Every finding on record at Future Care Northpoint

Based on record review and interviews with staff, it was determined that the facility failed to ensure specific resident clinical information accompanied residents upon transfer to the hospital. This was found to be evident for 3 (#158, #9, #155) out of 6 residents reviewed for hospitalizations and discharges during the annual recertification survey. When the facility transfers a resident, the facility must ensure that correct, appropriate, and necessary information is communicated to the receiving health care institution to ensure a safe and effective transition of care. 1. A review of Resident #158's medical record on 07/29/2026 at 9:05 AM revealed a facility Hospital Transfer Form completed when the resident was transferred via 911 emergency services to the acute care hospital on [DATE]. Under the Medications: On antibiotics section of the form, Staff #34 documented Null. An Acute Care Transfer Document Checklist form was initiated at the time of transfer but was entirely blank, except for the resident's name, facility name, and phone number. This indicated the checklist was not utilized during the transfer process. There was no evidence that the resident's current medication list, current Medication Administration Record (MAR), Advance Directives, or Advance Care orders (MOLST - Medical Orders for Life-Sustaining Treatment) accompanied the resident to the hospital. A subsequent review of Resident #158's medical record on 07/29/2026 at 11:50 AM revealed an active physician's order dated 06/04/2026 for: Vancomycin HCl Intravenous Solution 750MG/150ML. Inject 750 mg intravenously two times a day for Sepsis for 14 Days and Cefepime HCl Solution Reconstituted 2 GM Use 2 gram intravenously three times a day for Sepsis for 14 Days. This confirmed the resident was actively receiving intravenous antibiotics at the time of transfer, directly contradicting the Null status recorded on the Hospital Transfer Form. During an interview on 07/29/2026 at approximately 11:55 AM, Staff #2 confirmed that Resident #158's Hospital Transfer Form was incorrect and that the resident was actively on antibiotics. Staff #2 stated, The Acute Care Transfer Document Checklist is blank and should have been used by means of checking off each item to ensure documentation, including the Medication Administration Record (MAR) and Medical Orders for Life Sustaining Treatment (MOLST) form, accompanied the resident to the hospital. 2. A review of Resident #9's medical record on 07/31/2026 at 8:45 AM revealed a facility Hospital Transfer Form completed when the resident was transferred to the hospital on [DATE]; however, the form indicated 03/04/2026 as the date the form was completed. Under the Medications: On antibiotics / Indication section of the form, Staff #35 documented Amoxicillin, but listed the treatment duration as None. An Acute Care Transfer Document Checklist form was initiated at the time of transfer but was entirely blank except for the resident's name, facility name, and phone number. This indicated the checklist was not utilized during the transfer process. There was no documentation or evidence to confirm that the resident's current list of medications, current Medication Administration Record (MAR), or Advance Care orders (MOLST - Medical Orders for Life Sustaining Treatment) accompanied the resident to the receiving hospital. During an interview on 07/31/2026 at approximately 09:45 AM, Staff #2 confirmed that Resident #9's Hospital Transfer Form was incorrect, noting discrepancies between the actual date and time of the resident's transfer versus when the form was completed, as well as inaccurate documentation regarding the indication and duration of the antibiotic therapy. Staff #2 further verified that the Acute Care Transfer Document Checklist initiated on 03/04/2026 was left blank and should have been utilized to cross-reference and check off each item to ensure that the resident's medical information was communicated and accompanied the resident to the receiving hospital. 3. On 7/29/2026 at 10:22AM, during a review of Resident #155's electric medical record, the Surveyor discovered that the resident was transferred to the hospital on 6/11/2026 for further evaluation and treatment. A further review revealed a Hospital Transfer Form completed at the time of transfer on 6/11/2026 that contained an incomplete, Acute Care Transfer Document Checklist, which should include what documents were sent with the resident. According to the facility's, Transfer: Resident to Acute Hospital policy, required transfer documents include physician orders, MOLST (Medical Orders for Life-Sustaining Treatment), current Medication Administration Record (MAR), current Treatment Administration Record (TAR), SBAR form (Situation, Background, Assessment, and Recommendation), history and physical, advanced directives, face sheet, labs, X-ray reports, complete immunization record, and care plans. However, the checklist incorrectly identified these documents as recommended to accompany the resident to the hospital or send these documents, if available. There was no documentation verifying that the pertinent records were sent with Resident #155 to ensure continuum of care. On 7/29/2026 at 11:55AM, during an interview with Regional of Clinical Operations # 2, the Surveyors confirmed that the Acute Care Transfer Document Checklists were not always completed as part of the Hospital Transfer Form but should be utilized to ensure all pertinent documents accompany the resident to the hospital and are recorded as so in the resident's medical record. Subsequently, the form should not use the term recommended, as these documents are required to accompany the resident upon transfer to the hospital. Staff #2 was informed of the Surveyors' concerns regarding missing information and verifying sent documentation (including the MARs, TARs, and Advanced Care orders) and ensured that the facility would correctly implement completion of the Acute Care Transfer Document Checklist form for future resident transfers.

Based on observations, administrative and medical record reviews, and interviews it was determined that the facility failed to ensure that clinical staff followed the infection control processes related to the hanging of the nephrostomy tube bag off the floor. This was evident to be true for 1 (Resident #1) of 3 residents observed with urinary drainage bags during a complaint survey. The findings include:A nephrostomy bag is a drainage bag that collects urine directly from the kidney through a tube to outside of the body.On 10/23/2025 at 08:00 AM the surveyor initiated a tour of the 2nd floor clinical unit. Breakfast trays were being served at that time. At 08:15 AM the surveyor observed resident #1 in room [ROOM NUMBER] in bed by the door. The surveyor observed two bags containing urine on the left side of the bed, bag A was a foley catheter bag cover in place, bag B was the nephrostomy bag lying on top of a white towel folded on the floor mat to the left of the bed. At 08:20 AM the surveyor observed LPN # 5 enter the resident's room, greeted the resident and asked the resident if he/she had any needs. On 10/23/2025 at 08:25 AM the surveyor interviewed the assigned LPN # 5, who stated that she has been an employee with the facility for the past eight months. The surveyor asked LPN #5 to explain the types of urinary drainage tubes the resident currently had in place. LPN #5 stated the resident had a left nephrectomy and a left urostomy bag. The surveyor pointed out that the left nephrectomy bag was resting on a towel on top of the fall mat on the left side of the resident's bed. The surveyor asked LPN #5 to explain why the left nephrostomy bag would be on the floor as opposed to hanging on the side of the resident's bed off the floor. LPN #5 stated that sometimes nephrostomy bags leak so placing the bag on top of a towel on the fall mat would prevent the urine from running onto the floor of the resident's room. LPN#5 stated that when she left her shift yesterday that nephrostomy bag was hanging on the left side of the bed and was off the floor; therefore the night shift must have placed the left nephrostomy bag on the towel on the floor mat next to the resident's bed. Additionally, LPN#5 did not make any attempt to hang the nephrostomy on the left side of the resident's bed rather than to have the nephrostomy bag remain on the towel on top of the floor mat, on the floor.On 10/24/2025 at 10:11 AM the surveyor observed the resident's left nephrostomy bag was hanging from the bedrail however the cap of the nephrostomy bag was touching the floor. On 10/24/2025 at 10:18 AM the surveyor conducted an interview with the two second floor unit managers, staff #6 and staff #7 regarding Resident #1. The surveyor shared the observation of the nephrostomy tube bag was not hanging from the frame of the bed/bed railing and was lying on a towel on the fall mat on 10/23/2025 and that the surveyor observed that the nephrostomy bag's cap was touching the floor on 10/24/25. Staff #7 stated that the bags should not be hitting the floor. Staff # 7 and Staff #6 stated that the clinical staff would be provided additional training by the infection control preventionist, staff # 8, related to adhering to the infection control policies in regard to keeping the nephrostomy drainage bag positioned off the floor and hanging appropriately the urinary drainage on the railing of the resident's bed appropriately.On 10/27/2025 at 10:34 AM the surveyor interviewed the infection control nurse, staff #8 regarding the facility's current infection control issues related to position of the nephrostomy bags hanging above the floor. Staff #8 stated once notified on 10/24/2025, that she recommended immediate education of the staff on the second floor related to the reports of non-compliance with the proper hanging of the Resident#1's left nephrostomy bag.On 10/27/2025 the surveyor discussed the concerns related to the deficient practice during the exit conference.

Based on surveyor observation, review of the medical record, and interviews with facility staff, it was determined that the facility staff failed to ensure that advance directives were discussed with residents and/or responsible representatives and ensure that a current copy of residents' advanced directives were in the residents' medical record. This was evident for 6 (Resident #130, #74, #47, #20, #189, and #95) out of 47 residents reviewed during the recertification survey. The findings include: An advance directive is a legal document outlining a person's wishes for medical care should they become unable to make decisions for themselves because of illness, injury, or incapacity. It allows individuals to specify their preferences for treatment, including life-sustaining measures, and to appoint a healthcare agent to make decisions on their behalf. Essentially, it is a way to ensure your healthcare preferences are followed, even when you cannot communicate them directly. On 6/16/25 at 11:55 AM review of Resident #74's medical record failed to reveal an advance directive. On 6/16/25 at 11:56 AM review of Resident #130's medical record failed to reveal an advance directive. On 6/16/25 at 11:57 AM review of Resident #47's medical record failed to reveal an advance directive. On 6/16/25 at 11:58AM in an interview with Unit Manager #7 when asked where advanced directives are kept, she stated if we have them, because we do not have them for everybody, it would be in their paper chart and scanned into the documents tab of PCC (Point Click Care), the facility's electronic medical record (EMR). On 6/16/25 at 1:32 PM review of Resident #20's medical record failed to reveal an advance directive. On 6/16/25 at 2:32 PM review of Resident #189's medical record failed to reveal an advance directive. On 6/16/25 at 2:34 PM review of Resident #95's medical record failed to reveal an advance directive. On 6/17/25 at 12:46 PM in an interview with the Social Services Director (SSD #9) when asked about the process for advanced directives, she stated that on admission every resident is asked if they have an advanced directive. During the interview, SSD #9 stated every new admission is offered to complete an advanced directive during the admission process. Additionally, she stated, if they want to do one, they do it with them, give them a copy, put it in their paper chart, and then upload a copy into PCC. For the Long Term Care residents, if they do not already have one, staff should offer one quarterly and complete it with them if they want, and they will also do one upon request. When asked if during the admission process, the resident and/or resident representative stated they have an advance directive, what she does, SSD #9 stated, we ask them to bring in a copy so we can have it in the facility. When asked if she followed up if they have not provided a copy, SSD #9 stated yes and if she had not seen it by the care plan meeting, about 2 weeks after admission, she would ask again at that time. Additionally, she stated she would try to follow up again after that care plan meeting and that all those conversations should be documented as a social services note or an advanced directive note. On 6/17/25 at 12:52 PM the surveyor requested a copy of Resident #130's advance directive. On 6/17/25 at 12:55 PM SSD #9 stated she did not have an advanced directive on file for Resident #130. On 6/17/25 at 1:00 PM, the surveyor requested a copy Resident #74, Resident #47, Resident #20, Resident #189, and Resident #95's advance directive and documentation from the medical record where advanced directives were discussed. On 6/17/25 at 2:26 PM in an interview with SSD #9, she stated that she did not have documentation of discussions on admission regarding advance directives with Resident #130 or Resident #74. During the interview, she stated she did not have a copy of Resident #74's advance directive in his/her medical record. Furthermore, she stated that Resident #20, Resident #189, and Resident #95 were not offered to formulate an advance directive upon admission, but after surveyor intervention, she went and offered one and documented what they each said. On 6/17/25 at 2:35 PM the surveyor shared the concerns regarding advance directives and SSD #9 verbalized and confirmed understanding of the concerns.

Based on surveyor observation and interviews with residents and facility staff, it was determined that the facility failed to ensure a clean, comfortable, and homelike environment as evidenced by a heavily soiled privacy curtain. This was evident for 1 (Resident #67) of 7 residents reviewed during the investigation phase of the facility's recertification survey. The findings include: On 6/23/25 at 9:08 AM in an interview with Resident #67, s/he stated the privacy curtain was dirty and s/he had asked them to change it. During the interview, s/he also stated that in his/her previous room, the curtain became soiled and was not changed for months. S/he stated that in both instances, various facility staff verified it was soiled and dirty and still it was not changed timely. On 6/23/25 at 9:34 AM during dual observations with both the Regional Mobile Director of Nursing (RMDON#26) and Licensed Practical Nurse (LPN #18) they observed and verified Resident #67's privacy curtain was dirty and soiled with brown marks all over it. When asked if that is how a resident's curtain should look LPN #18 stated, no ma'am it is not appropriate. The surveyor shared the concerns with RMDON #26 who stated she would have housekeeping come and change it.

Based on interview and record review it was determined the facility staff failed to report an allegation of abuse within 2 hours of the allegation and failed to report the results of all investigations within 5 working days of the incident, to the State Survey Agency, the Office of Health Care Quality (OHCQ). This was evident for 1 (Resident #194) of 47 residents reviewed during a recertification survey. The findings include: On 6/17/2025 at 7:50 AM during initial pool screen, Resident #194 reported to the surveyor that the Aide [Geriatric Nursing Assistant (GNA)] who worked on the night shift was very rough while changing her/him. The resident stated that when s/he asked the Aide to stop, the Aide said, How am I going to get this diaper into your creases. When asked if the resident told anybody about this, Resident #194 stated s/he told the night nurse that the Aide was rough and mean. On 6/17/2025 at 8:15 AM Surveyor informed the Unit Manager (UM #7) about Resident #194's allegations of abuse by a nightshift GNA. UM #7 stated that she was not aware of the above allegation. However, UM #7 stated she was going to talk to Resident #194 and follow up with staff. On 6/18/2025 at 7:30 AM, in an interview with UM #7, when asked if the initial self- report was submitted to OHCQ, UM #7 stated she did not know but would follow up with the Director of Nursing (DON), who according to UM #7, was aware of the allegation of abuse. On 6/18/2025 at 8:29 AM, in a follow up interview with UM #7, she stated they did not do a self-report because they did an investigation and Resident #194 did not feel it was intentional. UM #7 added that Resident #194 stated s/he felt the GNA was just rushing to do her (GNA) task. On 6/18/2025 at 8:56 AM, in an interview with the DON, she stated that the expectation was to submit a self-report to OHCQ within 2 hours of any allegation of abuse. When asked if the facility submitted an initial self-report of the above allegation of abuse to OHCQ, the DON stated that a self-report was not submitted to OHCQ because during their investigation Resident #194 stated s/he felt the GNA did not do anything with a malicious intent. When asked about when to submit the final investigation report to OHCQ, DON stated 5 days. On 6/26/2025 at 9:15 AM, a follow up interview was conducted with the DON in the presence of the Nursing Home Administrator (NHA). DON confirmed that the facility did not submit an initial self-report within 2 hours and/or their final investigation report within 5 working days required by regulation of any allegation of resident abuse. Thus, failing to report an allegation of resident abuse to the State Survey Agency (OHCQ). On 6/26/2025 at 9:52 AM, a review of the record of the facility investigation report of the above allegation of abuse failed to reveal that facility staff reported the allegation to the appropriate agencies required by regulation. On 6/27/2025 at 1:50 PM, during the exit conference with the NHA, DON, and corporate staff, no further information was provided to validate the reporting of an alleged abuse.

Based on medical record review and staff interviews, it was determined that the facility failed to notify the resident/resident representative in writing about the bed hold policy when the resident was transferred/discharged from the facility to an acute care facility. This was evident for 1 (Resident #56) of 2 residents reviewed who were transferred to an acute care facility during the recertification/complaint survey. The findings include: Review of the medical record for Resident #56 on 06/26/25 12:55 PM revealed that the Resident #56 was admitted to the facility on [DATE] and was sent to an acute care facility on 06/23/25 for a change in his/her medical condition. Further review of the medical record failed to produce written evidence that the Resident and/or the Resident representative were given written notice of the bed hold policy. The facility's documentation on change in condition transfer form, nurse's progress notes, and the eINTERACT SBAR Summary dated 6/23/2025 23:03 revealed that the bed hold policy was not given to the resident and/or the Resident representative. On 06/26/25 at 02:10 PM, in an interview, Licensed Practical Nurse (LPN) staff #43 revealed that the Bed hold policy is signed by the Nurse in charge, and sent it off to the hospital after notifying the family. On 02/26/25 at 2:30 PM, during the review with the Director of Nursing (DON), it was revealed that a copy of the bed hold policy was provided when the Resident was sent out to the hospital; however, he/she could not produce written evidence that the Resident # 56, or the Resident representative, was given written notice of the bed hold policy.

Based on complaint reviews, medical record review, and staff interview, it was determined that the facility failed to provide needed activities of daily living (ADL) for a resident dependent on bathing assistance. This was evident for 1 (Resident #386) of 15 complaints reviewed during the survey. The findings include: Review of complaints MD00214746 and MD00213586 on 06/17/25 revealed allegations that Resident #386 was not receiving showers or baths. On 06/23/25 at 2:20 PM Resident #386's closed medical record was reviewed and revealed Resident #386 was admitted to the facility in March 2024 with a history of having seizures, muscle weakness, and osteoarthritis. The MDS is part of the Resident Assessment Instrument that was Federally mandated in legislation passed in 1986. The MDS is a set of assessment screening items employed as part of a standardized, reproducible, and comprehensive assessment process that ensures each resident's individual needs are identified, that care is planned based on those individualized needs, and that the care is provided as planned to meet the needs of each resident. Review of the admission MDS assessment with an assessment reference date of 6/28/23 documented that Resident #386 was dependent on staff for bathing. Review of Resident #386's GNA (geriatric nursing assistant) Kardex documented Resident #386 was assigned to receive showers on Mondays and Thursdays. Review of Resident #386's ADL's documented that resident did not receive any showers in January 2025 from 01/01/25 to 01/31/25. There was no documentation Resident #386 had a bed bath or had refused bathing or a shower. On 06/24/25 at 2:22 PM, an interview was conducted with Corporate Director of Nurses #25, who stated confirmed that Resident #386 did not receive a shower or bath in January 2025 and that the nursing staff did not document Resident #386 had refused a bath or shower in January 2025.

Based on the surveyor's observation, medical record review, and interview with facility staff, it was determined that the facility failed to administer medication as ordered by the physician and sanitize or wash hands before the administration of medication. This was evident for 1 (#83) of 3 Residents reviewed for medication administration via gastrostomy tube, during the recertification survey. The findings include: On 06/26/25 at 8:30 AM, Review of Resident #83's medical records revealed the resident was admitted to the facility on [DATE] and was receiving long-term care. The physician ordered: 1. Aspirin 81 mg, one tablet via G Tube one time a day. 2. Polyethylene Glycol powder, give 17 grams enterally, one time a day for bowel regimen and hold for loose stool. 3. Theragran-M tablet, give one tablet via G tube, one time a day as a supplement. 4. Proheal liquid protein, two times a day for supplement, 30 ml via peg tube. 5. Captopril tablet 25mg, give one tablet via G tube, every eight hours, for hypertension. Medications #1 through #5 were scheduled to be administered at 9 AM daily via gastrostomy tube. A gastrostomy tube is a feeding tube inserted through the abdominal wall directly into the stomach, providing a way to deliver nutrition, fluid, and medications when a person is unable to eat or swallow adequately. On 06/26/25 at 10: 45 AM, the Surveyor observed Registered Nurse (RN) # 44 administered medications #1 through #5 to the Resident #83 via gastrostomy tube. The surveyor also observed RN #44, administered the medications via G Tube, without changing the gloves after touching the faucet in the resident's bathroom and after touching the Resident's bed control. On 06/26/25 at 10:05 AM, an Interview with the RN #44 revealed that the administration of the medication can be done one hour before or one hour after the scheduled time. However, administration was further delayed because a Certified Medicine Aide (CMA) was not scheduled to work, who assisted with medication administration. The surveyor reviewed with the RN #44, and he/she agreed with the surveyor's observation that he/she failed to administer the medication at the scheduled time, and did not change gloves or wash hands after touching bathroom faucets and bed controls, before administering medication. On 06/26/25 at 11:11 AM, the concern was reviewed with the Regional staff #25 who acknowledged the concern.

Based on observation, medical record review and staff interview, the facility failed to provide treatment/services to maintain vision. This is evident for 1 out of 8 residents (Resident #38) selected for review during the investigation stage of the survey process. The findings include: On 06/16/25 at 08:15 AM during the screening process of the survey, the surveyor observed Resident #36 eating breakfast with eyes closed, not wearing glasses, and feeling with hands for food items. During an interview on 06/16/25 at 12:45 PM, surveyor asked the resident if they has difficulty seeing, and resident replied yes. The resident was opening and closing eyes during the interview and was not making eye contact. Review of the resident's medical record on 06/16/25 at 12:58 PM revealed the resident MDS (Minimum Data Set) assessment on May 21, 2025, at 07:39AM in section B1000. Vision Ability to see in adequate light (with glasses or other visual appliances) identified Resident as Impaired. B1200. Corrective Lenses Corrective lenses (contacts, glasses, or magnifying glass) used in completing B1000 marked, yes. On 06/18/25 at 09:03 AM review of the orders written on 4/3/2023 indicated ophthalmology eval test and treat PRN (as needed). Review of the health drive eye care group eye exam on 1/8/2024 noted a plan to Monitor; follow: Priority Comprehensive 3/30/2024 and recall: comprehensive 3/30/2024. An interview was conducted on 06/18/25 at 08:55 AM with Director of Nursing (DON) about the process for eye exams. The DON stated that a service provider who examined the resident and would follow up with further exams. The surveyor asked how the facility knew that the follow-up comprehensive eye exam was provided. DON stated that service provider provided a list of residents to be seen in the upcoming months. DON also stated that she would call service provider to see if Resident #38 was seen for follow-up care. On 6/20/2025 at 1:50 PM, the Administrator informed the surveyor that Resident #38 was now scheduled for an eye appointment. The surveyor explained that this appointment was obtained after surveyor's intervention and that was a concern. The surveyor also added that Resident #38 was supposed to have a follow up eye exam back in March 2024. The Administrator agreed.

Based on medical record review, resident and staff interviews, it was determined the facility staff failed to ensure that a resident was given pain medication consistent with professional standards of practice. This was evident for 2 (#131, #189) of 2 residents reviewed for pain management during the survey. The findings include: 1) During an initial pool screen of Resident #131 on 6/16/2025 at 9:15 AM, the resident complaint of pain rating it at 10/10 to the back of his/her neck going down their back. Resident #131 further stated that the staff did not give them pain medications regularly and were making him/her wait for long periods. Review of Resident #131's clinical records on 6/18/2025 at 8:00 AM revealed the resident was re-admitted to the facility in June 2025 with medical diagnoses that include but not limited to acquired absence of other left toe(s) encounter for orthopedic aftercare following surgical amputation, type 2 diabetes with other skin complications, bacteremia, unspecified atrial fibrillation, need for assistance with personal care. On 6/18/2025 at 8:09 AM, a review of physician orders revealed the following active orders: Oxycodone HCl Oral Tablet 5 MG (Oxycodone HCl). Give 1 tablet by mouth every 6 hours as needed for Pain, start date 6/13/2025. Of note, there were no parameters/pain scale indicated for administration of this PRN (as needed) pain medication. There were also discontinued orders for: PRN Oxycodone HCl Oral Tablet 5 MG (Oxycodone HCl), Give 1 tablet by mouth every 6 hours as needed for moderate to severe pain 6-10, start date 6/2/2025 and discontinued on 6/9/2025, On 6/18/2025 at 10:56 AM, record review revealed that Resident #131's pain was not managed consistently. A review of the Medication Administration Record (MAR) and Treatment Administration Record (TAR) for June 2025 was completed. Staff documentation revealed that the resident was given: PRN Oxycodone HCl Oral Tablet 5 MG (Oxycodone HCl), Give 1 tablet by mouth every 6 hours as needed for moderate to severe pain 6-10 was given outside ordered parameters on 6/5/2025 at 1901 (7:01 PM) for pain score of 0. Oxycodone HCl Oral Tablet 5 MG (Oxycodone HCl), Give 1 tablet by mouth every 6 hours as needed for pain (of note, there were no parameters indicated for administration), was given for a pain score of 0 on 6/14/2025 at 2111 (9:11 PM) and On 6/15/2025 at 1715 (5:15 PM), pain score was 0. Staff did not document any non-pharmacological interventions (NPIs) attempted prior to the PRN pain med administration. On 6/23/2025 at 1:34 PM, in an interview with the Director of Nursing (DON), she stated that PRN pain meds should be given following physician orders. Regarding non-pharmacological interventions (NPIs) prior to PRN pain med administration, DON stated that NPIs were imbedded in the resident's care plan and ideally staff were expected to document in their progress notes that they attempted NPIs prior to PRN pain med administration. However, she added that staff did not usually document in their progress notes that they attempted NPIs. Surveyor also reviewed with the DON Resident #131's MAR and TAR for June 2025 regarding staff not following ordered parameters for PRN pain med administration. DON stated that the pain medications should be given according to doctor's orders. Surveyor reviewed resident's Oxycodone that was ordered PRN without parameters. DON stated that it was not appropriate to give Oxycodone for a pain score of 0. 2) On 6/17/2025 at 8:45 AM in an interview with Resident #189, s/he stated that her/his pain was not well managed in the facility. S/he described the pain as chronic dull pain that was sometimes throbbing and rated it at 10+/10 to their right hip and head. Resident #189 added that s/he was constantly in pain. Review of Resident #189's clinical records on 6/20/2025 at 10:06 AM revealed the resident was admitted to the facility in June 2025 with medical diagnoses that include but not limited to urinary tract infection, idiopathic aseptic necrosis of right femur, low back pain, atrial fibrillation, muscle weakness, unspecified abnormalities of gait and mobility, legal blindness. On 6/20/2025 11:04 AM Review of physician orders revealed the following active orders: Oxycodone HCl Oral Tablet 10 MG (Oxycodone HCl) Give 1 tablet by mouth every 6 hours as needed for Breakthrough pain 7-10, start date 6/17/2025 Acetaminophen Oral Tablet 500 MG (Acetaminophen) Give 2 tablet by mouth every 8 hours as needed for Pain 2 tabs to make 1000 mg, start date 6/5/2025. Of note, there's no ordered parameters/pain scale indicated for PRN pain medication administration. Further review of physician orders revealed the following discontinued/completed orders: Oxycodone HCl Oral Tablet 10 MG (Oxycodone HCl) Give 1 tablet by mouth every 12 hours as needed for Breakthrough pain, ordered 6/5/2025 and discontinued on 6/17/2025 Of note, there was no ordered parameters/pain scale for this PRN pain medication. On 6/20/2025 at 11:28 AM, record review revealed that Resident #189's pain was not managed consistently. A review of the Medication Administration Record (MAR) and Treatment Administration Record (TAR) for June 2025 was completed. Staff documentation revealed that the resident was given: PRN Acetaminophen 500mg (2 tabs) ordered without parameters for pain management was given for pain scores ranging from 0 to 8. On 6/13/2025 at 0217 (2:17 AM), pain score was 5; On 6/15/2025 at 2306 (11:06 PM), pain score was 0; and On 6/18/2025 at 2045 (8:45 PM) pain score was 8. Oxycodone HCl Oral Tablet 10 MG (Oxycodone HCl) Give 1 tablet by mouth every 12 hours as needed for Breakthrough pain. (Of note, no ordered parameters for PRN pain med administration) was given for pain score of 0 on 6/10/2025 at 0106 (1:06 AM). Oxycodone HCl Oral Tablet 10 MG (Oxycodone HCl) Give 1 tablet by mouth every 6 hours as needed for Breakthrough pain 7-10 was given outside ordered parameters on the following dates/times: On 6/19/2025 at 1717 (5:17 PM) for pain score of 6. On 6/20/2025 at 0758 (7:58 AM) for pain score of 4. More so, there was no documentation of non-pharmacological interventions attempted prior to PRN pain med administration. On 6/23/2025 at 1:26 PM, in an interview with the Director of Nursing (DON), she stated that PRN pain medications should be given according to physician orders. Regarding non-pharmacological interventions (NPIs) prior to PRN pain medication administration, DON stated that NPIs were imbedded in the resident's care plan and ideally staff were expected to document in their progress notes that they attempted NPIs prior to PRN pain med administration. However, she added that staff did not usually document in their progress notes that they attempted NPIs. Surveyor reviewed with the DON Resident #189's MAR and TAR for June 2025 regarding pain management and staff not following ordered parameters for PRN pain med administration. DON reviewed and validated surveyor's findings. On 6/27/2025 at 8:05 AM, an interview was conducted with Licensed Practical Nurse (LPN #18). Regarding administration of PRN pain medications, LPN #18 stated that prior to giving any pain medication, she will assess the resident's pain and choice of pain medication to be given will be based on physician orders/ordered parameters. She stated that each PRN pain medication order must have a pain scale/parameters for administration: Tylenol for pain score 1-5 and any narcotic such as Oxycodone for pain score of 6-10. LPN #18 stated that ordered parameters for PRN pain medications should always be followed. She further stated that she would not administer Tylenol for pain score of 8 unless the resident requested it.

Based on review of staff records and interviews with facility staff, it was determined that the facility failed to conduct annual performance reviews of Geriatric Nursing Assistants (GNAs). This was evident for 1 (GNA #34) of 2 randomly selected GNAs' employee files reviewed during the facility's recertification survey. The findings include: Performance reviews are to be completed for every GNA at least every 12 months to identify in-service education based on the outcome of those reviews. On 6/26/25 at 9:46 AM, the employee files of 2 GNA's were reviewed during the staffing facility task. During the review, it was noted that GNA #34 was hired on 4/7/22; however, failed to reveal a performance evaluation had been completed for GNA #34 in the 2023 calendar year. On 6/26/25 at 10:02 AM the Human Resources Director (HRD #31) stated that everything was in the employees' files except for the online training from HealthStream and Relias. On 6/26/25 at 10:17 AM the surveyor shared the concern with HRD #31that there was no performance review for 2023 in GNA #34's employee file. She stated she knew she had some she had not filed by her desk because she did not want to misplace them. The surveyor and HRD #31 went to her office, and she looked through folders and file cabinets. On 6/26/25 at 10:23 AM HRD #31 stated for some reason she could not put her fingers on 2022, 2023, or 2024 performance reviews, but she could talk to the Director of Nursing (DON) who may have the performance reviews in her office. She confirmed she did not have a 2023 performance review for GNA #34. On 6/26/25 at 10:30 AM in an interview with the DON, the surveyor shared the above concerns, and they walked to her office together. The DON stated there was a binder with performance reviews and began flipping through pages but was unable to locate a 2023 performance review for GNA #34. Then, the DON stated, And you checked with HRD #31, and she said she did not have them? The surveyor shared HRD #31 stated said she did not have any performance reviews from 2022, 2023 or 2024. The DON stated she does not normally keep copies of performance reviews, but knew this binder was here from the previous DON. After flipping through more pages, the DON then stated if HRD #31 did not have them, she did not have them. Additionally, she stated she did not have binders with copies of 2023 or 2024 performance reviews and that she just had a binder from the previous DON with 2022 performance reviews, but had wanted to check and make sure it was not in another section of the 2022 binder. The surveyor shared this was a concern and the DON verbalized and confirmed understanding.

Based on review of medical records and interviews with facility staff, it was determined that the facility failed to respond to recommendations made by consulting pharmacists and agreed upon by the medical director in a timely manner. This was evident for 1 (Resident #87) out of 5 residents reviewed for unnecessary medications during the facility's recertification survey. The findings include: The Medication Regimen Review (MRR) is a review of the medication regimen (plan) of each resident with the goal of promoting positive outcomes and minimizing adverse (negative) consequences and potential risks associated with medications. The MRR must be completed at least once a month by a licensed pharmacist and includes a review of the residents' medical record to identify, report, and resolve medication-related problems, errors, and/or other irregularities. Lorazepam, also known by the brand name Ativan, is a psychotropic medication and classified as a Schedule IV controlled substance. It is commonly used to treat anxiety disorders and is also used for short-term relief of the symptoms of anxiety or anxiety caused by depression. The Centers for Medicare & Medicaid Services (CMS) defines a psychotropic medication in the regulations at §483.45(c)(3), as any drug that affects brain activities associated with mental processes and behavior (CMS, 2023). These drugs include, but are not limited to, drugs in the following categories: antipsychotic, anti-depressant, anti-anxiety, and hypnotic medications. These medications can have serious potential risks, including side effects, drug interactions, and the possibility of neuroleptic malignant syndrome (a rare but potentially life-threatening condition) or tardive dyskinesia (a movement disorder that can develop if you take an antipsychotic medication) therefore requiring careful consideration and monitoring. The medical abbreviation PRN stands for 'pro re nata' (a Latin phrase), which means the medication is taken on an as needed basis and is not prescribed to be administered at scheduled times. On 6/20/25 at 7:39 AM the surveyor reviewed the medical record for Resident #87 which revealed on 12/27/24 and 1/22/24 the pharmacy MRRs noted to refer to a report for irregularities and/or recommendations. On 6/20/25 at 8:44 AM the surveyor requested copies of the two abovementioned medication regimen reviews and pharmacy recommendations for Resident #87 from the Director of Nursing (DON). In an interview with the DON on 6/20/25 at 8:28 AM when asked what happens during the monthly pharmacy MRR, she stated Pharmacist #40 comes in monthly and reviews all residents in the building. Then, she emails her recommendations to the DON, QA/IP (Quality Assurance/Infection Preventionist), Unit Manager (UM), and Clinical Care Coordinator (CCC). The DON further stated there was an individual form for each resident if Pharmacist #40 had a recommendation, and if there was no recommendation for a resident, there would be an evaluation in PCC (the facility's electronic medical record). After receiving the individual pharmacy recommendations, each unit prints them out and physically hands the individual recommendations to the physicians to review, document their response (by checking if they agree, disagree, or other with the Pharmacist), and then signing/dating the form. Then, the physicians give them back to the UM (1st floor unit) and CCC (2nd floor unit) who are responsible for putting in new orders and/or discontinuing orders, and who after doing so, faxes the completed/signed recommendations back to the Pharmacist, and the facility keeps a copy as well. On 6/20/25 at 10:24 AM the surveyor reviewed the 12/27/24 MRR and pharmacy recommendations which revealed the following recommendation from Pharmacist #40: Resident has an order for PRN Lorazepam concentrate. Please add a duration to this order. Hospice residents are not exempt from this regulation. Per CMS regulations, PRN or psychotropic drugs (a psychotropic drug is any drug that affects brain activities associated with mental processes and behavior) are limited to 14 days. Antidepressants, antianxiety, sedative hypnotics, antihistamines, muscle relaxants. To extend the PRN order past 14 days the prescriber must: 1. Document their rationale in the medical record 2. Indicate the duration for the PRN order (example: 'for 30 days, for 60 days, etc.'). Further review of the documentation revealed the prescriber/physician had checked that they agreed with the Pharmacist's recommendation and signed/dated the form. On 6/20/25 at 10:31 AM the surveyor conducted a review of Resident #87's medical orders, which revealed an active order for Lorazepam Oral Concentrate 2 milligrams/milliliter *Controlled Drug*. Give 0.25 ml by mouth every 4 hours as needed for anxiety, agitation, and dyspnea with an order date of 4/18/25 and an end date of indefinite. On 6/20/25 at 11:25 AM the surveyor requested documentation where the provider, who agreed with the pharmacist's recommendation, documented their rationale in the medical record and indicated the duration for the PRN lorazepam order. On 6/20/25 at 12:21PM in an interview with the DON and the Regional Director of Operations (RDO #5) stated there was no documentation in the medical record for the PRN lorazepam, but she, the prescriber/physician, after surveyor intervention, added an addendum to the order today. When the surveyor asked for clarification, the DON stated, no, prior to today there was no documented rationale in the medical record of Resident #87. Furthermore, the RDO #5 verified and confirmed there was no duration on the PRN Lorazepam order.

Based on interviews with residents, review of the medical record, and interviews with facility staff, it was determined that the facility staff failed to ensure a resident received routine dental services in a timely manner. This was evident for 1 (#20) out of 47 residents reviewed during the facility's recertification survey. The findings include: On 6/16/25 at 9:25 AM in an interview with Resident #20 s/he stated s/he had bad teeth and needed to see the dentist. On 6/18/25 at 8:06 AM review of Resident #20's medical record revealed s/he was admitted to the facility on [DATE]. Further review of the medical record revealed 3 HealthDrive (facility's dental provider) notes from the Registered Dental Hygienist (RDH #37) dated 5/3/24, 11/5/24, and 5/7/25. The 5/3/24 dental note from RDH #37 stated, Periodic oral exam 10/16/24 and Annual exam 4/16/25; however, there was no documentation that the resident had been seen by a dentist for his/her periodic oral exam or annual exam. The 11/5/24 dental note from RDH #37 also stated, Periodic oral exam 10/16/24 and Annual exam 4/16/25; however, there was no documentation that the resident had been seen by a dentist for his/her periodic oral exam or annual exam. The 5/7/25 dental note from RDH #37 again stated, Periodic oral exam 10/16/24 and Annual exam 4/16/25; however, there was no documentation that the resident had been seen by a dentist for his/her periodic oral exam or annual exam. On 6/18/25 at 8:55 AM the surveyor requested the upcoming list of residents to be seen by the dentist. On 6/18/25 at 9:13 AM in an interview with the Director of Nursing (DON) when asked who completed dental exams for residents, she stated she would let the surveyor know. On 6/18/25 at 9:44 AM in an interview with the Medical Scheduler (MS #38) [for HealthDrive], the surveyor stated that in a HealthDrive note from RDH #37, the Recall section stated, Annual Exam. During the interview, the surveyor asked who performs the annual exams and MS #38 stated the dentist performs the annual exams and the hygienist performs the cleanings. Furthermore, MS #28 stated, Any exams need to be done by the dentist. On 6/18/25 at 10:04 AM review of Resident #20's care plan revealed a Problem: Impaired dentition r/t poor oral hygiene. Further review of the care plan revealed in the Approaches (to address the Problem) section: Consult with dentist and follow up with recommendations. On 6/18/25 at 11:09 AM in an interview with the DON she stated the dental exams are performed by the dentist. During the interview, the DON provided a list of residents scheduled to be seen by the dentist and Resident #20 was not on the list. On 6/18/25 at 11:10 AM the surveyor requested all dental notes from the dentist (not RDH) for Resident #20 and also specifically, the note(s) documenting his/her Annual Exam and Periodic Oral Exam. On 6/18/25 at 2:01 PM the DON provided a dental note dated 4/16/24 from Dentist #39 for Resident #20's Initial Exam. It was observed and noted that Dentist #39 had documented in the Recommended Treatment section, Periodic Exam and Annual Exam; however, there was no further documentation provided that the resident had been seen by the dentist for his/her periodic exam or annual exam since being admitted to the facility. After surveyor intervention, the DON provided a new list of residents to be seen by the dentist and Resident #20's name was now observed on the list. On 6/20/25 at 10:11 AM in an interview with the DON and the Nursing Home Administrator (NHA), the surveyor shared the concerns that since the 5/3/24 dental note from RDH #37 and subsequently on 11/5/24 and 5/7/25, Resident #20 had not been seen by the dentist for his/her periodic oral exam and/or annual exam. During the interview in a dual observation with the DON and NHA of the 4/16/24 dental note, when asked if Resident #20 was seen by the dentist for either exam, the DON stated that the resident was seen yesterday. The surveyor shared that all dental and hygienist notes documented that Resident #20 was to have his/her exam around 10/16/24; however, s/he was not seen until 6/19/25 after surveyor intervention and asked if this was timely care. The DON stated no and verbalized and confirmed understanding of the concerns.

Based on observations of the facility's kitchen, review of kitchen records, and interview of staff, it was determined that the facility failed to prevent ice from building up in the walk-in freezer and in the refrigerator. This was evident for two refrigerators/freezers observed during the survey. The findings include: On 06/16/25 at 07:39 AM, Surveyor's initial observation of the cold storage/Freezer room in the kitchen, accompanied by the dietary staff, # 41 revealed that Ice was built on the floor and Ice particles were covering almost 75% of the freezer room Ceiling. Staff #41 was not aware of the preventive maintenance schedule for the freezer room. On 06/16/25 at 12:40 PM, the Surveyor observed the refrigerator/freezer in the second-floor nourishment room, to store residents' food, brought from outside. More than an inch of ice was built around the freezer. The surveyor also noted that the residents' snacks were placed in the refrigerator. On 06/25/25 at 11:45 AM, findings were reviewed with Dietary staff # 41 and with the Nursing home administrator. On 06/25/25 at 2:15 pm, the Nursing home administrator provided preventive maintenance schedules for the freezer room and for the refrigerators.

Based on complaints, reviews of a closed medical record and staff interview, it was determined that the facility staff failed to maintain complete and accurate medical records in accordance with accepted professional standards. This was evident for 2 (Residents #344, #340) of 15 complaints reviewed during the survey. The findings include. A medical record is the official documentation of a healthcare organization. As such, it must be maintained in a manner that follows applicable regulations, accreditation standards, professional practice standards, and legal standards. All entries to the record should be legible and accurate. 1) A review of Resident #344's closed medical record on 06/24/25 at 1 PM revealed 2 physician certifications of incapacity. The first physician certification of incapacity was regarding Resident #344. It was dated and signed on 09/06/2022 at 12 PM by Resident #344's physician due to dementia. The second certificate of incapacity was regarding a totally different Resident. It was dated and signed on 09/08/2022 at 9:23 AM by a second facility physician which listed dementia as the reason for the incapacity certification. This was brought to the attention of the facility administrator on 06/25/25 at 3 PM. The administrator indicated that S/he was not aware of the error until the surveyor brought the error to his/her attention. 2) Review of complaint MD00214284 on 06/18/25 at 10 AM revealed an allegation that Resident #340's pain medication was not properly administered. A review of Resident #340's closed medical record on 06/18/25 revealed that Resident #340 was admitted to the facility on [DATE] after having surgery on his/her lower extremities. Resident #340's physician wrote orders for pain medication instructing the nursing staff to administer the pain medication as needed to Resident #340. A review of Resident #340's November 2024 medication administration records revealed that the nursing staff administered a dose of Dilaudid, 4 mg, orally, at 12:01 am, at 8:59 AM, and at 7:18 PM on 11/27/24. The surveyor then asked the facility director of nurses (DON) for a printout of any medication the nursing staff removed from the facility interim medication storage dispensing machine for Resident #340. The DON provided an interim medication dispensing print out that indicated Resident #340 was also administered a dose of Dilaudid 4 mg orally at 4:37 AM. A further review of Resident #340's closed medical record failed to reveal any nursing documentation that a nursing staff member administered a dose of Dilaudid 4 mg orally to Resident #340 at 4:37 AM on 11/27/24. In an interview with RN#36 on 06/25/25 at 12:18 PM, RN#36 stated that S/he reviewed Resident #340's closed medical record and stated that S/he recalled administering a dose of Dilaudid 4 mg orally to Resident #340 on 11/27/24 at 4:37 AM but admitted S/he forgot to document administering the pain medication in Resident #340's medical record.

Based on observations and interviews with staff, it was determined the facility failed to ensure: 1.) Staff wore the appropriate personal protective equipment (PPE) when administering medications to residents on droplet precautions and 2.) Residents' medical equipment was maintained in a sanitary manner. This was found to be evident for 6 of 32 residents observed during the facility's annual Medicare/Medicaid survey (Residents #169, #170, #171, and #53). The findings include: 1. A medication administration observation was done on 7/1/22 at 9:40 AM and the following concerns were identified: a. At 9:40 AM of Staff #16, a Registered Nurse (RN) administered medications to Resident #169. There was a sign posted on the door that read Droplet and Contact Precautions with instructions on PPE ( eye protection) is to be worn before entering the room. Staff #16 wore glasses and did not put on goggles or a face shield before entering the resident's room carrying the resident's medications inside small medication cups. Staff #16 placed the medication onto the resident bedside table which contained a bath basin that was used to clean the resident. Staff #18, a GNA was in the room cleaning the resident and stepped to the side to allow the nurse to administer the medications to the resident. Staff #16 did not clean the bedside table before placing the resident's medications on top of the table. b. On 7/5/22 at 10:15 AM Staff #16 administered medications to Resident #170. There was a sign posted on the door that read Droplet and Contact Precautions with instructions on PPE (eye protection) that is to be worn before entering the room. Staff # 16 wore glasses and did not put on goggles or a face shield before entering the resident's room carrying the resident's medications inside small medication cups. Staff #16 placed the medication onto the resident bedside table which contained a urinal that was half full of urine. Staff #16 did not clean the bedside table before placing the resident's medications on top of the table. While in the room with the resident, Staff #16 removed her eyeglasses from her eyes and placed them on top of her forehead. c. An observation was made on 7/5/22 at 10:25 AM of Staff #16 administering medications to Resident #171. There was a sign posted on the door that read Droplet and Contact Precautions with instructions on personal protective equipment (eye protection) that is to be worn before entering the room. Staff #16 wore glasses and did not put on goggles or a face shield before entering the resident's room. While in the room with the resident, Staff #16 removed her eyeglasses from her eyes and placed them on top of her forehead. During an interview with Staff #16 at 10:40 AM, she was asked to explain the purpose of the sign that was placed on each of the resident doors pertaining to droplet precautions and she stated that she was to follow the instructions for wearing appropriate PPE when entering a resident room that is placed on that precaution. Staff #16 stated that she was supposed to wear appropriate PPE. An interview was conducted with the ADON and the Regional Clinical Director on 7/5/22 at 11:30 AM and they were made aware of the concerns and stated that all staff is aware of the appropriate PPE to be worn for residents on droplet precautions and the infection control policy and guidelines. They stated that staff re-education will be done. 2. A foley bag is a urine drainage bag to collect urine. The bag will attach to a catheter (tube) that is inside your bladder. On 6/29/2022 at 10:34 a.m. observation of Resident #53, foley bag sitting on the floor on the left side of the resident's bed. Licensed Practical Nurse (LPN #9) was showed the foley bag. The LPN acknowledged it should not be on the floor. On 6/29/2022 at 10:40 a.m. interview with LPN #9, verified observation of foley bag lying on floor. Administration made aware of concerns at time of exit.

Based on medical record review and staff interviews, the facility failed to accommodate the needs of residents by failing to ensure residents received preferred incontinent brief sizes (Residents #45 and #66). The findings include: 1. On 6/27/22 at 9:00 am, during initial observation rounds, the surveyor interviewed Resident #45 regarding the resident's preferences. Resident #45 stated that the facility runs out of his/her preferred incontinent brief size regularly. Facility staff will use a smaller incontinent brief and Resident #45 stated that the smaller incontinent brief size causes excessive chafing. On 6/29/22 at 8:26 am, an interview with Clinical Care Coordinator #8 revealed the facility's supply order process. Clinical Care Coordinator #8 stated that when facility staff observes a low number of needed supplies, facility staff will tell the unit manager. The unit manager will check the main unit supply closet for the item. If the item isn't available for restocking, the unit manager will contact Supply Clerk #19 to order the item. Also, Supply Clerk #19 will inform the Director of Nursing or Administrator about the new order for the needed supply item. On 7/1/22 at 10:30 am, in an interview with the Director of Nursing regarding Resident #45 not receiving his/her preferred incontinence brief size. The Director of Nursing stated the medical supply company changed the colors of the incontinence diaper so the resident may have received the right size but the resident believes that the size is different because of the color. On 7/5/22 at 7:35 am, the surveyor interviewed Resident #45 regarding the changed incontinence brief color sizes. The resident stated he/she was aware of the change in the color of his/her preferred incontinent brief size. The facility normally runs out of his/her preferred incontinent brief size regularly. The size the facility uses, when they run out of the preferred incontinent brief size, causes him/her to [NAME] in the area around his/her pressure ulcer. 2. On 06/28/22 at 9:00 a.m., Resident #66 was interviewed, when asked if he/she had any concerns the resident stated, I don't always get the right size [adult breif]. Surveyor asked the resident, Have you voiced your concerns regarding brief size to staff? Resident #66 responded, Yes. On 07/05/22 at 8:42 a.m. an interview with Resident #66, I'm still not getting the correct [adult brief] size. On 7/5/2022 at 8:45 a.m., in an interview, LPN #9 was asked if he/she was familiar with Resident #66 incontinent care needs? LPN #9 replied, I have provided incontinence care to the resident. When asked if she/he was aware of Resident #66's concerns that she/he is not receiving the correct size adult brief, LPN #9 stated, I was not aware that she/he was having a problem with the size of [adult briefs] they received. On 7/5/22 at 8:47 a.m. Surveyor and LPN #9 upon knocking the Surveyor and LPN #9 entered Resident #66 room, LPN #9 asked the resident, What's wrong with your [adult breif]? Resident #66 answered, It's not the size I need. The surveyor observed LPN #9 check the size of Resident #66's adult brief. Observation revealed Resident #66's brief was coded in a shade of green. Resident #66 verbalized, I want the (white) [adult breifs], they are larger. LPN #9, stated she would correct the issue.

Based on observations and interviews it was determined the facility failed to provide a homelike environment as evidenced by residents having scrapped paint and drywall and broken equipment in residents' rooms. This was evident for 3 of 5 residents assessed for a clean and comfortable homelike environment (#26, #34 & #87). The finding includes: On 6/28/2022 at 10:59 a.m. while performing observation rounds on the second floor, the surveyor observed: an exposed wire on the floor at the foot of Resident #26's bed, scraped drywall, and paint on the wall behind the bed, and a pillow stuck under the resident's bed. On 6/28/2022 at 11:44 a.m. the surveyor observed scraped paint on the wall behind Resident #87 bed. On 6/28/2022 at 11:55 a.m. the surveyor observed a missing dresser drawer on the left side of Resident #34's dresser. On 7/5/2022 at 12:05 p.m. during an interview with the Director of Maintenance #13 regarding the regular maintenance in the facility. He/she stated the facility utilize the TELS electronic system for maintenance request and they have daily and monthly logs. Filters and emergency lighting are checked daily on the first and second floors. A maintenance logbook is on both the units and is available to employees, residents, or family members who have a maintenance concern. The maintenance logbook is checked daily by the director or his/her assistant.

Based on record review and interview the facility failed to initiate a care plan for a resident who had a significant weight loss. This was evident in 1(#107) of 3 resident records reviewed for care plan timing. The findings include: A review of Resident # 107 electronic medical record on 06/29/22 at 11:53 am revealed on 05/09/22 the resident's weight was documented as 199 pounds. On 06/22/22 the resident's weight was documented as 188 pounds which was a 5.53% weight loss. On 07/05/22 at 12:05 pm during an interview with Staff #11, he/she was asked what type of interventions were put in place for the resident's weight loss? He/she made the surveyor aware the resident's notes were reviewed and made aware of the resident's weight loss. He/she reported not putting any interventions in place or reducing food from his/her end. Staff#11 was unable to provide documentation that a care plan was initiated to address the resident's weight loss.

Based on record review and interview it was determined the facility staff failed to carry out physician's orders for treatment administration. This was evident in 1 in 3 resident records reviewed for timely treatment administration (Resident #26). The findings include: On 07/01/22 at 9:30 am a review of Resident #26's treatment administration record (TAR) revealed multiple orders were not initialed as completed in the electronic medical record: On 01/14/21 at 7:00 am Resident #26 was ordered to have the sacral (lower back and tailbone) wound cleaned with an antimicrobial solution every day and evening shift. The treatment was not initialed as provided on the day shift on 04/02/22. On 02/11/21 at 3:00 pm Resident #26 received orders to have an antimicrobial solution and skin prep the area surrounding the sacral wound and water-insoluble dressing to the wound bed and to cover the wound with a foam dressing. The treatment was not signed off as completed on 04/02/22 on the day shift and 06/23/22 on the evening shift. On 03/25/22 at 7:00 am Resident #26 was ordered a topical antibiotic treatment to the lateral (side part) of the right hand. The treatment was not initialed as completed during the day shift on 04/02/22. On 07/01/22 at 10:20 am during an interview with the Director of Nursing (DON) #2 she was made aware of the treatments that were not signed off in the months of April and June. The DON was unable to verify if the treatments were provided as ordered by the nursing staff.

Based on medical record review and interview, the facility staff failed to follow a resident ' s plan of care and prevent injury to a resident during a transfer (Resident #2). This resulted in harm to Resident #2. This was evident for 1 out 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 during transfers. Therefore, this deficiency will be cited as past non-compliance. The date of correction was 10/29/2021. The findings include: On 12/3/21 a review of Resident #2 ' s medical record revealed the resident was admitted to the facility on [DATE] and readmitted to the facility from the hospital on 9/11/21. On 12/3/21 a review of Resident #2's care plans revealed that on 12/21/20 the facility staff initiated a care plan titled Self-care deficit related to musculosketal impairment with an approach for transfer as requires mechanical lift with 2-person assistance. On 12/6/21 a review of the resident ' s medical record revealed a Daily Note written on 9/14/21 by Physical Therapist #1 that stated, Resident seen bedside for physical therapy evaluation only. Resident presents at his/her functional baseline for significant assistance, Hoyer lift transfers, non-ambulatory. Hoyer lift is an assistive device that allows patients to be transferred between a bed and a chair by the use of electrical power. Further review of the Resident #2 ' s medical record on 12/6/21 revealed the facility staff completed a quarterly MDS (Minimum Data Set) assessment of the resident on 9/24/21 and coded the resident in Section G- Functional Status Transfer as total dependence and two plus (or more) person physical assist. Review of a hospital discharge record for Resident #2 on 12/14/21 revealed the Resident was admitted to the hospital on 10/2/21 and had a bilateral femur X-ray completed on 10/2/21. A review of the X-Ray impressions in the hospital record read: 1. Minimally displaced acute fracture of the left intratrochanteric region and 2. Displaced fracture of the right femoral metaphysis. Review of the hospital social worker ' s assessment note dated 10/6/21 stated, Pt explained that he/she is only to be transferred via Hoyer lift, though assigned GNA attempted to transfer him/her without Hoyer lift. Social work spoke to nursing home director of nursing who was aware of the incident and stated she was taking appropriate measures to report the GNA responsible to the state. A review on 12/14/21 of the hospital discharge summary dated 10/28/21 stated, On 10/2/21 [Resident #2] was admitted from a long-term care facility after a mechanical fall resulting in both left intratrochanteric femur and right distal femur fractures. On 12/6/21 the review of the facility's investigation of Resident #2's fall revealed the following: On 10/4/21 the facility's Director of Nursing (DON) interviewed Geriatic Nursing Assistant (GNA) #2. The DON asked GNA #2 if she got report from the Resident ' s nurse. GNA #2 stated yes, she wrote it down but I didn ' t look at it. The DON asked how did you transfer the Resident to the chair? GNA #2 stated I put my arms under his/her arms and sat him/her in the chair. He/she sat towards the front of the chair. I asked my coworker (GNA #1) to help me pull him/her back in the chair. The Resident slid forward off the chair and landed on his/ her butt. On 10/4/21 of the DON ' s interview of GNA #1 revealed the following: GNA #1 stated she was in the hallway and GNA #2 said, I need your help. Resident #2 was in the chair already and his/her butt was toward the front of the chair. I was on one side and the other GNA was on the other and we went under his/her arm pits to pull him/her back. There was a Hoyer pad under him/her in the chair so I turned to get Hoyer which was right outside of the room. As I turned around, I saw her (GNA #2) reach over the resident and try to pull the Resident up and that ' s when the Resident slid out to his/her butt but his/her legs were behind him/her. On 12/6/21 further review of the facility ' s investigation that began on 10/4/21 revealed a statement from the Director of Nursing to the Board of Nursing regarding the 10/2/21 fall of Resident #2 that read, GNA (geriatric nursing assistant) #2 was assigned to Resident #2. GNA #2 received report from LPN (licensed practical nurse) #1 that Resident #2 was totally dependent. GNA #2 proceeded to attempt to transfer Resident #2 to the chair. GNA #2 then realized she needed help to reposition Resident #2 and flagged down GNA #1. GNA #1 and #2 attempted to pull the resident up in the chair without success. GNA #1 realized the Resident had a Hoyer lift pad under him/her and turned to get the Hoyer. GNA #1 witnessed GNA #2 reach over to pull Resident #2 by herself and saw the Resident slide down to the floor with his/her knees with his/her legs behind him/her. GNA #2 transferred the Resident by herself and the Resident sustained bilateral femur fractures. During interview with the Director of Rehabilitation (DOR) on 12/6/21 at 9:45 AM, the DOR stated the Resident #2 was dependent on staff for transfers and required a Hoyer lift for transfers. During interview with GNA #1 on 12/6/21 at 9:22 AM, GNA#1 stated she had never worked with Resident #2 prior to 10/2/21 and was not assigned to Resident #2 that day. GNA #1 stated on 10/2/21 GNA #2 had flagged her down and asked to help reposition Resident #2. GNA #1 stated when she entered the room Resident #2 was in the chair but on the edge of the chair. GNA #1 stated she and GNA #2 each put an arm under the resident ' s arm and moved the resident back in the chair but the resident was not straight in the chair. GNA #1 stated at that time she noticed a Hoyer lift pad underneath the resident. GNA #1 stated she went to get the Hoyer lift to reposition the resident. GNA #1 stated as she was leaving the resident ' s room when she saw GNA #2 try to pull Resident #2 up by herself. GNA #1 stated she saw the resident slide out of the chair and hit the floor. During an interview with LPN #1 on 12/6/21 at 10:02 AM, LPN #1 stated on 10/2/21 she was assigned to Resident #2 and gave report to GNA #2 that the resident was a total care dependent resident. LPN #1 stated she was at the nurses ' station and she knew Resident #2 had a visitor coming, so she went to see if the resident was ready. LPN #1 stated when she went in the room the resident stated he/she was in pain. The resident reported to her that the GNA didn ' t use the Hoyer lift and he/she fell . LPN #1 stated she assessed the Resident at the time and the Resident ' s right leg was internally rotated. LPN #1 stated she notified the doctor who ordered the resident be sent to the hospital via 911. The Surveyor attempted to interview GNA #2 on 12/6/21 at 8:55 AM without success. An interview with the Director of Nursing on 12/6/21 at 9:42 AM confirmed the facility staff failed to follow Resident #2 ' s plan of care for transfer resulting in harm to the Resident on 10/2/21. The DON also stated that the facility reported GNA #2 to the Maryland Board of Nursing as well as reported the incident to the staffing agency that employed GNA #2 and notified other facilities in their company not to use GNA #2. On 12/7/21 the Regional Nurse presented the Surveyor with the facility ' s Plan of Correction that was initiated on 10/3/21 with a compliance date of 10/29/21. The facility ' s Plan of Correction included the following immediate actions taken related to the facility ' s staff failure to follow Resident #2 ' s plan of care: 1. Regional Nurse is responsible to ensure review of last 30 days of falls to determine whether any were related to failure to follow the plan of care. 2. Unit Managers are responsible to ensure all residents ' care plans to ensure that an Activities of Daily living (ADL) care plan is included that specifies amount of assistance needed for repositioning and transfers and that information links to GNA Kardex. 3. DON is responsible to ensure all GNAs receive reeducation on ensuring they are following the resident ' s care plan as outlined on the GNA Kardex which will include that GNAs will demonstrate how to long into Point Click Care (electronic medical record) and access each resident ' s Kardex. GNAs will receive report prior to starting care. 4. The Performance Improvement Supervisor is responsible to ensure the review of incident reports daily for 30 days then weekly for 4 weeks then monthly for 2 months to ensure that proper follow-up occurs if any falls are related to failure to follow the resident ' s plan of care. The results of these audits and any trends identified will be reported monthly for 4 months to the Quality Assurance Performance Improvement Committee. On 12/7/21 The Surveyor was able to verify the Plan of Correction had been completed.

Based on medical record review and interviews with facility staff, it was determined the nursing staff failed to notify the physician in a timely manner of a resident's change in condition (Resident #134). This is evident for 1 of 35 residents selected for review in the Stage 2 survey sample. The findings included: On 2/4/16 Nurse #1 writes at 7:30 AM Upon assessment of resident (#134) I found her hard to arouse verbally, sternum rub (hand with direct contact to the chest) aroused resident, resident is normally AXOX2 (alert and oriented to name and place), unable to tell me her name or where she is, unable to keep alert long enough to talk, took nurse manager in the room to assess resident and she found her to be the same, she was able to arouse resident with sternum rub, resident V/S (vital signs or blood pressure, pulse, respirations and temperature) at 0730 were 142/68, 97.1, 85, 18, 95% O2 sat (amount of oxygen in the blood circulation), lung sounds were clear, on room air, blood sugar was 200, unable to stay awake long enough to eat her breakfast, upon looking around room, in the resident top draw(er) were a case 5 HR(energy drinks) drinks and one was missing and [MEDICATION NAME] 25mg ( .) there were only 2 (of 3 tabs) tabs in bottle (and) 50 mg [MEDICATION NAME][MEDICATION NAME]. I called the husband and told him what I found and asked him what it was and why it was there. He said he brings it and that she uses it at home. He was then educated on the importance of not giving or bringing medication into the facility and that he could ask her MD(physician) and we could supply it if there were no contraindications ( .) I also told him that his wife was out of it today he asked if we were gonna send her out I told husband that we were assessing her here and MD was made aware, if need be we will send resident out. Interview with Nurse #1 and Unit Manager on 6/23/16 at 11:30 AM and Nurse #1 stated they had to press on chest to wake Resident #134 and noticed gurgling in lungs around 11:30 AM. Nurse #1 did recall calling doctor on 2/3/16 about a change but did not recall calling again on 2/4/16. Nurses note of 2/4/16 indicates Nurse Practioner was called at 12:30 PM. Interview on 6/23/16 at 1:11 PM with the Speech Therapist (ST) and stated they had to bill for 70 minutes because Resident #134 kept closing eyes, could not feed, and needed time to sleep. The Director of Nursing stated on 6/27/16 at 12:30 PM that Resident #134 actively participated in a Care Plan meeting on 2/4/16 but the Resident did not sign the attendance record and the facility does not have notes from the meeting. The medical record does indicate that on 1/28/16 the Brief Interview for Mental Status (BIMS) completed by the social worker which measures cognitive impairment was 14/15. With 15 as the highest score and indicates no impairment. On 1/30/16 the BIMS was 14/15 but on 2/4/16 the BIMS was 7/15 indicating cognitive change and impairment. Nurse note of 2/4/16 indicated the Nurse Practioner (NP) was notified at 12:30 PM of Resident #134's lethargy, 5 hours after 7:30 AM assessment by nurse. When asked during interview of 6/24/16 at 8:23 AM, the Nurse Practioner did not recall if they received a telephone call or not and on arrival at facility sometime in the afternoon only did a visual of Resident #134. Nurse#1 writes on 2/4/16 the NP gave orders for stat labs, chest xray, and blood cultures X 2. This order was written at 2:20 PM. Last recorded V/S taken after the Nurse Practioner assessment was 128/75, 74, 20, 97.3, O2 sat 90% on room air oxygen was given, shortness of breath, and abnormal lung sounds. On 2/4/16 Nurse #1 writes Medical Director assessed Resident and gave order to give [MEDICATION NAME] (used to reverse effects of narcotics or drugs and works within 2 minutes), it was not effective, and Resident sent out 911 to hospital. The [MEDICATION NAME] order was written at 3:00 PM and Resident left the facility at 4:50 PM. There is no notation in the medical record on 2/4/16 by the NP or physician except for the [MEDICATION NAME] order written [REDACTED]. Resident #134 was sent to the hospital by the physician at 4:50 PM some 9 hours after Nurse #1 had difficulty waking Resident #134 at 7:30 AM and the vital signs went from 142/68, 85 and 95% O2 sat on room air at 7:30 AM to 128/75, 74 to 90% sat on room air now requiring oxygen in the afternoon and Nurse #1 noticing gurgling in lungs around 11:30 AM, the cognition change indicated by the BIMS from the Social Worker around 11:30 AM, and the ST difficulty feeding the Resident at lunch. The facility staff failed to notify the physician of Resident #134's change in condition in a timely manner. The subsequent emergency treatment by the hospital included treatment for [REDACTED].