Every finding on record at Good Shepherd Nursing Home

Based on record review and staff interviews the facility failed to provide an environment free from accident hazards by not assessing the need for hand rail assist bars. This failure created an immediate jeopardy situation and caused the entrapment of one resident who was found deceased with their head and arm between the hand rail and mattress. This failed practice had the potential to affect all residents residing in the long term care facility because all residents except one (1) have the bilateral hand rail assist bar. Resident identifier: #100. Facility census: 174. Findings Include:a) Resident #100A review of the Facility Reported Incident (FRI) completed on [DATE] at approximately 11:00 AM revealed the following:On [DATE] at 10:25 PM upon entering the resident's room, staff noticed the resident's lower body was on the floor but her head was between the hand held assist rail and mattress. Staff immediately placed her back into bed and assessed her. It was determined that this resident had no vitals. Physician, Director of Nursing (DON), Administrator, and Medical Power of Attorney (MPOA) notified.Further record review of the five day follow up was completed [DATE] and contained the following Director of Nursing (DON) statement: I was notified at approximately 10:30 PM via phone of the incident with Resident #100. I got to the facility at approximately 11:00 PM and went to the three (3) south back hall and interviewed the staff members that were caring for Resident #100 at the time of the incident. Primary care Physician was notified and came to the facility Primary Care Physician (PCP) notified the MPOA of the incident and residents passing at approximately 11:15 PM, local police were notified and did respond on the scene at approximately 1:00 AM. Immediate reporting completed, statements were received from the individuals caring for Resident #100.Review of Resident #100's care plan on [DATE] revealed the following interventions:Resident #100 has limited mobility of her bilateral upper and lower extremities.Be sure Resident #100's call light is within reach and encourage her to use it for assistance as needed. Resident #100 needs prompt response to all requests for assistance. She needs a safe environment with even floors free from spills and/or clutter; adequate light; a working and reachable call light, the bed in low position at night; Side rails as ordered, handrails on walls, personal items within reach.Further record review revealed the following order:Bilateral Bed Assist rails for turning and repositioning. No directions specified for order.During an interview with the DON on [DATE] at 1:45 PM it was determined that on [DATE] all bed mattresses in the facility were checked to ensure they were not moving. When this surveyor asked about the hand rail assist bars being checked she stated they are assessed upon admission/readmission,Quarterly, and with any significant change. During an interview with the Administrator she stated, The beds were sold to us as guaranteed to be 100% entrapment free.Observation on [DATE] at 2:00 PM of the measurements of the bed was one (1) inch and and one (1) inch and an 8th. FDA guidelines in 4 inches for the entrapment zones did not work with these particular hand rail assists due to resident #100 being found with head wedged between the handrail and the mattress according to the police report, and staff statement given . Physician progress notes [DATE] at 12:30 [NAME] was called by staff and a resident was found with head wedged between hand rail and mattress. Then called by the (Administrators name here). Told her i would be over, was told last checked on at 8:30 PM and was in bed ok. Then at 10:25 PM went in to check and found her on her knees with head in between the rail and mattress. They called (nurses name here) LPN#103 he (the nurse) thought she (Resident #100) was still alive, but when he turned to move Resident #100 he realized she was deceased . Noted arm was also wedged and was discolored and she (Resident #100) had Petechie-(tiny, flat, red, purple, or brown pinprick spots caused by broken capillaries (small blood vessels) leaking blood into the skin) on the face. But he (LPN#103) was able to get Resident #100 back in bed. When I (Doctor) arrived she (resident #100) was in bed I noted mild linear redness bade (L) Left neck outerian. I was then able to talk with (Administrators name here) and (Director of Nursing name here) we went to a separate room and tried to reconstruct how this could happen. It appeared she probably tried to get out of bed (she usually sleeps on her right side per LPN#103's name here) and then somehow got her head wedged and was unable to get free. Staff didn't hear any calling out. Roommate wouldn't been awake either. I then called her (Resident #100) son (who i had been talking with recently due to her having a near syncopal episode (fainting or passing out) and un legible words here. We were able to improve her status with IV & lysis with return to normal NA (sodium) and the day before was back out in the day room with the other residents.) I did tell him she passed but unfortunately there was this scenario. Obviously he was shocked by the manner of death. But as a physician himself (The son) he had some understanding of issues like this. The Administrator will contact the appropriate people and i'll call the death certificate on how to handle this. They will probably sign it. (Dr signature here)DON Statement for the five day follow up report to the FRI: I was notified approximately 10:30 PM via phone of the incident with (Resident #100's name here). I got to the facility at approximately 11:00 PM and i went to the three (3) south back hall and interviewed the staff members that were caring for (Residents name here) at the time of the incident. The primary care physician was notified and came to the facility. (Dr's name here) notified the Medical Power of Attorney (MPOA) (Son of residents #100's name here) od the incident and residents passing at approximately 11:15 PM (Police department name here ) were notified and did respond on scene at approximately 1:00 AM. Immediate reporting completed. Statements were received from the individuals caring for (Residents #100's name here) (DON signature here)LPN #103's statement I was in the process of passing meds on the three (3)s back hall when i stepped into the breakroom to order my dinner when (NA #104's name here) came in saying she needed help that she had found ( Resident #100's name here) on the side of the bed. Upon entering the room (Resident #100's name here) was found kneeling on the floor next to the bed with her head in between the siderail and mattress. It wasn't until I removed her from that position that it was evident that she had already expired. She was then moved back into her bed and Supervisor was notified. (LPN #103's signature here.)Nurse Aide(NA) # 104's statement I put (Resident #100's name here) to bed around 8:30 PM and went to check her for rounds at around 10:30 PM. Nobody from the room had rang in that time or called out. When i found her i went to get (LPN #103's name here) and she had no pulse. I found her on her knees with her head kind of between the rail and bed with her hands down. I wouldn't say it was lodged but it was between it a little bit.NA #105's statement. Arrived into section four(4) at 9:00 PM did not see resident prior to being found unresponsive. Resident had no rand/yelled out since i arrived to the unit the room mate also did not ring or yell out. When i arrived to the residents room she was found in between the mattress with her head facing down parallel with the bedrail, the resident appeared to be on her knees with her body about a 70 degree angle towards the mattress with her right arm limp/hanging to the ground. (NA #105's signature here) On [DATE] C11 was requested by Sgt Detective (name here) to have officers go to (Facilities name and address here) to investigate a D.O.A (Dead on arrival) at approximately 12:24 AM C11 dispatched my self (officers name here) along with (officers name here). At approximately 12:55 AM officers arrived on scene at (facility's name here). When i arrived on scene i spoke with the manager (administrators name here). She advised a Aide(NA#104) and charge nurse had found (residents 100's name here) DOA inside her room. (Administrators name here) advised the aide found the resident in her room halfway off the bed with her head wedged between the mattress and handrail. After finding her she went and got the Carge Nurse for help getting back into the bed. (Administrators name here) advised that the aide hat ad found her had already left due to her shift ending. (administrators name here)advised that the Charge Nurse (LPN #103's name here) was still here. (administrators name here) escorted us to the 3rd floor where (Resident #100's name here) was residing. While on the 3rd floor, i spoke to the Charge Nurse (LPN#103) I asked (LPN #103's name here) to walk me through what happened. (LPN#!)#'s name here) advised that (NA#104's name here) came and got hi and advised that Resident 100 had fallen out of bed. (LPN#103's name here) advised, when he and (NA#104 name here) got back to the room, they got (Resident #100's name here) back in bed into a resting position and noticed she did not have vitals. (LPN #103s name here) advised he then notified (Administrators name here). (LPN#103's name here) advised the time frame was approximately 10:22PM. He advised the last time anyone had spoken to (Resident #100's name here) was approximately 9:30 PM From the statements from (LPN #103's name here ) and (administrators name here) it seems that (resident #100's name here) was attempting to get out of bed and fell back into the bed, wedging her head between the handrail and the mattress. The facility was notified of the Immediate Jeopardy on [DATE] at 5:30 PM. Plan of Correction1. Corrective action for resident affected by the deficient practice:This deficient practice could not be corrected as resident passed away. All beds were assessed toensure proper fit and installation. All beds were confirmed to be installed per manufacturerinstruction.2. Identification of other residents having the potential to be affected by the same deficientpractice:This deficient practice had the potential to affect all residents with assist bars.3. To ensure this deficient practice does not reoccur:All residents with assist bars will be assessed by the interdisciplinary team to determineappropriateness, safety, manufacturer compatibility, and potential entrapment risk. Any devicedetermined to be unsafe, inappropriate, improperly installed, incompatible, or no longerclinically indicated will be immediately removed and alternative interventions implemented asappropriate.All licensed nurses, nursing assistants, therapy staff, maintenance staff, and other appropriatepersonnel will receive education regarding: Assessment prior to use Signed consents Care planning Safety monitoring Safety checks for positioningResidents have the right to refuse; device must not act as a restraintEducation will be completed immediately and prior to the employee's next scheduled shift. Staff who have not completed education will not be permitted to provide care until training iscomplete.4. How the facility will monitor corrective actions to ensure the deficient practice will not recur:The Director of Nursing and/or designee will audit all residents with bed rails or assistive devices weekly for 4 weeks, then monthly for 3 months for:Completion of assessments and care plan updates bed system inspections and maintenance documentation.The plan of correction was accepted on [DATE] at 6:37 PM.The IJ was abated on [DATE] at 11:20 AM

Based on staff interviews, observation and document reviews, the facility failed to complete an accurate bed rail assessment for a resident.The current assessment did not fully assess resident's risks/needs for side rails. This was true for Resident #100. and had the potential to affect more than a minimal number of residents residing in the long term care facility. Facility Census: 174. Findings included: a) Resident #100During an interview with Facility Administrator on 05/06/26 at 3:27 PM, she reported new beds had recently been obtained for everyone but bariatric residents in the facility and denied that any resident had been assessed for need of bed rails. Side Rail Safety Assessments are completed for the beds quarterly but not for the need of the side rail as it pertain to specific residents. A review of document entitled GSNH-Side Rail Safety Assessment was reviewed with the following questions that were assessed by looking at the bed and/or an Interdisciplinary Team discussing the residents (not assessing the resident in person) per Director of Nursing on 05/06/26 at approximately 5:00 PM. Assessing the mattress/side rail:1.The bars within the side rails are closely spaced to prevent entrapment resulting from a resident's head passing through openings.2.The mattress-to-bed rail interface prevents the resident from falling between the mattress and side rails and possibly smothering the resident when supine.3. The mattress-to-side rail interface prevent the resident from falling between the mattress and side rail and possibly smothering the resident when laying on their side. 4. The mattress is appropriately sized for the selected bed frame and has not shrunk; there is no space between rail and mattress to permit entrapment of a resident. 5.The mattress does not compress to create gaps between the mattress and side rail when pressure is applied. 6. The space between the side rail and the mattress, and the space and the space between the headboard and the mattress, is filled by an added firm inlay, or the mattress creates an interface with the side rail that prevents a resident from falling between the mattress and side rails.7. Latches on the side rails are stable and will not fall when shaken.8. If an air mattress or overlay is utilized, it does not move or have straps that could entrap a resident or have the effect of pouring a resident into a side rail.9. When a side rail is used, elevation of the head of the bead does not create a gap between the mattress and the side rail.-Interventions/Alternatives1.None indicated2. Bed Alarms3. Side Rails4.Side Rails with Controls5.Low Bed6. Mattress with raised edges7. Decrease time in bed to________;8.The resident requires a low bed but has difficulty getting into the low bed from a standing position.9. The resident requires a low bed and is in danger of hurting self while trying to get up from the low bed or is in danger of an unsteady transfer after standing up.10. Side Rail pads/Rail liners11. Mats on the floor next to the bed. 12. Restorative plan to increase strength and tolerance.13. Frequent staff monitoring.14. Scheduled toileting.15.Visual and verbal reminder to use the call bell16. Use of pillows and cushions as bed boundary reminder.17. Stuffers to fill the space at the foot/side of bed.

Based on record review, facility policy review and interview, the facility failed to have a water management plan that followed nationally accepted standards (CDC), and incorporated measures to control and prevent Legionella and other opportunistic waterborne pathogens. Facility Census: 181. Findings Include:a) During an interview on 08/19/25 at approximately 11:13 AM the Maintenance Director (MD) #130 provided legionella testing results for four (4) different locations around the facility. The results were negative. Monthly temperature logs were reviewed. MD #130 provided monthly flushing and disinfection logs for dead ends and unused rooms, equipment and showers, verifying that the facility performed control measures, such as flushing and draining dead ends, and unused showers. MD #130 stated that there had been no outbreaks of Legionella or other waterborne infections. Upon requesting a copy of the facility's Water Management Plan, MD #130 stated that he did not have a copy of the Water Management Plan. During an interview with the Administrator on 08/20/25 at approximately 3:30 PM, the administrator produced a Water Management Plan which stated the following: [Typed as Written] GOOD SHEPHERD NURSING HOMEWater Management PlanBuilding Water SystemWater enters the building through the water main on [NAME] Lane. The cold water then disperses throughout the building. Water also goes to the water softener system and returns to the hot water boilers to be dispersed throughout the building. The garden fountain is filled when in use but is not a continuous feed. Backflow values prevent this water from returning to the system. The sprinkler system has its own water main entrance into the building, also on [NAME] Lane. There is backflow prevention throughout the system, throughout the building. Aerators on all sinks are anti-microbial.Cold water is distributed directly to ice machines, showers, whirlpools, and faucets on all 3 floors and to outer building laundry area. Cold water also goes directly to garden fountain. Backflow prevention throughout the cold water system. Garden fountain cleanliness is maintained with chlorine.Cold water is treated to 140 degrees by 2 water heaters and water storage areas. The laundry hot water is treated to 160 degrees and the final rinse on dish machine id heated to 180 degrees.Hot water is distributed throughout the building from the hot water tanks and water storage area through mixing valves, reducing the temperature to 110 degrees. There is backflow prevention throughout the system. Hot, cold and waste water is discarded through the sewer line UV lights installed in ice machines at point of water entrance Air conditioner units have UV lighting inside. Legionella/HPC testing completed semi-annually by SDI Environmental.The facility's water management plan did not incorporate measures to control and prevent Legionella and other opportunistic waterborne pathogens that followed nationally accepted standards (CDC). The plan did not include the measures MD #103 was taking monthly to prevent issues or the locations where the legionella testing had occurred. During the interview with the Administrator on 08/20/25 at approximately 3:30 PM, the administrator confirmed that the documents provided were the facility's water management plan. The administrator also confirmed that the maintenance department did not have a copy of the water management plan.Upon being asked how the maintenance staff knew what policies to follow, the administrator stated that the facility had contracted with a water management company that notified the facility's maintenance staff of the actions and protocols to be taken monthly.Upon request, the Administrator submitted a copy of a quotation for legionella testing dated 09/07/23. The quotation was signed on 05/19/25. A review of the submitted contract revealed the following verbiage: The following quotation is in response to your request for pricing regarding potable legionella testing throughout the various locations you manage. It covers annual and bi-annual culture-based legionella testing at the following locations.The contract did not include a water management plan or an arrangement to provide water management services to the facility.

Based on observation and staff interviews, the facility failed to store food in a safe sanitary manner in regard to expired milk and storing medical supplies in the freezer in the resident's pantry. This has the potential to affect more than a limited number of residents. Facility census: 181.Findings Included: a) Kitchen During the initial kitchen tour on 08/21/25 at 11:35 AM observations found: Walk-in refrigerator -found 4 half gallons of milk expired. During an interview on 08/21/25 at 11:40 a.m., the Dietary manager confirmed the milk was expired. During the tour on 08/18/25 at 11:45 AM of the resident pantries found medical Ice packs stored in resident freezers in four (4) of five (5) pantries. An interview on 08/18/25 at 11:45 AM with the Dietary Manager confirmed the medical ice packs should not be stored with resident food.

Based on record review and interview, the facility failed to ensure that the recommendations by the pharmacist were reviewed, addressed, responded to, and signed by the physician. Resident identifiers: #16, #1, #15, #23, and #19. Facility Census: 181. a) Resident #16 Resident #16's record review on 08/202/5 at 2:00 PM revealed the following recommendations: On 03/11/25 the Consulting Pharmacist stated: Patient has had significant weight loss. Recommend assessing for weight loss and the possible need for the initiation of medication to help with appetite. There was no review, or acknowledgement of the recommendation by the physician. The recommendation was unsigned. On 07/16/25 the Consulting Pharmacist noted: Patient has had several soft blood pressures located in their vital signs. Recommend adding monitoring/hold parameters for BP (blood pressure) medications. There was no review, or acknowledgement of the recommendation by the physician. The recommendation was unsigned. During an interview with the DON on 08/20/25 at approximately 11:35 AM, a request was made for any documentation or orders, confirming that the physician had reviewed the pharmacist's recommendations, and either disagreed or acted upon those recommendations. No documentation was received prior to the end of the survey. Record review of the facility's policy titled, Medication Regimen Review, (MRR) with a revision date 11/2020 showed: --Physician must sign that they agree or disagree with the consultant pharmacist recommendations on the MRR form. -- If the MRR form was not signed or comments were not made during the physician visit, the RN will call the physician for comments needed or fax a copy of the form to the Physician's office for comments. b) Resident #19 A medical record review for Resident #19 revealed monthly drug regimen reviews response without signature, actions or rational if no action taken by the physician. --12/21/24 Recommendation to consider titrating Trulicity to 3mg for better blood sugar control --05/22/25 Recommendation PALT guidelines recommend utilizing GDMT (guideline-directed medical therapy) to maintain blood sugar between 100-200 --07/25/25 Recommendation to consider PALT guidelines recommend utilizing GDMT to maintain blood sugar between 100-200 Consider need for additional blood sugar management. During an interview on 08/21/25 at 11:30 AM the Director of Nursing verified that the physician did not sign, document the action or rational. c) Resident #15 A medical record review for Resident #15 revealed monthly drug regimen reviews response without signature, actions or rational if no action was taken by the physician. 04/07/25 Recommendation PALT guidelines recommend utilizing GDMT to maintain blood sugar between 100-200 08/13/25 Recommendation Patient has significant weight gain noted in their vital signs. Assess cause for weight gain and possible need for medication adjustments. Currently prescribed Tricor Consider a lipid panel to assess need for medication. During an interview on 08/21/25 at 11:30 AM the Director of Nursing verified that the physician did not sign, document the action or rational. d) Resident #1 Record Review on 08/20/25 revealed missing medical doctor's signature on two (2) medication regimen reviews dated 07/31/25 and 06/30/25. 'Sign here tags were in place for the medical doctor but no signature had been obtained. During an Interview on 8/20/25 the pharmacist stated that they place a copy in the hard chart for the MD to review and sign. e) Resident (23) The medication regimen review (MRR) for Resident #23. The MRR dated 07/31/25 and 06/30/25 were not signed. Sign here tags were in place for the signature of the MD. On 8/20/25 the pharmacist stated that they place a copy in the hard chart for the MD to review and sign.

Based on record review, staff interviews and resident interviews, the facility failed to ensure residents receive the help and care they need without waiting long periods of time. This deficient practice had the potential to affect more than a limited number of residents. Resident identifiers: #86, #181, #161, #23, #400, #19, #48, #86, #45, and #99. Facility Census: 181Findings included:a) On 08/18/25 at 2:53PM, In an interview with Resident #26, She stated on Sunday(08/19/25) she had to wait 45 minutes to get staff to take her to the restroom and stated she was going to soil herself. She said I know I wear briefs, but it is not comfortable to wet in them. I try not to if I can help it. She stated that long wait times often happen on the weekends and evening shifts but also sometimes on day shift as well. She also stated that staff will come in and turn off the call light, say they will be right back, leave the room and not return causing her to have to repush the call light button.On 08/21/25 at approximately 11:18 AM Resident # 193's daughter stated that her mother was a resident of the facility. She further stated that she was very pleased with the care and services provided to her family members. Upon being asked whether there was anything she was not pleased about, she stated that there were staffing shortages on weekends.Based on a record review of Section C of the most recent MDS records, Resident #26 had capacity and was cognitively intact. During Resident Council Meeting on 08/20/25 at 2:00 PM, Resident #23, #48, #19, #86, #181, #123, #164, and #78 with capacity attended and complained that mostly on weekends and sometimes on dayshift they have had to wait long periods for staff to answer their call lights. b) Resident # 86Resident #86 stated that on Monday (08/19/25), while she was using the exercise bike in The Day Room, she used her phone and called staff 4 times during a 45-minute wait for staff to take her to the bathroom.c) Resident #181Resident #181 stated a couple of weeks ago, during weekend shift, she was placed on the toilet and had a 40-to-50-minute wait for staff to get back to her. d) Resident #161 Resident #161 stated that it can take 20 to 30 minutes and longer for staff to answer the call light and at times staff will turn it off and not return.e) Resident #23Resident #23 acknowledged that at times, the call lights do take long periods of times, but he had no other concerns at this time.On 08/20/25 at approximately 3:30 PM, during an interview with the DON, related to concerns reported during the Resident Council meeting, she acknowledged the resident complaints of long waits for call lights to be answered On 08/21/25 at 10:30 AM a review of past Resident Council Past Meeting Minutes, dated 12/18/24, 03/27/25, 06/26/25, and 07/31/25 revealed Resident #48, #400, #86, and #19 had complained of long waits for call lights to be answered and staff turning off the call light then not returning for long periods of time.f) Resident #400 Resident #400 reported that during the day, the wait can be long. Resident #400 filed a grievance on 12/18/24 stating that call bell wait times can be long during the day.g) Resident #19 On 03/27/25, Resident #19 reported that at times it can take a long time for her call to be answered.h) Resident #48 On 06/26/25, Resident #48 reported that staff would turn off the call light and leave to get help then not return for long periods.i) Resident #86 On 07/31/25, Resident #86 reported she had to get up later than she wanted. During a grievance record review 0n 08/20/25 at 3:45PM, it was discovered there were 3 past grievances filed by 2 residents. j) Resident #45 Resident #45 filed grievances on 08/29/24 and on 11/21/24 stating in both grievances that she had pushed her call button. The nurse aide came into her room, turned off the call light, and told her they would return. On 08/20/25 staff did not return at all, then on 11/21/24 the staff did not come back for a long period of time. k) Resident #99On 08/19/25, at approximately 1:20 PM, during an interview with Resident #99, she stated that she had been at the facility for about four years and had noticed many changes over the past year. The resident mentioned that previously, the staffing was consistent, with few changes.Resident #99 expressed that she preferred to be dressed and out of bed by around 7:30 AM; however, she often must wait until approximately 8:30 AM or 9:00 AM to do so. Additionally, she mentioned that on 08/16/25, she had to wait for dinner until 7:30 PM. She indicated that, in her opinion, these delays were primarily due to staff being reassigned to other areas of the facility.On 08/20/25, a record review of grievances filed by residents revealed that several residents had complaints regarding late and cold meals. Resident #19 filed a grievance indicating that her meals were often served late. Additionally, Residents #23, #48, and #78 voiced similar concerns during the resident council meeting, stating that their food was frequently delivered late.On 08/20/25, at approximately 12:55 PM, this surveyor was approached by a family member of Resident #193 while riding the elevator. The family member mentioned staffing concerns. Specifically, she reported, There have been times when I had to leave the room to find someone because the call-bell wasn't answered, or my family member's food tray didn't arrive.During an interview on 08/20/25 at 10:51 AM with Licensed Practical Nurses (LPN) #176 and #218, they stated that they were not aware of any staffing shortages. During an interview with Nursing Assistants (NA) #48, #106 and #200 on 08/19/25 and 08/20/25, they confirmed that when staff called out, they had to manage with the staff who were on duty. They stated that sometimes they had to take care of the whole hallway of residents by themselves.

Based on observation and staff interviews, the facility failed to ensure the resident environment remained as free of accident hazards as possible; and that the resident received adequate supervision and assistance devices to prevent accidents. Mounted wall heaters had maintenance access panel covers missing exposing thin sharp metal edges, wires and hot pipes in 3 (three) resident rooms. This failed practice was a random opportunity for discovery. Resident identifiers #58, #146, #33, and #74. Facility Census: 181. Findings Included:a) On 08/18/25 at 11:50 AM, during a facility entrance walkthrough it was observed that the wall mounted heater maintenance access panel covers were missing and exposing thin sharp metal edges, hot pipes, and wires in room [ROOM NUMBER], #343, and #347, where Resident #58, #146, #33, and #74 reside.On 08/20/25 at approximately 9:28 AM, during a walk through and interview with Employee #136, she acknowledged the wall heaters maintenance access panel covers were missing and exposing thin sharp metal edges, wires, and hot pipes in resident room [ROOM NUMBER], #343, and #347 . This finding was also verified by the facility Maintenance #261 on 08/20/25 at approximately 9:48 AM. He stated he had a plan for replacement covers and would be replacing them immediately.

Based on staff interview, resident interviews, and observation the facility failed to ensure residents knew they had the right to file grievances anonymously. This deficient practice had the potential to affect more than a limited number of residents. Facility Census: 181 Findings included: a) Resident #470 and #26 During facility entrance observation and resident interviews on 08/18/25 at approximately 2:40 PM, Resident #470 stated she did not know how to file a grievance anonymously.In an interview with Resident #26 On 08/18/25 at 2:53PM, She stated she did not know how to file a grievance/complaint anonymously.Based on a record review of Section C of the most recent Minimum Data Set (MDS) records, both Residents #470 and #26 had capacity and was cognitively intact. Based on the facilities Grievance policy and Procedure, the residents have the right to file grievances without discrimination or reprisal. The facility will notify residents individually and through postings on the right to file grievances verbally, in writing, or anonymously. During resident council meeting on 08/20/2025 at 1:45 PM, Resident #23, #48, #19, #78, #86, #123, and #164 were in attendance and all had capacity. They stated they did know how to file a grievance/complaint by filling out the form with the social worker. When asked if they could file anonymously, they did not know how to file a grievance form anonymously and stated they were never told how or where to file it. Based on record review of Section C of the most recent MDS record verified Resident #23, #48, #19, #78, #86, #123, and #164 had capacity and were cognitively intact. Staff Interviews;On 08/20/25 at 11:50AM, during an interview with Social Worker (SW) #183, she confirmed the residents do come to her office to file grievances. SW #183 and acknowledged residents did not know how to file grievances anonymously. During an interview with the Administrator, on 08/20/25, she stated she was unaware the residents did not know how to file grievances anonymously and discussed that the facility did not have grievance boxes on the wall for resident safety and that residents can give the forms to any staff member.

Based on record review and interview, the facility failed to ensure that the recommendations by the pharmacist were reviewed, addressed, and responded to, by the physician. This effected 2 out of 4 residents sampled. Resident Identifier 23 and 1. Census:181 The facility FAILED TO MEET STANDARD as evidenced by:The facility failed to ensure the pharmacist recommendations where address by the physician to ensure medication need or adjustment for residents #1 and #23. There were no copies of the recommendations in the electronic charts, the hard copies had the recommendations in them, but were unsigned by MD for the last two months. Resident (1) Record Review: 08/20/2025 MRR - was not signed into the resident's chart. There was not an electronic or hard copyMissing signature of MD on last two MRR's dated 7/31/25 & 6/30/25 Had sign here tags in place for MDInterview: 8/20/2025Pharmacist stated that they place a copy in the hard chart for the MD to review and sign.Resident (23) Record Review :08/20/2025 MRR - was not signed into the residents chart. MRR - was not signed into the resident's chart. There was not an electronic or hard copyMissing signature of MD on last two MRR's dated 7/31/25 & 6/30/25 Had sign here tags in place for MDInterview : 8/20/2025Pharmacist stated that they place a copy in the hard chart for the MD to review and sign.

Based on record review and staff interview, the facility failed to update the PASARR for Resident #19, after the resident was diagnosed with a major mental disorder after admission to the facility. This was true for one (1) of four (4) residents reviewed for PASARR during the survey process. Resident Identifier: 19. Facility census: 181. a) Resident #19On 08/21/25, a record review of the resident's electronic medical record (EMR), the resident's admission PASARR, dated 08/31/23, indicated no level II was needed. Section lll #30 MI/MR Assessment indicated Other developmental disabilities.A continued record also revealed Resident#19 received a diagnosis of Paranoid Schizophrenia on the diagnosis listed after admission on [DATE] but did not receive a new PAS to address whether specialized services were needed. On 08/21/25 at 11:06 AM, an interview with the Director of Nursing confirmed the PAS presented to the surveyor did not indicate Paranoid Schizophrenia and was never updated.

Based on record review and interview, the facility failed to notify the Office of the Long-Term-Care Ombudsman of the resident's discharge from the facility. Resident Identifier: #188. Facility Census: 181. Findings Include:a) Resident #188The resident was no longer at the facility. A closed record review performed on 08/20/25 at 9:30 AM revealed that the resident was transferred to the hospital on [DATE]. Record review revealed that the resident's Power of Attorney (POA) was notified on 05/24/25. During an interview with Social Worker #183 on 08/20/25, at approximately 1:20 PM, she presented a document that verified the notification of the resident's family members and the responsible party. When asked whether the Ombudsman had been notified, SW #183 indicated that she would need to check for that information.At approximately 10:00 AM on 08/21/25 SW #183 stated that she did not have any documentation to verify that the Ombudsman had been notified.During an interview with the Administrator on 08/21/25, at approximately 12:00 PM, the Administrator confirmed that they could find no record of a notification to the ombudsman.

Based on observation and staff interviews, the facility failed to provide a safe, clean, comfortable, and homelike environment for room [ROOM NUMBER] and #340. This failed practice was a random opportunity for discovery. Facility Census: 181. Findings included:a) room [ROOM NUMBER]:Upon survey entrance and resident interviews on 08/18/25 at 12:05 PM, a discolored surface of residue build up at the base of the pipe behind the raised toilet seat was discovered. b) room [ROOM NUMBER]:Upon survey entrance and resident interviews on 08/18/25 at 1:05PM, two (2) dried brown substance smears were observed on the right-side wall below the toilet seat.On 08/20/25 at 9:28AM, during a walk through and staff interview with Employee #136, she acknowledged the brown smears in room [ROOM NUMBER]'s bathroom. The discolored residue build-up in room [ROOM NUMBER]'s bathroom was still there, and she stated she would have them taken care of.

Based on record reviews and interviews, the facility failed to follow weight policy and ensure resident weight was accurate and if needed a re weight preformed. Resident #51's weights were not rechecked per policy. This was a random discovery during the survey process and had the potential to effect more then a limited number of residents. Resident identifier: #51. Facility census: 181 a) Resident #51Resident #51 had five weights entered into the charting that should have triggered a re-weigh on that same day, as well as notification to the Medical Doctor. The facility failed to preform the re-weigh or notify the MD per facility policy. Record review on 08/21/25 at 9:55 AM revealed the following:Five weight events of 5% loss / gains from 01/01/25 - 08/12/25 01/01/25 145.8 pounds ( 5.5% (7.6 pounds) from previous weight01/01/25 145.8 lbs, 5.5% / 7.6 lbs from previous weight used by system01/04/25 145.8 lbs, 5.5% / 7.6 lbs from previous weight used by system. 07/01/25 143 lbs, 7% / 10 lbs from previous weight used by system08/04/25 133 lbs, 7% /10 lbs from previous weight used by system08/10/25 133.2 lbs 6.9% / 9.8 lbs from previous weight used by system. On each of these occassions there was no re-weight or notification of the medical provider. The facility policy on weights was as follows:resident with significant weight loss (greater or equal to 5% of body weight in 30 days , or 10% in 180 days) need weighed weekly until stable.if there is a 5lbs change from previous weight, resident must be re-weighed to verify.use same scale each time.CNA to record all weekly and monthly weights in POCNurse supervisor to maintain/check weights and notify MD of significant changes. During an interivew on 08/21/25 at 9:30 AM Licensed Practical Nurse (LPN) #269 said the nurse aides typically do the weights and enter them into the system. They come and tell the nurses and if there is a big difference they are rechecked When asked what was considered a big difference LPN #269 was unsure of the actual policy and when a reweight is needed. She said something like 10 lbs they look at a reweight. Policy review revealed the trigger weight was defined as 5 pounds or 5% per policy. On 08/21/25 at 11:27 AM Director of Nursing #32 [NAME] stated there was not a specific Nursing Supervisor assigned to checking on the resident weights. DON #32 said, Its more on each section to monitor them and notify the MD if needed.

Based on record review and interview, the facility failed to ensure the clarification of a resident's medication order for a drug that was required to be taken with food h. This was a random opportunity for discovery. Resident Identifier #40. Facility Census: 181.Findings Include: a) Resident #40 Record review on 08/20/25 at 8:59 AM revealed that Resident #40 had the following order dated 05/01/25, prescribed by her physician:Sensipar Oral Tablet 30 MG (Cinacalcet HCl)Give 1 tablet by mouth one time a day for elevated calciumThe United States Food and Drug Administration (FDA) guidelines state the following for administration of Cinacalcet (Sensipar):For all indications, Cinacalcet (Sensipar) should be taken with food or shortly after a meal and should always be taken whole and not divided. Sensipar lowers serum calcium and, therefore, patients should be carefully monitored for the occurrence of hypocalcemia. Potential manifestations of hypocalcemia include paresthesia's, myalgias, muscle cramping, tetany, and convulsions. Serum calcium should be measured within 1 week after initiation or dose adjustment of Sensipar. Once the maintenance dose has been established, serum calcium should be measured approximately monthly.During an interview with the Director of Nursing (DON) on 08/21/25, the DON produced a copy of the Physicians Drug Reference (PDR) and confirmed that the guidelines stated that Sensipar should be administered with food. However, the DON insisted that the medication was administered at mealtime. The DON further stated that the facility's mealtimes coincided with the medication administration times.A review of the medication administration schedule provided by the facility on 08/21/25 revealed that the medication administration time for a once a day (QD) medication was 8:00 AM to 10:00 AM.

Based on observation and interview, the facility failed to promote the resident's right to a dignified existence. Resident #41 was observed in the hallway in only his brief. This was a random opportunity for discovery. Resident Identifier #41. Facility census: 181.Findings Include: a) Resident #41On 08/20/25, at approximately 9:31 AM, Resident #41 was observed in a wheelchair outside his room, wearing only a brief. He was clearly visible to staff and other residents walking down the hallway. Staff members were seen passing by the resident without expressing any concern about his attire. This concern was brought to the attention of Licensed Practical Nurse (LPN) #24, who responded, I don't know why he hasn't been dressed yet! LPN #24 then went directly to the resident and wheeled him back to his room. She was observed to instruct a Nursing Assistant (NA) to help Resident #41 get dressed. The Director of Nursing was notified of this finding on 08/202/25 at approximately 10:30 AM.

Based on observation, policy review, medical record review, resident interview and staff interview, the facility failed to implement an ongoing resident centered activities program designed to meet the interest of and support the physical, mental and psychosocial well-being of each resident. This practice was found for four (4) of four (4) Residents reviewed for the Activity Care Area during the Long term care survey process. Resident identifiers: #6, #36, #1 and #72. Facility census: 181. Findings included: A review of the facility policy titled Activity Policy with a revision date of 04/13/23 read as follows: .Individualized and group activities are provided that reflect the schedules, choices and rights of the residents. They are offered at hours convenient to the resident, including evenings, holidays and weekends. They reflect the cultural and religious interests, hobbies, life experiences, and personal preferences of the residents. Activities appeal to men and women as well as those of various age groups residing in the facility. a) Resident #6 During a interview on 06/26/23 at 3:06 PM, Resident # 6 stated that there is not enough activities and I don't like Bingo and that's all we do. During a record review on 06/27/23 at 6:30 PM Resident # 6 medical record revealed an activity assessment dated [DATE] read as follows: Section titled: K. Activity Settings Resident Preferred activity setting coded as follows: -1:1 -activity room -small group Section titled: L Activity Preference Time coded as follows: 3. Afternoon 4. Evening Section titled: M. Activity Interest coded as follows: -cards and games -crafts/art -current events -helping others -music -spiritual/religious -time outdoors A further review of the medical records revealed the following care plan: Focus Statement: Resident name is dependent on staff etc. for meeting emotional, intellectual, physical and social needs related to (r/t) physical limitations. The focus statement was initiated on 12/27/22 and revised on 2/27/23. Goal: Resident's name will attend/participate in activities of choice and have one on one visits with activity aides 1-2 times weekly by next review date. inventions included: Past Volunteered for meals on wheels, past knitting/cross-stitch/painting. Lutheran, Enjoyed sewing, baking/crafts. The residents' preferred activities are: word search, current events, music, reading the newspaper, church service, talking and conversing, watching TV/movies, pet visits. Further record review of the activity participation records for the last 30 days revealed the following: -Intellectual-Games was void of any record of participation -Intellectual Activities was void record of participation on the following days: -06/27/23 -06/26/23 -06/25/23 -06/24/23 -06/23/23 -06/22/23 -06/21/23 -06/20/23 -06/19/23 -06/18/23 -06/17/23 -06/16/23 -06/14/23 -06/13/23 -06/12/23 -06/11/23 -06/10/23 -06/08/23 -06/05/23 -06/03/23 -06/02/23 -06/01/23 -Spiritual Domain was void of any record of participation. During an review of the monthly activity calendar found the following group scheduled activities during the Long Term Care Survey Process: -On Monday 06/26/23 -11:55 AM Mass -2:30 PM Bingo -On Tuesday 06/27/23: -11:55 AM Mass -2:30 PM Dice it up Game -On Wednesday 06/28/23 -11:55 AM Mass -2:30 PM Pretty Nails -On Thursday 06/29/23 -11:55 AM Mass -2:30 PM Resident Council Meeting -On Friday 06/30/23 -11:55 AM Mass -2:30 PM Auction There was only one other group activity every day other than Mass at 11:55 AM, for the months of June, May and April. No further information was provided at the close of the survey. b) Resident #36 During an interview on 06/26/23 at 1:11 PM, Resident #36 stated there were no activities. Resident #36 said, only thing I like is bingo and they don't have it very often weekly I think. During a record review on 06/27/23 at 6:39 PM Resident # 36 medical record revealed an activity assessment dated [DATE] read as follows: Section titled: K. Activity Settings Resident Preferred activity setting coded as follows: -1:1 -small group Section titled: L Activity Preference Time coded as follows: -3. Afternoon -4. Evening Section titled: M. Activity Interest coded as follows: -cards and games -crafts/art -current events -helping others -music -spiritual/religious -conversing -watching movies A further review of the medical record revealed the following care plan: Focus Statement: Resident name is dependent on staff etc. for meeting emotional, intellectual, physical and social needs r/t cognitive deficits, physical limitations. This focus statement was initiated on 11/02/22 and revised on 11/02/22. Goal: Resident's name will attend/participate in activities of choice and have one on one visits with activity aides 1-2 times weekly by next review date. Inventions included: Past worked as a bookkeeper and housewife. Presbyterian/past hobbies was traveling, bowling. tennis, deer hunting. Still plays the organ. The residents' preferred activities are: bingo, current events, music, church service, talking and conversing, watching TV/movies, pet visits, nail care bunco and dice it up. Further record review of the activity participation records for the last 30 days revealed the following: -Intellectual-Games was void record of participation on the following days: -06/24/23 -06/23/23 -06/22/23 -06/21/23 -06/18/23 -06/15/23 -06/13/23 -06/11/23 -06/10/23 -06/09/23 -06/08/23 -06/07/23 -06/06/23 -06/03/23 -06/02/23 -06/01/23 -05/31/23 -Intellectual Activities was void record of participation on the following days: -06/27/23 -06/26/23 -06/24/23 -06/23/23 -06/21/23 -06/19/23 -06/18/23 -06/17/23 -06/16/23 -06/15/23 -06/13/23 -06/12/23 -06/11/23 -06/10/23 -06/09/23 -06/07/23 -06/05/23 -06/04/23 -06/02/23 -06/01/23 -05/31/23 -05/30/23 -Spiritual Domain was void of any record of participation. c) Resident #1 During an observation on 06/26/23 at 3:16 PM, Resident #1 sitting in wheelchair in dayroom holding baby, not playing bingo. During an observation on 06/27/23 at 1:46 PM Resident #1 sitting in the day room asleep in her wheelchair, holding her baby. During an observation on 06/28/23 at 1:15 PM Resident #1 was sitting in her wheelchair asleep at the Nurses Station, holding her baby. During a record review on 06/27/23 at 6:48 PM, Resident #1 medical record revealed an activity assessment dated [DATE] read as follows: Section titled: K. Activity Settings Resident Preferred activity setting coded as follows: -activity room -1:1 -small group Section titled: L Activity Preference Time coded as follows: -3. Afternoon Section titled: M. Activity Interest coded as follows: -cards and games -music -spiritual/religious -parties/social events -spiritual/religious -time outdoors A further review of the medical record revealed the following care plan: Focus Statement: Resident name is dependent on staff etc. for meeting emotional, intellectual, physical and social needs r/t cognitive deficits, physical limitations. This focus statement was initiated on 04/10/22 and revised on 03/18/22. Goal: Resident's name will attend/participate in activities of choice and have one on one visits with activity aides 1-2 times weekly by next review date. Inventions included: Past worked as a telephone operator. Helped out at church club (homemakers enjoys flowers Methodist. The residents' preferred activities are: music, socials, church service, talking and conversing, time outdoors wheel chair (w/c) rides, holding baby, bible read to her. Further record review of the activity participation records for the last 30 days revealed the following: ~Intellectual-Games was void of any record of participation for 30 days. -Intellectual Activities was void record of participation on the following days: 06/27/23 -06/26/23 -06/25/23 -06/24/23 -06/23/23 -06/22/23 -06/21/23 -06/20/23 -06/19/23 -06/18/23 -06/16/23 -06/15/23 -06/14/23 -06/13/23 -06/12/23 -06/11/23 -06/09/23 -06/07/23 -06/06/23 -06/05/23 -06/04/23 -06/03/23 -06/02/23 -06/01/23 -05/31/23 -05/30/23 -Spiritual Domain was void of any record of participation for 30 days. d) Resident #72 Observation throughout the Long-term survey revealed Resident #72 sitting alone with no activities being provided. --06/26/23 at 12:23 PM sitting in hallway by her room door, sleeping. --06/26/23 at 1:31 PM sitting in activities room by herself-sleeping. --06/26/23 at 3:24 PM sitting in activities room by herself-sleeping. --06/27/23 at 8:25 AM sitting in activities room by herself-sleeping with a people magazine placed in her lap. --06/27/23 at 9:53 AM sitting in activities room by herself-sleeping. --06/27/23 at 11:44 AM sitting in hallway by her room door. --06/28/23 at 9:14 AM sitting in activities room by herself-sleeping. A review of Resident #72's current care plan revised 06/09/22 found the following: Focus: Resident #72 is dependent on staff for meeting emotional, intellectual, physical and social needs related to physical limitations and cognitive deficits. Goal: Resident #72 will attend and participate in activities of choice and receive one on one with activities 1 or 2 times weekly. Interventions: -- Invite the resident to scheduled activities. -- Prefers country music, crafts, wheelchair rides, prayers, special events A medical record review of Resident #72's Activities participation sheets revealed she participated in one (1) scheduled group activity on 06/16/23 and no evidence of one-on-one activities provided in the last 30 days. No evidence documented refusals or declining activities programing. Resident #72's MDS with an ARD of 05/08/23 noted the resident had a score of four (4) on the BIMS. A BIMS score of 04 indicated the resident is severely impaired cognitively. Section G for question H. (locomotion) was assessed for: - 1. Self-Performance 4. (Total Dependent.) - 2. Support 2. (One-person physical support.) During an interview on 06/27/23 at 2:43 PM the Activity Aide #142 stated, We only provide the group activities that are scheduled on the calendar, Mass daily at 11:55 AM and then another group activity at 2:30 PM. We do 1:1 visits to every resident every day. During an interview on 06/28/23 at 10:45 AM, the Activity Director stated, What is on the monthly calendar is the group activities that are provided. We do 1:1 with all the Residents. If the Resident wants to do something we can provide it, but they need to tell us if it's not scheduled. The staff work 11:00 AM -7:00 PM, and only one activity person is here from 9:00 AM to 11:00 AM. I have six (6) people here at 11:00. They do room visits all day, 11:00-11:55 AM they transport residents to Mass, 12:00-1:30 pass the lunch trays. From 2:00 to 3:30 a group activity, 4:00 to 4:45 Break for staff. At 4:45 staff start serving trays for dinner. Three (3) of the staff help in the dining room and three (3)help with trays and do 1:1's. There is not a specific 1:1 visit schedule, everyone is visited daily. The activity participation documentation is marked for active but not for refusal. The staff have assigned rooms and they must ask each resident to attend and document if they attended. We do 1:1 with all our residents, not a lot of group activities. On 06/28/23 at 10:14 AM, the above issues were discussed with Administrator, Regulatory Compliance Office #37 and the Activity Director, they acknowledged the above issues were not meeting the needs of the Residents for a person centered activity program. The Activity Director stated that I am still stuck in COVID mode with the 1:1 room visits, and less group activities. During an interview, on 06/28/23 at 10:45 AM, the Activities Director stated Resident #72 should not be placed alone in the activities room. On 06/29/23 at 10:25 AM, during an interview with the Administrator, Assistant Administrator and Activities Director, it was confirmed the facility did not have evidence of activities provided to the resident or refusals of activities documented. During an interview on 06/27/23 at 2:43 PM the Activity Aide #142 stated, We only provide the group activities that are scheduled on the calendar, Mass daily at 11:55 AM and then another group activity at 2:30 PM. We do 1:1 visits to every resident every day. During an interview on 06/28/23 at 10:45 AM, the Activity Director stated what was on the monthly calendar was the group activities that were provided. The Activity Director said, We do 1:1 with all the Residents. If the Resident wants to do something we can provide it, but they need to tell us if it's not scheduled. The staff work 11:00 AM -7:00 PM, and only one activity person is here from 9:00 AM to 11:00 AM. I have six (6) people here at 11:00. They do room visits all day, 11:00-11:55 AM they transport residents to Mass, 12:00-1:30 pass the lunch trays. From 2:00 to 3:30 a group activity, 4:00 to 4:45 Break for staff. At 4:45 staff start serving trays for dinner. Three (3) of the staff help in the dining room and three (3)help with trays and do 1:1's. There is not a specific 1:1 visit schedule, everyone is visited daily. The activity participation documentation is marked for active but not for refusal. The staff have assigned rooms and they must ask each resident to attend and document if they attended. We do 1:1 with all our residents, not a lot of group activities. On 06/28/23 at 10:14 AM, the above issues were discussed with Administrator, Regulatory Compliance Office #37 and the Activity Director, they acknowledged the above issues were not meeting the needs of the Residents for a person centered activity program. The Activity Director stated, I am still stuck in COVID mode with the 1:1 room visits, and less group activities. 45174

Based on record review and staff interview, the facility failed to manage pain in accordance with professional standards of practice for one (1) of six (6) residents reviewed for the care area of pain. Resident identifier: #51. Facility census: 181. Findings included: a) Resident #51 Review of Resident #51's medical records showed an order written on 05/30/23 for hydrocodone-acetaminophen every four (4) hours as needed for severe pain [rated] 6-10. The resident had no other pain medication ordered. On the following dates, at the following times, hydrocodone-acetaminophen was given even though the Resident reported her pain level was less than six (6): - 05/31/23 at 6:04 AM, pain level was rated five (5). - 06/04/23 at 3:50 AM, pain level was rated one (1). - 06/08/23 at 6:07 AM, pain level was rated four (4). - 06/13/23 at 2:49 PM, pain level was rated four (4). During an interview on 06/28/23 at 2:22 PM, the Director of Nursing (DON) confirmed Resident #51 had received hydrocodone-acetaminophen when her pain level was less than the physician-ordered pain level parameters for the medication. The DON also confirmed Resident #51 had no pain medication ordered for pain levels of 1-5. No further information was provided through the completion of the survey.

Based on medical record review, policy review, resident interview and staff interview, the facility failed to ensure the residents had the right to participate and must be given the opportunity to participate in development, review and revision of his/her care plan. This was true for four (4) of 36 reviewed for care plans during the Long-Term Care Survey Process. Resident identifiers: Resident #6, Resident #158, Resident #116 and Resident #43. Facility census: 118. Findings included: A review of the facility policy titled Care Planning-Interdisciplinary Team with a revision date of 04/13/23 read as follows: .3. The resident, the resident's family and/or the resident's legal representative/guardian or surrogate are encouraged to participate in the development of and revisions to the resident's care plan a) Resident #6 During an interview on 06/26/23 at 3:06 PM Resident #6 stated that I have never attended a care meeting or been invited. During an interview on 06/26/23 at 2:48 PM Social Services (SS) #155 stated the care plan meetings are held two (2) weeks after the Minimum Data Set (MDS) is completed. We send a letter to the Medical Power of Attorney (MPOA). The team consists of the Social Worker, Nursing, Nurse Aide (NA), Care plan nurse, Dietary and Activity Director. During a record review on 06/26/23 at 3:15 PM, Resident #6 medical records revealed a plan of care note,dated 04/14/2023 at 10:33 AM Typed as written: 4/11/23 Quarterly care plan meeting for (resident name) who is alert and independent with decision making. (Resident name) had no concerns to discuss in the meeting. Her daughter attended via conference call. An update was provided and questions were addressed. (Resident's name) has made a successful adjustment to her new room on 3 North. Daughter offered that (Resident's name) reports to her that her room is too hot. I will address with Maintenance. SS {Social Services} will continue to monitor and assist as needed. SS goals reviewed and updated as needed. Maintenance informed after the meeting that (Resident's name) feels her room is too warm. They are to address. During a record review on 06/27/23 at 10:30 AM , Resident # 6 medical records revealed a Physician Determination of Capacity dated 01/24/23 was coded Resident demonstrates capacity to make decisions. Further review of the medical record reviewed revealed an MDS with Assessment Reference Date (ARD) of 03/27/23 Section titled C-Cognitive Patterns, C0500 Brief Interview of Mental Status (BIMS) Summary Score of 14 which indicates intact cognition. Further record review of the care plan meeting summary dated 04/11/23, the section titled: Persons attending: was void of Resident attendance coded yes or no. On 06/27/23 at 3:30 PM SS #155 provided a copy of the care plan meeting letter invitation address to the family member dated 03/28/23. During an interview on 06/28/23 at 11:22 AM SS #155 stated that two (2) days prior to the meeting asked the Resident do you have concerns you need me to bring to the care plan meeting. She verified there was no evidence of inviting the Resident to the care plan meeting. b) Resident #158 During a interview on 06/26/23 at 12:31 PM, Resident # 158 stated that I am not invited to attend care meetings. During an interview on 06/26/23 at 2:48 PM SS #155 stated that the care plan meetings are held two (2) weeks after the MDS is completed. We send a letter to the MPOA. The team consists of the Social Worker, Nursing, NA, Care plan nurse, Dietary and Activity Director. During a medical record review on 06/26/23 at 3:17 PM, Resident #158 medical records revealed a Plan of Care note dated 3/31/2023 at 11:38 AM Typed as written 3/28/23 Quarterly care plan meeting for (Resident's name) who is alert and independent with decision making. (Resident's name) had no concerns to discuss at the meeting. Her daughter/MPOA was in attendance via conference call. An update was provided and questions were addressed. (Resident's name) continues to spend her time as she chooses. She is always very pleasant and cooperative with this worker. No SS concerns have been reported. SS will continue to monitor and assist as needed. SS goals reviewed and updated as needed. During a record review on 06/27/23 at 10:30 AM, Resident #158's medical record revealed a Physician Determination of Capacity dated 06/24/23 was coded Resident demonstrates capacity to make decisions. Further review of the medical record revealed an MDS with an ARD 03/13/23 Section titled C-Cognitive Patterns, C0500 BIMS Summary Score 10 which indicates moderately impaired cognition. Further record review of the care plan meeting summary dated 03/28/23, the section titled: Persons attending: was void of Resident attendance coded yes or no. On 06/27/23 at 3:30 PM the SS #155 provided a copy of the care plan meeting letter invitation address to the family member dated 03/14/23. During an interview on 06/28/23 at 11:22 AM the SS #155 stated two (2) days prior to the meeting I asked the Resident do you have concerns you need me to bring to the care plan meeting. She verified there was no evidence for inviting the Resident to the care plan meeting. c) Resident # 116 During an interview on 06/26/23 at 12:18 PM Resident # 116 stated that I am not sure about care plan meetings, don't think I have ever been to one or invited to attend. During an interview on 06/26/23 at 2:48 PM SS #155 stated that the care plan meetings are held two (2) weeks after the MDS is completed. We send a letter to the MPOA and the team consists of the Social Worker, Nursing, NA, care plan nurse, Dietary and Activity Director. During a medical record review on 06/26/23 at 3:23 PM, Resident #116's medical record revealed a Plan of Care note dated 4/6/2023 at 8:27 AM typed as written 4/4/23 Quarterly care plan meeting for (Resident's name) who is alert and independent with decision making. (Resident's name) had no concerns to be addressed in the meeting. Daughter and son in attendance via conference call. An update was provided and questions were addressed. No SS concerns reported. (Resident's name) seems to have successfully adjusted to her room on the 3 north unit. She is always very pleasant and cooperative with this worker. SS will continue to monitor and assist as needed. Continued assistance offered. SS goals reviewed and updated as needed. During a record review on 06/27/23 at 10:30 AM, Resident #116's medical record revealed a Physician Determination of Capacity dated 12/17/22 was coded Resident demonstrates capacity to make decisions. Further review of the medical record revealed an MDS with an ARD of 03/20/23 Section titled C-Cognitive Patterns, C0500 BIMS Summary Score 13 which indicates cognitively intact Further record review care plan meeting summary dated 04/04/23, the section titled: Persons attending: was void Resident attendance coded yes or no. On 06/27/23 at 3:30 PM SS #155 provided a copy of the care plan meeting letter invitation address to the family member dated 03/21/23. During an interview on 06/28/23 at 11:22 AM, SS #155 stated two (2) days prior to the meeting I asked the Resident do you have concerns you need me to bring to the care plan meeting. She verified there was no evidence of inviting the resident to the care plan meeting. d) Resident #43 A review of Resident #43's comprehensive care plan showed the focus, [Resident's name] is ordered opioid medication. Review of Resident #43's medication orders showed no current orders for opioid medication. Further review of Resident #43's medication orders showed the resident's opioid medication, Percocet, had been discontinued on 02/28/23. During an interview on 06/28/23 at 1:45 PM, the Director of Nursing (DON) confirmed the comprehensive care plan needed revision because Resident #43 was no longer receiving opioid medication. 45174

Based on record review and staff interview, the facility failed to provide Notice of Discharge to the Office of the State Long Term Care (LTC) Ombudsman during a discharge/transfer. This was true for one (1) of one (1) residents reviewed for hospitalization . Resident identifier #178. Facility census 181. Findings included: a) Resident #178 Record review on 06/28/23 at 10:27 AM, revealed Resident #178 was discharged to the hospital on 04/27/23. Subsequent review of the Resident #178's medical record showed it did not contain evidence the Notice of Transfer or Discharge was provided to the Ombudsman upon discharge on 04/27/23. On 06/28/22 at 10:04 AM during an interview the Director of Nursing (DON) confirmed the Ombudsmen was not notified of the discharge on 04/27/23.

Based on record review and staff interview, the facility failed to ensure the residents Preadmission Screening and Resident Review (PASRR) reflected the admission diagnosis. This was true for three (3) of five (5) reviewed for the PASRR care area during the Long-Term Care Survey. Resident identifiers: Resident #30, Resident #76, Resident #8. Facility census: 181. Findings included: a) Resident #30 During a record review on 06/27/23 at 10:37 AM, Resident #30's medical record revealed admitting diagnoses of anxiety disorder and bipolar disorder. Further review of the medical record revealed a PASRR dated 09/15/22, Section 30 Current Diagnosis, was coded None. During an interview on 06/27/23 at 2:48 PM with Social Services #155 stated I do not complete the PASRR, I just send it to the state for approval. The physician and a nurse complete them. During an interview on 06/27/23 at 3:09 PM, the DON acknowledged the PASRR was not completed with the diagnosis of bipolar disorder. b) Resident #76 A medical record review on 06/27/23, of the list of admission diagnoses for Resident #76 indicated a diagnosis of a schizoaffective disorder since 03/13/17. The schizoaffective disorder had not been added as a mental illness (MI) for question 30 of the PASRR dated 04/19/23. In an interview with the DON on 06/28/23 at 11:32 AM, acknowledged the schizoaffective disorder was not included as a mental illness on the PASRR for Resident #76. c) Resident #8 A medical record review on 06/27/23, of the list of admission diagnoses for Resident #8 had a diagnosis of affective bipolar disorder since 03/13/17. The affective bipolar disorder had not been added as a mental illness (MI) for question 30 of the PASRR dated 08/02/22. In an interview with the DON on 06/27/23 at 3:08 PM, acknowledged the affective bipolar disorder was not included as a mental illness on the PASRR for Resident #8.