegatables not dated. These items were pulled from the dry storage area, as well. The refrigerator had a case of strawberries that was delivered 3 days ago that had mold growing on them. The Director of Dietary Services was made aware of these concerns on 6/2/23 at 10:30 AM.

Based on interviews and review of medical records, and resident interviews, it was determined that the facility failed to: 1) update a care plan to reflect the current needs of the resident, and 2) involve the resident in the care planning process. This was evident of 4 (Residents #80, #97, #142 and #148) of 7 residents reviewed for care planning during an annual and complaint survey. The findings include: 1a) On 6/7/23 at 7:51 AM, the surveyor reviewed Resident #80's medical record. The review revealed that Resident #80 had a past medical history of, muscle weakness, unspecified fall, and anemia (low amount of red blood cells). On 6/13/23 at 7:19 AM, the surveyor reviewed the change in condition notes for Resident #80. The review revealed that Resident #80 had documented change of condition related to falls on 5/27/23, 5/30/23 and 6/5/23. Further review of the change of condition note written on 5/27/23 recommended re-educating the Resident regarding unassisted ambulation. On 6/13/23 at 8:16 AM, the surveyor reviewed Resident #80's care plan. An actual fall care plan was initiated on 5/30/23, however the first initial fall happened on 5/27/23. No new intervention was placed after the 5/27/23 fall. On 6/13/23 at 10:29 AM the surveyor interviewed the Director of Nursing (DON). During this interview the DON acknowledged initiating the actual fall care plan was missed on 5/27/23. 1b) Review of Resident #142's medical record on 6/6/23 at 8:23 AM revealed the resident had a foley catheter (tube that drains urine from the bladder) inserted on 5/25/23, with no corresponding revision or addition to the resident's comprehensive care plan to address the foley catheter. During an interview on 6/8/23 at 10:30 AM no documentation of the foley catheter having been care-planned could be provided to the surveyor at which time the Corporate Clinical Nurse Consultant confirmed verbally that Resident # 142's foley catheter had not been care-planned. Cross Reference F842. 2a) On 6/1/23 at 10:29 AM, the surveyor interviewed Resident #97. During the interview Resident #97 stated he/she never participated in care plan meetings. On 6/9/23 at 5:39 AM, the surveyor reviewed Resident #97's medical record. The review revealed that Resident #97 was admitted to the facility in late 2022 and was his/her own Responsibly Party (RP). On 6/9/23 at 5:42 AM, the surveyor reviewed a progress note dated 5/4/23, written by Licensed Practical Nurse (LPN) Staff #37. The progress note stated that the Nurse Practitioner reviewed laboratory results for Resident #97 and no new orders were given. It also stated that Resident #97 was aware of the laboratory results and is his/her own RP. Further review of the progress notes written on 5/4/23 revealed a note written by Unit Manager Staff # 26. The note stated, a care plan meeting was conducted with Resident #97's son via the telephone. It further stated that medications were reviewed with the family and no concerns were expressed. There was no documentation that Resident#80 was present or invited to participate in the care plan. On 6/9/23 6:20 AM, the surveyor reviewed Resident #97's care plan attendance log with the Corporate Clinical Nurse Consultant. Resident #97 was documented in attendance, along with his/her son, on the care plan meeting that was conducted in December of 2022; however the care plan meeting that was conducted in March only had Resident #97's son. No attendance documentation was found for the 5/4/23 care plan meeting on the attendance log. The Corporate Clinical Nurse Consultant stated she would look into the concern. No new documentation was provided at the time of the survey exit on 6/16/23. 2b) On 6/14/23 at 1:23 PM a resident interview was held. Resident # 148 stated she/he had never been invited to a care plan meeting, although his/ her family has attended. Record review on 6/12/2023 at 12:21 PM revealed the resident is alert and oriented x 3. Further review of the record and Social Worker interview on 6/14/2023 at 1:23 PM indicated that on 5/10/23 Social Worker # 37 called the responsible party to advise of the care plan meeting to be held on 5/15/23 at the preferred time. Social Worker # 37 stated that a message was left by phone. The family attended along with the Interdisciplinary team and all the names of those who attended the meeting were on the care plan assignment sheet. Social Worker # 37 stated that he/she believed the resident refused, but there was no documentation of that in the record. The Social Worker and Regional Clinical Services Nurse (RCS) were informed by the surveyor on 6/14/23 at 2:30 PM, that this would be a deficiency. 47200

Based on observations, record review, and interviews of facility staff it was determined the facility failed to ensure that tube feedings were managed appropriately according to professional standards. This was evident for 4 residents (#142, #156, #12 and #123) out of 4 residents who were observed to have tube feedings in place. The findings include: On [DATE] at 12:36 PM the surveyor observed Resident # 142's tube feed and line to be disconnected from the resident. Upon further observation, the tube feed container hanging in the room next to the resident was found to have a label which included a date of [DATE], and a time of 7:30 PM. The tubing line that was connected to the feed container was observed to have a label dated [DATE] and failed to include an expiration time for the line. During an interview with Staff #37, Charge Nurse, Licensed Practical Nurse, on [DATE] at 12:50 PM, they reported that staff is not expected to fill out everything on the tube feed labels and the facility's policy is that tube feed lines expire after 24 hours. The surveyor brought the concern regarding Resident #142's tube feed to the attention of Staff #37 and accompanied them to Resident #142's room to observe the concern. Regarding the tube feed line, Staff #37 confirmed the surveyor's observation and stated: It should be changed after 24 hours. On [DATE] at approximately 1:24 PM the surveyor observed an open system tube feed (feed bag that has tube feed poured into it) hanging in the room next to Resident #123. The cream colored solution contained in the open system tube feed was observed to have a curdled appearance. The surveyor further observed worn off writing in marker on the back of the feed bag which appeared to have a date of [DATE]. The tubing line was observed to be labeled clearly with a date of [DATE] and failed to include a time of expiration. On [DATE] at approximately 1:24 PM the surveyor observed Resident #156's tube feeding infusing with a tube feeding line that was labeled with a date and time of [DATE] at 6:00 AM. On [DATE] at approximately 1:25 PM the surveyor observed Resident #142's tube feeding to now be connected to the resident and infusing with the same tube feeding line dated [DATE] with no expiration time which was brought to the attention of Staff # 37 at 12:50 PM. On [DATE] at approximately 1:25 PM, Resident #12's tube feeding was observed and found to be connected to the resident infusing with the tube feeding line that had no label present to indicate the date and time the line should expire. On [DATE] at 1:38 PM the surveyor rounded with Staff #37 in the rooms of Resident #142, #12, #123, and #156. Staff #37 acknowledged surveyor's concerns and additionally confirmed that the tube feed lines were expired. Regarding Resident #123, Staff #37 reported the following: the bag looks gross and should have been thrown away. On [DATE] at 1:58 PM the surveyor's concerns were brought to the attention of the facility's Executive Director, Director of Nursing, and Corporate Clinical Nurse Consultant. On [DATE] at 9:26 AM, the surveyor requested and reviewed the facility's tube feed policy which included solution expiration times, however, did not address the feeding tube line expiration times or the facility's policy for labeling of feed solutions and lines. At this time, the surveyor inquired to the Corporate Clinical Nurse Consultant as to the protocol employees are taught during the orientation process, at which time they stated the following information: employees are expected to refer to the manufacturer's guidelines for the tubing itself and I read it and it is 24 hours expiration. On [DATE] at 10:00 AM, the general guidelines being taught by the facility for tube feedings were reviewed and no information could be found relating to labeling and expiration of tube feed lines. On [DATE] at 10:00 AM the Corporate Clinical Nurse Consultant reported to surveyors that they would be calling the tubing manufacturer to clarify how long the tubing can be used for. During an interview with Staff #8, Director of Education on [DATE] at 10:36 AM, they stated that during orientation for employees they are taught to date, label, and initial anything they open, including the spike set (tubing line for tube feed administration). Regarding surveyor's observation of Resident #123's open system, Staff #8 stated that bag should have been thrown away. On [DATE] at 11:28 AM, the surveyor made another observation of Resident #123's tube feeding. The open system tube feeding was observed to be hanging in the room with a date of [DATE] written on the bag and no time indicating when the solution would expire, and no date or time found on the tubing line. On [DATE] at 11:30 AM Staff #43, Unit Manager, Regional Mobile Resource RN, accompanied the surveyor to observe the concern for Resident #123's tube feeding at which time they verbally confirmed the feed should have been discarded and proceeded to appropriately discard the feed system. On [DATE] at 11:29 AM the surveyor provided an opportunity for the facility to submit any and all further documentation of the complete tube feeding policy and expectations for nurses when they go to hang tube feedings.

Based on observation, medical record review and interview it was determined that the facility failed to ensure the accuracy of medical orders/records and bathing documentation. This was evident for 1 (Resident #142) out of 2 residents that were reviewed for bowel and bladder, 1 (Resident #24) out of 9 residents reviewed for pressure ulcer/injury, and 1 (Resident #41) out of 1 resident that was reviewed for neglect. The findings include: 1) Upon review of Resident #142's medical orders on 6/5/23 at 9:17 AM, no order was present directing the insertion/placement of a foley catheter (tube that drains urine from the bladder). On 6/5/23 at 9:17 AM a nursing note dated 5/25/23 at 4:12 PM was reviewed which stated the following information: MD (medical doctor) ordered to place foley catheter for wound healing however, the medical order stated the following information: Patient has Foley catheter ,size French 16, for wound healing. Provide catheter care every shift. On 6/5/23 at 11:11 AM the surveyor requested documentation of the order for insertion/placement of Resident #142's foley catheter from the Corporate Clinical Nurse Consultant. During an interview on 6/5/23 at 1:30 PM, the facility's Corporate Clinical Nurse Consultant could not provide documentation of a medical order that directed insertion or placement of Resident #142's foley catheter and reported the following information: When the order was transcribed it does not say insert the foley, it says patient has foley catheter, but the progress note says MD ordered to place foley catheter for wound healing. Is this a records issue or a practice issue? Cross Reference F657. 2) On 6/15/23 at 10:13 AM, Resident #24 was observed sleeping in bed with bilateral (both sides) pressure relieving foot boots in place. Upon surveyor review of Resident #24's medical orders on 6/15/23 at 12:33 PM, no active order could be found for application of bilateral pressure relieving foot boots. Further review of Resident #24's medical record on 6/15/23 at 12:33 PM revealed physician medical provider evaluations dated 6/1/23, 6/2/23, and 6/14/23 which included documented assessment of the resident that states: Patient has bilateral feet boot in place. On 6/15/23 at 1:11 PM, the surveyor's concern was brought to the attention of the Director of Nursing and the Corporate Clinical Nurse Consultant and an opportunity to provide any documentation regarding a medical order for the boots was provided. On 6/16/23 at 8:29 AM, Resident #24 was again observed in bed with bilateral pressure relieving boots in place. On 6/16/23 as of 11:26 AM, no documentation of a medical order for the pressure relieving boots was provided from the facility and upon record review no order had yet been obtained. 3) On 6/12/23 at 10:28AM during an interview with Staff #10, Unit Manager, reported to the surveyor that Resident #41 frequently refused showers. On 6/12/23 at 11:40 AM, medical records for Resident #41 were reviewed which revealed that documentation of the resident's bathing was inaccurate. The Geriatric Nursing Assistant (GNA) task list (place where gna's document the bathing of a resident) was completed which reported the resident had received showers on 6/1, 6/6, and 6/10/23. On the treatment administration record (TAR) (record where nurses document care of a resident) the resident was documented as having been administered a shower on 6/2, 6/4, 6/5, 6/6, 6/7, 6/8, 6/9, 6/10, 6/11, 6/13, 6/14, and 6/15/23, with the treatment order stating the following information: shower twice weekly Tuesday, Friday, 3-11 shift. Further review of the medical record revealed staff had documented the resident had received tub baths on 10/9/22, 10/27/22, and 10/31/22. On 6/12/23 at 11:45 AM the Director of Nursing and the Corporate Clinical Nurse Consultant confirmed that there were no bathtubs within the facility. On 6/16/23 at 9:55 AM medical record review revealed several documented resident refusals of showers. During an interview on 6/16/23 at 10:59 AM, the surveyor had brought concerns to the attention of the Administrator and they confirmed that the check marks on the TAR meant a shower had been administered. They further stated the following information: Residents can have showers every day if they want. At this time the surveyor shared concerns about conflicting documentation between the TAR and the GNA task list.

Based on interview and review of medical records it was determined that the facility failed to obtain a resident's advanced directives. This was found evident for 1 of 3 residents (Resident #367) reviewed for advanced directives during an annual and complaint survey. Advanced Directive: A written statement of a person's wishes regarding medical treatment, often including a living will, made to ensure those wishes are carried out should the person be unable to communicate them to a doctor. It is a legal document in which a person specifies what actions should be taken for their health if they are no longer able to make decisions for themselves because of illness or incapacity. The findings include: On 6/9/23 at 9:03 AM, the surveyor reviewed Resident #367's medical record. The review revealed that Resident #367 was admitted to the facility in late May 2023. The Brief Interview for Mental Status (BIMS) evaluation was done on 5/25/23, and indicated Resident #367 was cognitively intact, with a score of 15. Further review of Resident #367's medical record revealed a progress note written by Social Worker Staff #19. The note stated that Resident #367 had an appropriate Medical Order for Life-Sustaining Treatment (MOLST) in the record. The note further stated that the Social Worker would follow up with the resident's daughter regarding obtaining a copy of Resident #367's advanced directives. On 6/9/23 at approximately 9:20 AM, the surveyor further reviewed Resident #367's medical records. A MOLST order, dated 3/17/23, was reviewed. In the section labeled The basis of these orders a box was checked on health care agent as named in the patient's advanced directives, indicating the life-sustaining treatment order was discussed and consented from Resident #367's health care agent. Further review of the medical record revealed no advanced directive was found for Resident #367. On 6/9/23 at 9:55 AM, the surveyor conducted a phone interview with Staff #19. During the interview, Staff #19 stated she remembered that Resident #367 had advanced directives indicated in his/her MOLST order. She stated she had not reached out the hospital to obtain a copy and that she was planning on reaching out to Resident #367's daughter first. When asked if she had reached out to Resident # 367's daughter, Staff #19 could not remember. The surveyor could not find any documentation that Resident #367's daughter was contacted or the status of obtaining the advanced directives. On 6/9/23 at 10:28 AM, the surveyor interviewed the Corporate Clinical Nurse Consultant. During the interview the surveyor discussed the concerns that a cognitively intact resident, with a BIMS score of 15, had an order based off of his/her advanced directives; however the advanced directives were not in the medical record.

Based on record review, staff, and resident interviews it was determined that the facility failed to ensure that a resident was free from verbal abuse. This was found to be evident for 1 (Resident # 115) out of 2 residents reviewed for verbal abuse. The findings include: On 6/1/23 at 10:30 AM, the surveyors reviewed the Facility Reported Incident dated 11/7/22, the facility investigation alleged that Geriatric Nursing Assistant (GNA) # 3 had verbally abused Resident # 115. The surveyors reviewed the facility's Abuse and Neglect of Residents Policy on 6/1/23 at 10:44 AM. The definition of verbal abuse means the use of oral, written, or gestured communication or sounds that willfully includes disparaging and derogatory terms to residents, or within hearing distance, regardless of their age, ability to comprehend, or disability. On 6/2/23 at 9 AM, the surveyors conducted an interview with the Administrator, Regional Clinical Services Manager (RCSM) and the Director of Nursing (DON) about the verbal abuse investigation. During the interview the RCSM confirmed that GNA # 3 spoke inappropriately about Resident # 115 while providing care, therefore, the GNA was educated for customer service and the allegation for verbal abuse was unsubstantiated (compliant). During an interview conducted on 06/06/23 at 08:37 AM, the surveyors asked Resident # 115 if s/he remembered the incident that occurred with the GNA in the bathroom. Resident # 115 stated yes, GNA # 3 verbally abused me while providing my care. She stepped out of the room first, but I heard it. The resident further stated, I felt like I'd been talked about for no reason, it didn't feel good, and she doesn't work with me anymore. On 6/6/23 at 10:14 AM, the surveyors reviewed the consult with psychology from 11/14/22, that stated Resident # 115 reported that GNA # 3 had been verbally abusive and had not listened to or met the resident's needs. The resident also reported that since GNA # 3's assignment was changed, s/he now felt safe from verbal abuse.

Based on record review and interviews it was determined that the facility failed to ensure that a resident was free of pain as evidenced by a resident that was sent out to the hospital for tooth/mouth pain. This was found to be evident for 1 out of 1 resident (Resident #44) reviewed for pain management. This deficient practice resulted in harm to the resident. The findings include: During an interview conducted with Resident #44's Responsible Party on 11/30/2022 at 8:31 AM, the Responsible Party (RP) stated that the resident had suffered from tooth pain for several days and went without treatment of the toothache pain. The Responsible Party further stated that he/she was advised the resident had an order for Oxycodone but for some reason the facility would not give the pain medication to the resident. After several days of the resident's untreated toothache pain, the Responsible Party called 911 and the resident was sent out to the hospital on the evening of 08/19/2022. According to the Centers of Medicare and Medicaid Centers (CMS) the Minimum Data Set (MDS) is a powerful tool for implementing standardized assessment and for facilitating care management in nursing homes (NHs). BIMS stands for Brief Interview for Mental Status. The BIMS test is used to get a quick snapshot of how well a resident are functioning cognitively at the moment. It is a required screening tool used in nursing homes to assess cognition. The resident can score 0 to 15 points on the test. A score of 13 to 15 suggests the patient is cognitively intact, 8 to 12 suggests moderately impaired and 0 to 7 suggests severe impairment. On 11/30/2022 at approximately 8:45 AM a review of Resident #44's MDS quarterly assessment dated [DATE] revealed the resident was assessed and scored a 15 on his/her Brief Interview for Mental Status. On 12/01/2022 at 8:30 AM a review of Resident #44's progress note, dated 08/14/2022, revealed a change in condition note that stated that the resident complained of a toothache, no redness or swelling noted provider (Physician #43) recommendation feedback: order a dental consult. Review of the change in condition note revealed that the provider's recommendation did not include treatment of the toothache pain. Further review of the progress notes confirmed a dental consult was requested on 08/15/2022. Review of the resident's Medication Administration Record (MAR) revealed an order for Tylenol Extra Strength Tablet 500 milligram (mg) every 8 hours as needed for pain. Review of the administration record showed that the resident had not received Tylenol on 08/14/2022 or any other time for the month of August for tooth pain. Record review conducted on 12/01/2022 at approximately 10:15 AM revealed the License Practical Nurse (LPN) #38 sent a message to Physician #43 through a message system called eMediCall on 08/18/2022 at 6:53 PM. The message stated, resident complained of tooth pain and stated that Tylenol 500 mg is not effective. She states that the last time this occurred Oxycodone was given and was effective, is that an option to be given? Physician # 43 responded OK on 08/18/2022 at 7:11 PM through eMediCall. On 08/18/2022 at 7:41 P.M., LPN #38 sent another message to Physician #43 through eMediCall that stated, would you like Oxycodone 5 mg (milligram) PRN (as needed) for pain 6-10 (pain scale) and a dental consult to treat as needed? On 08/18/2022 at 7:42 P.M. the physician responded via EmediCall yes please. Further review of the Patient Orders revealed that LPN #39 sent a message to the Certified Registered Nurse Practitioner (CRNP) #44 through eMediCall on 08/19/2022 at 2:27 PM. The message stated, Patient needs C2 form to Oxycodone 5 mg and flagged in patient chart. Thanks The CRNP #44 responded through eMediCall, OK. A pain scale is a tool that is used to help assess a person's pain. A person usually self-reports their pain using a specially designed scale. The numeric rating scale (NRS) is a pain screening tool, commonly used to assess pain severity at that moment in time using a 0-10 scale, with zero meaning no pain and 10 meaning the worst pain imaginable. On 12/01/2022 at approximately 9:15 AM a review of Resident #44's MAR revealed an order for Oxycodone HCI Tablet 5 mg. Give 1 tablet by mouth every 4 hours as needed for toothache. The order start date was 08/18/2022 at 23:45 (11:45 PM). Review of the Administration documentation revealed that Resident #44 did not receive the first dose of the pain medication Oxycodone 5 mg until 08/19/2022 at 17:42 (5:42 PM). The resident's pain score was assessed at an 8 out of 10 at the time of administration of the Oxycodone 5 mg. Further review of the MAR revealed the Pain Level Record showed Resident #44 pain level was documented as an 0 on 08/14/2022 and 08/18/2022, however the resident complained of a toothache. On 08/19/2022 at 17:42 (5:42 PM) the resident was administered Oxycodone 5 mg and assessed at a pain level of 8 out 10 however the Pain level Record documented the pain level at an 0. Review of the resident's progress note dated 08/19/2022 at 00:13 (12:13 AM) revealed a change in condition that documented the situation for the change in condition as Pain (uncontrolled). On 12/01/2022 at approximately 9:45 AM review of Resident #44's Emergency Medical Technicians (EMT) report assessment conducted on 08/19/2022 at 20:03 (8:03 PM) stated, assessment shows some minor swelling to the left cheek and left bottom molar. Redness and irritation were noticed on the left bottom molar. Pt (patient) rates pain as an 8 or 9 [out of 10]. On 12/01/2022 at approximately 9:55 AM review of Resident #44's Hospital Final Report stated during triage pt. (patient) has mild swelling to the left side and pain score (1-10): 8. Review of the history of present illness stated that Resident #44 stated he/she still able to eat, drink and swallow however does have pain. Review of the physical exam for ears, nose, mouth and throat: mildly poor dentition throughout. Left mandibular (lower jaw) second molar has some periapical (surrounding the tip of the root of a tooth) or swelling and degradation (the process of something becoming worse or weaker or being made worse or weaker) of the tooth. No visible abscess. There is no facial swelling. Treatment: resident started on a 7-day course of clindamycin (antibiotic) and advised to follow-up with Dentist within the next week. Return to the ED (emergency department) for any new or worsening symptoms. Tylenol 500 mg every 8 hours as needed for pain. During an interview conducted on 12/01/2022 at approximately 10:05 AM, the Director of Nursing (DON) stated she was made aware of Resident #44's tooth pain and pain medication was not administered at the end of the day shift (7AM -3PM) on 08/19/2022. The DON stated that she contacted the physician and obtained the C2 form that is required to obtain Oxycodone 5 mg and an order for an antibiotic based on the resident's tooth pain. On 12/01/2022 at approximately 2:00 PM the Surveyor advised the Administrator, Regional Clinical Nurse #4, and the Director of Nursing of the deficient level of practice that had been identified as a Harm.

Based on review of complaint MD 571, facility report MD 643, facility investigation information, medical record review and staff interview it was determined the facility failed to ensure Resident #1 remained free of restraints as evidenced by the resident being found on 1/2/20 on the 7:00 AM to 3:30 PM shift with a gown tied around his/her legs impeding his/her ability to access the perineal area. This was evident for 1 of 12 residents reviewed for abuse during this complaint survey. These failures posed an immediate threat to the health and safety of other vulnerable residents. Therefore, an immediate jeopardy situation was identified on January 8, 2020 at 2:45 PM. The facility submitted a plan of action at 7:54 PM on January 8, 2020 that was reviewed and accepted by the surveyor and the Office of Health Care Quality. The immediate jeopardy was removed on January 10, 2020 at 2:16 PM while the surveyor was on-site. After removal of the immediate jeopardy, the deficient practice remained for potential for more than minimal harm and at a scope and severity of G. The findings include: Physical restraint is defined as any manual method, physical or mechanical device, equipment, or material that is attached or adjacent to the resident's body, cannot be removed easily by the resident, and restricts the resident's freedom of movement or normal access to his/her body. The Minimum Data Set (MDS) is a comprehensive assessment of the resident completed by the facility staff. The MDS is a multi-disciplinarian tool that allows many facets of the resident's care (cognition, behavior, mobility, activities of daily living, accidents, activities, weight, pain and medications to name a few) to be addressed. The MDS assessment is part of a broader RAI (Resident Assessment Instrument) process. The RAI process ties the assessment and care plan to the delivery of care to meet the needs of the resident. Medical record review on 1/7/20 revealed Resident #1 was a long-term care resident with a history of Chronic [MEDICAL CONDITIONS] (stroke), Right-Sided [MEDICAL CONDITION] (paralysis of one side of the body), [MEDICAL CONDITION], Depression, Anxiety, [MEDICAL CONDITION] and Contractures of both lower extremities. A [MEDICAL CONDITION] is a surgical procedure to create an opening through the neck into the trachea (windpipe). A tube is usually placed through this opening to provide an airway and to remove secretions from the lungs. This tube is called a [MEDICAL CONDITIONS]. Contractures are a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints. Review of complaint MD 571 revealed a concern that Resident #1 was found in the bed with a gown tied around his/her legs. The complainant also noted the resident was bed bound. Review of facility reported incident MD 643 revealed the resident was observed by facility staff in his/her room with the bottom of his/her gown tied at the back potentially limiting his/her ability to access his/her front and back side. The report noted the staff responsible for the application of the restraint was suspended. Review of the quarterly (MDS) Assessment, dated 10/27/19, Section C-Cognitive Patterns revealed facility staff coded the resident as severely cognitively impaired. Review of Section B0700, Ability to Make Self Understood, revealed the resident was rarely/never understood and in section B0[AGE]0, Ability to Understand Others, facility staff indicated the resident rarely/never understands. Review of the Director of Nursing's (DON) written interview with Registered Nurse (RN) #1, dated 1/3/20, revealed that on 1/2/20 during the day shift rounds RN #1 noted the resident's gown was tied around his/her legs. RN #1 indicated she sought out another nurse, Licensed Practical Nurse (LPN) #1, to witness the resident's condition, then untied the gown from around the resident's legs. Review of the DON's written interview with Geriatric Nursing Assistant (GNA) #1 revealed GNA #1's concern was that Resident #1 had behaviors of smearing and eating feces. In an effort to curtail the resident's behavior she tied the ends of the resident's gown together. Medical record review failed to reveal a care plan that addressed the resident's behaviors of smearing and eating feces. In the written interview with GNA #1, conducted by the DON on 1/3/20, GNA #1 reported she took both ends of the gown, looped them around the resident's legs, and then brought the ends of the gown back through the legs. Review of the facility's investigation revealed a suspension notice issued to GNA #1 that did not indicate the date the suspension would begin but was signed by the DON on 1/3/20. Review of GNA #1's time card revealed she returned to work on the night of 1/2/20 and again on 1/5/20 before the investigation was concluded. In interview with the surveyor on 1/8/20 at 10:23 AM LPN #1 stated RN #1 asked her to witness the resident's condition around the change of shift (approximately 7:00 AM) on 1/3/20. LPN #1 stated she saw the gown tied in a knot on the bottom of the gown and it was tucked under the resident's legs. During an interview with the surveyor on 1/8/20 at 10:33 AM RN #1 stated that during rounds on 1/2/20 at approximately 7:00 AM she observed the resident with the gown tied around him/her. RN #1 stated she called LPN #1 to witness the finding. RN #1 further stated she noticed the bottom of the gown was knotted around the resident's legs below the knee. RN #1 stated she reported this to the Unit Manager, RN #2. In interview with the surveyor on 1/8/20 at 12:28 PM the DON confirmed the incident occurred on 1/2/20. The DON stated that once she received a report of the alleged abuse from RN #2, Unit Manager, on 1/3/20 she reported the allegation to the Administrator and a self-report to the Office of Health Care Quality was completed. The surveyor asked why GNA #1 was permitted to return to work before the investigation was completed and the DON replied that a determination was made that the incident did not constitute abuse. During an interview with the surveyor, on 1/8/20 at 12:45 PM RN #2, Unit Manager, 1 North unit stated she was notified by RN #1 on 1/2/20 between 8:00 AM and 9:00 AM that the resident had a gown tied around him. RN #2 stated that when she entered the room, she saw that the gown was tied in a knot but was not sure if the position of the gown was changed during RN #1's assessment. RN #2 confirmed she did not notify the DON until 1/3/20. RN #2 stated she directed LPN #1 to notify the resident's spouse on 1/3/20. When asked why she did not notify the DON on 1/2/20, RN #2 stated she wanted to talk to GNA #1, who was assigned to the resident, to get her statement before reporting to the DON. RN #2 confirmed that GNA #1 returned to work on the 11-7 PM shift and worked the full shift on 1/2/20. Further review of the facility's investigation packet failed to reveal a plan to ensure residents' safety upon GNA #1's return to duty on the night of 1/2/20. GNA #1 had not received education or counseling and the facility had not concluded the investigation at the time GNA #1 returned to duty. Because of these findings, an immediate jeopardy situation was identified on January 8, 2020 at 2:45 PM. The facility submitted an initial plan of action to the surveyor and the Office of Health Care Quality for review at 7:38 PM. This initial plan was not accepted. The facility submitted a revised plan of action at 7:54 PM that was reviewed by the surveyor and the Office of Health Care Quality. The plan was accepted but the immediate jeopardy was not removed until January 10, 2020 at 2:16 PM after validation by the surveyor that the plan had been fully implemented. The Plan included: The physician and responsible party were notified of the incident on 1/3/20 and a report was filed with the Office of Health Care Quality on 1/3/20. GNA #1 was re-educated by the Director of Nursing on authorized use of restraints and the abuse policy on 1/3/20. The Nursing Supervisors conducted rounds on 100% of the resident population to ensure no other resident was found with an unauthorized restraint. Compliance date 1/3/20 The Assistant Nursing Home Administrator reviewed the last 30 days of all abuse allegations and the unauthorized use of restraints on 1/8/20 to ensure the physician and responsible party were notified, the abuse allegation was promptly reported to the Office of Health Care Quality and thoroughly investigated. Education was initiated by the corporate Director of Education, Staff Educator, Assistant Director of Nursing, Performance Improvement Supervisor, Unit Managers and Nurse Supervisors on the restraint and abuse policies. Licensed nursing staff are to be re-educated on prompt reporting and notification of resident representative and physicians of any allegations of abuse and the unauthorized use of restraints, and the policy on abuse investigations to include resident, family and staff interviews, resident assessment and record review. The Care Planning in-service will include discussion of resident behaviors such as verbal, physical and sexual behavior, touching others' property, wandering and resisting care that may put residents at risk of abuse. Training will be initiated on 1/8/20. Staff will be trained according to this plan today sufficient to meet the supervision of the resident. Ongoing training will occur with additional staff members as they are scheduled for work and will not be allowed to work until completed. Nursing Management will review allegations of abuse daily in the clinical meeting to ensure they are promptly reported to the physician, resident representative and Office of Health Care Quality and thoroughly investigated. Staff members involved in any abuse allegation will be monitored through the Performance Improvement Process for any additional concerns for 90 days. The Nursing Home Administrator, Director of Nursing, Assistant Nursing Home Administrator will review abuse allegations monthly to ensure immediate reporting of allegations of abuse to the administrator, resident representative, physician, safety of residents, and completion of an investigation. The results of these audits will be submitted to the Quality Assurance/Performance Improvement (QAPI) Committee for review and further recommendations. The compliance date for this plan is 1/8/20.