Every finding on record at Greenfield Rehabilitation & Health Care Center

Based on clinical record review, staff interviews, and policy review, the facility failed to fully inform the resident and/or representative of alternative psychotropic medication options by failing to identify target behaviors (TBs) or non-pharmacologic interventions (NPIs) on psychotropic medication (medications that affect a person's mental state, emotions, and behavior) consent forms for 5 of 5 residents (#5, #8, #4, #30, #42). The facility reported a census of 43 residents. Findings include:1.Resident #5's quarterly Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 04 out of 15 which indicated severely impaired cognition. It included diagnoses of non-Alzheimer's dementia with other behavioral disturbances, and depression. It revealed the resident took antipsychotic and antidepressant medications in the 7-day look-back period. It indicated the resident was independent with eating, dependent with footwear, and shower and bed transfers, and required maximal assistance with all other Activities of Daily Living (ADLs) and bed repositioning. The Electronic Health Record (EHR) included a physician's order dated 5/07/26 for trazodone (antidepressant) by mouth daily for insomnia, a second physician's order dated 5/08/26 for duloxetine (antidepressant) by mouth daily for depression, and a third physician's order dated 6/08/26 for Rexulti (antipsychotic) by mouth daily for dementia with behavioral disturbances. Each medication had (2) documents titled Consent For Psychotropic Medication Therapy dated 12/23/24 and 5/11/26. Neither set of consents included the required TBs or NPIs for any of the three (3) prescribed psychotropic medications. On 8/25/26 at 2:13 PM, Staff B, Licensed Practical Nurse (LPN) stated Resident #5 withdrew from interactions, refused to eat, and stayed in bed when she became depressed and hallucinated during psychotic moments. She stated staff tried to anticipate her needs or provided 1:1 reassurance when she became depressed or had a psychotic hallucination. On 8/25/26 at 2:30 PM, Staff D, Certified Nurse Aide (CNA) stated the resident would appear spaced out as though she's unable to comprehend information when she became depressed and would ask about people who were no longer alive as though they were when she had a psychotic episode. She also stated staff provided therapeutic communication during the resident's behavioral symptoms. The Care Plan revised 6/05/26 indicated the resident had behavior problems and directed staff to monitor behavior episodes but did not identify what the resident-specific behaviors were. The Care Plan also failed to include NPIs for staff to attempt. 2. Resident #8's MDS assessment dated [DATE] identified a BIMS score of 15 out of 15 which indicated completely intact cognition. It included diagnoses of depression and post-traumatic stress disorder (PTSD). It revealed the resident took antidepressant medications in the 7-day look-back period. It indicated the resident required supervision with bathing and ambulatory mobility, and was independent with all other ADLs and mobility. The EHR included a physician's order dated 5/15/26 for trazodone by mouth daily for insomnia, a second physician's order dated 5/16/26 for bupropion (antidepressant) by mouth daily for depression, and a third physician's order dated 8/10/26 for duloxetine by mouth for depression. Each medication had a consent form titled Consent for Psychotropic Medication Therapy dated 5/15/26 but did not include the required TBs or NPIs for any of the three (3) prescribed psychotropic medications. A subsequent consent form dated 8/10/26 to increase the duloxetine also did not include the TBs or NPIs. On 8/25/26 at 2:19 PM, Staff B, LPN stated Resident #8 became more snarky when he felt depressed. She stated staff attempted therapeutic communication as an alternative to medications. On 8/25/26 at 2:30 PM, Staff D, CNA stated the resident self-isolated when he became depressed. She also stated staff would redirect him as a NPI for his depression. A policy titled Psychotropic Medication Use approved 4/26 revealed prior to starting psychotropic medications, informed consent will be obtained from resident and/or representatives. Psychotropic consents should be obtained with any change of psychotropic medication. 3. Review of Resident #4's Minimum Data Set (MDS) dated [DATE] indicated Resident #4 admitted into the facility on 7/29/24. The MDS further indicated that Resident #4 was taking antidepressant medication during the look back period. Review of Resident #4's Electronic Healthcare Record (EHR) page titled, Clinical Physician Orders revealed an order for Sertraline (antidepressant) 100mg daily with a start date of 10/1/25, as well as an order for Trazodone (antidepressant) 100mg daily with a start date of 7/25/24. Review of Resident #4's Care Plan with a revision date of 6/5/26 revealed no individualized target behaviors or non-pharmalogical interventions related to antidepressant medication usage. Review of a facility provided document titled, Consent for Psychotropic Medication Therapy dated 6/3/26 for Resident #4 revealed no target behaviors or non-pharmalogical interventions as required. Interview 8/25/26 at 12:20 PM with the Director of Nursing (DON) confirmed that there were no target behaviors or non-pharmalogical interventions listed on the consent forms for the antidepressant medications. 4. Review of Resident #30's MDS dated [DATE] was admitted into the facility on 6/26/26. The MDS further indicated that Resident #30 utilized antianxiety medication, and antidepressant medication during the look back period. Review of Resident #30's EHR page titled, Clinical Physician Orders revealed orders for Alprazolam (antianxiety) 0.5mg daily with a start date of 6/26/26, Duloxetine (antidepressant) 30mg twice daily with a start date of 6/26/26. Review of a facility provided document titled, Consent for Psychotropic Medication Therapy dated 6/26/26 for Resident #30 revealed no target behaviors or non-pharmalogical interventions as required. Follow up interview 8/25/26 at 1:53 PM with the DON confirmed that there were no target behaviors or non-pharmalogical interventions mentioned specifically listed as required on the consent form for antianxiety, and antidepressant medication. 5. Review of Resident #42's MDS dated [DATE] indicated that Resident #42 was admitted to the facility 7/26/24. The MDS further indicated that Resident #4 utilized antipsychotic medication, antianxiety medication, and antidepressant medication during the look back period. Review of Resident #42's EHR page titled, Clinical Physician Orders revealed orders for Rexulti (antipsychotic) 2mg daily with a start date of 6/25/25, Buspirone (antianxiety) 10mg daily with a start date of 7/25/24, and Sertraline (antidepressant) 50mg 1.5 tablets daily with a start date of 8/7/26. Review of a facility provided document titled, Consent for Psychotropic Medication Therapy dated 4/26/26 and 4/27/26 for Resident #42 revealed no target behaviors or non-pharmalogical interventions as required. Follow up interview on 8/25/26 at 1:34 PM with the DON revealed she would have expected to see the targeted behaviors as well as non-pharmalogical interventions related to antipsychotic, antianxiety, and antidepressant medication usage for residents utilizing these medications on the consent forms.

Based on clinical record reviews, staff interview, and policy review, the facility failed to develop a personalized Care Plan that included resident specific target behaviors (TBs) or non-pharmacological interventions (NPIs) for 5 of 5 residents (#5, #8, #4, #30, #42) who received psychotropic medications (medications that affect a person's mental state, emotions, and behavior). The facility also failed to develop a personalized Care Plan that included the use of insulin and diuretics. The facility reported a census of 43 residents. Findings include:1.Resident #5's quarterly Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 04 out of 15 which indicated severely impaired cognition. It included diagnoses of non-Alzheimer's dementia with other behavioral disturbances, and depression. It revealed the resident took antipsychotic and antidepressant medications in the 7-day look-back period. It indicated the resident was independent with eating, dependent with footwear, and shower and bed transfers, and required maximal assistance with all other Activities of Daily Living (ADLs) and bed repositioning. The Electronic Health Record (EHR) included a physician's order dated 5/07/26 for trazodone (antidepressant) by mouth daily for insomnia, a second physician's order dated 5/08/26 for duloxetine (antidepressant) by mouth daily for depression, and a third physician's order dated 6/08/26 for Rexulti (antipsychotic) by mouth daily for dementia with behavioral disturbances. On 8/25/26 at 2:13 PM, Staff B, Licensed Practical Nurse (LPN) stated Resident #5 withdrew from interactions, refused to eat, and stayed in bed when she became depressed and hallucinated during psychotic moments. She stated staff tried to anticipate her needs or provided 1:1 reassurance when she became depressed or had a psychotic hallucination. On 8/25/26 at 2:30 PM, Staff D, Certified Nurse Aide (CNA) stated the resident would appear spaced out as though she's unable to comprehend information when she became depressed and would ask about people who were no longer alive as though they were when she had a psychotic episode. She also stated staff provided therapeutic communication during the resident's behavioral symptoms. The Care Plan revised 8/08/25 indicated the resident had depression and identified negativity, tearful, and had insomnia as TBs but did not identify what NPIs staff should attempt as an alternative to medications. Another revision dated 12/10/25 indicated the resident had behavior problems and identified negative comments as the TB but did not indicate if the negative comments were associated with depression or psychosis. The Care Plan directed staff to monitor behavior episodes and attempt to determine underlying cause but did not identify what the resident-specific NPIs staff should attempt as an alternative to medications. 2. Resident #8's MDS assessment dated [DATE] identified a BIMS score of 15 out of 15 which indicated completely intact cognition. It included diagnoses of depression and post-traumatic stress disorder (PTSD). It revealed the resident took antidepressant medications in the 7-day look-back period. It indicated the resident required supervision with bathing and ambulatory mobility, and was independent with all other ADLs and mobility. The EHR included a physician's order dated 5/15/26 for trazodone by mouth daily for insomnia, a second physician's order dated 5/16/26 for bupropion (antidepressant) by mouth daily for depression, and a third physician's order dated 8/10/26 for duloxetine by mouth for depression. On 8/25/26 at 2:19 PM, Staff B, LPN stated Resident #8 became more snarky when he felt depressed. She stated staff attempted therapeutic communication as an alternative to medications. On 8/25/26 at 2:30 PM, Staff D, CNA stated the resident self-isolated when he became depressed. She also stated staff would redirect him as a NPI for his depression. The Care Plan revised 5/22/26 indicated the resident had depression and included the resident's TBs and instructed staff to administer medications as ordered but did not identify NPIs for staff to attempt as an alternative to medications, or identify the medications staff should administer. 3. Review of Resident #4's Minimum Data Set (MDS) dated [DATE] indicated Resident #4 admitted into the facility on 7/29/24. The MDS further indicated that Resident #4 was taking antidepressant medication, diuretics, and insulin during the look back period. Review of Resident #4's Electronic Healthcare Record (EHR) page titled, Clinical Physician Orders revealed orders for Sertraline (antidepressant) 100mg daily with a start date of 10/1/25, Furosemide (diuretic) 20mg daily with a start date of 7/29/24, Lispro (insulin)100 units/milliliter 7 units before meals with a start date of 1/21/26, and Glargine (insulin) 100units/milliliter 20 units at bed time with a start date of 1/21/26. Review of Resident #4's Care Plan with a revision date of 6/5/26 revealed no comprehensive care plan for the use of antidepressant, diuretic, or insulin utilization. Interview 8/25/26 at 12:20 PM with the Director of Nursing (DON) confirmed that insulin, antidepressants, and diuretic medication was not mentioned in the care plan. 4. Review of Resident #30's MDS dated [DATE] was admitted into the facility on 6/26/26. The MDS further indicated that Resident #30 utilized antianxiety medication, antidepressant medication, and diuretic medication during the look back period. Review of Resident #30's EHR page titled, Clinical Physician Orders revealed orders for Alprazolam (antianxiety) 0.5mg daily with a start date of 6/26/26, Duloxetine (antidepressant) 30mg twice daily with a start date of 6/26/26, and Furosemide (diuretic) 40mg daily with a start date of 6/26/26. Review of Resident #30's Care Plan with a revision date of 7/6/26 revealed no comprehensive care plan for the use of antianxiety medication, antidepressant medication, or diuretic medication. Follow up interview 8/25/26 at 1:53 PM with the DON confirmed that Resident #30's antianxiety, antidepressant, and diuretic medications were not listed on Resident #30's care plan. 5. Review of Resident #42's MDS dated [DATE] indicated that Resident #42 was admitted to the facility 7/26/24. The MDS further indicated that Resident #4 utilized antipsychotic medication, antianxiety medication, and antidepressant medication during the look back period. Review of Resident #42's EHR page titled, Clinical Physician Orders revealed orders for Rexulti (antipsychotic) 2mg daily with a start date of 6/25/25, Buspirone (antianxiety) 10mg daily with a start date of 7/25/24, and Sertraline (antidepressant) 50mg 1.5 tablets daily with a start date of 8/7/26. Review of Resident #42's Care Plan with a revision date of 5/15/26 revealed no comprehensive care plan for the use of antipsychotic medication, antianxiety medication, or antidepressant medication. Follow up interview 8/25/26 1:34 PM with the DON revealed she would have expected to see the medications listed in the care plan. Review of a facility provided policy titled, Care Planning dated 12/2024 indicated the comprehensive plan of care must address all care issues that are relevant to the individual.

Based on observations, staff interviews, and facility document review, the facility failed to secure prescribed medications from the possibility of unauthorized access. The facility reported a census of 43 residents. Findings included:On 8/24/26 at 11:35 AM, a medication cart was observed unlocked with Staff A, Licensed Practical Nurse (LPN) on the other side of the nurses' station with her back to cart area and a pillar blocking her direct line-of-sight to the medication cart. The medication cart contained blood thinners (Eliquis) and antidepressants (trazodone). Staff A approached the cart and stated the cart is normally not left unlocked but she went to get a resident to come get his medications.On 8/27/26 at 10:10 AM, the Director of Nursing (DON) stated she would expect that all drawers on the medication carts are closed, locked so no meds are available to be seen or grabbed. If the cart is not within arms-reach, the items should be secured. An undated document titled Skills Checklist indicated staff should lock the medication cart as part of medication administration skills.

Based on observations and staff interviews, the facility failed to properly protect resident information from unauthorized access by leaving 16 residents' information accessible when staff walked away from the Electronic Health Record (EHR) laptop. The facility reported a census of 43 residents. Findings include: On 8/24/26 at 11:35 AM, a laptop was observed with 16 residents' Electronic Health Record information present on the screen. Staff A, Licensed Practical Nurse (LPN) was on other side of the nurses' station with her back to the cart and a pillar blocking her view. Staff A approached the cart and stated the laptop is normally not left unlocked but she went to get a resident to come get his medications. On 8/25/26 at 7:28 AM, Staff B, LPN walked away from her computer with 16 residents' EHR information visible on the computer. There were 25 residents in the dining area adjacent to the nurses' station.On 8/27/26 at 10:10 AM, the Director of Nursing (DON) stated she would expect that all computers are shut so no information is available to be seen. If it is not within arms reach, the items should be secured. On 8/27/26 at 11:10 AM, the Administrator indicated the facility did not have a policy specific to securing resident records but stated the facility followed standard guidelines.

Based on clinical record reviews, staff interview, and policy review, the facility failed to consistently monitor target behaviors (TBs) or document attempted non-pharmacologic interventions (NPIs) for 5 of 5 residents (#5, #8, #4, #30, #42) who received psychotropic medications (medications that affect a person's mental state, emotions, and behavior). The facility reported a census of 43 residents. Findings include:1.Resident #5's quarterly Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 04 out of 15 which indicated severely impaired cognition. It included diagnoses of non-Alzheimer's dementia with other behavioral disturbances, and depression. It revealed the resident took antipsychotic and antidepressant medications in the 7-day look-back period. It indicated the resident was independent with eating, dependent with footwear, and shower and bed transfers, and required maximal assistance with all other Activities of Daily Living (ADLs) and bed repositioning. The Electronic Health Record (EHR) included a physician's order dated 5/07/26 for trazodone (antidepressant) by mouth daily for insomnia, a second physician's order dated 5/08/26 for duloxetine (antidepressant) by mouth daily for depression, and a third physician's order dated 6/08/26 for Rexulti (antipsychotic) by mouth daily for dementia with behavioral disturbances. The Progress Notes did not include behavior notes which indicated consistent behavior or NPI monitoring. The Point-Of-Care (POC) Behavior Monitoring Response History did not include documented TB and NPI monitoring. The Medication Administration Record (MAR), Treatment Administration Record (TAR), and Behavior Monitoring form did not contain documented resident TB monitoring or attempted NPIs. On 8/25/26 at 2:13 PM, Staff B, Licensed Practical Nurse (LPN) stated Resident #5 withdrew from interactions, refused to eat, and stayed in bed when she became depressed and hallucinated during psychotic moments. She stated staff tried to anticipate her needs or provided 1:1 reassurance when she became depressed or had a psychotic hallucination. On 8/25/26 at 2:30 PM, Staff D, Certified Nurse Aide (CNA) stated the resident would appear spaced out as though she's unable to comprehend information when she became depressed and would ask about people who were no longer alive as though they were when she had a psychotic episode. She also stated staff provided therapeutic communication during the resident's behavioral symptoms. The Care Plan revised 8/08/25 indicated the resident had depression and identified negativity, tearful, and had insomnia as TBs but did not identify what NPIs staff should attempt as an alternative to medications. Another revision dated 12/10/25 indicated the resident had behavior problems and identified negative comments as the TB but did not indicate if the negative comments were associated with depression or psychosis. The Care Plan directed staff to monitor behavior episodes and attempt to determine underlying cause but did not identify what the resident-specific NPIs staff should attempt as an alternative to medications. 2. Resident #8's MDS assessment dated [DATE] identified a BIMS score of 15 out of 15 which indicated completely intact cognition. It included diagnoses of depression and post-traumatic stress disorder (PTSD). It revealed the resident took antidepressant medications in the 7-day look-back period. It indicated the resident required supervision with bathing and ambulatory mobility, and was independent with all other ADLs and mobility. The EHR included a physician's order dated 5/15/26 for trazodone by mouth daily for insomnia, a second physician's order dated 5/16/26 for bupropion (antidepressant) by mouth daily for depression, and a third physician's order dated 8/10/26 for duloxetine by mouth for depression. The Progress Notes did not include behavior notes which indicated consistent behavior or NPI monitoring. The Point-Of-Care (POC) Behavior Monitoring Response History did not include documented TB and NPI monitoring. The Medication Administration Record (MAR), Treatment Administration Record (TAR), and Behavior Monitoring form did not contain documented resident TB monitoring or attempted NPIs. On 8/25/26 at 2:19 PM, Staff B, LPN stated Resident #8 became more snarky when he felt depressed. She stated staff attempted therapeutic communication as an alternative to medications. On 8/25/26 at 2:30 PM, Staff D, CNA stated the resident self-isolated when he became depressed. She also stated staff would redirect him as a NPI for his depression. The Care Plan revised 5/22/26 indicated the resident had depression and included the resident's TBs and instructed staff to administer medications as ordered but did not identify NPIs for staff to attempt as an alternative to medications, did not direct staff to monitor for the behaviors or identify the medications staff should administer. A policy titled Psychotropic Medication Use approved 4/26 revealed residents will only receive psychotropic medications when necessary to treat specific conditions for which they are indicated and effective. It also revealed an assessment will be completed for any medication prescribed to manage behaviors. 3. Review of Resident #4's Minimum Data Set (MDS) dated [DATE] indicated Resident #4 admitted into the facility on 7/29/24. The MDS further indicated that Resident #4 was taking antidepressant medication during the look back period. Review of Resident #4's Electronic Healthcare Record (EHR) page titled, Clinical Physician Orders revealed an order for Sertraline (antidepressant) 100mg daily with a start date of 10/1/25, as well as an order for Trazodone (antidepressant) 100mg daily with a start date of 7/25/24. Review of Resident #4's Care Plan with a revision date of 6/5/26 revealed no individualized target behaviors or non-pharmalogical interventions related to antidepressant medication usage. Interview 8/25/26 at 12:20 PM with the Director of Nursing (DON) confirmed that there were no individualized target behaviors or non-pharmalogical interventions mentioned specifically related to Resident #4 utilizing antidepressant medication. 4. Review of Resident #30's MDS dated [DATE] was admitted into the facility on 6/26/26. The MDS further indicated that Resident #30 utilized antianxiety medication, and antidepressant medication during the look back period. Review of Resident #30's EHR page titled, Clinical Physician Orders revealed orders for Alprazolam (antianxiety) 0.5mg daily with a start date of 6/26/26, Duloxetine (antidepressant) 30mg twice daily with a start date of 6/26/26. Review of Resident #30's Care Plan with a revision date of 7/6/26 revealed no individualized target behaviors or non-pharmalogical interventions related to antianxiety medication, or antidepressant medication. Follow up interview 8/25/26 at 1:53 PM with the DON confirmed that there were no individualized target behaviors or non-pharmalogical interventions mentioned specifically Resident #30 related to antidepressant or antianxiety medication usage. 5. Review of Resident #42's MDS dated [DATE] indicated that Resident #42 was admitted to the facility 7/26/24. The MDS further indicated that Resident #4 utilized antipsychotic medication, antianxiety medication, and antidepressant medication during the look back period. Review of Resident #42's EHR page titled, Clinical Physician Orders revealed orders for Rexulti (antipsychotic) 2mg daily with a start date of 6/25/25, Buspirone (antianxiety) 10mg daily with a start date of 7/25/24, and Sertraline (antidepressant) 50mg 1.5 tablets daily with a start date of 8/7/26. Review of Resident #42's Care Plan with a revision date of 5/15/26 revealed targeted behaviors or non-pharmalogical interventions related to Resident #30's antipsychotic medication, antianxiety medication, or antidepressant medication usage. Follow up interview on 8/25/26 at 1:34 PM with the DON revealed she would have expected to see the targeted behaviors as well as non-pharmalogical interventions related to antipsychotic, antianxiety, and antidepressant medication usage for residents utilizing these medications.

Based on observation, clinical record review, staff interview, and policy review, the facility failed to use foot supports while transporting a resident (#20) in a shower chair from his room to the designated shower room. The facility reported a census of 43 residents.Findings include:Resident #20's quarterly Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 03 out of 15 which indicated severely impaired cognition. It included diagnoses of diabetes mellitus, non-Alzheimer's dementia, and muscle weakness. It revealed he required supervision with eating, maximal assistance with toileting hygiene, bathing, and dressing, and was dependent with all other Activities of Daily Living (ADLs) and mobility. It also revealed he used a wheelchair for mobility.A Behavior Note Progress Note dated 3/17/26 indicated the resident required assistance from staff getting into a wheelchair and is then able to propel self with staff encouragement. Another Behavior Note Progress Note dated 4/12/26 at 2:12 PM indicated the resident required a mechanical lift for transfers.The Care Plan revised 6/10/26 revealed the resident required two (2)-staff participation and used a full body lift for transfers. It also revealed the resident had limited physical mobility.On 8/24/26 at 1:27 PM, Staff C, Certified Medication Aide (CMA) transported Resident #20 in a bath chair without foot supports or pedals from his room to the shower room. At 2:13 PM, Staff C stated the resident usually is transported on the whirlpool chair but stated it had been broken for the last two (2) weeks and the shower chair had been used to transport the resident since then. She also stated the resident required a mechanical lift for transfers.On 8/27/26 at 10:10 AM, the Director of Nursing (DON) stated residents being transferred should always have foot rests and not pulled backwards. She would prefer residents to be transferred correctly using the leg support. A policy titled Safe Lifting and Movement of Residents approved 12/24 indicated resident safety, dignity, comfort and medical condition will be incorporated into goals and decisions regarding the safe lifting and moving of residents.

Based on observation, clinical record review, staff interviews, and policy review, the facility failed to correctly administer insulin by failing to prime a newly attached insulin pen needle before administering it for 1 of 1 resident (#8). The facility reported a census of 43 residents.Findings include:Resident #8's Minimum Data Set (MDS) assessment dated [DATE] identified a BIMS score of 15 out of 15 which indicated completely intact cognition. It included diagnoses of heart disease, kidney failure, and diabetes mellitus. It revealed the resident took insulin in the 7-day look-back period. It indicated the resident required supervision with bathing and ambulatory mobility, and was independent with all other ADLs and mobility.The Electronic Health Record (EHR) included a physician's order dated 7/15/26 for 40 units of a concentrated (Humulin R U-500 units/mL, 5 times stronger than standard Humulin U-100), fast-acting insulin with a KwikPen daily (breakfast); 35 units twice daily; and 15 units once daily at bedtime.The Care Plan revised 8/12/26 did not include the resident's insulin use.A continuous medication observation on 8/25/26 that began at 7:12 AM revealed Staff B, Licensed Practical Nurse (LPN) prepared an insulin KwikPen to administer Resident #8's insulin. She removed the insulin pen from the medication cart, placed a needle on the tip of the KwikPen, dialed 40 units on the pen, swabbed the resident's injection site area, placed the needle tip against the abdomen, and injected the insulin. She did not prime the needle to remove the air and ensure the resident received the full dose of insulin. At 7:16 AM, Staff B stated she always primes the insulin pen but forgot to because she was being observed.A Manufacturer document titled HUMULIN R U-500 KWIKPEN - insulin human injection, solution revised 2/24 directed the end user to prime the injection needle with 5 units of insulin prior to administration to ensure the correct amount of insulin is administered.On 8/27/26 at 10:10 AM, the Director of Nursing (DON) stated she would expect staff to prime insulin pens before administering.A policy titled Pen Devices for Insulin Administration approved 3/26 directed staff to prime pen prior to each injection to release a small amount of insulin into pen to remove any air bubbles in pen which may affect flow of insulin and cause inaccurate dosage.

Based on record review, resident and staff interviews, and facility policy review the facility failed to provided incontinent cares on the overnight shift for 1 of 3 residents reviewed (Resident #3). The facility reported a census of 42 residents.Findings include:According to the quarterly Minimum Data Set (MDS) assessment tool with a reference date of 12/11/2025, Resident #3 had a Brief Interview of Mental Status (BIMS) score of 15 out of 15, which suggested no cognitive impairment. The MDS documented she exhibited no rejection of care during the review period and had impairments to her bilateral upper and lower extremities. Resident #3 required substantial/maximal assistance with toileting hygiene and personal hygiene. Resident #3 was frequently incontinent of urine and always incontinent of bowel. The following diagnoses were listed for Resident #3: ulcerative colitis, paraplegia, anxiety, and depression.A Care Plan Focus Area with a revision date of 8/13/2024 documented Resident #3 had bladder incontinence. The Care Plan intervention revised 11/5/2024 encouraged staff to change her disposable brief daily and as needed (PRN). The Care Plan intervention revised 8/13/2024 also encouraged staff to check Resident #3 per her request and as required for incontinence: wash, rinse and dry perineum. An additional Care Plan Focus Area with a revision date of 11/5/2024 documented she had bowel incontinence related to immobility and disease process. The Care Plan intervention dated 11/5/2024 encouraged staff to provided peri care after each incontinent episode.On 1/13/2026 at 1:36 PM Resident #3 was lying in bed watching television. When asked how things were going during the overnight shift, she stated not good. When asked what she meant by that she stated she was not getting changed like she should be. Sometimes when she has a bowel movement, she will pull her call light. Staff will either just let the call light go or come in and say they will be right back. Then they will shut the light off and never return. She added this happens about once a week and always happens when she is incontinent of urine. She indicated they will not assist her with incontinent cares. Resident #3 stated she has had issues with her skin around the area and they now use cream to help preventing skin issues.On 1/13/2026 at 2:34 PM Staff B, Certified Nursing Assistant (CNA) stated Resident #3 talked to her about the overnight shift not cleaning her up after becoming incontinent. Resident #3 told her the staff will come in to her room, turn off her call light, tell her they would be back but they never come back.On 1/13/2026 at 2:57 PM Staff A, CNA stated Resident #3 talked to her about how the overnight shift did not complete incontinent cares for her. She heard CNAs talk about how the overnight shift not very good about doing areas and ensuring their residents are not wet. She added this had been mentioned quite frequently. Staff A stated when Resident #3 had a bowel movement it will come up the front but not all staff will clean her up properly.On 1/14/2026 at 11:42 AM the Administrator indicated she was not aware of issues on the overnight shift with incontinent cares being completed.On 1/14/2026 at 11:58 AM the Director of Nursing (DON) was asked when staff were to complete cares on residents, she stated when they round on residents every 2 hours to check and change the residents that were incontinent, offer toileting to the ones that require assistance or remind to go to the bathroom.The facility provided a document titled Activities of Daily Living with an approved date of 9/24/2025. The policy stated the facility will provide each resident with care, treatment, and services according to the resident's individualized care plan.

Based on record review, staff and family interviews, and facility policy review the facility failed to obtain all of 1 of 3 resident's (Resident #1) medications once they were admitted to the facility. The facility reported a census of 42 residents.Findings include:According to the admission Minimum Data Set (MDS) assessment tool with a reference date of 10/31/2025, Resident #1 was admitted to the facility on [DATE]. The MDS documented a Brief Interview of Mental Status (BIMS) score of 15 out of 15, which suggested no cognitive impairment. The MDS listed the following diagnoses for Resident #1: hypertension, hip fracture, stroke, depression, cognitive communication deficit and atrial fibrillation.Record review of the scripts sent to the facility's pharmacy revealed the following order: doxazosin mesylate (treat high blood pressure) 2 milligram (mg). Give 0.5 tablet by mouth two times a day (BID). The order was electronically signed on 10/29/2025 at 10:54 AM. Review of Resident #1's October 2025 Medication Administration Record (MAR) revealed she had an order for doxazosin mesylate 1 mg. Give 0.5 tablet by mouth BID. The order had a start date of 10/29/2025 at 4:00 PM and discontinued date of 10/31/2025 at 4:05 PM. Staff had documented 6 on the following administration dates and times: 10/29/2025 PM dose, 10/30/2025 AM and PM doses, and 10/31/2025 AM dose. The number 6 meant to see progress notes.Review of Resident #1's Progress Notes revealed the following:a.10/29/2025 at 2:03 PM: resident arrived to the facility at 10:00 AM accompanied by family.b. 10/29/2025 at 11:17 PM: doxazosin mesylate not given as waiting for pharmacy delivery. The Progress Notes lacked documentation on why the doses were not given on 10/30/2025 and 10/31/2025.Review of the resident's blood pressure revealed the following readings:a. 10/29/2025 at 1:24 PM 131/58 b. 10/29/2025 at 11:32 PM 103/78c. 10/30/2025 at 8:48 PM 158/76Review of the facility's emergency kit (medications available at all times) medication list revealed doxazosin was not available to be given.On 1/13/2026 at 11:23 AM, Resident #1's family stated the resident called her and told her she did not get her medications on the day she was admitted to the facility. She also told the family member that she did not get all of her medication that night as well. When she went in to the facility to talk to someone about it the charge nurse told her the day nurse did not do their job and follow through with the orders.On 1/13/2026 at 12:11 PM, Staff D, Registered Nurse (RN), was asked to talk about the admission process, specifically getting the resident's medication, when a resident is admitted . She stated they would obtain all the MARs from where the resident was admitted from, obtain orders from the physician, put them in the computer, and send a facsimile to the pharmacy. When asked if the pharmacy delivered medications to the facility timely, she indicated they did. When asked what happens if the medication that is due was not available, she stated get an order to start the next day. If it needed to be started right away, they could get the medication from the Emergency Kit.On 1/13/2026 at 12:30 PM, Staff C RN, charge nurse, was asked why she documented 6 on Resident #1's doxazosin order on 10/30/2025 and 10/31/2025. She stated the medication was not in the building from pharmacy. She added depending on what time the resident was admitted , will need to call pharmacy to order the medication or it should be at the facility, she could not remember what had happened with that medication.On 1/14/2026 at 11:58 AM the Director of Nursing (DON) stated the medication could have been delivered late on the day Resident #1 was admitted . If the medication had not been delivered on the day of her admission, staff would need to put calls in place to get the medication as soon as possible. If staff had called her about the issue she would have asked them to see if it was in the emergency kit.On 1/15/2026 at 4:07 PM the Assistant Director of Nursing (ADON)/MDS Coordinator stated she dug into this on 1/14/2026 and noticed the script that was sent to the pharmacy did not match the order that was put on the MAR. Staff should have put in a progress note indicating why they medication was not given and she would have followed up on it. She was not aware of the medication not being available.The facility provided a document titled admission Policy with an approved date of 12/2024. The objectives of our admissions policies are to admit residents who can be cared for adequately by the facility. Prior to or at the time of admission, the resident's attending physician must provide the facility with information needed for the immediate care of the resident, including orders covering at least .medication orders.

Number of residents sampled: 3Number of residents cited: 1Based on clinical record review, family interview, staff interviews, hospital record review and policy review, the facility failed to properly supervise a resident and failed to implement interventions to prevent a fall for 1 of 3 residents reviewed. Resident #49 sustained a femur fracture after she fell from the commode. The facility reported a census of 43 residents. Findings include:According to the Minimum Data Set (MDS), dated [DATE], Resident #49 had a Brief Interview for Mental Status (BIMS) score of 15 (intact cognitive ability). She was admitted to the facility on [DATE], and totally dependent on staff for hygiene, dressing, and transfers. Resident #49 had impairment on both sides of her lower extremities, was frequently incontinent of urine and always continent of bowel. Her diagnoses included: Multiple Sclerosis (MS), malnutrition, anxiety disorder, depression and muscle spasm. The Care Plan dated 3/20/25, showed that Resident #49 was admitted to the facility for a short-term respite stay and scheduled to discharge on [DATE]. Her husband was her main caregiver and she preferred to have him involved in discussions of her care. Resident #49 was at risk for falls, related to deconditioning. Staff were to assist her to the bathroom upon request and to be sure her call light was within reach. The resident had been educated on being safe on the commode, and staff encouraged her to have supervision, but she declined and choose to have privacy. The resident used physical restraints, described as a chest strap, used while she was in the wheelchair to keep her from falling out. Staff were to ensure that the resident was positioned correctly with proper body alignment while restrained. Resident #49 had constipation related to MS, staff were to ensure that her feet were flat on the floor or flat on an elevated support during evacuation and her knees were at a 90 degree or above hip height to promote ease of evacuation.A Fall Risk Data Collection document dated 3/20/25 at 5:23 PM, showed that Resident #49 was unable to come to a standing position independently and she was a low risk for falls. A document titled: Device/Restraint Evaluation, dated 3/21/25 at 7:09 PM, showed that the staff were using a chest strap in the wheelchair that allowed the resident to sit up without falling over. She was unable to get out of the wheelchair on her own related to MS and muscle deconditioning.An Incident Report dated 4/2/25 at 9:30 PM, showed that on that date, a Certified Nurse Aide (CNA) found Resident #49 on the floor shortly after they had put her on the commode. The resident told the nurse she thought she had broken her leg, and they sent her to the emergency room. According to the Emergency Medicine History and Physical dated 4/3/25 at 1:40 PM, when Resident #49 presented to the emergency room, Orthopedic service was consulted for an evaluation of possible bilateral distal femur fractures. The patient reported that she struck her legs on the bed frame in front of her. She had significant swelling of left knee and mild bruising of her right. After X-rays, she was found to have an acute fracture of the distal left femur, no surgical intervention was recommended at that time. She was to keep the knee immobilizer on at all times.The following was found in the facility Nursing Progress Notes: a. On 3/21/25 at 3:51 PM, upon admission, Resident #49 requested to use a Gait Belt (GB) while she was sitting on the commode. The resident was educated on the designed use of a GB and it would be considered a restraint, so the facility would not be using that. The resident voiced understanding. b. On 4/2/25 at 9:52 PM the nurse was alerted by the CNA that the resident had fallen from the commode. c. On 4/2/25 at 11:41 PM, the facility received a call from the husband that the resident had a broken leg and was admitted to the hospital. On 7/15/25 at 2:23 PM, a Family Member (FM) for Resident #49 said that when she was admitted to the facility, they provided a commode that the resident agreed to use. He asked them to put something around her to keep her in the chair so she wouldn't fall out while having a bowel movement. The FM told them he would sign a consent because that was how they had managed her toileting at home. He said that he bought the Velcro belt that supported her in the wheel chair, and they had used for years. At the time of admission, there were 4 people in the room, including the Administrator and the Director of Nursing. When he asked about a GB to secure her on the commode, they didn't seem to know how to answer, and they didn't say no so he thought they were going to provide that for her. The FM said that he didn't learn until after the fall that the facility hadn't actually used the gait belt while on the commode because it was considered a restraint. He said he hadn't signed a consent for the belt used in the wheelchair, and he would have been more than willing to sign a consent for one on the commode. When asked if the resident had told the staff that she didn't want anyone in the room while she was on the commode, he said he wasn't aware, but it didn't surprise him because she really needed her privacy. He said that he usually signed papers for her because, with her MS she had difficulty writing.On 7/15/25 at 4:00 PM Staff D, LPN acknowledged that she was the nurse on duty when Resident #49 fell from the commode. She said that the CNA came and got her right away, she assessed the resident and she had a lot of pain. When she entered the room, the resident's leg was laying in an unnatural way so she knew it was going to be broken, and the resident said right away my leg is broken. She said that the resident requested privacy when on the commode, she would bend at the waist forward and back to evacuate, and it made us all nervous because she didn't seem stable on the commode. It was her understanding that they could not use the gait belt because it would have been a restraint.On 7/16/25 at 8:30 PM, Staff C, Licensed Practical Nurse (LPN) did work with Resident #49 and assisted with transferring her to the commode with the mechanical lift. She couldn't remember if the residents' feet were resting on a platform or dangling, or if she could reach the floor. She said they didn't have any trouble with her balance on the commode and the CNA would stay with the her. Staff C was not aware of a time that the resident got upset about having someone in the room or that she asked them to leave for privacy.On 7/15/25 at 3:52 PM, the Director of Nursing (DON) said that Resident #49 used a Velcro belt while in the wheel chair. She was accustomed to using it, and she could open and close the Velcro herself. She said they didn't have a consent for that, it was part of her routine daily process. Upon admission, they provided a gel cushion on the seat of the commode and protection on the handles. The resident insisted on having her privacy so they provided that for her. When asked if she would have done anything differently, she said she may have insisted on someone staying in the room or maybe insisted that she use a bed pan.On 7/16/25 at 10:50 AM, Staff B Registered Nurse (RN) said that Resident #49 was very particular on how she wanted things done. They provided a cushion on the seat, and a pressure relieving pillow on the back of the commode. The resident would sit forward and if she was having a BM, staff would step out of the room. Staff B said that when the resident would lean forward and rock back, it was concerning and looked like she could fall. Staff B was not aware of conversations suggesting bands that be used on the commode or an alternative to secure her on the commode.On 7/16/25 at 1:55 PM, Staff E, Certified Nurse Aide (CNA), said that she put assisted to transfer Resident #49 onto the commode the night she fell off. The resident wanted it sitting right next to the bed with the call light hooked to the bedding, where she could reach it. Her feet needed to be flat on the floor, and the resident asked them not to leave the room until she was perfectly situated. Staff E said that the resident didn't want the staff in the room when she was on the commode, so they would leave.On 7/16/25 at 2:20 PM, Staff F, CNA said that they used a strap when the resident was in the wheelchair, but not when she was on the commode. The call light had been attached to the bed spread, and the resident would put on the light when she was done. If she hadn't put on her light after about 15 minutes, they would go in and check on her. They heard her calling for help and found her on the floor, in front of the commode, she had one leg under her and her head was under the bed. The resident didn't want them to be in the room, but if her husband was visiting, he would stay in the room with her.On 7/17/25 at 7:45 AM, the Administrator, DON, Staff K, LPN and Staff B, RN demonstrated how the resident preferred to sit on the commode and the action/movement/thrusting that she performed when she was trying to have a BM. The showed how the resident wanted her feet positioned and the back and forth thrusting she used. The Administrator maintained that they had offered to put up a curtain in the room so staff could stay with her, but she refused. (The chart lacked documentation of this attempted intervention). When asked if they had offered a Velcro strap for her legs which would not have been a restraint if the resident could remove it herself, they did not have knowledge that anyone had suggested this option. They said that the resident only wanted a gait belt around her legs, and they determined that would have been a restraint and they would not restrain her to the commode.On 7/17/25 at 9:15 AM, the Medical Director (MD) for the facility said that he had not provided care for Resident #49 while she was at the facility. When her condition and how she would evacuate bowel with a thrusting movement was explained to him, he said that if this was the routine that the resident had used at home, and it worked for her, with close monitoring, he could see how a restraint could have been considered. He said there were situations where they use restraints safely in the hospital. The MD said that he certainly would not want anyone left alone on the commode restrained for a long period of time, but with the proper assessments and monitoring, this would possibly approve of this type of a restraint to prevent falls if that was the families wishes.According to facility policy titled: Restraints, dated 12/2024, a physical restraint was defined as any manual method or physical or mechanical device material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to one's body. Restraints may only be used if/when the resident had a specific medical symptom that cannot be addressed by another less restrictive intervention and a restraint was required to:a. treat the medical symptom;b. protect the resident's safety; c. help the resident attain the highest level of his/her physical or psychological well-being.Prior to placing a resident in restraints, there would be an assessment and review to determine the need for restraints. A review of resident record to determine alternative interventions to the restraint were attempted and documented.Restraints would only be used upon the written order of a physician and after obtaining consent from the resident and or representative. The order would include:a. The specific reason for the restraintb. The type of restraint, and period of time for the use of the restraint.c. Care Plans for the resident in restraints would reflect interventions that address the medical symptoms.

Number of residents sampled: 11Number of residents cited: 8Based on clinical record review, staff interview and guidance from the 2024 Resident Assessment Instrument (RAI) Manual, the facility failed to complete and transmit Comprehensive Minimum Data Set (MDS) Assessments within federal guidelines for 6 of 11 residents (#1, #2, #4, #6, #8, #18) reviewed for MDS Assessments. The facility reported a census of 43 residents.Findings include:1. The admission (Comprehensive) Minimum Data Set (MDS) of Resident #1 documented an Assessment Reference Date (ARD) of 3/18/25. The MDS recorded the resident had an admission date to the facility of 3/12/25. Page 58 of the MDS recorded a completion date of 4/2/25, day 22 of the resident's stay.2. The admission (Comprehensive) MDS of Resident #2 documented an ARD date of 1/15/25. The MDS recorded the resident had an admission date to the facility of 1/3/25. Page 58 of the MDS recorded a completion date of 1/28/25, day 26 of the resident's stay.3. The admission (Comprehensive) MDS of Resident #4 documented an ARD date of 8/2/24. The MDS recorded the resident had an admission date to the facility of 7/26/24. Page 58 of the MDS recorded a completion date of 8/16/25, day 22 of the resident's stay.4. The admission (Comprehensive) MDS of Resident #6 documented an ARD date of 5/22/25. The MDS recorded the resident had an admission date to the facility of 5/7/25. Page 58 of the MDS recorded a completion date of 5/22/25, day 16 of the resident's stay.5. The admission (Comprehensive) MDS of Resident #8 documented an ARD date of 6/19/25. The MDS recorded the resident had an admission date to the facility of 6/6/25. Page 58 of the MDS recorded a completion date of 6/27/25, day 22 of the resident's stay.6. The admission (Comprehensive) MDS of Resident #18 documented an ARD date of 1/10/25. The MDS recorded the resident had an admission date to the facility of 12/30/24. Page 58 of the MDS recorded a completion date of 5/22/25, day 16 of the resident's stay.According to the 2024 RAI, for an admission (comprehensive) assessment, the MDS Completion Date (Item ZO500B) must be no later than the 14th calendar day of the resident's admission (admission date + 13 calendar days). On 7/16/25 at 12:30 pm, the Director of Nursing stated she signs the MDS Assessments as complete due to the MDS Coordinator being an LPN (Licensed Practical Nurse) rather than an RN (Registered Nurse) and the MDS requires an RN to sign the assessments as complete. She stated she does not really have any MDS knowledge of the regulations. She stated the MDS Coordinator normally tells her verbally when she needs assessments signed or may email her or leave a note on her desk. She stated she normally will sign them on the same day she is told they are ready to be signed and does not delay signing them. On 7/16/25 at 2:15 pm, the Administrator of the facility stated the facility does not have a policy regarding MDS Assessments and they follow the guidelines of the RAI Manual.

Number of residents sampled: 3Number of residents cited: 1Based on staff interviews, Electronic Health Record (EHR) review, policy review and document review, the facility failed to provide the estimated cost of service with the end of a Medicare part A stay or when all of part B therapies were ending to 1 of 3 resident representatives (Resident #6). The facility reported a census of 43 residents.Findings include:1. The Minimum Data Set (MDS) dated [DATE] documented Resident #6's Brief Interview for Mental Status (BIMS) documented Resident #6 was rarely / never understood. Review of the document dated 5/28/25 titled, Declaration Relating to Life-sustaining Procedures (Living Will) and Durable Power of Attorney For Health Care Decisions (Medical Power of Attorney) documented Resident #6's daughter as power of attorney for health care decisions. Review of Resident #6's EHR titled, Profile documented Resident #6's daughter as the responsible party.Review of document titled, Notice of Medicare Non-Coverage for Resident #6 documented no signature of date from Resident #6 or Resident #6's representative.Review of document with mailed date of 5-30-25 titled, Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage for Resident #6 did not document the estimated cost of the services per day/item or service. The document also contained no signature of patient or authorized representative. Review of email dated 6/27/25 from Resident #6's daughter documented on the notice of non-coverage, the estimated cost was not included. Can her secondary insurance cover some of that cost? If physical therapy will help her build strength and rehabilitate after the trauma, Resident #6's daughter explained she would like to review the costs and logistics of providing Resident #6 that care.Review of email response dated 6/27/25 to Resident #6's daughter from Staff L, Licensed Practical Nurse (LPN) / Social Services Department Staff documented, Let's talk about this. Review of email response dated 6/27/25 to Resident #6's daughter from Staff M, MDS Coordinator / Assistant Director of Nursing (ADON) documented Therapy cannot work with Resident #6 as she is unable to follow directions. Medicare will not pay for therapy if there is no progress. If you would like to pay privately for therapy you may. Review of email response dated 7/15/25 to Resident #6's daughter from Staff L documented a forward of the email that Staff M sent on 6/27/25. Email documented a request after reading let the facility know if there are any further questions. Email explained Staff L emailed form, Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage and requested the form signed and returned.Review of email response dated 7/15/25 from Resident #6's daughter to Staff L documented the form Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage was not attached. Resident #6's daughter explained in the email she did not necessarily need the form as she had been carrying the one she received in the mail with her awaiting a response to her questions. Resident #6's daughter explained in the email she had not received an answer to her question about the secondary insurance covering physical therapy. Resident #6's daughter explained further she had asked about an estimated cost for the physical therapy. Resident #6's daughter explained in the email the estimated cost was left blank on the form that was sent and the form came with option 3 already checked as if it was already chosen by the facility without giving her the information for the other options. Resident #6's daughter continued to explain she did not feel comfortable signing and mailing back until she received the answers to the questions she had posted on 6/27/25.On 7/16/2025 at 3:40 PM Staff L, stated she was unable to determine the cost of therapy services. Staff L stated she had a resident that was private pay and could not determine the breakdown of cost when requested. Staff L stated she did not complete the NOMNC / CMS 10123. Staff L stated she spoke with the Administrator about the estimated cost of services and the Administrator discussed it with therapy as well. Staff L stated eventually she did get an estimated cost of services.On 7/16/2025 at 4:21 PM the Administrator stated Resident #6's daughter came into the facility and paid for her mothers stay and the form titled, Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage was not brought up to Resident #6's daughter's attention then. The Administrator acknowledged the estimated cost was not on CMS-10055 form. The Administrator explained the beneficiary notice should have been followed up on once Resident #6's daughter had requested the information. On 7/16/2025 at 4:28 PM Staff M stated Resident #6's daughter was emailed the form Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage and it that she had been given the 48 hour notice. Staff M stated Resident #6 had met her potential and because of her dementia she could not remember her education after it was provided. Staff M stated Resident #6's daughter accepted taking Resident #6 off the skilled services. Staff M acknowledged she was the staff that sent the forms out to the resident and resident family. Staff M stated she does not usually apply the estimated cost of services in any of the CMS-10055 forms. Staff M stated she had never applied an estimated cost of services on any of the CMS-10055 forms she had sent to residents or resident family members. Review of document dated 2024 titled, Form Instructions Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN FormCMS-10055) documented the estimated cost section should include the estimated cost of the corresponding care that may not be covered by Medicare. The SNF should enter an estimated total cost or a daily, per item, or per service cost estimate. SNFs must make a good faith effort to insert a reasonable cost estimate for the care. The lack of a cost estimate entry on the SNF ABN or an amount that is different from the final actual cost charged to the beneficiary does not invalidate the SNF ABN. If for some reason the SNF is unable to provide a good faith estimate of projected costs of care at the time of the SNF ABN delivery, the SNF should indicate in the cost estimate area that no cost estimate is available. This should not be a routine or frequent practice but allows timely issuance of the SNF ABN during rare instances when a cost estimate is not available.

Number of residents sampled: 3Number of residents cited: 1Based on clinical record review, staff interview and guidance from the 2024 Resident Assessment Instrument (RAI) Manual, the facility failed to complete Quarterly Minimum Data Set (MDS) Assessments within federal guidelines for 1 of 3 (Resident #39) residents reviewed. The facility reported a census of 43 residents. Findings include: The MDS portion of the Electronic Health Record (EHR) of Resident #39 recorded the resident's admission MDS was dated 11/28/24 with a Quarterly MDS dated [DATE]. The Resident then had a discharge MDS dated [DATE] with a re-entry dated 5/14/25. Per the MDS tracker built into the software, the next quarterly MDS was due 5/23/25. Upon review on 7/15/25 at 11:45 am, no further Quarterly assessments had been scheduled or completed. A Medicare - 5 day MDS dated [DATE] was the last MDS scheduled or completed. Page 2-35 of the 2024 RAI Manual documented a Quarterly Assessment must be within 92 days of the Previous OBRA assessment which includes Quarterly, Admission, Annual, SCSA (Significant Change in Status Assessment), SCPA or SCQA (Significant Correction to Prior Annual or Prior Quarterly). OBRA Assessments are assessments mandated by the Omnibus Budget Reconciliation Act of 1987. OBRA assessments are standardized assessments used in nursing facilities to evaluate the needs of the residents.On 7/15/25 at 1:29 pm, the MDS Coordinator stated she had completed a five day assessment (a payment assessment that is not part of the OBRA assessment schedule) and did not realize she had to complete the quarterly assessment as well.On 7/16/25 at 2:15 pm, the Administrator of the facility stated the facility does not have a policy regarding MDS Assessments and they follow the guidelines of the RAI Manual.

Number of residents sampled: 13Number of residents cited: 2Based on clinical record review, staff interviews, information from a drug manufacturer and guidance from the 2024 Resident Assessment Instrument (RAI) Manual, the facility failed to accurately reflect the status of 2 of 13 residents in the Minimum Data Set (MDS) Assessments (Resident #2, Resident #6). The facility reported a census of 43 residents. Findings include: 1. The MDS of Resident #2 dated 4/10/25 identified a Brief Interview for Mental Status Score of 14 which indicated cognition intact. The MDS coded the resident had a start date for Speech therapy as 3/18/25. The MDS recorded the resident had zero minutes of speech therapy during the seven day lookback period of April 4/4/25 - 4/10/25. The MDS coded the resident had a start date for Occupational Therapy of 3/18/25 and also recorded zero minutes of Occupational Therapy during the same seven day lookback period. The MDS coded the resident had a start date for Physical Therapy of 3/19/25, also with zero minutes of therapy recorded. On 7/14/25 at 3:02 pm, Resident #2 stated she had recently completed therapy and had been improving her balance during therapy sessions. On 7/15/25, a member of the facility's therapy team ran a report for the therapy minutes during the seven day lookback period. The therapy minutes stated Resident #2 received 145 minutes of Speech Therapy, 135 minutes of Occupational Therapy and 93 minutes of Physical Therapy during this time period. On 7/15/25 at 1:11 pm, the MDS Coordinator stated that therapy minutes are normally pulled automatically onto the assessment. She explained that at times, the minutes did not carry over as expected, and in those instances, she would request a therapy minutes report from the therapy department. She also stated there had recently been a software change which had caused some glitches. She acknowledged it was her error in missing the therapy minutes not being recorded on the MDS Assessment. The 2024 RAI Manual directs for Speech-Language Pathology and Audiology Services and Occupational and Physical Therapies to enter the total number of minutes of therapy that were provided on an individual basis in the last seven days, as well as minutes provided as concurrent minutes, group minutes and co-treatment minutes and to enter the number of days therapy services were provided in the last seven days. 2. The MDS of Resident #6 dated 5/13/25 documented diagnoses that included diabetes Mellitus. The MDS recorded Resident #6 was administered insulin injections on one of the last seven days of the look-back period. The Medication Administration Record (MAR) for May of 2025 failed to reflect the resident had received any insulin during the month. On 7/15/2025 at 1:29 pm, the MDS Coordinator stated she had recorded an insulin injection due to the Resident receiving Ozempic once a week. She stated she was unaware Ozempic was not an insulin. The Ozempic Clinical Overview by the manufacturer of the medication documented Ozempic is a GLP-1 RA (a glucagon-like peptide-1 receptor agonist (a class of medications that mimic the effects of the GLP-1 hormone, which helps regulate blood sugar levels and reduce appetite). On 7/16/25 at 2:15 pm, the Administrator of the facility stated the facility does not have a policy regarding MDS Assessments and they follow the guidelines of the RAI Manual.

Number of residents sampled: 13Number of residents cited: 1Based on clinical record review and staff interviews, the facility failed to implement a Baseline Care Plan within 48 hours of admission for 1 of 13 residents reviewed (Resident #2). The facility reported a census of 43 residents. Findings include: The Census Line portion of the Electronic Health Record (EHR) of Resident #2 recorded the resident had moved from the facility's Assisted Living into the Long Term Care portion of the facility on 1/3/25. The Minimum Data Set (MDS) Assessment of Resident #2, dated 1/3/25, additionally recorded an admission date of 1/3/25. The Care Plan Section of Resident #2 EHR identified her most recent Care Plan had been initiated on 1/15/25. The prior Care Plan had an initiation date of 11/22/2022. When reviewed on 7/15/25, the Care Plan reflected initiation dates that varied by focus area. The earliest initiation date was documented as 1/20/25, which was five days after the Care Plan was noted as initiated and 17 days after the resident was admitted to the Long Term Care portion of the facility. On 7/15/25 at 3:53 pm, the Director of Nursing (DON) stated Resident #2 had not had a Baseline Care Plan done. She stated no Care Plan was initiated until 1/15/25. She voiced she had not identified any reason why it was not done. On 7/16/25 at 12:30 pm, the DON stated she had spoken to the MDS Coordinator the prior evening. She stated the MDS Coordinator told her that when Resident #2 moved from the Assisted Living area into the Long Term Care area, her Assisted Living Care Plan came through with her on the EHR. She stated the MDS Coordinator failed to close that Care Plan and initiate a current one for Long Term Care. She said the MDS Coordinator had caught the error on 1/15/25 and that is when she started her current Comprehensive Care Plan. On 7/16/25 at 1:44 pm, the MDS Coordinator stated when she initiates a new care plan she normally will complete the Focus Areas of Falls, Code Status, Activities of Daily Living (ADLs) and Discharge Planning immediately. She stated typically she completes those areas first and then goes from there over the next several days until the Care Plan is complete. She stated she was unaware of why none of the Focus Areas had dates prior to 1/20/25 for Resident #2. The policy titled Care Planning, approval date 12/2024, failed to address any timelines for the required completion of either a baseline or comprehensive care plan.

Number of residents sampled: 3Number of residents cited: 3Based on observations, clinical record review, staff interviews, and policy review, the facility failed to prevent indwelling catheters from potential contamination by securing the urine drainage bag on a resident's trash can and allowing a drainage bag on rest on the floor for 2 of 3 residents reviewed (#3, #22). Staff also failed to don Personal Protective Equipment (PPE) or perform proper hand hygiene during indwelling catheter care for 1 of 3 residents reviewed (#29). The facility reported a census of 43. 1. On 7/14/2025 at 12:24 PM, Resident #22 was observed seated at a dining room table with an indwelling urinary catheter. At 2:21 PM, Resident #22’s urinary bag was observed hanging on the side of the trashcan to the right of his recliner. The Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 6 out of 15 which indicated severely impaired cognition. It included diagnoses of chronic kidney disease, obstructive uropathy (blocked urine flow), and difficulty walking. It indicated he was independent with eating, dependent with oral hygiene and required maximum assistance with all other Activities of Daily Living (ADLs) and all forms of mobility. The Care Plan revised 8/15/24 directed staff to position catheter bag and tubing below the level of the bladder and away from the entrance door. On 7/16/25 at 1:48 PM, Staff I, Certified Nurse Aide (CNA), stated indwelling catheter tubing or collection bag should not touch the ground, the collection bag should always have a dignity cover, be hung below the level of the resident’s bladder, and secured under the resident’s wheelchair high enough to not touch the floor. She also stated the collection bag can be placed in a dedicated basin, or hung on the side of the trash bin but wasn’t sure it was an approved location. She was not sure whether hanging a urinary collection bag was directly addressed during training. On 7/16/25 at 2:00 PM, Staff J, CNA stated she received indwelling catheter care education upon hire and in school. She stated staff hangs Resident #22’s catheter bag on his trash can but they know they’re not supposed to. She stated there was nowhere else to hang it when he’s in his recliner. On 7/16/25 at 4:10 PM, the Director of Nursing (DON) stated staff should position the indwelling catheter drainage bag in compliance with Infection Prevention practices. A policy titled “Infection Prevention and Control Program” dated 2019 indicated the Infection Prevention and Control Program follows national standards and guidelines to prevent, recognize and control the onset and spread of infection whenever possible. A policy titled “Catheter Care, Urinary” dated 12/2024 directed staff to be sure the catheter tubing and drainage bag are kept off the floor. 2. The MDS for Resident #29 dated 6/12/25 in progress revealed a BIMS score of 15/15 indicating normal cognitive function. The document revealed diagnoses of renal insufficiency, neurogenic bladder, end stage renal disease and benign prostatic hyperplasia with lower urinary tract symptoms. Resident #29’s Care Plan dated 7/8/25 under development revealed a Focus Area with a catheter with neurogenic bladder dated 7/26/24. Interventions for staff included catheter care, positioning of the catheter, monitoring and documenting the output and enhanced barrier precautions (EBP). A Focus Area for EBP due to wounds and urinary catheter was initiated on 9/16/24. Interventions for staff included resident education and staff to wear gown and gloves while completing high-contact resident care activities. On 7/14/25 at 1:05 PM observed personal protective equipment (PPE) on Resident #29’s door. On 7/14/25 at 1:10 PM Staff A, Licensed Practical Nurse (LPN), entered Resident #29’s room, completed hand hygiene, closed the resident’s curtain and donned gloves. Observed the resident's catheter bag hanging from the bed without a dignity bag. The staff removed the resident’s blankets, pants, and initiated opening the brief. The staff upon discovering the resident’s brief was slightly soiled, stopped, removed gloves, obtained wipes and donned new gloves. Staff A used the right hand to obtain wipes and the left hand to complete peri care. When additional staff and the resident’s roommate entered the room, Staff A used the left gloved hand to adjust the curtain. Staff A applied the treatment to the peri area using the right gloved hand. Following the treatment Staff A removed the right glove, had staff hand her an additional glove, donned the glove and completed donning of a clean brief, and pulling his pants up. Staff A placed a barrier on the ground with a graduated cylinder on top for emptying the catheter bag. The staff used an alcohol swab to wipe the tubing, emptied the catheter, wiped the tubing with a new swab and took the cylinder to the bathroom for emptying. The staff removed gloves, completed hand hygiene and adjusted Resident #29’s blankets. Staff A demonstrated inconsistent hand hygiene practices with glove removal/application, did not utilize a gown with medical treatment, peri cares, and emptying of catheter. On 7/15/25 at 2:00 PM the Director of Nursing (DON) stated the expectation was for all nurses and Certified Nurse Assistants (CNAs) to wear gowns and gloves when providing treatments and cares to residents with catheters. The staff stated she expected hand hygiene to be completed during glove changes, as well as maintain clean and dirty. The DON stated it was expected that dignity bags were used for catheter bags. The U.S. Department of Health and Human Services Centers for Disease Control and Prevention EBP sign on Resident #1 and Resident #32’s doors revealed providers and staff must wear gloves and gown during high contact resident care activities including dressing, bathing, transferring, hygiene, changing briefs or assisting with toileting, and wound care. 3. The MDS dated [DATE] for Resident #3 showed that she had a BIMS score of 15 (intact cognitive ability.) She required substantial assistance with hygiene and dressing and was totally dependent for transfers. The resident had an indwelling catheter and was always incontinent of bowel. Her diagnoses included: renal failure and urinary tract infections. The Care Plan, last updated on 6/11/25, showed that Resident #3 had a catheter due to neurogenic bladder. Staff were to provide catheter care every shift, to monitor output and to position the catheter bag and tubing below the level of the bladder. On 7/15/2025 at 6:14 AM, observed Resident #3 in bed sleeping, her catheter bag resting on the floor and it looks to be empty. On 7/15/25 at 1:54 PM, the Director of Nursing (DON) said that all urinary catheters should be in a privacy bag and should never be on the floor. On 7/17/25 at 6:10 AM, Staff G Certified Nurse Aide (CNA) said that the catheter bag should never be on the floor. On 7/17/25 at 6:15 AM, Staff H, CNA said that they should always have a catheter in a privacy bag.

Based on clinical record review, staff interview and policy review the facility failed to establish comprehensive, resident specific care plans for 4 of 4 residents reviewed (Resident #9, #13, #4 and #26). The facility reported a census of 29 residents. Findings include: 1. According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #9 had a Brief Interview of Mental Status (BIMS) score of 15 (intact cognitive ability). The resident was independent with eating, dressing, transfers and toileting. Her diagnosis included heart failure, renal insufficiency, diabetes and depression. The resident was taking an anticoagulant, insulin, opioid, antidepressant and a diuretic medication. The resident was admitted to the facility on [DATE]. The Care Plan dated 8/12/24, showed that Resident #9 had the potential for nutritional problems related to diagnosis of congestive heart failure, diabetes mellitus, depression, obesity and chronic kidney disease. She had weight fluctuations related to edema/diuresis. The Care Plan lacked references to the high-risk medications that Resident #9 was taking, and lacked direction to staff to monitor for specific side effects of these medications. 2. According to the MDS assessment dated [DATE], Resident #13 had a BIMS score of 1 (severe cognitive deficit). The resident was totally dependent on staff for dressing, hygiene, transfers and toileting. Resident #13 was taking an antipsychotic and opioid medications. He had diagnosis that included cancer, dementia, senile degeneration of brain, muscle weakness. The Care Plan updated on 8/26/24 showed that Resident #13 had the potential for nutritional problem related to weight loss and dementia. He had impaired cognitive function, administer medications as ordered. The Care Plan lacked references to the specific needs related to antipsychotic medications or signs and symptoms to monitor. The care plan lacked reference to dementia symptoms and/or interventions to use other than medication administration. The care plan lacked reference to opioid medication use and the side effects. 49628 3. The MDS assessment for Resident #4 dated 7/30/24 identified a BIMS score of 6 which indicated severe cognitive impairment. The MDS documented diagnoses that included: Non-Alzheimer's Dementia, Anxiety Disorder and Depression. The MDS documented Resident #4 received antipsychotic, antianxiety and antidepressant medications on 7 out of 7 days of the assessment reference period. The Care Plan printed on 8/28/24 directed staff to monitor/document for side effects of behavior, depressant, dementia, and skin medications but did not state what the side effects were. Resident #4's Medication Administration Record (MAR)/Treatment Administration Record (TAR) for 8/24 documented entries for the medications of Abilify, Aricept, Clonazepam, Buspirone, and Sertraline. The document further provided entries for side effects for antidepressant, antianxiety, and antipsychotic. 4. The MDS assessment for Resident #26 dated 8/2/24 identified a BIMS score of 4 which indicated severe cognitive impairment. The MDS documented diagnoses that included: Non-Alzheimer ' s Dementia, and Anxiety Disorder. The MDS documented Resident #26 received antianxiety and dementia medication on 7 out of 7 days of the assessment reference period. The Care Plan printed 8/28/24 informed the staff Resident #26 received medication related to anxiety and dementia. The Care Plan directed staff to monitor for side effects and effectiveness. The document did not provide detail of what side effects the staff were to monitor. Resident #26's Medication Administration Record (MAR) for August 2024 documented entries for Rivastigmine Patch 24 Hours 4.6MG/24HR, Rivastigmine Patch 24 hour 9.5MG/24HR from 8/22 through 8/27, Lorazepam, and Mirtazapine. The document further provided entries for side effects for antianxiety, and antidepressant. On 8/27/24 at 3:00 PM the Assistant Director of Nursing (ADON) stated behaviors were charted by nurses in the Progress Notes of the electronic health record (EHR). The side effects of the medications were captured on the MAR/TAR. On 8/28/24 at 1:20 PM the Administrator acknowledged that the certified nursing assistants needed to know what medication side effects to monitor, and the Care Plan would be the best place to see that. The facility document, Care Planning - Interdisciplinary Team Policy, reviewed 1/2017, revealed each resident will have a comprehensive Plan of Care (POC) that will assist them in maintaining and achieving the highest practical level of mental and physical functioning, and wellbeing. The document further stated the POC would identify each resident's strengths, weaknesses, and needs. The policy stated the comprehensive POC must address all care issues that are relevant to the individual, whether or not they are specifically covered in the MDS.

Based on observation, staff interview and policy review the facility failed to ensure that opened food items were dated. They failed to mitigate possible food contamination by using proper hand hygiene and hair net use. The facility reported a census of 29 residents. Findings include: On 8/26/24 at 10:25 AM, in an initial tour of the kitchen, Staff E, [NAME] was found at the sink in the kitchen. He had a full beard and mustache that was not covered. A survey of the refrigerator revealed a tray of drinks uncovered, and a large open bag of shredded lettuce undated. The dry storage area contained a large open bag of cheerios undated. On 8/27/24 at 11:55 AM, in an observation of the lunch service, Staff F, Dietary Aide, prepared a grilled cheese sandwich. She put a glove on her left hand, then opened a container of butter, opened the bread bag and reached into the bag and got bread, all with the same gloved hand. She then opened a container with cheese slices and took out a slice of cheese with same gloved hand. On 8/27/24 at 7:55 AM, the Dietary Manager (DM) said she understood that Staff E should have covered his beard in the kitchen. She said that she didn't have any face nets on hand, so he made the decision to shave his face. On 8/27/24 at 2:27 PM, the DM said that she was working on education with staff on the glove use and hand hygiene/cross contamination. She said that the staff should have used tongs for things like bread and cheese. An undated policy titled: Hair Restraints, showed that hair restraints, hats and/or beard guards would be used to prevent hair from contacting exposed food. Facial hair was discouraged. Any facial hair that was longer than the eyebrow shall require coverage with a beard guard in the production and dishwashing areas. An undated policy titled: Food Storage (Dry Refrigerated, and Frozen), showed that general storage guidelines included: All food items would be labeled. The label must include the name of the food and the date by which it should be sold, consumed or discarded. Discard food that had passed the expiration date. Leftover contents of can and prepared food would be stored in covered labeled and dated containers in refrigerators and/or freezers. An undated policy titled: Hand Washing and Glove Usage; showed that all employees would use proper hand washing procedures and glove usage in accordance with State and Federal Sanitation Guidelines. Gloves were changed any time hand washing would be required. This would include when leaving the kitchen .or if the gloves became contaminated by touching the face hair, uniform or other non-food contact surface, such as door handles and equipment.

Based on clinical record reviews, observations, resident interview, staff interviews, and policy review, the facility failed to review and revise the care plan to include focus area and interventions for 2 of 15 residents (Resident #7 and Resident #15) reviewed. The facility reported a census of 29 residents. Findings include: 1. The Minimum Data Set (MDS) assessment for Resident #7 dated 8-2-24 identified a Brief Interview for Mental Status (BIMS) score of 15 which indicated cognition intact. The MDS documented diagnoses that included: arthritis, pain in the right leg and hip, and history of falling. Resident #7's Clinical Census revealed the resident admitted to the facility on [DATE]. The Care Plan printed 8/28/24 informed the staff Resident #7 did not wear edema garments. Resident #7's Clinical Physician Orders revealed the use of compression stockings on during the day and off at night with a start date of 8/9/24. The Progress Note dated 8/7/24 indicated the primary care provider completed rounds with a new order for compression stockings. Observation on 8/26/24 at 12:38 PM revealed Resident #7 wearing bilateral lower extremity compression stockings. On 8/27/24 at 8:34 AM Resident #7 wore compression stockings, shoes, and completed ambulation with staff assistance from her bedroom to the dining room. On 8/26/24 at 12:38 PM Resident #7 stated she swelled in her left lower extremity and had recently had the right hip replaced. The resident stated she only recently had been able to get her shoes on. Staff D, Certified Nursing Assistant (CNA), on 8/28/24 at 2:51 PM stated compression garments were worn for edema, and she would know if a resident wore compression stockings from the Care Plan. 2. The MDS assessment for Resident #15 dated 8-2-24 identified a Brief Interview for Mental Status (BIMS) score of 11 which indicated moderate cognitive impairment. The MDS documented diagnoses that included: Parkinson's Disease, personal history of transient ischemic attack and cerebral infarction, and personal history of COVID-19. The MDS documented Resident #15 did not require oxygen on admission to the facility and during the assessment period. Resident #15's Clinical Census revealed admission to the facility on [DATE]. The Care Plan printed 8/28/24 did not inform the staff Resident #15 used oxygen, signs/symptoms of hypoxia, and parameters of oxygen use. Resident #15's Physician Orders revealed use of oxygen at 1-2 Liters as needed to keep oxygen saturations above 90% with a start date of 8/9/24. Observation on 8/26/24 at 1:34 PM noted a concentrator in Resident #15's room with oxygen tubing. Observation on 8/27/24 at 8:30 AM revealed oxygen tubing and a concentrator in Resident #15's room. Observation on 8/28/24 at 9:26 AM of Resident #15's room found a concentrator and oxygen tubing. Resident #15 stated on 8/26/24 at 1:35 PM she had to use oxygen one time since returning to the facility. On 8/28/24 at 11:35 AM the Assistant Director of Nursing (ADON), stated resident supports should be on the care plan. The ADON acknowledged that not all the care plans were where she wanted them to be since reopening the facility in July. In an interview on 8/28/24 at 1:20 PM the Administrator stated she was aware of care plans requiring revisions and the sole responsibility of the care plans did not sit on the ADON. The facility document, Care Planning - Interdisciplinary Team Policy, reviewed 1/2017, revealed each resident will have a comprehensive Plan of Care (POC) that will assist them in maintaining and achieving the highest practical level of mental and physical functioning, and wellbeing. The document further stated the POC would identify each resident's strengths, weaknesses, and needs. The policy stated the comprehensive POC must address all care issues that are relevant to the individual, whether or not they are specifically covered in the MDS.

Based on observation, pharmacist interview, staff interview and clinical record review the facility failed to follow physicians' orders for 1 of 4 residents reviewed during medication pass. Resident #128 had a medication order for 100 milligrams (mg) of Sertraline, and the pharmacy sent a bubble pack of pills for 75 mg. Staff did not notice the discrepancy and had administered the wrong dose 26 times. The facility reported a census of 29 residents. Findings include: According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #128 had a Brief Interview for Mental Status (BIMS) score of 11 (moderate cognitive deficits). He was independent with eating, hygiene, dressing and transferring. The resident was taking an antidepressant and antianxiety medications. The Care Plan updated on 8/15/24, showed that Resident #128 had an anxiety disorder, edema, obesity and intellectual disabilities. The Care Plan lacked reference to antidepressant and antianxiety medications. The census tab in the electronic record showed that Resident #128 was admitted to the facility on [DATE]. In an observation of the medication pass on 8/28/24 at 7:34 AM, Staff A, Registered Nurse (RN) prepared medications for Resident #128. She discovered that the Sertraline in the bubble pack contained 50mg tabs with one and one-half tab in each pack. She decided not to give the medication and said that she needed to recheck the orders. An Order Summary dated 7/25/24 at 11:03 AM, showed that Sertraline 75 mg. had been discontinued on that date, and at 11:28 AM, an order was entered for Sertraline 100 mg. one tab daily for depression. A Medication Review Report from the referring facility, signed on 8/1/24, showed an order for Sertraline 100 mg. daily. A review of the Medication Administration Record (MAR) for Resident #128 showed that the 75 mg. dose had been administered 26 times. On 8/28/24 at 9:07 AM, the Pharmacist said that the Sertraline bubble pack for 75 mg had been delivered to the facility on [DATE]. The Pharmacist said that they were not aware that the order had been changed from 75 mg to 100 mg. On 8/28/24 at 1:20 PM, the Administrator acknowledged that when the dosage on the card did not match the order in the computer, the nurses should have double checked and caught that sooner. On 8/29/24 at 6:02 AM, the Director of Nursing (DON) said that the nursing staff should have practiced the 5 rights before giving Resident #128 his medication. She said that the resident was not aware enough to understand his medications so they wouldn't have been able to get a clear answer from him regarding dosage or if there were changes. According to the facility Skills Checklist; Administration of Meds, compare label on each medication to EMAR (Electronic Medication Administration Record).

Based on observations, record review, and staff interviews, the facility failed to utilize proper infection control protocols in an attempt to prevent the spread of COVID-19 for 1 of 4 residents reviewed ( Resident #1). On 8/11/20, 8/12/20, and 8/13/20 Staff A completed the screening tool/Health Assessment for COVID-19 prior to her shift. Staff A answered yes to the screening questions, including a question regarding whether or not she was exposed to [MEDICAL CONDITION]. Staff A informed staff that she was not feeling well and Staff D reported the concerns to the Director of Nursing. Staff A was allowed to enter the facility and worked with Resident #1 on 8/12/20. Staff A subsequently tested positive for COVID-19 in a test conducted 8/12/20 during routine facility-wide testing and received the results on 8/14/20. The facility tested Resident # 1 for COVID-19 on 8/19/20 during routine testing and received positive results on 8/21/20. Due to these findings, immediate jeopardy (IJ) was identified to residents' health and safety. The facility reported a census of 37 residents. Findings include: According to the Minimum Data Set (MDS) with an assessment reference date of 6/25/20, Resident #1 had the following Diagnoses: [REDACTED]. The MDS showed there resident had a Brief Interview for Mental Status (BIMS) score of 14, which meant the resident displayed intact cognition. The MDS documented the resident required assist of 1 staff for dressing, personal hygiene, ambulation (walking), and bowel and bladder care. Review of State Hygienic Laboratory Report revealed Resident #1 was tested for [DIAGNOSES REDACTED]-CoV-2 RNA on 7/8/20, 7/15/20, 7/22/20, 8/8/20, and 8/12/20 with negative test results. The resident was tested on [DATE] with a positive test identified on 8/21/20 at 10:50 PM. Review of State Hygienic Laboratory Report showed Staff A Certified Nursing Assistant (CNA) was tested for [DIAGNOSES REDACTED]-CoV-2 RNA on 7/8/20, 7/15/20, 7/22/20, 8/5/20, and 8/8/20 with a negative result. Staff A was tested on [DATE], which yielded positive test results on 8/14/20 at 5:53 PM. Review of the working schedule for 8/11/20 shows Staff A CNA worked the evening shift and Staff B Licensed Practical Nurse (LPN) worked the day shift. Review of the Employee Screening Tool/Health assessment dated [DATE] revealed Staff A CNA answered yes to the questions regarding a runny nose, a new headache, exposure to anyone with cold or flu-like symptoms within the last 14 days, and exposure to any individual with suspected or confirmed cases of COVID-19 within the last 14 days. Staff A's temperature was recorded at 98.7 F. The screening showed the signature of Staff B LPN on the line which verified the questionnaire/temperature was reviewed. During an interview on 8/26/20 at 9:30 AM, Staff B LPN confirmed it was her signature on the Employee Screening Tool/Health Assessment for Staff A CNA dated 8/11/20. Staff B stated she did not ask Staff A CNA about answering yes to the questions on the screening tool. Staff B was asked if she looked at the screening tool before signing it and Staff B stated I was naughty and didn't even look at the paper and stated it just becomes a habit. Review of the working schedule for 8/12/20 showed Staff A CNA and Staff C Certified Medication Aid (CMA) worked the evening shift. Review of the Employee Screening Tool/Health assessment dated [DATE] showed Staff A CNA answered yes to questions regarding a runny nose, a new headache, new loss of taste and or smell, exposure to anyone with cold or flu-like symptoms within the last 14 days, and exposure to any individual with suspected or confirmed cases of COVID-19 within the last 14 days. The temperature was recorded as 98.7 F and showed the signature of Staff C, CMA which verified the questionnaire/temperature was reviewed. During an interview on 8/25/20 at 2:35 PM, Staff C stated she remembered screening Staff A CNA and informed a nurse about the questions that were answered with a yes, but she could not remember which nurse she told. She reported she did not ask Staff A about the questionnaire answers. Review of working schedule for 8/13/20 showed Staff A CNA worked the evening shift with Staff D Registered Nurse (RN) and Staff E Director of Nursing (DON) working day shift. Review of the Employee Screening Tool/Health assessment dated [DATE] showed Staff A CNA answered yes to questions regarding a runny nose, new headache, new loss of taste and or smell, exposure to anyone with cold or flu-like symptoms within the last 14 days, and exposure to any individual with suspected or confirmed cases of COVID-19 within the last 14 days. The sheet revealed Staff A's temperature as 98.3 F and Staff D RN's signature verifying the questionnaire/temperature was reviewed. During an interview on 8/25/20 at 2:50 PM Staff D RN reported they remembered screening Staff A, CNA. She stated Staff A looked tired and run down and one could tell she did not feel good. Staff D stated she reported the screening tool answers to her supervisor, Staff E. Staff D states Staff E asked if Staff A was running a fever; when staff D said no, Staff E cleared Staff A to enter the building and work. Staff D stated she was concerned and asked Staff A if she reported not feeling well to the administrative staff. Staff D states that Staff A replied I told them and they didn't care. In an interview on 8/25/20 at 3:10 PM, Staff E reported she worked the floor on 8/13/20 from 2 pm to 10 pm and did not recall Staff D informing her of Staff A's responses to the screening tool, and added Staff A never approached her about not feeling well. When Staff E was asked about the protocol for yes answers on the screening tool, she said there should be further questioning and assessment of the employee. Staff E stated she never talked to Staff A about the Employee Screening Tool/ Health Assessment. In an interview with Staff An on 8/25/20 at 3:40 PM, she verified recalled that Staff D questioned her about the Employee Screening Tool/ Health Assessment questions and that she (Staff A) told the charge nurse and her coworkers that day that she did not feel well. She clarified she was being very vocal about not feeling well, but the other staff mocked her (Oh, she thinks she has it), did not take her seriously and would have been upset if she asked to go home. Staff A added she would have been asked to find a replacement to work if she wanted to go home. Staff A reported she informed Staff G Assistant Director of Nursing (ADON) that her roommate had tested positive for COVID-19. An interview conducted with Staff G revealed a Staff A told Staff G that she had concerns since her roommate tested positive for COVID-19, although Staff G could not remember what day or time the telephone conversation took place. Review of the Documentation Survey Report for August 2020 showed Staff A assisted Resident #1 with dressing, locomotion, personal hygiene, bathroom assistance, and delivery of snacks on 8/12/20. The report also identified Staff A also delivered snacks to the resident on 8/13/20. Review of the progress notes revealed the following entries: a. On 8/22/20 at 10:48 am, staff told Resident #1 and daughter of the positive COVID-19 results and room change. b. On 8/42/20 a returned fax verified Resident #1's medical provider was aware of the positive COVID-19 results. c. On 8/25/20 at 8:09 am, staff documented Resident #1 still on droplet precautions due to positive COVID test. The COVID-19 action plan dated 8/7/20 directed all community staff are screened prior to their shift for fever and respiratory symptoms along with completion of a health assessment. Anyone noted to have a temperature equal to or greater than 100.0 will not be allowed to work. Any questions answered with a YES response will be reviewed to identify if the employee was appropriate to work. If a staff member becomes ill during their shift, they are to immediately remove themselves from resident care areas, and notify the administrator and Infection Preventionist. The employee is to leave the workplace and not interact with other staff, visitors, or residents. In an interview Staff F DON, she stated it was never brought to her attention that Staff A had answered yes to her question on the screening tool or that Staff A was not feeling well. She verified she was the DON on duty on 8/11/20 and 8/13/20 and started vacation on 8/13/20, with Staff E as acting DON at that time. Staff F reported her expectations are for staff to review the screening tool and further investigate yes answers to the possible cause of the signs and symptoms. The facility was notified of the Immediate Jeopardy on 8/26/20, and they abated the IJ on 8/27/20 by taking the following actions: A. Facility conducted an education for all the Nurses, CNA's and CMA's to read the entire screening questionnaire for any YES answers before permitting anyone into the facility. B. Educated staff to notify nurse management if they have signs/symptoms or outside exposures to COVID. C. Facility documented they will not allow any staff member or contracted employee to enter the facility until they have read and acknowledged the education. D. Nurse Management team will examine thoroughly the screening sheets every shift to make sure screenings are being done properly and the education and proper protocol for screening are being followed. E. Screeners will apply a dated sticker to each staff member's name badge each day they work to signify they have been properly screened and deemed safe to enter the building. F. Facility Management team will conduct sticker audits throughout the day to ensure only staff that have passed the entrance screening are allowed into the facility. G. Facility will hold an all-staff mandatory meeting on 8/27/20 at 1:30 PM to review the screening process.

Based on record review and physician, nurse practitioner and staff interviews, the facility failed to assess a resident which represented a change in physical condition after a fall with swelling and increased pain present. (Resident #2). Twelve days after the fall, it was determined the resident had a fracture located at the distal left femur (above left knee). The sample consisted of 6 residents. The facility identified a census of 38 residents. Findings include: The Medication Record dated February, 2013 for Resident #2 listed [DIAGNOSES REDACTED]. The MDS (Minimum Data Set) assessment with a reference date of 12/11/12 documented a BIMS (Brief Interview for Mental Status) score of 9 which identified moderate cognitive impairment. The MDS documented Resident #2 required extensive assist of 2 persons for toileting, and extensive assist of 1 person for bed mobility, transfers, and dressing. The MDS documented Resident #2 as frequently incontinent of bladder and continent of bowel. The Care Plan with the effective date of 12/18/12 documented Resident # 2 to be independent with locomotion in the Mobie (electric scooter). The Care Plan documented Resident #2 did not have pain normally. The Care Plan contained new interventions dated 2/16/12 which documented Resident #2 required the increased assistance of 2 persons for transferring, toileting, bed mobility and perineal care. The Incident/Accident Report dated 2/16/13 At 11:05 AM reflected Resident #2 to be on the floor lying on his/her left side. The report documented a skin tear to the right hand on the palm next to the ring finger. The report identified Resident #2 complained of left knee pain. Review of the Patient Transfer and Referral Record dated 2/16/13 noted a transfer to the hospital emergency room with complaints of left knee pain. The transfer record also noted a phone report had been given to the emergency room nurse. The Nurse's Notes identified the following: On 2/16/13 at 11:05 AM, the resident complained of pain to the left hip, left knee, and left side of the head after the fall. On 2/16/13 at 11:10 AM, Resident #2 was transported to the hospital with the paramedics and had received an oral report. On 2/16/13 at 1:50 p.m., Resident #2 returned to the facility and per the hospital physician, the resident did not have a fracture. On 2/17/13 at 1:20 AM Resident #2 complained of left leg pain and the left ankle and left lower leg swollen. On 2/17/13 at 4:10 AM, the resident had more complaints of pain in the left leg since the fall. The Nurse Practitioner had been notified and the facility received an order for [REDACTED]. On 2/18/13 at 4:30 AM the resident held on to the left leg to help during cares. An entry on 2/18/13 (no time) documented Resident #2 requested pain medication for leg/knee pain. An entry for 7:00 PM noted Resident #2 to be more receptive to staff offering assistance. On 2/19/13 at 5:15 AM, the resident required the assistance of 3 people to be moved from the commode and he/she and bearing little weight when up. At 10:40 AM, the resident complained of pain to the left leg. At 9:00 PM, the Nurse ' s Notes documented the resident ' s left lower leg/ankle/foot had 3+ [MEDICAL CONDITION]. On 2/20/13 at 9:10 AM documented a change to Resident #2's pain medication. The HS (Hour of Sleep) pain medication had been changed from [MEDICATION NAME] 5/500 mg (milligrams) every HS was changed to [MEDICATION NAME] 5/325 mg at HS and to continue with the order received on 2/17/13 for [MEDICATION NAME] 5/325 mg every 6 hours PRN. On 2/21/13 at 9:00 PM Resident #2 complained of being achy all over and had been encouraged the resident to request pain medication sooner. On 2/25/13 at 11:35 AM, Resident #2 complained of pain to the left leg and had mild bruising and notable swelling to the left knee. The Nurse's Notes documented the Nurse Practitioner had been contacted and ordered a left knee x-ray. The facility made an x-ray appointment for 2/26/13 at 9:30 AM. The Nurse's Notes documented that due to the weather on 2/26 - 2/27/13 the Resident could not be sent for the x-ray. On 2/28/13 at 10:10 A.M., Resident #2 obtained an x-ray. On 2/28/2013 at 2:00 P.M. the nurse obtained the results of the x-ray which revealed a recent acute displaced angulated [MEDICAL CONDITION] distal femur. Review of a document titled Major Injury Determination Form dated 2/28/13 indicated the physician identified the left femur fracture to be a major injury. The Medication Record dated February, 2013 documented the increased use of pain medications. Before the fall Resident #2 received [MEDICATION NAME] 5/500 mg (a pain medication) routinely at HS only. Following the fall on 2/16/13, Resident #2 received 2 doses of [MEDICATION NAME] 5/325 mg and 1 dose of [MEDICATION NAME] 5/500 mg at HS on 2/17/13. On 2/18/13 the resident received one dose of [MEDICATION NAME] and one dose of [MEDICATION NAME], on 2/19/13 one dose of [MEDICATION NAME] and one dose of [MEDICATION NAME], on 2/20/13 one dose of [MEDICATION NAME], on 2/21/13 one dose of [MEDICATION NAME], on 2/22/13 two doses of [MEDICATION NAME], on 2/23/13 two doses [MEDICATION NAME], on 2/24/13 two doses of [MEDICATION NAME], and on 2/25/13 three doses of [MEDICATION NAME], and 1 dose on 2/26/13. On 3/6/2013 at 3:55 P.M., the Director of Nursing (DON) stated the facility has had a problem with getting x-ray results back from the hospital. She admitted that the facility should have called for the ER (emergency room ) report and the resident's x-ray report of 2/16/13. The staff had not requested copies until 2/28/13 and only then did the facility realize Resident #2 only had a pelvic X-ray on 2/16/13. The DON stated she asked the hospital ER Physician why only a pelvic x-ray had been performed and not one of the leg or knee since the staff documented pain of the left knee. The physician stated the resident only complained of hip pain. The Nurse Practitioner was interviewed on 3/8/13 at 8:20 AM, and stated the facility should have contacted her sooner. She stated the facility did not notify her of the increased pain medication use and did not contact her when the resident could not be transferred to the hospital for an x-ray on 2/25/13. The Nurse Practitioner stated the resident went way to long with a fracture and with a displaced fracture (like that), the staff should have seen something.

Based on record review and interviews with staff and residents, the facility failed to implement interventions and provide adequate supervision to prevent falls for Resident #1. The facility reported a census of 38 residents with five residents reviewed. Findings include: 1. Review of the Minimum Data Set ((MDS) dated [DATE] for Resident #1 revealed a Brief Interview for Mental Status to equal a score of 12 (represents moderately impaired cognition). The assessment identified the resident required extensive assistance of one person physical assist for bed mobility, transfers, walking in room, dressing and toilet use. The assessment revealed the resident incontinent of bladder and history of falls and no injury. The same assessment revealed pertinent [DIAGNOSES REDACTED]. Review of the resident's Care Plan dated 11/27/12 revealed the resident required assistance of two for ambulation, and transfers dated 11/20/12. The resident had limited range of motion (ROM) to upper and lower extremities, ambulate using front wheeled walker and assistance of two for using the toilet and providing peri care. Review of the Transfer and Lifts dated 11/1/10 revealed, the facility will ensure that all staff members are instructed in safe transfer and lifting techniques and how to report suspected injuries. The staff are directed to know the Resident's Needs: a. The resident's care plan should be very explicit on exactly how the resident is to be transferred and or lifted. If staff thinks changes need to be made to the way the resident is lifted, they are directed to discuss it with the charge nurse. b. Know the resident's weight bearing status and balance problems. c. Always transfer to the resident's strongest side. d. Know the resident's ability to understand and assist. e. Always explain to the resident what you are going to do. Know how to do Transfers and Use of Lifting Equipment g. Gait Belt, Fasten it securely around the resident's waist, Grip the belt when moving the resident. Review of the Incident/Accident Report dated 12/11/12 documented a fall at 1135 (11:35 AM), when Staff A, Certified Nursing Assistant (CNA) transferring the resident off the toilet, the resident complained of left lower leg pain, noted active bleeding of left lower leg and displacement of left lower leg above ankle. Review of the Nurse's Notes dated 12/11/12 at 1135 revealed a nursing aide, Staff A, alerted Staff B, Licensed Practical Nurse (LPN) for assistance. When entered Resident #1's room, found the resident supine, body perpendicular to the toilet, left lower leg observed to have abnormal flexion above left ankle, bright red blood and active bleeding noted to left ankle/lower leg. Staff B alerted nursing for assistance and to call 911. Resident #1 comforted and Staff B instructed Staff A to obtain something to use for a tourniquet. A tourniquet applied to left lower leg 6-8 inches above the fractured area. Active bleeding to a minimum. The resident complained of pain of left lower leg and right shoulder. He/she denied pain of head, neck or pelvis. The resident alert and oriented times three. At 1141, no active bleeding noted of left lower leg, blood pressure unable to be obtained, pulse oximetry unable to be obtained, pulse palpated to be at 90 beats per minute and thready. At 1142, the emergency medical team arrived and transported the resident to the hospital. Review of the Patient Transfer and Referral Record dated 12/11/13 revealed Resident #1 stood to pivot off the toilet, held onto grab bar and instantly went down. Possible left ankle fracture and left arm pain. Review of the Radiology Report dated 12/11/12 of left ankle revealed acute markedly angulated displaced comminuted fracture is seen in the distal tibia showing about 60 degrees medial angulation with the apex of the angle pointing laterally and anteriorly. A fracture of the distal fibula is seen at the same level distally showing about 60 degrees medial angulation deformity. Review of the Radiology Report dated 12/11/12 of right shoulder revealed acute markedly angulated fracture of the proximal right humerus showing about 60 degrees lateral angulation with the apex pointing medially. Review of the Major Injury Determination Form dated 12/11/12 at 1145 AM, signed by physician on 12/11/12, revealed the injury is a major injury. Review of the Clinical Health Record (physician orders) signed by the resident's primary care physician on 12/3/12 revealed an order to follow Care Plans as written. Staff Interviews: A telephone interview with Staff A, CNA on 12/31/12 at 10:28 AM revealed he was very upset after Resident #1 fell . Staff A stated he never tried to transfer Resident #1 alone. Staff A stated he stood him/her up, changed his/her brief and slacks and had asked him/her to hang onto the grab bar and asked him/her not to move. He stated he turned to obtain his/her wheelchair and the gait belt which was across the room, then he saw from the corner of his eyes that Resident #1 was standing up on his/her own. When he turned to assist him/her, and the resident fell , hitting his left leg as he/she went down. Staff A stated he stated again he never assisted Resident #1 to stand nor told him/her to stand. Staff A stated he was planning to get his/her wheelchair then call for help. He went on to say, others were transferring two assist residents by themselves because they were so short of help all the time. He stated everyone was supposed to use their walkie-talkies and communicate but the communication was terrible at the home. He stated he has requested help before and the help never arrived. He stated when he assisted a two assist resident before, when Staff B walked in, the resident was tired of waiting and he stood up on his/her own. He stated he knows it ' s important to provide good care. During a follow up interview with Staff A on 1/4/13 at 9:15 AM, he stated he was always short of staff and he would always call for help more than once using his walkie-talkie first and when no one would show up then he would turn on the bathroom light. Staff A stated the communication there was really bad. After Resident #1 fell , all the aides said they weren't aware of how many staff was required to do the resident transfers. He stated when asked, they were required to refer to the resident care plan. He stated Resident #1's bathroom was so small everybody would transfer him/her alone, because of the tight quarters. Staff A stated one staff would hold the wheelchair, while the second staff assisted him/her into the wheelchair. He stated he was just turning to obtain his/her wheelchair and gait belt. Staff A stated he heard a loud popping noise that he ' d never heard before and then saw Resident #1's foot lying over to its side. He stated he saw blood, felt sick to his stomach and yelled for Staff B to come right away. Staff B requested he obtain something to stop the bleeding and he grabbed a pillow case when other administrative staff began to help. Staff A's personnel record contained documentation of verbal warning dated 10/14/12. On 10/14/12 Staff A failed to transfer a two assist resident with assistance of another staff member, with the result of the resident being lowered to the floor. During interview on 12/27/12 at 2:30 PM, the facility Administrator stated she felt bad about the fall that anyone that transfers a 2-assist resident by themselves, they would be fired on the spot. She stated she had a good facility and it made her sick to think of this happening. The Administrator stated she knew Staff A had done this once before but as far as she knew, that was the only one. During interview on 12/27/12 at 3 PM, the Director of Nursing (DON) stated she worked with Staff A at another facility and felt bad when this happened again while under her supervision. She started at the facility a couple of weeks after Staff A. When Staff A transferred a 2-assist resident alone, she spoke with him the next day. She stated that she felt he did a good job and had not heard differently. During interview on 1/9/13 at 11:10 AM, Staff F, CNA stated she called Staff B and he assisted her to put Resident #1 on the toilet prior to the fall. She stated they used a gait belt, one behind the resident and the second staff assisted the resident to hold onto the grab bars and transferred onto the toilet. She requested to sit awhile and sat alone until she needed assistance to get off the toilet. She stated this had been normal for the resident. She stated they are expected to read the communication book or go to the charge nurse and get report verbally. She stated if she were unsure of something, she would always ask. She stated as a CNA, its second nature to find a way to make things work and if there wasn't enough room in the bathroom and one would manage the wheel chair and hold onto the resident from the back side. She stated they always had the option to use a bedside commode when a resident had dizziness or weakness. During interview on 12/27/12 at 9:45 AM, Staff B stated when he entered Resident #1's room, he did not find a gait belt on the resident, near the resident or on Staff A. He further stated, prior to this fall, he found Staff A transferring a two assist resident and he gave him a verbal warning at that time. Interviews with Residents: During interview on 1/2/13 at 11:20 AM, Resident #1 stated the aide assisted him/her off the toilet and h/she fell . The aide had assisted to place their hands on the grab bars and assisted him/her to stand. An interview was conducted with Resident #2 on 12/27/12 at 9:00 AM. Resident #2 reported he had been transferred by only one staff before, by Staff A. Resident #2 reported when Staff A couldn ' t find anyone to help, he just picked him/her up and moved him/her to his/her bed. Resident #2 stated it happened that way more often than not. Resident #2 stated when asked, that Staff C had also transfers him/her by her/her(self), and she used her gait belt and lifted him/her from the front with hands around his/her waist. Resident #2 stated he does not want to fall anymore, his/her hip has given him/her a lot of trouble and needs to stay as he/she is so he/she can see his/her spouse. An interview was conducted with Resident #8 on 1/2/13 at 1:45 PM. The resident reported he/she likes living at the nursing home and feels safe for the most part. He/She stated he remembered Staff A. Resident #8 stated he/she fell when Staff A was assisting him/her and his/her legs were going to give out. Resident #8 requested the wheelchair to sit in, however he/she went down. Resident #8 stated most staff always got help transferring him/her but when Staff A worked, he almost always helped him/her alone. The resident stated Staff A was strong but he knew they were to always have two staff to help him/her. The resident then stated, thank god he/she never got hurt. Additional Staff Interviews: During further interview on 1/2/13 at 12:40 PM, the Director of Nursing (DON) stated she expects staff to follow the resident care plan, they are also required to review the communication sheets daily and then initial when they had reviewed it. The aides are also required to do rounds together with the oncoming shift and receive report about changes of the residents. She further stated when the walkie talkie is used to request help and if no one comes to assist, she expects the staff to turn on the bathroom call light. During interview on 12/26/12 at 3:50 PM, Staff C, CNA stated before Resident #1 had surgery on him/her hand, he/she only required one person to assist, then after surgery, the care plan changed to a two person assist because he/she could not hold on. He/she also had been able to stand before surgery then after h/she could not stand well. She further stated when they requested help from their walkie talkies and no help came, then they were expected to use the bathroom call light and wait for assistance when indicated. During interview on 1/9/13 at approximately 2 PM, Staff D, CNA stated she had cared for Resident #1 prior to fall and would always get a second staff member to transfer the resident because h/her legs would be weak at times and she did not always see any warning. She stated she just always wanted to work safe. She stated she does know the consequences of not caring for the residents in safe manner. She stated any changes would be documented in the communication book and they were required to read and initial it each day they worked. She stated if no one came to assist her with a transfer, then she is expected to use the bathroom call light system and never leave the resident alone, if indicated. During interview on 1/9/13 at 11:35 AM, Staff E, CNA stated she had taken care of Resident #1, h/she had shaky legs at times but for the most part, h/she had been able to stand well. She stated the resident only required one assist before surgery on h/her hand. She stated the resident required help holding onto the grab because of stiff fingers. She stated she used the red light if no one answered her using her walkie talkie.