Every finding on record at Grand Cove Nursing & Rehabilitation Center

Based on record review and staff interviews, the facility failed to ensure medical records were complete and accurately documented for 1 (#R1) of 4 residents reviewed for medical record accuracy. This deficient practice had the potential to affect a census of 87.Findings: Review of the facility policy titled Medical Records, with a revision date of 09/2025 and an annual review date of 01/2026, revealed in part: This community maintains a separate electronic clinical record on each resident in accordance with regulations and accepted professional standards of practice that are complete, accurate, readily accessible, and systematically organized. The resident clinical medical record shall contain sufficient information to identify the resident, a record of the resident's assessments, the comprehensive plan of care and services provided, and the results of any preadmission screenings, progress notes, and any lab, radiology, and other diagnostic services. Review of Resident #R1's electronic medical record (EMR) revealed an admission date of 03/29/2021 with diagnoses that included dementia and hypertensive heart disease without heart failure. Further review of Resident #R1's EMR revealed a progress note dated 02/10/2026 at 4:45 p.m. referencing Multaq oral tablet 400 mg (milligrams), give 2 tablets by mouth two times a day related to paroxysmal atrial fibrillation. This dosing regimen of 2 tablets two times per day exceeds the usual dosing regimen of 1 tablet two times per day. The single dose of 2 tablets exceeds the maximum recommended single dose of 1 tablet as indicated by a black box warning which is issued by the FDA (Federal Drug Administration) for prescription drugs.Review of Resident #R1's February 2026 Medication Administration Record (MAR) revealed no evidence of a physician's order for Multaq, either current or discontinued.On 03/10/2026 at 1:00 p.m., an interview was conducted with S1DON. S1DON reviewed Resident #R1's EMR and confirmed the resident did not have a physician's order for Multaq, either current or discontinued. S1DON also reviewed a progress note dated 02/12/2026 at 11:56 a.m., which documented the following: ORDER REVIEW - It was noted Multaq order was put in as 2 tab/400 mg BID (twice daily). Correct order was for one tab/400 mg BID. Order immediately changed. On 03/10/2026 at 1:30 p.m., an interview was conducted with S2MDS. After reviewing Resident #R1's EMR, S2MDS confirmed the documentation entered in the progress note dated 02/12/2026 at 11:56 a.m. had been documented in incorrectly in Resident #R1's medical record.

Based on interview, and record review, the facility failed to ensure medical records were accurately documented and maintained in accordance with professional standards of practice for 2 (#1 and #9) residents out of 6 (#1, #2, #3, #4, #6, #9) sampled residents investigated for wound care in a total sample of 9 residents. Findings: Resident #1Review of Resident #1's medical record revealed she was admitted to the facility on [DATE] with diagnoses including non-pressure chronic ulcer of left ankle with unspecified severity.Review of Resident #1's physician's orders revealed an order dated 10/16/2025 that read: clean diabetic ulcer to left lateral malleolus with normal saline; apply moist hydrofera blue; cover with border gauze dressing. Replace prevalon off-loading boot every Tuesday, Thursday and Saturday until healed.Review of Resident #1's October and November 2025 TAR (Treatment Administration Record) revealed the following: clean diabetic ulcer to left lateral malleolus with normal saline; apply moist hydrofera blue; cover with border gauze dressing. Replace prevalon off-loading boot every Tuesday, Thursday and Saturday until healed. Further review of the October 2025 TAR revealed no documentation the treatment was completed on 10/25/2025.On 11/24/2025 at 11:25 a.m., a review of Resident #1's October 2025 TAR and interview was conducted with S1DON (Director of Nursing). S1DON confirmed the wound care for Resident #1 was not documented on the TAR for 10/25/2025. She stated she could not confirm or deny if the wound care had been completed on 10/25/2025. Resident #9Review of Resident #9's medical record revealed she was admitted to the facility on [DATE] with diagnoses including stage 4 pressure ulcer (PU) to right hip and stage 4 PU to left hip.Review of Resident #9's physician's orders revealed orders dated:10/10/2025 - Clean DTI (deep tissue injury) to left lateral malleolus with betadine. Cover with dry dressing every Monday, Wednesday, Friday (QMWF) until healed.10/10/2025 - Clean stage 4 PU to rear left trochanter with normal saline (NS). Apply Santyl to wound bed; apply calcium Alginate (CaAlg) sheet to wound bed and cover with dry dressing QMWF until healed.10/10/2025 - Clean stage 4 PU to right ischial tuberosity with NS. Apply Santyl to wound bed; apply CaAlg sheet to wound bed; cover with dry dressing QMWF until healed.10/10/2025 - Clean unstageable PU to left lower back with NS. Apply Santyl to wound bed; apply CaAlg sheet to wound bed; cover with dry dressing QMWF until healed.10/10/2025 - Clean stage 2 PU to right malleolus with betadine. Cover with dry dressing QMWF until healed.11/05/2025 - Clean stage 3 PU to left scapula with NS. Apply medihoney to wound and cover with dry dressing QMWF until healed. Review of Resident #9's October and November 2025 TAR revealed the following:Clean stage 2 PU to right lateral thoracic region with betadine. Cover with dry dressing QMWF until healed with discontinue (D/C) date of 11/12/2025.Clean DTI to left lateral malleolus with betadine. Cover with dry dressing QMWF until healed with D/C date of 11/12/2025.Clean DTI to left heel with betadine. Cover with dry dressing QMWF until healed with D/C date of 11/12/2025.Clean skin tear to left inner forearm with NS. Apply triple antibiotic ointment (TAO) to wound and cover with dry dressing QMWF until healed with a D/C date of 11/12/2025.Clean stage 4 PU to rear left trochanter with NS. Apply Santyl to wound bed; apply calcium Alginate (CaAlg) sheet to wound bed and cover with dry dressing QMWF until healedClean stage 4 PU to right ischial tuberosity with NS. Apply Santyl to wound bed; apply CaAlg sheet to wound bed; cover with dry dressing QMWF until healed.Clean stage 2 PU to right malleolus with betadine. Cover with dry dressing QMWF until healed.Clean unstageable PU to left lower back with NS. Apply Santyl to wound bed; apply CaAlg sheet to wound bed; cover with dry dressing QMWF until healed.Further review of the October 2025 TAR revealed no documentation of the treatments completed on 10/24/2025. Review of the November 2025 TAR revealed no documentation of the treatments completed on 11/17/2025. On 11/24/2025 at 11:30 a.m., a review of Resident #9's October 2025 TAR and interview was conducted with S1DON (Director of Nursing). S1DON confirmed the wound care for Resident #9 was not documented on the TAR for 10/24/2025. She stated she could not confirm or deny if the wound had been completed on 10/24/2025. S1DON stated she had provided wound care to Resident #9, on 11/17/2025 and did not document on the TAR the treatment had been provided. On 11/24/2025 at 2:30 p.m., an interview was conducted with S2CRN (Corporate Registered Nurse), she confirmed the documentation for wound care for Resident #9 was not documented on the TAR or in the medical record on 11/17/2025.

Based on observations, interviews and record reviews, the facility failed to provide services to meet professional standards in accordance with the resident's written plan of care by failing to administer daily medication on time as ordered for 3 (#1, #R1 and #R2) out of 11 (#1- #4 and #R1 - #R7) sampled residents. The deficient practice had the potential to effect a census of 87.Findings: Review of the facility's policy titled, Administration of Medication with last revision date 03/2025, read in part, purpose: to administer medications in accordance with best practice.Procedure: 3. Drugs and biologicals are administered no more than one hour before or no more than one hour after the dosage time is ordered.Resident #1Review of Resident #1's EHR (electronic health record) revealed she was admitted to the facility on [DATE] with diagnoses that included in part, congestive heart failure, anxiety and depression.Review of Resident #1's most recent Quarterly Minimum Data Set (MDS) dated [DATE], revealed the resident's Brief Interview for Mental Status (BIMS) score was 13, indicating her cognition was intact.Review of Resident #1's MAR (Medication Administration Record) for September 2025 reviewed resident received her p.m. (evening) medications on 09/04/2025 from S4LPN (Licensed Practical Nurse). The insulin injection revealed the 8:00 p.m. medication was administered at 10:25 p.m.Review of the resident's medication administration history report revealed: Medications due at 8:00 p.m. included:1. Humalog insulin per sliding scale, 2. Mupirocin external ointment 2% (percent), 3. Lantus 20 units, 4. Metformin 500mg (milligrams), 5. Mirtazapine 7.5mg, 6. Timolol Maleate Ophthalmic Solution 0.5%Medications due at 9:00 p.m. included:1. Atorvastatin 40mg2. Lantanoprost Solution 0.005% eye drops, On 09/02/2025, Resident #1's medications were documented as administered at 10:14 p.m. On 09/04/2025, the resident received Lantus 20 units, Metformin 500mg, Mirtazapine 7.5mg, and Timolol Maleate Ophthalmic Solution 0.5% at 10:25 p.m. However, these medications were due at 8:00 p.m. The resident was also administered Atorvastatin 40mg and Lantanoprost Solution 0.005% eye drops at 10:25 p.m., but these medications were due at 9:00 p.m. On 09/29/2025 at 1:00 p.m., an interview was conducted with Resident #1 who stated she did not get her medications when she was supposed to.On 09/30/2025 at 12:45 p.m., an interview was conducted with S1DON (Director of Nursing). She reviewed the September 2025 MAR for Resident #1 and confirmed the night medications that were due at 8:00 p.m. and 9:00 p.m. on 09/02/2025 and 09/04/2025, were administered late and should have been administered within an hour before to after the scheduled time of administration.Resident #R1On 09/30/2025 at 11:36 a.m., an observation was made of S3LPN administering medication to Resident #R1 which included the following medications that were due at 9:00 a.m.:1. Aspirin 81 mg2. Diltiazem 60mg 3. Eliquis 5mg4. Hydralazine 25mg 5. Lactobacillus 4 capsules 6. Lasix 20 mg7. Losartan potassium 25mg8. Metoprolol Tartrate 37.5mg 9. Pantoprazole 40mg10. Theophylline ER 300mg The above medications for Resident #R1, were administered at 11:36 a.m. S3LPN, confirmed the medications were administered late.Resident #R2On 09/30/2025 at 11:25 a.m., an interview was conducted with S3LPN who stated she was still passing morning medications that were due at 8:00 a.m. and 9:00 a.m. She confirmed the medications would be administered greater than 1 hour past the time they should have been administered. On 09/30/2025 at 11:43 a.m., an observation was made of S3LPN administering Resident #R2's medications at this time: Aspirin EC 81mg and Clopidogrel 75mg due at 8:00 a.m.; and Lasix 20mg due at 9:00 a.m. S3LPN, confirmed the medications were being administered late.

Based on record reviews and interviews, the facility failed to revise a comprehensive person-centered plan of care for 1 (#1) out of 11 (#1, #2, #3, #4, and #R1-#R7) sampled resident as evidenced by failing to revise a care plan with changes in ADL (activities of daily living) care. Findings: Review of Resident #1's EHR (electronic health record) revealed she was admitted to the facility on [DATE] with diagnoses that included in part, congestive heart failure, anxiety and depression.Review of Resident #1's most recent Quarterly Minimum Data Set (MDS) dated [DATE], revealed the resident's Brief Interview for Mental Status (BIMS) score was 13, indicating her cognition was intact. Further review of the MDS revealed resident was independent with eating, oral hygiene, toileting, dressing, transfers; and supervision or touch assistance for shower/bathe.Review of Resident #1's care plan date initiated: 06/23/2025 revision on: 08/19/2025 revealed resident needs partial/moderate assist with bathing/showering. Resident needs supervision to transfer to and from a bed to a chair/wheelchair. Resident needs assist with toileting. On 09/29/2025 at 1:00 p.m., an interview was conducted with Resident #1, she stated she was able to do everything for herself, except for shower/bathing, they will help if needed.On 09/30/2025 at 3:15 p.m., an interview was conducted with S2CRN (Corporate Registered Nurse), she reviewed the care plan for Resident #1 and confirmed the care plan had not been updated to reflect the current ADL status of the resident and should have been.

Based on record reviews and interviews, the facility failed to develop and/or implement a comprehensive person-centered plan of care and/or physician's orders for (#2) out of 11 (#1, #2, #3, #4, and #R1-#R7) sampled resident as evidenced by failing to identify and implement interventions for refusal of care for Resident #2.Findings: Review of Resident #2's EHR revealed she was admitted to the facility on [DATE] with diagnoses that included in part, schizoaffective disorder, unspecified, unspecified dementia, moderate, with other behavioral[MC1] , anxiety disorder and major depressive disorder.Review of Resident #2's complex alert documentation report from 07/01/2025 to 09/08/2025 revealed resident refused hygiene care every day in July 2025, and on 08/13/2025, 08/15/2025, 08/25/2025, 09/01/2025 and 09/02/2025.Review of Resident #2's hospice records revealed aide visit notes from 07/14/2025 to 08/29/2025 unable to document: patient refused nail care, nurse notified. Review of Resident #2's care plan revealed no evidence of with refusal of nail care and hygiene. On 09/29/2025 at 2:40 p.m., an interview was conducted with S6LPN (Licensed Practical Nurse), she stated the hospice CNA (Certified Nursing Assistant) had reported to her on multiple occasions the resident refused a bath and nail care and the facility staff did try to encourage the resident to bathe and provide nail care to which the resident continued to refusal care.On 09/30/2025 at 11:02 a.m., an interview was conducted with S7LPN, she stated the resident had history of mental illness and would at times refuse care. S7LPN stated the last few months she would refuse care often, almost daily, and she was at times difficult to redirect. On 09/30/2025 at 12:37 p.m., an interview was conducted with S5MDS (Minimum Date Set) nurse. She reported she was responsible for completing MDS and updating the care plan for Resident #2. She confirmed the care plan did not identify the refusal of care nor interventions for the refusals of care for the resident, but should have. [MC1]

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services that ensured accurate administration of medication to meet the needs of 1 (#72) of 6 residents observed during medication administration. The deficient practice had the potential to effect the facility census of 84 residents. Findings: On 06/11/2025 at 9:40 a.m., S10LPN (Licensed Practical Nurse) was observed during medication pass. During her preparation for medication administration for Resident #72, S10LPN stated that the prescribed Carbidopa-Levodopa ER Tablet 25-100 mg (milligrams) orders on her computer indicated Resident #72 was to take 1 tablet PO (by mouth) TID (three times per day) but that the instructions on the medication blister pack read to take 2 tablets PO TID. In that moment, S10LPN reviewed Resident #72's physician's orders on her computer and read from the prescribed Carbidopa-Levodopa order, take 1 tablet PO TID. S10LPN returned to the Carbidopa-Levodopa blister pack and read, take 2 tabs PO TID. S10LPN then removed a round, bright orange sticker from a drawer on her medication cart and applied it to the top of the Carbidopa-Levodopa blister pack. The nickel-sized decal read, Direction Change See Chart. S10LPN stated in addition to her reporting this to the DON (Director of Nursing) as soon as possible, this would help to flag the medication. S10LPN also verified that this blister pack was the only blister pack in the medication cart that contained Resident #72's Carbidopa-Levodopa medication. Resident #72's medication was contained in a plastic pill cup and was counted, identified, and noted to include only one Carbidopa-Levodopa 25-100 mg tablet. This observation was confirmed by S10LPN, and on 06/11/2025 at 9:47 a.m., Resident #72 was observed swallowing his medication, including only one Carbidopa-Levodopa 25-100 mg tablet. Review of Resident #72's physician's orders indicated he was prescribed Carbidopa-Levodopa Tablet Extended Release 50-200 MG (milligrams) on 05/15/2025. The orders read, Give 1 tablet by mouth three times a day for Parkinson's disease. A review of Resident #72's June 2025 electronic Medication Administration Record (eMAR) was conducted. An entry on page 3 read, Carbidopa-Levodopa ER Tablet Extended Release 50-200 MG. Give 1 tablet by mouth three times a day for Parkinson's disease -Start Date- 05/15/2025. S10LPN's initials were noted as having given the morning dose on 06/11/2025. There was no note of irregularity to indicate there was conflict between the orders and administration of the medication on Resident #72's eMAR. On 06/11/2025 at 10:38 a.m., an interview with record review with S2DON (Director of Nursing) was conducted. S2DON was asked to verify orders regarding Resident #72's Carbidopa-Levodopa medication regimen. S2DON reviewed physician's orders and eMAR for Resident #72's prescribed medication on her computer, as well as a photo of the Carbidopa-Levodopa blister pack from which the morning dose was taken. S2DON confirmed Resident #72's physician's orders, as well as his eMAR, read to administer 1 Carbidopa-Levodopa 50-200 mg tablet three times a day. S2DON then verified that the medication blister pack instructed to administer 2 Carbidopa-Levodopa 25-100 mg tablets by mouth, three times each day. S2DON stated she understood the complication, as physician's orders read to administer one each of the 50-200 mg tablets of Carbidopa-Levodopa, but the blister pack in the medication cart contained 25-100 mg tablets and read to admin 2 each, in order to total the prescribed dose of 50-200 mg.

Based on record review and interview, the facility failed to accurately code the resident's Minimum Data Set (MDS) assessment for use of antiplatelet medication for 1 (#56) out of 30 sampled residents. Findings: Review of Resident #56's Quarterly MDS with an ARD (Assessment Reference Date) of 02/12/2025 revealed, in part: Section N- Medications High Risk Drug Classes E. Anticoagulant, Is taking- checked Yes .I. Antiplatelet, Is taking- checked No. Review of Resident #56's electronic medication administration record (EMAR) for February 2025 revealed he had taken Plavix, an antiplatelet medication. On 06/11/2025 at 12:45 p.m., an interview and record review was conducted with S7MDS. She verified that Resident #56 was administered Plavix, an antiplatelet medication during the lookback period for his Quarterly MDS with an ARD of 02/12/2025. S7MDS confirmed that Resident #56's Quarterly MDS was coded incorrectly as him taking an anticoagulant instead of an antiplatelet medication.

Based on record review and interview, the facility failed to ensure that the resident's quarterly MDS (Minimum Data Set) assessment was completed and submitted to CMS (Center for Medicare and Medicaid Services) in a timely manner for 1 (#44) of 5 (#29, #41, #44, #46, #56) residents investigated for resident assessments in a final sample of 30 residents. Findings: Review of Resident #44's electronic medical record revealed a quarterly MDS assessment with an Assessment Reference Date (ARD) of 05/06/2025. Review of the MDS assessment signature page revealed the assessment had been completed and signed on 06/05/2025. On 06/11/2025 at 3:30 p.m., an interview was conducted with S7MDS who stated she was responsible for Resident #44's MDS assessments. S7MDS reviewed Resident #44's quarterly MDS with an ARD of 05/06/2025 and confirmed the assessment had not been completed in the CMS required timeframe of 14 days.

Based on record review and interviews, the facility failed to develop and implement a comprehensive person-centered care plan for 2 (#9, #41) out of a final sample of 30 residents. The deficient practice had the potential to affect a total census of 84 residents. Findings: Resident #9 Review of Resident #9's EMR (Electronic Medical Record) revealed an admission date of 03/24/2025 and diagnoses that include Hemiplegia following Cerebral Infarction affecting right dominant side, Type 2 Diabetes Mellitus, and Morbid Obesity. Review of Resident #9's Quarterly MDS (Minimum Data Set) dated 03/28/2025 indicated Resident #9 was dependent on staff for personal hygiene. On 06/09/2025 at 10:30 a.m., an observation was made of Resident #9 unshaven with long unkempt facial hair and fingernails that were long, curling under with brown debris under them. On 06/11/2025 at 8:37 a.m., an interview was conducted with S8LPN (Licensed Practical Nurse). S8LPN confirmed the resident had unkempt facial hair and fingernails. She stated the resident refuses ADL (activities of daily living) care almost on a daily basis. S8LPN confirmed this has been reported to administration to address. On 06/11/2025 at 1:51 p.m., a concurrent records review and interview was conducted with S7MDS. S7MDS viewed Resident #9's resident centered care plan. S7MDS confirmed that the Resident #9's care plan failed to identify and address the resident's refusals of ADL care and confirmed this information should be addressed in the care plan and was not. Resident #41 Review of Resident #41's EMR revealed an admission date of 11/23/2022 with diagnoses that included Hemiplegia following Cerebral Infarction affecting right dominant side, Hemiplegia following Cerebral Infarction affecting left side, and Type 2 Diabetes Mellitus. Review of Resident #41's Quarterly MDS dated [DATE] indicated Resident #41 required substantial to maximal assistance from staff for personal hygiene. On 06/09/2025 at 10:00 a.m., an observation was made of Resident #41 with fingernails that were long and curling under.

Based on observation and interview, the facility failed to serve food in accordance with professional standards for food service safety as evidenced by failing to ensure: 1. dietary staff with facial hair utilized a hair restraint to prevent hair from contacting food; 2. dietary staff utilized gloves when handling and preparing food; and, 3. dietary staff utilized proper sanitary procedures when serving ice with a ice scoop. These deficiencies had the potential to affect the entire census of 80 residents who consumed food and beverages prepared in the kitchen. Findings: A review of the facility's policy titled Employee Work Practice, with a revised date of 05/2018 and annual policy review date of 01/30/2025, read in part: Policy: Food service employees shall follow sanitary practices to prevent the spread of food borne illness. Procedure: 2. Proper Work Attire a.maintain their hair and skin to prevent the transfer of pathogens to food and food equipment .c. ii. Wears a clean hat or other hair restraint (hair net, hat, surgical cap and/or beard restraint) in the food production area. The restraint must cover all hair and prevent the hair from contacting exposed food. A review of the facility's policy titled Hand Sanitation Practices, with a revised date of 05/2018 and annual policy review date of 01/30/2025, read in part: Procedure: 6. Use of gloves a. gloves are worn to protect food by creating a barrier between the hands and food but should be used only when doing one task. On 06/09/2025 at 10:40 a.m., an observation of pureed food preparation was done with S4DC (Dietary Cook). S4DC was observed preparing the pureed food without the use of gloves nor did he have his facial hair covered with a restraint. On 06/09/2025 at 11:15 a.m., an observation of S5DC measuring temperature at the steam table for lunch meal was conducted. S5DC was observed not wearing gloving while taking food temperatures. On 06/09/2025 at 11:30 a.m., an observation of S6DA (Dietary Aide) was conducted while scooping ice from the icemaker and putting ice into glasses of a red drink. As S6DA scooped ice into the glasses of red drink, she tapped the ice in the red drinks with the back of the ice scoop. Red drink was then observed dripping from the back of the ice scoop. Without cleaning the scoop, S6DA then reached into icemaker to get another scoop of ice. S3DM (Dietary Manager) informed S6DA, the scoop needed to be cleaned before reaching for more ice. On 06/09/2025 at 11:45 a.m., a 2nd observation was made of S4DC in the kitchen area without the use of a hair restraint to cover his facial hair. On 06/09/2025 at 11:50 a.m., an interview was conducted with S3DM. She confirmed all of the above findings. S3DM confirmed that all persons should have hair restraints to cover all hair, including facial hair, while in the kitchen area. S3DM also confirmed that staff should wear gloves when handling food and the ice scoop should not touch anything while serving ice without cleaning the scoop before returning to the ice bin.

Based on record reviews and interview, the provider failed to ensure that a resident's assessment accurately reflected the resident's status for 1 (#68) out of 3 (#38, #3, #68) residents' records reviewed in a final sample of 25 residents. The deficiency had the potential to affect a census of 73. Findings: Review of Resident #68's EMR (Electronic Medical Record) revealed an admitted [DATE] with diagnosis not limited to Schizophrenia and Bipolar Disorder. Further review of Resident #68's EMR had a PASRR (Pre-Admission Screening and Resident Review) Level II determination date 01/17/2024 indicating the individual had a serious mental illness and was recommended nursing home admission. Lesser services were commended and specialized services were recommended. Review of Resident #68's Significant Change (SC) MDS (Minimum Data Set) assessment with an ARD (Assessment Reference Date) 01/17/2024 revealed resident evaluated by PASRR - No. On 06/04/2024 at 12:30 p.m., an interview was conducted with S4MDS. S4MDS reported the SC MDS was completed on 01/17/2024. S4MDS confirmed the PASRR was not identified on the SC MDS dated [DATE]. She stated she was not aware the resident had a PASRR Level II.

Based on policy review, observation, and interview, the facility failed to ensure medication was stored securely and discarded upon expiration and was not available for improper resident use as evidenced by an expired medication being left in an unlocked refrigerator designated for resident food storage. The facility had a census of 73. Findings: On [DATE] at 12:05 p.m., a review of a policy titled Medication Storage ,with a last revision date of ,d+[DATE], read in part: There shall be storage areas provided that assure . security for medications within the facility, including .a lock and key system with suitable protection against access by unauthorized personnel. This locked system shall be secured when not in use by authorized personnel. A separate and secure area shall be provided for the storage of medications that are discontinued, expired, or otherwise unusable. On [DATE] at 9:20 a.m., an observation of an unlocked refrigerator labeled Resident Refrigerator centrally located on Hall A was conducted with S3ADON (Assistant Director of Nursing). She confirmed the refrigerator was for the use of resident food items and not for medication storage. She stated that residents and their families had access to this refrigerator at any time. During the inspection of the resident food storage refrigerator, a one gallon container of Gavilyte G (a laxative used to clean out the colon), which was half full was observed. The container contained a prescription label for Resident #53 which indicated that it had been dispensed by the pharmacy on [DATE] and had an expiration date of [DATE]. S3ADON confirmed the Gavilyte G was Resident #53's medication, and should not have been placed within the resident food storage refrigerator where anyone had access to and the medication should have been discarded due to it being expired.

Based on record review, observation, and interviews, the facility failed to maintain an effective infection control and prevention program as evidenced by staff failing to put on the appropriate Personal Protective Equipment (PPE) for a resident on Enhanced Barrier Precautions (EBP) and perform hand hygiene and glove changes when indicated during a nephrostomy tube dressing change for 1 (#280) of 2 (#61, #208) residents who were investigated for catheters in a final sample of 25 residents. Findings: On 06/04/2024, a review of the facility's policy titled, Enhanced Barrier Precautions with the latest review date of 03/2024 revealed in part . Enhanced Barrier Precautions require the use of gown and gloves only for high-contact resident care activities. Enhanced Barrier Precautions are indicated for residents with any of the following: Wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO (multidrug-resistant organism). On 06/04/2024, a review of the facility's policy titled, Dressing Change Policy and Procedure with the latest review date of 08/2021 revealed in part . 3. Wash your hands thoroughly before beginning the procedure. 9. Put on disposable gloves. 11. Remove dressing. Pull gloves over dressing and discard into appropriate plastic waste bag. 12. Perform hand hygiene. Put on disposable gloves. 13. Irrigate/cleanse the area as ordered. 16. Perform hand hygiene. Apply disposable gloves. 18. Dress the area with prescribed dressing, date and initial the dressing. A review of Resident #280's electronic health record (EHR) revealed the resident was admitted to the facility on [DATE] with diagnoses that included in part, Malignant Neoplasm of Cervix Uteri, Secondary Malignant Neoplasm of Bladder. A further review of Resident #280's EHR revealed following the physician's orders in part: 1) 05/24/2024 Replace occlusive dressing to (left) nephrostomy tube daily. 2) 05/24/2024 Replace occlusive dressing to (right) nephrostomy tube daily. A review of Resident #280's care plan revealed the following problem in part, Resident has bilateral nephrostomy tubes to lower back flank (Catheter 10.2 French). The interventions included in part, Change dressings to nephrostomy tubes as ordered. Enhanced barrier precautions followed. On 06/04/2024 at 11:39 a.m., an observation was made of S4LPN (Licensed Practical Nurse) as she conducted a dressing change to Resident #280's to left and right nephrostomy tubes. S4LPN entered the room that had an EBP sign on the door and a box outside to the right of the door with PPE available. S4LPN did not put on a gown or gloves before entering the room. S4LPN entered the resident's room then put on a pair gloves. She obtained a piece of saline soaked gauze and held it in her left hand. She then removed the soiled dressing to the right nephrostomy tube site, placed the soiled dressing in her left hand, then cleaned the site with the saline soaked gauze. S4LPN discarded the soiled dressing and gauze into the trash. S4LPN used the same gloves and grabbed another saline soaked gauze. She removed the dressing from the left nephrostomy tube site then cleaned the site with the saline soaked gauze. S4LPN removed her gloves then put on a clean pair of gloves without performing hand hygiene. She proceeded to apply the dressing to the right and left nephrostomy tube sites wearing contaminated gloves since she did not change gloves or perform hand hygiene between both sites. On 06/04/2024 at 11:49 a.m., an interview was conducted with S4LPN. She confirmed Resident #280 was on Enhanced Barrier Precautions and she should have worn a gown to perform wound care. S4LPN confirmed she did not change gloves or perform hand hygiene after she removed the soiled dressing and before she cleaned the wound site and should have. S4LPN confirmed she did not change gloves or perform hand hygiene between the dressing changes on the left and right nephrostomy tubes and should have. On 06/04/2024 at 11:57 a.m., an interview was conducted with S3ADON (Assistant Director of Nursing/Infection Preventions) who confirmed Resident #280 was on Enhanced Barrier Precautions related to bilateral nephrostomy tubes. S3ADON confirmed a gown and glove should have been worn before entering the room and during wound care to the nephrostomy sites. She also confirmed the nurse should have completed glove changes and perform hand hygiene after removing the soiled dressing and between the glove and dressing changes to the left and right nephrostomy tube sites. On 06/04/2024 at 11:59 a.m., an interview was conducted with S2DON (Director of Nursing) confirmed S4LPN should have changed gloves and performed hand hygiene after removing the soiled dressing, before cleaning the site, and between the left and right nephrostomy tube sites.

Based on record review and interview, the facility failed to ensure a reentry MDS (Minimum Data Set) assessment was completed timely for 1 (Resident #14 ) out of 25 sampled residents. The deficient practice had a potential to affect a total census of 73. Findings: A review of Resident #14's electronic medical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included Urinary Tract Infection and Vascular Dementia. A review of Resident #14's electronic medical record revealed the resident was admitted to the hospital on 05/27/2024 and returned on 05/30/2024. Further review of Resident #14's MDS assessments failed to reveal a reentry MDS assessment had been initiated indicating the resident had readmitted from the hospital. On 06/05/24 at 9:51 a.m., an interview and record review was conducted with S7RN (Registered Nurse). S7RN confirmed Resident #14 had a recent hospital stay with a readmitted [DATE]. She reviewed the Resident #14's assessments and confirmed a reentry assessment had not been initiated and was overdue.

Based on record review and interview, the facility failed to maintain a complete medical record on each resident for 1 (#1) out of 3 (#1, #2, #3) sampled residents. This was evidenced by failing to ensure medications were documented as administered on the MAR (medication administration record) after administering to the resident. This deficient practice had the potential to affect a census of 84 residents. Findings: Review of the facility's policy titled, Administration of Medications, read in part: Oral Medication Administration Procedure . 2. Ensure that an appropriate physician's order is in place. 3. Verify the physicians order, comparing the medication label to the MAR to verify the following: a. right medication, b. right dose, c. right route, d. right time, e. right resident. Review of Resident #1's EHR revealed the resident was admitted to the facility on [DATE] with diagnoses in part, but not limited to Gastroenteritis, Colitis, Chronic Kidney Disease, Acute Kidney Disease, Congestive Heart Failure, Schizoaffective Disorder, Bipolar Disorder, Major Depression and Anxiety. Review of the physician's standing orders revealed the following: nausea/vomiting (N/V) - Zofran ODT (orally disintegrating tablet) 4 mg SL (sublingual) Q4H (every 4 hours) times 2 doses, notify MD (Medical Doctor). Review of resident #1's nursing progress notes revealed in part: 11/07/2023 6:57 p.m. at 2:15 p.m., Resident complaining of nausea, no vomiting noted, PRN Zofran given. Signed by S4LPN (Licensed Practical Nurse) Further review of nursing progress notes revealed an entry on 11/09/2023 at 3:30 a.m., resident again called the nurse to her room where she was lying in bed with compliant of pain in her lower abdomen, left side, and nausea. Resident stated it feels like gas bubbles .Zofran administered. Signed by S5LPN. Review of Resident #1's MAR for November 2023 revealed no documentation of the Zofran order or administration of the medication. On 11/20/2023 at 3:00 p.m., an interview was conducted with S4LPN. She stated on 11/07/2023 Resident #1 complained of nausea and was given Zofran, but it was not documented on the MAR. She confirmed the order for Zofran should have been in the EHR and documented on the MAR. On 11/21/2023 at 9:30 a.m., in an interview with S2DON (Director of Nursing), she reviewed Resident #1's physician orders, nursing progress notes and the MAR. S2DON confirmed the nurses notes of Zofran being given to Resident #1 on 11/07/2023 at 6:57 p.m. and 11/09/2023 at 3:30 a.m., for N/V. She also confirmed the physician's standing orders included Zofran ODT 4 mg SL Q4H times 2 doses; notify MD for N/V. She further confirmed the standing order for Zofran was not entered into Resident #1's EHR and there was no documentation on the MAR showing the medication had been given. She stated the order should have been put into Resident #1's EHR and medication should have been documented on the MAR.

Based on record reviews and interviews, the provider failed to ensure that a resident's assessment accurately reflected the resident's status for 1 (#1) out of 3 (#1, #2, #3) residents' records reviewed. The deficiency had the potential to affect a census of 84. Findings: Review of Resident #1's EHR (electronic health record) revealed the resident was admitted to the facility on [DATE] with diagnoses in part, but not limited to Gastroenteritis, Colitis, Chronic Kidney Disease, Acute Kidney Disease, Congestive Heart Failure, Schizoaffective Disorder, Bipolar Disorder, Major Depression and Anxiety. A review of Resident #1's quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 10/18/2023 revealed the resident had a BIMS (Brief Interview for Mental Status) score of 15, indicating resident was cognitively intact. Also, resident was dependent for rolling left to right, sit to lying, lying to sitting on side of bed, sit to stand, chair bed-to-chair transfer, toilet transfer and wheelchair mobility. On 11/20/2023 at 12:30 p.m., an interview was conducted with Resident #1. She reported she was able to care for her own needs and got herself in and out of bed. On 11/20/2023 at 1:30 p.m., an interview was conducted with S3RN (Registered Nurse) MDS. She reviewed Resident #1's quarterly MDS with an ARD date of 10/18/2023. S3RNMDS stated the MDS documentation identified Resident #1 as dependent for rolling left to right, sit to lying, lying to sitting on side of bed, sit to stand, chair bed-to-chair transfer, toilet transfer and wheelchair mobility. S3RNMDS confirmed Resident #1 was independent with mobility and transfers, therefore the MDS was coded incorrectly.

Based on record reviews and interviews, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for 1 (#1) of 3 (#1, #2 and #3) sampled residents. The facility failed to ensure nursing staff: 1. effectively communicated a change in Resident #1's condition to a physician and 2. intervene by following up with the physician after the identified a change in condition for Resident #1 when she continued to display signs of injury and pain. This deficient practice resulted in an immediate jeopardy for Resident #1 on Friday, 10/13/2023 at 7:30 p.m., when S5LPN noted Resident #1's right arm tucked behind her back. She observed the resident whimpering and her right arm was swollen and puffy. S5LPN notified S9MD's office via fax at approximately 10:30 p.m. that same evening when the physician's office was closed and would have remained closed and not staffed for the weekend. Nursing staff verbalized the resident's arm was red and swollen and displayed signs of pain yet failed to assess and administer medication for pain or implement any interventions to address the resident's injury. On Monday, 10/16/2023 at 7:11 a.m. S3LPN observed the resident crying in pain due to her arm injury, notified the doctor by phone and sent the resident to the hospital for evaluation and treatment where she was diagnosed with a fracture of the right arm. The facility implemented corrective actions and was in substantial compliance on 10/16/2023 prior to the State Agency's investigation on 11/08/2023; thus, it was determined to be a Past Noncompliance citation. Findings: Review of the facility's policy for Change in Resident Medical Status revealed the following: A facility must immediately inform the resident; consult with the resident's physician when there is a significant change in the resident's physical, mental or psychological status. A significant change is defined as a major decline or improvement in the resident's status that will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions, is not self-limiting .A facility must immediately inform the resident; consult with the resident's physician and notify, consistent with his or her authority, the resident representative when there is an accident involving the resident which results in injury and has the potential requiring physician intervention . Review of the facility's policy for Pain Screen and Management revealed the following: .all residents have the right to treatment for pain .non-communicative residents are assess by observation on nonverbal behavior .A pain screen is completed when a resident has a new onset of pain, a new type of pain, new pain medication or treatment, or when a resident has not experienced an acceptable level of pain relief .when documenting regarding pain, the following elements should be addressed: date and time of onset, location of pain, character, severity, alleviate factors, exacerbation factors, treatments and medication, responses . Review of Resident #1's clinical record revealed the resident was admitted on [DATE] with diagnoses to included, but not limited to, Hemiplegia and Hemiparesis following Cerebral Infarction affecting Right Dominant Side, Dementia without Behavioral Disturbance, Cognitive Communication Deficit, Generalized Muscle Weakness, and Specified Disorders of Bone Density and Structure. Review of Resident #1's MDS (Minimum Data Set, a standardized health status assessment) with ARD (Assessment Reference Date) of 08/08/2023 (prior to injury) revealed Resident #1 had a BIMS (Brief Interview for Mental Status) score of 8 which indicated the resident to be mildly impaired. The MDS also revealed Resident #1 was dependent of staff for her functional status. Section GG, titled Functional Abilities and Goals, indicated the resident had impairment on one side of the upper extremity. Further review revealed she was not on a scheduled pain medication regimen nor was receiving as needed pain medication. Review of Resident #1's MDS (Minimum Data Set, a standardized health status assessment) with ARD (Assessment Reference Date) of 10/16/2023 (after injury) revealed Resident #1 had a BIMS (Brief Interview for Mental Status) score of 8 which indicated the resident to be mildly impaired. The MDS also revealed Resident #1 was dependent of staff for her functional status. Section GG, titled Functional Abilities and Goals, indicated the resident had impairment on one side of the upper extremity. Further review revealed the resident had occasional pain and received as needed pain medications. Review of Resident #1's Care Pan included the following, in part: Date initiated: 01/22/2021. ADL Function-bed mobility, transfers, locomotion requires total assistance. Goal: Resident will have needs met through next review. Approach: assist resident with turning and repositioning in bed and observe for and notify MD as needed for any joint pain and/or discomfort. Date initiated: 01/22/2021. Health Condition-resident has a diagnosis of hemiplegia/hemiparesis-CVA with right hemi (hemiparesis - one sided muscle weakness). Goal: Resident will have all needs met through next review. Approach: notify MD of any complications and assist resident with ADL's as needed. Date initiated: 01/22/2021. Resident is at risk for pain related to diagnosis of CVA (Cerebrovascular Accident) with hemi to right side. Goal: Resident will not have any unrelieved pain through next review. Approach: administer meds as ordered, notify MD of any unrelieved pain, and observe onset, location, severity, and duration of pain. Date initiated: 10/16/2023. Health condition-resident has a diagnosis of osteopenia. Goal: resident will have no complications through next review. Approach: notify MD of any unrelieved pain/discomfort. Review of Resident #1's October 2023 MAR (Medication Administration Record) revealed the following: -Monitor for edema every shift: Day shift: 10/13/2023 was documented as trace. 10/14/2023 & 10/15/2023 was documented as none. Evening shift: 10/13/2023, 10/14/2023 & 10/15/2023 was documented as no. Night shift: 10/13/2023, 10/14/2023 & 10/15/2023 was documented as no. -Observe for s/s abnormal bleeding/bruising every shift. All shifts for 10/13/2023, 10/14/2023 and 10/15/2023 were answered as no. Further review revealed that the Tylenol S7LPN documented as administered in her nurse's note dated and timed 10/13/2023 at 10:00 p.m. was not reflected on the resident's MAR nor were there any additional doses documented by any other staff from 10/13/2023 to 10/15/2023. Review of Resident #1 Nurses Notes revealed the following: 10/13/2023 10:00 p.m. Right arm and hand swollen and red. Resident repositioned off of arm. Tylenol given for pain. Doctor faxed and waiting for response. Sore noted to elbow area of right arm. Signed by S5LPN. 10/16/2023 7:11 a.m. During morning rounds, resident noted in bed with eyes open and crying. Resident complaining of severe pain to right arm. Assessment completed. Severe swelling noted to right mid arm. Right elbow dark red scab noted with red, light purple and yellow discoloration noted. Right arm warm to touch .Vital signs stable . 7AM verbal order received to transfer resident to ER for evaluation and treatment related to right arm edema, pain and discoloration. Signed by S3LPN. Further review of nurse's notes for the resident revealed that there were no notes regarding the resident's injury, pain, or additional attempts to notify a physician after Friday, 10/13/2023 at 10:00 p.m. until Monday, 10/16/2023 at 7:11 a.m. when S3LPN assessed the injury, notified the doctor and sent the resident to the hospital for evaluation and treatment. Review of Resident #1's hospital medical records revealed the attending physician, S10MD (Medical Doctor), noted on the resident's disposition: obvious area of ecchymosis (bruising) and the patient moans with pain upon palpation (physical exam). CT (cat scan) of the upper extremity for pain in the right arm revealed an acute transverse distal humeral (upper arm bone) fracture .additional non-displaced fracture through the base of the olecranon (part of the elbow) process suspected. On 11/06/2023 at 2:00 p.m., an observation was made of the resident sitting in her wheelchair in the hallway. She was pleasant and smiled when spoken to but did not answer any questions, only smiled. There was no evidence or outward displays of pain or discomfort observed. On 11/08/2023 at 10:40 a.m., an observation was made of the resident lying in her bed. Resident is awake and alert but did not communicate verbally. Resident is noted lying on left side with her right arm in a soft cast and elevated on a pillow. Resident did not demonstrate any outward signs or symptoms of pain or discomfort An interview was conducted on 11/06/2023 at 3:00 p.m. with S4CNA (Certified Nursing Assistant). She confirmed she cared for the resident on the evening of Friday, 10/13/2023. She stated when she initiated care, Resident #1's right arm was lying across her abdomen and stated this is when she noticed the discoloration and swelling of the resident's right arm. She then notified S5LPN (Licensed Practical Nurse) immediately and they elevated Resident #1's arm using a wedge after they changed the resident's bedding. She confirmed the resident had bruising to the right arm along with redness. An attempt for a follow-up interview with S4CNA was made on 11/08/2023 at 10:15 a.m. but was unsuccessful. An interview was conducted on 11/06/2023 at 3:15 p.m. with S5LPN who worked the 2:00 pm to 10:00 pm shift on 10/13/2023. She reported that on 10/13/2023 around 6:30 p.m. - 7:00 p.m., S4CNA notified her that Resident #1's right arm was red and crying in pain. S5LPN stated that when she entered the room, Resident #1's right elbow was tucked under her back and that resident's right arm was swollen and puffy and thought that it was caused by her being on the arm for an undetermined amount of time. She denied seeing any bruising at that time. She reported that the resident was whimpering but did not continue to cry or whimper after she was left alone. She stated that she did not immediately notify the doctor and continued to administer medications to other residents. She reported that when she did notify the doctor, it was by fax but should have called instead due to it being after normal business hours on a Friday evening. A phone interview was conducted on 11/07/2023 at 1:15 p.m. with S6LPN who worked the night shift (10:00 pm to 6:00 a.m.) on 10/13/2023 and cared for Resident #1. She confirmed that S5LPN told her Resident #1's right arm was red, swollen, painful, and that the doctor had been notified. She stated she never received any communication from the doctor and never followed up with any doctor regarding the resident's arm during her shift. She reported that she communicated the resident's change of condition to the oncoming nurse (S7LPN) at the end of her shift. A phone interview was conducted on 11/07/2023 at 2:12 p.m. with S7LPN. She established that she worked double shifts (from 6:00 a.m. to 10:00 p.m.) on both 10/14/2023 and 10/15/2023 and cared for Resident #1. S7LPN stated that the resident cannot move or reposition herself. She attested that upon her first assessment of the resident on 10/14/2023 at 8:00 a.m., the resident's right arm was swollen and had some mild yellow discoloration. She verified that she had received information about Resident #1's arm from S6LPN and that the doctor had been notified but did not clarify if the doctor had called or responded to the notification. She stated she first assessed the resident at around 8:00 a.m. on 10/14/2023 when she administered medications to the resident. She stated the resident's right arm was swollen and had some mild yellow discoloration but saw nothing immediately alarming. She stated that the resident never gave any cues of pain and therefore never administered pain medications. She stated that she did not assess the resident's range of motion or pulse because it was her paralyzed side and only visually inspected it. S7LPN stated that because she worked double weekend shifts, she never faxed a doctor to report changes in a resident's condition because no one would be in the office. She always called the on-call physician if needed. She confirmed that had she known that the physician was only faxed about the resident's arm, she would have called him for a follow up. She verified that she gave report to the oncoming nurse (S11LPN) that the resident's right arm was red, swollen, and that the physician had been contacted. An interview was conducted on 11/06/2023 at 1:45 p.m. with S3LPN. She stated she was first notified by S8CNA that Resident #1's right arm was swollen, red and she was crying in pain on Monday, 10/16/2023 at 7:11 a.m. Upon her assessment she noted yellow, blue, green and purple bruising to the resident's right outer arm (elbow area) spreading to the inner arm (elbow crease area) and also noted a skin tear to the outer elbow. She stated she attempted to perform an assessment but the resident would not allow her manipulate the arm due to pain. She verified that she immediately phoned the doctor to report her assessment, followed by phoning the ambulance services, the resident's family, S2DON, and finally the hospital to give a report. An interview was conducted on 11/06/2023 at 2:30 p.m. with S2DON (Director of Nursing). She confirmed that S3LPN notified her of Resident's #1's condition and that the resident was being transferred to the hospital for evaluation and treatment. S2DON confirmed that the physician should have been contacted by phone as opposed to fax when Resident #1's arm first appeared red and swollen on 10/13/2023. S2DON confirmed that the nurses had not documented bruising on this resident as listed on her MAR. She then reviewed resident's nurse's notes and confirmed that the only documentation the resident's injury was at the time of discovery on 10/13/2023 and again at the time the resident was sent to the hospital on 10/16/2023. She stated that that there was no evidence of monitoring for or assessment of the resident's injury for 3 days. She viewed nurse's note on 10/13/2023 by S7LPN at the time of initial discovery and stated that it failed to reflect that the resident had a full assessment of the right arm (including range of motion, pulse, capillary refill, hand grasps). An interview was conducted on 11/06/2023 at 4:20 pm with S2DON and S1ADM. S2DON reviewed the resident's plan of care for pain and agreed that the resident should have had pain monitoring especially because of the injury. She was unable to produce any evidence/documentation that staff had assessed and monitored the resident's pain. at this An interview was conducted on 11/08/2023 at 11:00 a.m. with S9MD. He confirmed that there is no one in his office after hours or on weekends to monitor faxes and confirmed his office hours are Monday -Friday, 8:00 a.m. - 5:00 p.m. S9MD confirmed, that if a resident demonstrated new onset extremity pain, swelling, tenderness, discoloration and/or temperature changes, he or the on-call physician should have been notified by phone, not fax. Interviews with multiple nursing and CNA staff verified that they were in-serviced and corroborated that the facility was conducting pain monitoring, ADL monitoring, MD notification monitoring, and abuse/neglect monitoring as per the corrective action plan. An interview was conducted on 11/08/2023 at 1:05 p.m. with S1ADM. She stated that the initial QA monitoring performed on Monday, 10/16/2023 resulted in the facility being in compliance with the exception of Resident #1's reported incident. She verified that the monitoring will continue weekly for another 2 months or longer if any negative outcomes are discovered. The facility implemented the following actions beginning Monday, 10/16/2023 to correct the deficient practice that occurred on 10/13/2023: 1. S2DON and S1ADM immediately opened an investigation into the injury of unknown origin. 2. On 11/16/2023, S1ADM and S2DON conducted staff re-education with all staff on the following: Proper assessment for Pain and Notification to MD, Pain Scales, Abuse Neglect Injury of Unknown Origin, ADL care & Transfers per lift status and care plan, Any and all PRN medications administered must be entered into AHT, Change of status of residents should be documented every shift and reported to physician and responsible party. 3. Monitoring performed by DON or Designee. Monitoring consists of accurate ADL care, accurate pain assessment, MD notification as needed, abuse/neglect/injury of unknown origin.

Based on interviews and record reviews, the facility failed to ensure nursing staff effectively notified the physician of a resident's injury for 1 (Resident #1) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents. This deficient practice resulted in an immediate jeopardy for Resident #1 on Friday, 10/13/2023 at 7:30 p.m., when S5LPN noted Resident #1's right arm tucked behind her back. She observed the resident's whimpering and her right arm was swollen and puffy. S5LPN notified S9MD's office via fax at approximately 10:30 p.m. that same evening when the physician's office was closed and would have remained closed and not staffed for the weekend. On Monday, 10/16/2023 at 7:11 a.m. S3LPN observed the injury, notified the doctor by phone and sent the resident to the hospital for evaluation and treatment where she was diagnosed with a fracture of the right arm. The facility implemented corrective actions and was in substantial compliance on 10/16/2023 prior to the State Agency's investigation on 11/08/2023; thus, it was determined to be a Past Noncompliance citation. Findings: Review of the facility's policy for Change in Resident Medical Status revealed the following: A facility must immediately inform the resident; consult with the resident's physician when there is a significant change in the resident's physical, mental or psychological status. A significant change is defined as a major decline or improvement in the resident's status that will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions, is not self-limiting. Review of Resident #1's clinical record revealed the resident was admitted on [DATE] with diagnoses to included, but not limited to, Hemiplegia and Hemiparesis following Cerebral Infarction affecting Right Dominant Side, Dementia without Behavioral Disturbance, Cognitive Communication Deficit, Generalized Muscle Weakness, and Specified Disorders of Bone Density and Structure. Review of Resident #1's MDS (Minimum Data Set, a standardized health status assessment) with ARD (Assessment Reference Date) of 08/08/2023 (prior to injury) revealed Resident #1 had a BIMS (Brief Interview for Mental Status) score of 8 which indicated the resident to be mildly impaired. The MDS also revealed Resident #1 was dependent of staff for her functional status. Section GG, titled Functional Abilities and Goals, indicated the resident had impairment on one side of the upper extremity. Further review revealed she was not on a scheduled pain medication regimen nor was receiving as needed pain medication. Review of Resident #1's MDS (Minimum Data Set, a standardized health status assessment) with ARD (Assessment Reference Date) of 10/16/2023 (after injury) revealed Resident #1 had a BIMS (Brief Interview for Mental Status) score of 8 which indicated the resident to be mildly impaired. The MDS also revealed Resident #1 was dependent of staff for her functional status. Section GG, titled Functional Abilities and Goals, indicated the resident had impairment on one side of the upper extremity. Further review revealed the resident had occasional pain and received as needed pain medications. Review of Resident #1's Care Pan included the following, in part: Date initiated: 01/22/2021. ADL Function-bed mobility, transfers, locomotion requires total assistance. Goal: Resident will have needs met through next review. Approach: assist resident with turning and repositioning in bed and observe for and notify MD as needed for any joint pain and/or discomfort. Date initiated: 01/22/2021. Health Condition-resident has a diagnosis of hemiplegia/hemiparesis-CVA with right hemi (hemiparesis - one sided muscle weakness). Goal: Resident will have all needs met through next review. Approach: notify MD of any complications and assist resident with ADL's as needed. Date initiated: 01/22/2021. Resident is at risk for pain related to diagnosis of CVA (Cerebrovascular Accident) with hemi to right side. Goal: Resident will not have any unrelieved pain through next review. Approach: administer meds as ordered, notify MD of any unrelieved pain, and observe onset, location, severity, and duration of pain. Date initiated: 10/16/2023. Health condition-resident has a diagnosis of osteopenia. Goal: resident will have no complications through next review. Approach: notify MD of any unrelieved pain/discomfort. Review of Resident #1 Nurses Notes revealed the following: 10/13/2023 10:00 p.m. Right arm and hand swollen and red. Resident repositioned off of arm. Tylenol given for pain. Doctor faxed and waiting for response. Sore noted to elbow area of right arm. Signed by S5LPN. 10/16.2023 7:11 a.m. During morning rounds, resident noted in bed with eyes open and crying. Resident complaining of severe pain to right arm. Assessment completed. Severe swelling noted to right mid arm. Right elbow dark red scab noted with red, light purple and yellow discoloration noted. Right arm warm to touch .Vital signs stable . 7AM verbal order received to transfer resident to ER for evaluation and treatment related to right arm edema, pain and discoloration. Signed by S3LPN. Further review of nurse's notes for the resident revealed that there were no notes regarding the resident's injury or additional attempts to notify a physician after Friday, 10/13/2023 at 10:00 p.m. until Monday, 10/16/2023 at 7:11 a.m. when S3LPN assessed the injury, notified the doctor and sent the resident to the hospital for evaluation and treatment. Review of Resident #1's hospital medical records revealed the attending physician, S10MD (Medical Doctor), noted on the resident's disposition: obvious area of ecchymosis (bruising) and the patient moans with pain upon palpation (physical exam). CT (cat scan) of the upper extremity for pain in the right arm revealed an acute transverse distal humeral (upper arm bone) fracture .additional non-displaced fracture through the base of the olecranon (part of the elbow) process suspected. On 11/06/2023 at 2:00 p.m., an observation was made of the resident sitting in her wheelchair in the hallway. She was pleasant and smiled when spoken to but did not answer any questions, only smiled. There was no evidence or outward displays of pain or discomfort observed. On 11/08/2023 at 10:40 a.m., an observation was made of the resident lying in her bed. Resident is awake and alert but did not communicate verbally. Resident is noted lying on left side with her right arm in a soft cast and elevated on a pillow. Resident did not demonstrate any outward signs or symptoms of pain or discomfort An interview was conducted on 11/06/2023 at 3:00 p.m. with S4CNA (Certified Nursing Assistant). She confirmed she cared for the resident on the evening of Friday, 10/13/2023. She stated when she initiated care, Resident #1's right arm was lying across her abdomen and stated this is when she noticed the discoloration and swelling of the resident's right arm. She then notified S5LPN (Licensed Practical Nurse) immediately and they elevated Resident #1's arm using a wedge after they changed the resident's bedding. She confirmed the resident had bruising to the right arm along with redness. An interview was conducted on 11/06/2023 at 3:15 p.m. with S5LPN who worked the 2:00 pm to 10:00 pm shift on 10/13/2023. She reported that on 10/13/2023 around 6:30 p.m. - 7:00 p.m., S4CNA notified her that Resident #1's right arm was red and crying in pain. S5LPN stated that when she entered the room, Resident #1's right elbow was tucked under her back and that resident's right arm was swollen and puffy and thought that it was caused by her being on the arm for an undetermined amount of time. She denied seeing any bruising at that time. She reported that the resident was whimpering but did not continue to cry or whimper after she was left alone. She stated that she did not immediately notify the doctor and continued to administer medications. She reported that when she did notify the doctor, it was by fax but should have called instead due to it being after normal business hours on a Friday evening. A phone interview was conducted on 11/07/2023 at 1:15 p.m. with S6LPN who worked the night shift (10:00 pm to 6:00 a.m.) on 10/13/2023 and cared for Resident #1. She confirmed that S5LPN told her Resident #1's right arm was red, swollen, painful, and that the doctor had been notified. She stated she never received any communication from the doctor and never followed up with any doctor regarding the resident's arm during her shift. She reported that she communicated the residents' change of condition to the oncoming nurse (S7LPN) at the end of her shift. A phone interview was conducted on 11/07/2023 at 2:12 p.m. with S7LPN. She established that she worked double shifts (from 6:00 a.m. to 10:00 p.m.) on both 10/14/2023 and 10/15/2023 and cared for Resident #1. She attested that upon her first assessment of the resident on 10/14/2023 at 8:00 a.m., the resident's right arm was swollen and had some mild, yellow discoloration. She verified that she had received information about Resident #1's arm from S6LPN and that the doctor had been notified. She stated that she did not clarify if the doctor had called or responded to the notification. She confirmed that had she known that the physician was only faxed about the resident's arm, she would have called him for a follow up. An interview was conducted on 11/06/2023 at 1:45 p.m. with S3LPN. She stated she was first notified by S8CNA that Resident #1's right arm was swollen, red and she was crying in pain on Monday, 10/16/2023 at 7:11 a.m. Upon her assessment she noted yellow, blue, green and purple bruising to the resident's right outer arm (elbow area) spreading to the inner arm (elbow crease area) and also noted a skin tear to the outer elbow. She stated she attempted to perform an assessment but the resident would not allow her manipulate the arm due to pain. She verified that she immediately phoned the doctor to report her assessment, followed by phoning the ambulance services, the resident's family, S2DON, and finally the hospital to give a report. An interview was conducted on 11/06/2023 at 2:30 p.m. with S2DON (Director of Nursing). She confirmed that S3LPN notified her of Resident's #1's condition and that the resident was being transferred to the hospital for evaluation and treatment. S2DON confirmed that the physician should have been contacted by phone as opposed to fax for Resident #1. An interview was conducted on 11/08/2023 at 11:00 a.m. with S9MD. He confirmed that there is no one in his office after hours or on weekends to monitor faxes and confirmed his office hours are Monday -Friday, 8:00 a.m. - 5:00 p.m. S9MD confirmed, that if a resident demonstrated new onset extremity pain, swelling, tenderness, discoloration and/or temperature changes, he or the on-call physician should have been notified by phone, not fax. Interviews with multiple nursing and CNA staff verified that they were in-serviced and corroborated that the facility was conducting pain monitoring, ADL monitoring, MD notification monitoring, and abuse/neglect monitoring as per the corrective action plan. An interview was conducted on 11/08/2023 at 1:05 p.m. with S1ADM. She stated that the initial QA monitoring performed on Monday, 10/16/2023 resulted in the facility being in compliance with the exception of Resident #1's reported incident. She verified that the monitoring will continue weekly for another 2 months or longer if any negative outcomes are discovered. The facility implemented the following actions beginning Monday, 10/16/2023 to correct the deficient practice that occurred on 10/13/2023: 1. S2DON and S1ADM immediately opened an investigation into the injury of unknown origin. 2. On 11/16/2023, S1ADM and S2DON conducted staff re-education with all staff on the following: Proper assessment for Pain and Notification to MD, Pain Scales, Abuse Neglect Injury of Unknown Origin, ADL care & Transfers per lift status and care plan, Any and all PRN medications administered must be entered into AHT, Change of status of residents should be documented every shift and reported to physician and responsible party. 3. Monitoring performed by DON or Designee. Monitoring consists of accurate ADL care, accurate pain assessment, MD notification as needed, abuse/neglect/injury of unknown origin.

Based on records reviewed and interviews, the facility failed to implement the person centered care plan by not following physician orders for 4 (#1, #15, #46, #57 and #58) residents out of a total of 32 sampled residents as evidenced by failing to: 1. obtain a monthly weights as per facility policy and procedure for Resident #1 and, 2. document dietary intake amount for each meal as ordered for Residents #1, #15, #57 and # 58, and, 3. obtain laboratory testing as ordered for Resident #46 This deficient practice had the potential to affect the 79 residents who resided in the facility. Findings: Resident #1 Resident #1 was admitted to the facility on [DATE] with diagnoses including: End Stage Renal Disease, Diabetes Mellitus, Dysphagia, Dementia, Malnutrition and Depression. Review of Resident #1's physician orders revealed in part: order entry dated 03/20/2023 Pureed/thin liquids, renal diet, and order entry dated 05/09/2023 Tube Feeding formula, Nepro at 40ml/hr (milliliters per hour) via PEG (percutaneous endoscopic gastrostomy) continuous with 100 ml water flush every shift. Okay to hold tube feeding while at dialysis. Review of Resident #1's Medicare 5 day MDS (minimum data set) assessment dated [DATE] revealed a BIMS (Brief Interview for Mental Status) score of 04, indicating the resident had severe cognitive impairment. The facility did not provide documentation of meal intake percentages for Resident #1 by survey exit. Resident #15 Resident #15 was admitted to the facility on [DATE] including diagnoses in part: Malnutrition, Abnormal Posture, Dementia, Depression, Diabetes Mellitus, Pressure Ulcer and Anxiety. Review of Resident #15's quarterly MDS assessment dated [DATE] revealed a BIMS score of 08, which indicated moderate cognitive impairment. Review of Resident #15's physician's orders revealed in part an order dated 05/26/2021 Mechanical soft diet, Record Diet intake amount for each meal. Review of meal intake percentages documentation from April 1, 2023 to May 8, 2023 failed to include documentation of all meals consumed by Resident #15 as ordered. The following dates did not include documented percentages for Resident #15's meals consumed: Breakfast: 04/01/2023, 04/02/2023, 04/04/2023, 04/08/2023, 04/09/2023, 04/15/2023, 04/16/2023, 04/21/2023, 04/22/2023, 04/23/2023, 04/26/2023, 04/30/2023, 05/04/2023, 05/06/2023 and 05/07/2023. Lunch: 04/01/223, 4/02/2023, 04/08/2023, 04/09/2023, 04/14/2023, 04/15/2023, 04/16/2023, 04/17/2023, 04/21/2023, 04/22/2023, 04/23/2023, 04/26/2023, 04/30/2023, 05/04/2023, 05/06/2023 and 05/07/2023. Dinner: only documented percentages were on 04/05/2023, 04/06/2023, 04/13/2023, 04/20/2023, 04/21/2023, and 04/30/2023. Resident #57 Resident #57 was admitted to facility on 01/21/2021 including diagnoses in part: Dementia, Cellulitis Left Lower Limb, Stage III Pressure Ulcer Left Heel, Stage III Pressure Ulcer to Right Heel, Malnutrition and Depression. Review of Resident #57's quarterly MDS assessment dated [DATE] revealed a BIMS score of 03, indicating a severe cognitive impairment. Review of Resident #57's physician's orders revealed in part: order entry dated 01/21/2021 - Diet: No Salt on tray, record diet amount for each meal. Review of resident #57's meal intake percentages documentation from April 1, 2023 to May 8, 2023 revealed not all meals were documented as ordered. The following dates did not include ordered meal intake percentages: Breakfast: 04/01/2023, 04/02/2023, 04/08/2023, 04/09/2023, 04/15/2023, 04/16/2023, 04/21/2023, 04/22/2023, 04/23/2023, 04/26/2023, 04/30/2023, 05/04/2023, 05/06/2023 and 05/07/2023. Lunch: 04/01/2023, 04/02/2023, 04/08/2023, 04/09/2023, 04/15/2023, 04/16/2023, 04/21/2023, 04/22/2023, 04/23/2023, 04/26/2023, 04/30/2023, 05/04/2023, 05/06/2023 and 05/07/2023. Dinner: only documented percentage were on 04/05/2023, 04/13/2023, 04/20/2023, 04/21/2023 and 04/30/2023. On 05/09/2023 at 1:00 p.m., an interview was conducted with S5LPN (Licensed Practical Nurse), she reported the LPN's were responsible for ensuring the meals percentages were documented for each meal in the residents electronic record. On 05/09/2023 at 2:45 p.m., an interview was conducted with S2DON, she confirmed the meal percentages were to be documented as ordered and the LPN was responsible for ensuring the meals were charted as ordered. On 05/09/2023 at 2:55 p.m., a review of each identified residents' electronic record was conducted with S5DON and surveyor. S5DON confirmed the staff were not documenting all meal percentages in the identified residents' electronic record and should have since they had physician orders to do so. 47251 Resident #46 Resident #46 was admitted on [DATE] with diagnoses of Chronic Systolic Heart Failure, Hypertensive Chronic Kidney Disease, Unspecified Atrial Fibrillation, Unspecified Severe Protein-Calorie Malnutrition, Chronic Obstructive Pulmonary Disease, Hypertension, Anxiety, Unspecified Dementia, and Schizophrenia. Review of the resident's Quarterly MDS dated [DATE] revealed a BIMS of 15 which indicated the resident is cognitively intact. Review of Resident #46's current Physician Orders for May 2023 revealed: Draw VPA (Valporic Acid), LFT (Liver Function Test) and CBC (Complete Blood Count) Every 3 Months (March, June, September, December). Review of Resident #46, Electronic Health Record and paper record revealed no documentation that an LFT or VPA had been completed for March 2023. In an interview conducted with S2DON on 05/09/23 at 04:31 a.m., she stated that there was no evidence that an LFT or VPA had been collected on Resident #46 for March 2023. Resident #58 Resident # 58 was admitted on [DATE] with diagnoses that included Mood Disorder, Major Depressive Disorder, Vascular Dementia, Hypertension, Schizophrenia, Anxiety Disorder, Essential Tremor, Dysphagia, and Chronic Kidney Disease. Review of the resident's Quarterly MDS (Minimum Data Set) dated 03/08/2023 revealed a BIMS (Brief Interview for Mental Status) of 5, indicated the resident had severe cognitive impairment. Review of Resident #58's current Physician's Orders for May 2023 revealed: Diet: NSOT (No Salt On Tray). Record Diet Amount For Each Meal 1=25%, 2=50%, 3=75%, 4= 100%, 5=Refused. Review of meal intake percentage documentation from May 01, 2023 to May 09, 2023 revealed that not all meals were documented as ordered. Percentage of breakfast consumption was not documented for the following: 05/01/2023, 05/05/2023, 05/06/2023, 05/07/2023, and 05/08/2023. Percentage of lunch consumption was not documented for the following dates as: 05/01/2023, 05/02/2023, 05/03/2023, 05/05/2023, 05/06/2023, 05/07/2023, and 05/08/2023. Percentage of dinner consumption was not documented for the following dates: 05/01/2023, 05/06/2023 and 05/07 2023. On 05/10/23 at 03:00 p.m., an interview was conducted with S2DON and she confirmed meal percentage documentation intake for Resident #58 was incomplete.

Based on record review, observation, and interviews, the facility failed to protect the residents' right to be free from physical abuse by other residents for 1 (#27) out of 32 sampled residents. The facility failed to protect Resident #27 from physical abuse when Resident #32 shoved Resident #27 in the left shoulder on 2/28/2023. The facility had a census of 79. Findings: Review of the facility's incident, investigation, and reporting policy revealed .Each resident residing in this facility has the right to be free from any type of abuse including: verbal, sexual, mental, physical abuse, neglect, exploitations, misappropriation of resident property .Relevant terms: Abuse: Abuse is the willful infliction of injury .Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Resident #27 Review of Resident #27's record revealed she was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, Unspecified Dementia Without Behavioral Disturbance, Alzheimer's Disease, Essential Hypertension, Anxiety Disorder, Hyperlipidemia, Review of Resident #27's most recent Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 11 indicating her cognition was moderately impaired. Review of Resident #27's comprehensive care plan, dated 02/28/2023, revealed in part Resident has physical behavior towards others-resident had altercation with roommate. Review of the facility's Incident Report for the past 120 days revealed one incident of Px (Physical) contact-res (resident) for Resident #27 dated 02/28/2023 at 8:08 p.m. Review of the facility's Incident Report dated 02/28/2023 at 08:08 p.m., revealed in part the following: Incident Type: Px contact-res Report Prepared By: S8LPN (Licensed Practical Nurse) Nursing Description: Separated from another resident (Resident #32) d/t (due to) verbal confrontation in res doorway. Res was pointing her finger and arguing with roommate stating, This is my apartment not yours. Removed and assisted to a chair in the hallway to deescalate the situation. Head to toe assessment performed without injury noted. Res stated, She (Resident #32) just pushed me a little. Denied pain. Removed other resident to another room for safety. Notified DON (Director of Nursing) and Administration. Notified Resident daughter. Injury Type: None apparent Location: Other Action Taken Description: Separated the two resident Review of Resident #27's weekly body audit dated 03/01/2023, revealed, in part, the following: Head to toe assessment completed. Resident had no skin tears, bruises or abrasions noted. Skin intact, warm and dry to touch, no complaints pain currently noted. On 05/10/2023 at 08:27 a.m., an interview and observation was conducted with Resident #27. She stated she did not remember any incident of her former roommate (Resident #32) pushing her. Resident #32 Review of Resident #32's record revealed she was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, Vascular Dementia Unspecified Severity, Major Depressive Disorder, Anxiety Disorder, Mild Cognitive Impairment, Essential Hypertension Review of Resident #32's most recent Quarterly MDS assessment, dated 04/05/2023, revealed the resident had a BIMS score of 6 indicating her cognition was severely impaired. Review of Resident #32's comprehensive care plan, dated 02/28/2023, revealed, in part, resident had roommate had altercation. Review of Resident #32's Nurses Notes revealed, in part, the following: 02/28/2023 at 8:06 p.m., written by S8LPN. Observed resident standing in doorway of resident assessment performed Denies pain. Denies other resident (Resident #27) hitting or touching her. Stated. hell no she did not hit me! Notified resident #32's daughter. On 5/9/2023 at 3:37 p.m., an interview and observation was conducted with Resident #32. She was asked about the incident with Resident #27 and she stated she had no idea why she was being asked that question because she just got to the facility yesterday. Resident #32 was confused and did not remember the incident. On 05/09/2023 at 09:06 a.m., an interview was conducted with S1ADM and S2DON. S2DON stated the LPN that was on duty for the shift for 2/28/2023 had not witnessed the incident. Per S2DON, S8LPN was an agency LPN that picked up shifts every now and again. S1ADM stated she was the one who investigated the incident. Per her investigation, Resident #32 was telling Resident #27 to get out of her room. Resident #27 and Resident #32 started arguing over whose room it was. Resident #32 took Resident #27's popcorn and threw it on the floor. After this, Resident #32 shook her finger in Resident #27's face. Resident #32 then proceeded to push Resident #27 on the left upper side of her chest. This was an unwitnessed incident. S1ADM stated that she instructed S8LPN to separate the residents since they were roommates Resident #27 was moved to a different room and there has been no further incidents between the two residents. Three attempts were made to retrieve S8LPN'S contact information from S1ADM, and S2DON on 05/09/2023 at 09:06 a.m. and at 3:02 p.m. as well as on 5/10/2023 at 08:00 a.m. S1ADM and S2DON failed to provide S8LPN's contact information.