Every finding on record at Hallmark Care Center

Based on clinical record reviews and staff interview, the facility failed to ensure residents were provided with education regarding the risks and benefits of psychotropic medications 4 of 5 residents reviewed for unnecessary medications (Resident #8, #18, #33, #38) . Additionally, the facility failed to offer alternative treatment options prior to the administration of the medications. The facility reported a census of 42 residents. Findings include:1. The admission Minimum Data Set (MDS) Assessment for Resident #8 dated 7/30/25 documented diagnoses that included: Non Alzheimer's dementia, anxiety disorder, and depression. The MDS recorded an admission date to the facility of 7/23/25. The resident's Medication Administration Record (MAR) dated July of 2025 reflected the resident had orders for Escitalopram, an antidepressant medication, start date 7/24/25; Buspirone, an antianxiety medication, start date 7/24/25 and Quetiapine, an antipsychotic medication, start date of 7/23/25. A clinical record review of the Resident's Electronic Health Record (EHR) failed to reveal consent obtained for any of the medications prior to administration. Additionally, no progress notes or assessments revealed education was provided of the side effects, risk versus benefits of psychotropic medications, or that alternative treatments were offered. On 4/7/26 at 1:00 pm, the Administrator stated the Director of Nursing (DON) started employment in October of 2025 and had been catching up the assessments for psychotropic medications since that time as they previously had been completed. 2. The admission MDS Assessment for Resident #18 dated 10/29/25 documented diagnoses that included: Anxiety disorder, post traumatic stress disorder (PTSD) and insomnia. The MDS recorded an admission date to the facility of 10/22/25. Resident #18's MAR for October 2025 reflected that the resident had orders for Sertraline, and Trazodone, antidepressant medications. The MAR of Resident #18 for March of 2026 reflected the resident was ordered Abilify, an antipsychotic medication in December of 2025, as well as Doxepin, an antidepressant/hypnotic used for insomnia, ordered in February of 2026. A clinical record review of Resident #18's EHR failed to reveal consent being obtained for any of the medications prior to administration. Additionally, no progress notes or assessments revealed education was provided of the side effects, risk versus benefits of psychotropic medications, or that alternative treatments were offered. 3. The Quarterly MDS Assessment for Resident #33 dated 3/19/26 documented diagnoses that included: anxiety disorder, depression, bipolar disorder and post traumatic stress disorder (PTSD). The MDS recorded an admission date to the facility of 9/25/25.The MAR for Resident #33 dated March 2026 reflected the resident was ordered bupropion, duloxetine and trazodone, all antidepressant medications, ordered September and November of 2025 and buspirone, an antianxiety medication ordered in September 2025.A clinical record review of Resident #33's EHR failed to reveal consent obtained for any of the medications prior to administration. Additionally, no progress notes or assessments revealed education was provided of the side effects, risk versus benefits of psychotropic medications, or that alternative treatments were offered. 4. The Quarterly MDS Assessment for Resident #38 dated 3/10/26 documented diagnoses that included: anxiety disorder and PTSD. The MDS recorded an admission date to the facility of 9/3/25. The MAR for Resident #38 dated March 2026 reflected the resident was ordered Abilify in February 2026, trazodone in December 2025, buspirone in December 2025, and duloxetine in September 2025.A clinical record review of Resident #38's EHR failed to reveal consent obtained for any of the medications prior to administration. Additionally, no progress notes or assessments revealed education was provided of the side effects, risk versus benefits of psychotropic medications or that any alternative treatments were offered. On 4/8/26 at 2:15 pm, the Administrator voiced she had just started her position at the facility a month earlier. She stated she would speak with the Director of Nursing regarding education and consents for psychotropic medications.The facility did not have a policy for use of psychotropic medications.

Based on clinical record review, Center for Medicare and Medicaid (CMS) Long-Term Care (LTC) Facility Resident Assessment Instrument (RAI) 3.0 User Manual, and staff interview the facility failed to accurately code resident falls with major injury, medications, smoking, and restraints on the Minimum Data Set (MDS) Assessment for 5 of 15 reviewed (Resident #8, #13, #18, #28 and #31). The facility identified a census of 42 residents. Findings include:1.Resident #13's Electronic Healthcare Record (EHR) Census showed he admitted to the facility on [DATE]. A 2/12/26 Hospital Discharge Summary documented Resident #13 with a diagnosis of a stroke and to discharge on aspirin (antiplatelet medication) 81 Milligrams (MG) chewable tablet daily and clopidogrel (antiplatelet medication) 75 MG, take 1 tablet daily. A 2/16/26 Provider Encounter Visit Progress Note documented Resident #13 on dual antiplatelet therapy for secondary stroke prevention. Resident #13's 2/19/26 MDS Assessment showed a Brief Interview for Mental Status (BIMS) score of 11/15, indicating a moderate cognitive impairment. The MDS included diagnoses of stroke with hemiplegia/hemiparesis (one-sided body weakness or paralysis due to nervous system injury (e.g., stroke) and documented Resident #13 received anticoagulant and antiplatelet medications. A Review of the February, March and April 2026 Electronic Medication Administration Records (EMAR's) documented the administration of aspirin 81 mg daily and Clopidogrel 75 MG daily. The records lacked documentation an anticoagulant was administered. On 4/08/26 at 3:06 PM the Director Of Nursing (DON) reported she would check to see if Resident #13 had taken any anticoagulant medications and check with corporate on the accuracy of all the MDS Assessments. On 4/09/26 at 10:13 AM the DON reported she reached out to the Corporate MDS Coordinator to review the MDS Assessments. The Corporate MDS Coordinator reported the MDS Assessments were not accurate. On 4/09/26 at 10:14 AM the Regional Nurse Consultant explained the facility used the CMS LTC RAI manual for coding the MDS Assessment. The CMS LTC RAI Manual, Chapter 3, Page N-9 directed do not code antiplatelet medications such as aspirin/extended release, or clopidogrel as anticoagulant (medications). 2. Resident #31's 1/06/26 MDS Assessment showed a BIMS Score of 15/15 indicating intact cognition. Resident #31 had no functional limitations in range of motion to the upper/lower extremities and required the use of a walker. Resident #31 was independent with dressing, personal hygiene, positioning in bed, getting in/out of bed, transferring and walking. The MDS documented Resident #31 utilized a bed rail daily. A 3/17/25 Bed Rail/Other Device Evaluation documented Resident #31 utilized one grab bar outer rail on the bed. Resident #31 was oriented to self, time, environment/situation and able to make her needs known. The Evaluation documented the grab bar device was an assistive device to turn and reposition in bed to maintain the resident's highest level of independence. The Device Evaluation Risk versus Benefit explained the grab bar was to remain in place per the resident's preference to maximize independence with bed mobility, and assist with getting in and out of bed. The Care Plan dated 5/11/23 documented Resident #31 wanted a grab bar on one side of her bed, and was able to utilize the grab bar to safely get in/out of the bed. On 4/06/26 at 2:10 PM, Resident #31 sat in the wheelchair in her room. Observation at this time revealed a loop style grab bar on the resident's upper left side of the bed. Resident #31 explained the grab bar really helped her to be independent in repositioning and getting in/out of bed. The grab bar did not restrict her from any movement or accessing her body in any way. It really helped her. Review of Resident #31's EHR Assessments, Progress Notes, miscellaneous(documents) on 4/8/26 lacked documentation of a physician order for a restraint. The CMS LTC RAI Manual documented the following definition for a Physical Restraint: 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 normal access to one's body. On 4/08/26 at 9:50 AM Staff A, Certified Medication Aide (CMA) voiced Resident #31 did not use restraints. She was up independent. The grab bar on her bed allowed her to reposition in the bed on her own and didn't restrain her in anyway. On 4/08/26 at 10:56 AM Staff B, Certified Nursing Assistant (CNA) reported there were no residents in the facility using restraints that she was aware of. On 4/08/26 at 2:05 PM Staff C, Licensed Practical Nurse (LPN) reported there were no residents using restraints in the facility. During an interview on 4/08/26 at 2:42 PM, the DON stated she noticed that the grab bars were being coded as restraints and she was trying to go through and change the care plans to reflect they were not restraints. There were no residents using grab bars that met the definition of a physical restraint. The grab bars were utilized for body positioning. The facility MDS Coordinator resigned from the facility in early March 2026 and she was covering the MDS in the interim. She had not done MDS for 12 years, and would have to defer to the corporate office if the MDS Assessment were coded accurately. The CMS LTC RAI defined a Physical Restraint 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 normal access to one's body. The Steps to Assessment included:1. Review the resident's medical record (e.g., physician orders, nurses' notes, nursing assistant documentation) to determine if physical restraints were used during the 7-day look-back period.2. Consult the nursing staff to determine the resident's cognitive and physical status/limitations.3. Considering the physical restraint definition as well as the clarifications listed below, observe the resident to determine the effect the restraint has on the resident's normal function. Do not focus on the type, intent, or reason behind its use.4. Evaluate whether the resident can easily and voluntarily remove any manual method or physical or mechanical device, material, or equipment attached or adjacent to their body. If the resident cannot easily and voluntarily do this, continue with the assessment to determine whether or not the manual method or physical or mechanical device, material or equipment restrict freedom of movement or restrict the resident's access to their own body.5. Any manual method or physical or mechanical device, material or equipment should be classified as a restraint only when it meets the criteria of the physical restraint definition. This can only be determined on a case-by-case basis by individually assessing each and every manual method or physical or mechanical device, material or equipment (whether or not it is listed specifically on the MDS) attached or adjacent to the resident's body, and the effect it has on the resident.6. Determine if the manual method or physical or mechanical device, material, or equipment meets the definition of a physical restraint as clarified below. Remember, the decision about coding any manual method or physical or mechanical device, material, equipment as a restraint depends on the effect it has on the resident.7. Any manual method or physical or mechanical device, material, or equipment that meets the definition of a physical restraint must have: physician documentation of a medical symptom that supports the use of the restraint, a physician's order for the type of restraint and parameters of use, and a care plan and a process in place for systematic and gradual restraint reduction (and/or elimination, if possible), as appropriate. Current Tobacco Use: 1.Ask the resident if they used tobacco in any form during the 7-day look-back period.2.If the resident states that they used tobacco in some form during the 7-day look-back period, code 1, yes. Fall with Major Injury: Includes, but is not limited to, traumatic bone fractures, joint dislocations/ subluxations, internal organ injuries, amputations, spinal cord injuries, head injuries, and crush injuries. Coding Instructions: Code 0, none: if the resident had no major injurious fall since admission/entry or reentry or prior assessment. Code 1, one: if the resident had one major injurious fall since admission/entry or reentry or prior assessment. Code 2, two or more: if the resident had two or more major injurious falls since admission/entry or reentry or prior assessment. 3. The Medication Administration Record (MAR) of Resident #8 for July 2025 reflected an order for Buspirone (an antianxiety medication), 10 milligram tablets, give two tablets three times daily for anxiety, with a start date of 7/24/25. This order was discontinued on 9/9/25. The MAR additionally reflected the resident had an order for Seroquel, an antipsychotic medication with a start date of 7/23/25. The MAR of Resident #8 for September 2025 reflected a new order started on 9/10/25 of the same dosage, with a minor scheduling change. This order remained active through the survey dates. The MDS for Resident #8 dated 7/30/25 failed to document the use of an antianxiety and antipsychotic medication. The resident's MDS dated [DATE] failed to document the use of an antianxiety medication. The MDS dated [DATE] failed to document the use of an antianxiety medication. The 2025 RAI Manual directed: Review the resident's medical record for documentation that any of these (high risk) medications were received by the resident and for the indication of their use during the 7-day look-back period (or since admission/entry or reentry if less than 7 days). Column 1: Check if the resident is taking any medications by pharmacological classification during the 7-day observation period (or since admission/entry or reentry if less than 7 days). On 4/8/26 at 4:12 pm, the Administrator stated the facility had no policy regarding the use of psychotropic medications. The Minimum Data Set (MDS) Assessment for Resident #8, dated 1/1/26, documented that he used bed rails daily as a restraint. An observation of Resident #8's bed on 4/7/2026 at 9:41 AM revealed two (2) grab bars on each side, though they did not appear to limit his ability to get out of bed. The current Care Plan for Resident #8 on 4/9/26 instructed him to use bed grab bars to help with repositioning in bed. 4. The MDS dated [DATE] for Resident #18 documented that she did not use tobacco. The 10/22/26 Admission/readmission Assessment documented that she was a smoker and will continue to smoke at the facility. On 4/6/26 at 12:02 PM, Resident #18 revealed she was a current smoker and had been since living at the facility. The current Care Plan for Resident #18 on 4/9/26 revealed starting on 10/22/25, she would smoke cigarettes. 5. A review of Resident #28's MDS logs in her EHR documented an admission MDS on 11/10/25 and a discharge MDS on 1/23/26. A Progress Note dated 1/19/26 documented that Resident #28 received a follow-up evaluation at the facility from her provider following a 1/16/26 emergency department visit, where she was diagnosed with a sacral fracture. The MDS dated [DATE] documented that Resident #28 had not sustained any falls with major injury. On 4/8/26 at 2:38 PM, the Director of Nursing (DON) revealed that staff should have coded tobacco use for Resident #18 on her admission MDS and a fall with major injury on Resident #28's discharge MDS. She also clarified that Resident #8 does not use a bed rail restraint; instead, the bars assist him with bed mobility.

Based on a review of records, staff interviews, and facility policy, the facility failed to provide education and obtain informed consent for 4 of 4 residents regarding eligibility for influenza vaccination (Resident #7, #12, #18, and #24) and 3 of 3 residents for pneumococcal vaccination (Resident #7, #18, and #24). The facility reported a census of 42 residents.Findings include:Review of the Census List on 4/9/26 for Resident #7 documented she was admitted to the facility on [DATE] and was a current resident. A review of her Electronic Health Record (EHR) on 4/9/26 revealed she had not received her influenza or pneumococcal vaccinations.Review of the Census List on 4/9/26 for Resident #12 documented he was admitted to the facility on [DATE] and was a current resident. A review of his EHR on 4/9/26 revealed he had not received the influenza vaccination.Review of the Census List on 4/9/26 for Resident #18 documented she was admitted to the facility on [DATE] and was a current resident. A review of her EHR on 4/9/26 revealed she had not received her influenza or pneumococcal vaccinations.Review of the Census List on 4/9/26 for Resident #24 documented she was admitted to the facility on [DATE] and was a current resident. A review of her EHR on 4/9/26 revealed she had not received her influenza or pneumococcal vaccinations.In an interview on 4/9/26 at 10:29 AM, the Director of Nursing stated the current Infection Preventionist was on leave. After reviewing past immunization records, the Director was unable to find documentation that Resident #7, #12, #18, and #24 were provided with education. There was also no signed documentation showing the residents refused the vaccinations.The facility's Infection Control Manual, last revised in 10/2025, required staff to educate residents, obtain consent for available vaccines, and document all immunizations in the EHR.

Based on clinical record review, staff interview, and instructions of CMS form 10123-NOMNC, and 10055-SNF ABN, the facility failed to ensure an accurate and timely Notice of Medicare Non-Coverage (NOMNC) was provided and failed to issue a Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) for 1 of 3 residents reviewed for Beneficiary Notification (Resident #50). The facility reported a census of 42 residents.Findings include: Record review of Resident #50's Minimum Data Set (MDS) assessment dated [DATE] and the Census line of the resident's Electronic Health Record (EHR) revealed the resident received Medicare-covered services from 2/10/26 through 3/3/26. On 3/4/26, the resident's payor source transitioned to private pay until discharge on [DATE]. A review of the facility-provided Notice of Medicare Non Coverage (NOMNC) form for Resident #50, signed by the resident's spouse/representative on 2/18/26, documented that Medicare coverage would end on 2/24/26. On 4/7/26, the facility noted on the SNF Beneficiary Protection Notification Review form that a Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) was not provided to Resident #50 because the plan was for her to discharge home the day after skilled care ending. The note also documented that the facility had a staff change over at the same time and the ABN was likely overlooked.The Encounter Note dated 2/20/26, authored by the Medical Provider noted the resident's husband was concerned about the projected discharge date of 2/24. The Encounter Note dated 2/27/26, authored by the Nurse Practitioner, documented that the resident was seen that day for evaluation of therapy follow-up and discharge planning.No notes were found in the resident's chart indicating that the original discharge date was delayed or the reason for the change of discharge. No discharge summary note was found in the resident's chart. The Assessment labeled Instructions for Discharge, dated 3/5/26 was noted as incomplete in the resident chart. On 4/9/26 at 10:44 am, the Administrator stated she was unable to locate an additional NOMNC issued to Resident #50 with the correct end of Medicare coverage date of 3/3/26. The document titled Notice Instructions for the Notice of Medicare Non Coverage (NOMNC) CMS 10123 documented the following: -Insert the actual date coverage of the service will end.The documented titled Form Instructions Advance Beneficiary Notice of Non-coverage (ABN) documented the following: -Deliver the ABN far enough in advance that the patient or representative has time to consider the options and make an informed choice.

Based on record review, staff and resident interviews, and policy review, the facility failed to maintain documentation of the information sent to the hospital to ensure that continuity of care and resident needs were maintained during the transfer process for 4 of 4 hospitalizations reviewed (Residents #2 and #6). The facility reported a census of 42 residents.Findings include: 1.The Census List for Resident #2 documented a hospital transfer from 1/19/26 to 1/23/26, and a second transfer from 3/25/26 to 4/2/26.A review of Resident #2's Progress Notes and Assessments revealed a lack of documentation regarding the information sent to the hospital for the 1/19/26 and 3/25/26 hospitalizations2. The Census List for Resident #6 documented hospital transfers from 2/18/26 to 2/27/26 and from 3/29/26 to 4/3/26.A review of Resident #6's Progress Notes and Assessments revealed a lack of documentation regarding the information sent to the hospital for the 2/18/26 and 3/29/26 hospitalizationsDuring an interview on 4/8/26 at 3:17 PM, the Director of Nursing (DON) and Administrator stated the facility did not have a written discharge policy or procedure. The DON noted her expectation that nursing staff send the Medication Administration Record (MAR), the Treatment Administration Record (TAR), and the Iowa Physician Orders for Scope of Treatment (IPOST), along with the Face Sheet and Bed Hold form. She further expected staff to record vital signs, provide a verbal report to the Emergency Medical Technicians (EMTs), and provide a verbal report to the hospital emergency room (ER) to notify them of the transfer. However, they acknowledged the facility was unable to locate the documentation sent with Resident #6 for the 2/18/26 and 3/29/26 hospitalizations, or for Resident #2 for the 1/19/26 and 3/25/26 hospitalizations.

Based on clinical record review, Pre-admission Screening and Resident Review (PASRR), and resident and staff interviews, the facility failed to ensure a resident's mental health diagnosis and medications were accurately reported to the designated state agency for 1 of 3 residents diagnosed with Post Traumatic Stress Disorder (PTSD) (Resident #38) and failed to implement PASRR level II recommendations into the care plan for 2 of 3 residents (Residents #6 and #18). The facility reported a census of 42 residents.Findings include:The Electronic Healthcare Record (EHR) Census documented Resident #38 admitted to the facility on [DATE]. A Facsimile (fax) Transmission dated 9/3/25 from a local hospital detailed a 9/2/25 PASRR (a federally mandated process for evaluating individuals with serious mental illness (SMI), intellectual disabilities (ID), or related conditions (RC) prior to admission into a Medicaid-certified nursing facility to ensure appropriate placement, and necessary services) which determined Resident #38 did not have SMI, ID, or another RC and a level two was not required. The PASRR listed a diagnosis of a suspected anxiety disorder and the use of antidepressant and a medication used for diagnosis of anxiety in the past 6 months. Further review of the clinical record lacked documentation of an updated PASRR. Resident #38's Hospital Discharge Summary Note dated 9/03/25 documented to follow up with psychiatry in 1-2 months, psychology therapy 1-2 weeks and included an order for trazodone (antidepressant medication) 100 Milligrams (MG) take 0.5 MG by mouth daily for a diagnosis of post-traumatic stress disorder (PTSD). The September 2025 Electronic Medication Administration Record (EMAR) documented Resident #38 received the trazodone medication for PTSD. The Care Plan dated 10/16/25 documented the use of Psychotropic Medication Use related to PTSD. The 11/21/25 Care Plan noted Resident #38 with a behavior problem related to PTSD and Psychosocial complications related to anxiety and PTSD. A 11/21/25 Referral Form for a telehealth psychiatry service documented Resident #38 resided in the nursing home and needed a referral for a diagnosis of, in part, anxiety disorder and PTSD. The Referral also had an Order Summary Report detailing Resident #38 was taking antidepressant medication for PTSD. A Physician Order dated 12/19/25 detailed to start Abilify (antipsychotic medication) 5 MG every morning related to PTSD. Review of the December 2025 EMAR documented Resident #38 started to receive the medication on 12/20/25 and continued to take the antipsychotic medication and Trazodone (antidepressant medication) from that time to current 4/07/06. On 4/07/26 at 4:00 PM the Director of Nursing (DON) reported the facility did not have any updated PASRR Evaluation for Resident #38. She reported the Social Worker was responsible for reviewing and completing the PASRR Evaluations. On 4/07/26 at 4:15 PM the Social Worker reported she was still working on her conditional training for PASRR. She honestly did not know if she would need to rescreen a PASRR for a diagnosis of PTSD or medication changes. The DON reported on 4/08/26 at 2:53 PM the PASRR was completed by the Social Worker and everything was a learning curve right now. The DON believed a new PTSD diagnosis and new psychotropic medications would require a new PASRR to be updated. On 4/08/26 at 4:03 PM, the Administrator reported the facility did not have a PASRR Policy. On 4/09/26 at 10:15 AM, the Regional Nurse Consultant reported the facility utilized the [State] PASRR site to comply with completing the PASRRs. 2. Resident #6's 3/16/26 PASRR Level II outcome identified her as Level II and directed the need for specialized and rehabilitative services. On 4/9/26 review of Resident #6's current Care Plan lacked her Level II outcome and the implementation of specialized and rehabilitative services directed in her 3/16/26 PASRR. 3. Resident #18's 1/1/26 PASRR Level II outcome identified her as a Level II and directed the need for specialized and rehabilitative services. Review of Resident #18's Care Plan review on 4/9/26 listed her Level II requirements but did not show who would oversee the services, when they would begin, or if the facility had completed the necessary referrals. In an interview on 4/8/26 at 3:17 PM, the Administrator explained the facility's Social Worker completed the PASRRs for the residents. She had been in the role for nine months; however, she had not had training on how to complete them.

Based on record review, staff and resident interviews, and policy review, the facility failed to implement interventions into the care plans for 2 of 2 residents following their return from hospitalizations (Residents #2 and #6). The facility reported a census of 42 residents.Findings include:1.The Census List for Resident #2 documented hospitalization from 1/19/26 to 1/23/26, and a second hospitalization from 3/25/26 to 4/2/26.Review of Resident #2's Progress Note by his Advanced Registered Nurse Practitioner (ARNP) revealed he was seen on 1/26/26 at the facility for an acute follow-up due to a recent hospitalization from 1/19/26 to 1/23/26. During his hospital stay, he was diagnosed with acute respiratory failure with hypoxia due to Influenza A and was also treated for a Urinary Tract Infection (UTI).Review of Resident #2's Progress Note by his ARNP revealed he was seen on 4/6/26 at the facility for an acute follow up due to a recent hospitalization that he returned from on 4/2/26. During his hospital stay, he was treated for kidney stones and treated for a UTI. He returned to the facility with a peripherally inserted central catheter (PICC) line and is receiving antibioticsIn an interview on 4/8/26 at 1:45 PM, Resident #2 denied having any issues with care at the facility. He stated that his hospitalizations went well and that if he didn't feel well, the nurses took it seriously and took action.Review of Resident #2's current Care Plan Report on 4/9/26 revealed it had not updated to include his recent hospitalization, his current need for antibiotic therapy, kidney stones, or the maintenance of his PICC site. 2. The Census List for Resident #6 documented hospitalizations from 2/18/26 to 2/27/26 and from 3/29/26 to 4/3/26.Review of Resident #6's Progress Note by her ARNP revealed the resident was seen on 3/2/26 at the facility for an acute follow up due to a recent hospitalization that she returned from on 2/27/26. During her hospital stay, she was treated for hypernatremia (too much salt in the blood) causing confusion and diabetes insipidus (kidneys unable to conserve water as they filter the blood). Review of Resident #6's Progress Note by her ARNP revealed the resident was seen on 4/6/26 at the facility for an acute follow up due to a recent hospitalization that she returned from on 4/3/26. During her hospital stay, she was treated for aspiration pneumonia and acute respiratory failure with hypernatremia and hyperkalemia (elevated potassium).Review of Resident #6's current Care Plan Report on 4/9/27 revealed it had not updated to include her recent hospitalization and if signs or symptoms could be monitored in the facility for hypernatremia. During an interview on 4/8/26 at 3:17 PM, the Director of Nursing (DON) confirmed that the Care Plans for Resident #2 and Resident #6 were not updated following their hospitalizations.A review of the facility's Care Plan Policy (last revised 3/2025) revealed a lack of instructions regarding whether care plans need to be reviewed following hospitalizations.

Based on clinical record review, document review and staff interview the facility failed to follow physician orders to obtain daily weights for 1 of 1 resident sampled on daily weights (Resident #5). The facility reported a census of 42 residents.Findings include:The Electronic Healthcare Record (EHR), last order review 2/09/26 documented a physician order for a daily weight in the morning related to heart failure, start date 11/25/25.The Risk for Altered Cardiovascular Functioning related to Heart Failure and Chronic Kidney Disease, Stage 4 Care Plan dated 10/7/25 directed to monitor weights as ordered. A 4/07/26 review of the 2026 Electronic Treatment Administration Records (ETARs) and the Vital Sign Weight Records revealed the following missing daily weights:a. January 1, 3, 4, 13, 18, 20, 29 and 31b. February 12, 19, and 21c. March 1, 3, 5, 17, 19, and 22d. April 4On 4/08/26 at 10:23 AM, Staff A, Certified Medication Aide (CMA) reported generally the certified nursing assistants (CNAs) got the daily weights first thing in the morning and then gave the weights to the nurses. The nurses documented the weights in the resident's electronic health record. On 4/08/26 at 10:26 AM, Staff D, Licensed Practical Nurse (LPN) explained the CNAs got the daily weights first thing in the morning before breakfast. They had two residents on dialysis which included Resident #5 that required daily weights before and after dialysis treatments. The CNAs reported the weights to the nurses and the nurses documented the daily weights in the ETAR or in the EHR vital signs tab. On 4/08/26 at 10:56 AM, Staff B, CNA reported occasionally the nurses asked her to get a weight, but other than that she was not sure what they did for daily weights. On 4/08/26 at 2:37 PM, the Director of Nursing (DON) reported she had talked with the nurses and the EHR was not marked with a heart to allow the nurses to enter the weight into the ETAR. If the nurse didn't enter the weight into the vital signs weight then the weight was probably not documented. The DON reported she expected the nurses to follow the physician order for daily weights and document the weights in the medication record. On 4/09/26 at 11:07 AM, the Administrator reported ideally the nurse who took the physician order should put the order in the resident's EHR. The nurses may need more education to know there was a supplemental area that prompted for more information to be placed within the order. She stated most likely the weight was taken and the nurse didn't enter the weight into the EHR Vital Sign area. The Physician Orders/Transcription of Orders Policy dated 7/2023 included a Purpose to correctly and safely receive/transcribe physician's orders so the correct order can be followed/administered. The policy further revealed the following per the Procedure section: Medication/Treatment orders would be entered in the EMAR or ETAR accordingly and active orders should be followed and carried out as written.

Based on clinical record review, staff interview, CMS 2567 review, and QAPI (Quality Assurance Performance Improvement) Plan review, the facility failed to implement effective quality assurance processes to address Pre-admission Screening and Resident Review (PASRR) deficiencies, resulting in F644 being cited in 2025 as well as the current survey. The facility reported a census of 42 residents.Findings include:A review of the facility CASPER report revealed the facility cited for F644 Coordination of Pre-admission Screening and Resident Review (PASRR) (a federally mandated process for evaluating individuals with serious mental illness (SMI), intellectual disabilities (ID), or related conditions (RC) prior to admission into a Medicaid-certified nursing facility to ensure appropriate placement, and necessary services) and Assessments March 2025.The facility CMS 2567 Plan Of Correction (POC) with a compliance date of 4/19/25 detailed the Administrative Nurses and Social Service Designee would continue to review the PASRR assessments during the referral process to ensure new admissions had all mental health diagnoses included on the PASRR completed prior to admission. The Social Service Coordinator, or Designee, would audit admissions monthly times three months to ensure all diagnosis were listed on the current PASRR. The results of the audits would be reviewed as a part of the facility's ongoing quality assurance process and the frequency of the audits thereafter would be based on the outcomes. A 4/07/26 review of Resident #38's Clinical Record revealed a PASRR completed by a local hospital 9/02/25 prior to admission which listed a suspected diagnosis of anxiety disorder and the use of antidepressant and antianxiety medications. Resident #38 was admitted to the facility on [DATE] with a physician order for antidepressant medication for a diagnosis of post-traumatic stress disorder (PTSD). A 12/19/25 Physician Order detailed to start Abilify (antipsychotic medication) every morning.During an interview on 4/07/26 at 4:00 PM the Director of Nursing (DON) reported the facility did not have any updated PASRR Evaluation for Resident #38 since 9/02/25. Interview on 4/09/26 at 11:09 AM the Administrator explained all audits from any tagged (non-compliance) areas would have proper audits placed, completed, and tracked through the Quality Assurance and Process Improvement (QAPI) program for compliance. The QAPI Plan Policy, effective date 2/18/20 documented the Administrator functioned as the chair of the QAPI Committee and would be responsible and accountable for ensuring the QAPI program defined, implemented, maintained and addressed identified priorities and sustained it during transitions. The Policy further documented regulatory outcomes including licensure survey results would be monitored and trended. Completion of investigations and review of those findings should demonstrate process improvement initiatives implemented in the assessment stage have been sustained and the focus area has not been re-identified in the investigation stage.

Based on document review, policy review, and staff interview the facility failed to ensure the Infection Preventionist attended the Quality Assurance and Performance Improvement (QAPI) quarterly meetings. The facility identified a census of 42 residents.Findings include:A 4/07/26 review of the Quality Assurance (QA) Sign-in (Attendance) Sheets for 10/24/25 and 1/21/26 lacked documentation the facility Infection Preventionist attended the quarterly QA meetings.On 4/08/26 at 3:00 PM the Director of Nursing (DON) reported the Infection Preventionist had still been an employee of the facility at that time and may have worked the floor so she was unable to attend the QA meetings.On 4/09/26 at 8:35 AM the Administrator reviewed all the QA Sign-In Sheets and verified the Infection Preventionist was not in attendance at the meetings. She reviewed the QAPI meeting notes for 10/24/25 and 1/21/26 to find there wasn't significant information regarding a quarterly review of the infection control program/tracking. The Administrator voiced if the Infection Preventionist had worked the floor, she wouldn't have been able to attend the meetings at those times. She would expect the Infection Preventionist to attend the QAPI meetings. The QAPI Plan Policy effective date 2/18/20 outlined the QA Committee included the Medical Director or Designee, DON, Administrator or other leader, and the Infection Prevention and Control Officer.

Based on a review of records, staff interviews, and facility policy, the facility failed to provide education and obtain informed consent for 2 of 5 residents regarding eligibility for COVID-19 vaccination (Resident #7 and #12). The facility reported a census of 42 residents.Findings include:1.Review of the Census List on 4/9/26 for Resident #7 documented she was admitted to the facility on [DATE] and was a current resident. A review of her Electronic Health Record (EHR) on 4/9/26 revealed no documentation that she received COVID-19 vaccination education or was provided informed consent.2. Review of the Census List on 4/9/26 for Resident #12 documented he was admitted to the facility on [DATE] and was a current resident. A review of his EHR on 4/9/26 revealed no documentation that he received COVID-19 vaccination education or was provided informed consent.In an interview on 4/9/26 at 10:29 AM, the Director of Nursing stated the current Infection Preventionist was on leave. After reviewing past immunization records, the Director was unable to find documentation that Resident #7 and #12 were provided with education. There was also no signed documentation that showed the residents refused the COVID-19 vaccinations.The facility's Infection Control Manual, last revised 10/2025, required staff to educate residents, obtain consent for available vaccines, and document all immunizations in the EHR.

Based on electronic health record review, Pre-Admission Screening and Resident Review (PASRR) review, resident interview, staff interview, and policy review the facility failed to ensure a resident's mental health diagnoses and medications were accurately reported to the designated state agency for 1 of 3 residents diagnosed with PTSD (Post Traumatic Stress Disorder) (Resident #17). The facility reported a census of 38 residents. Findings include: The Minimum Data Set (MDS) for Resident #17 dated March 3, 2025 included diagnoses of depression, anxiety disorder, and PTSD. The Brief Interview for Mental Status (BIMS) indicated the resident scored 15/15 which indicated intact cognition. The resident's Electronic Health Record (EHR) confirmed they had diagnoses of anxiety disorder, unspecified dated 9/20/24; post-traumatic stress disorder, unspecified dated 9/20/24; and depression, unspecified dated 9/20/24 which indicated they were present at admission. On 9/23/24 the resident signed medication consent forms for Alprazolam aka (also known as) Xanax (anxiety), Duloxetine aka Cymbalta (PTSD), Lamotrigine aka Lamictal (depression), and Aripiprazole aka Abilify (anxiety). Resident #17's EHR included a document titled Notice of PASRR Level I Screen Outcome, based on information submitted by the hospital, dated 9/20/24. Mental health diagnoses included Anxiety Disorder and Depression/Depressive Disorder. It did not include PTSD. The PASRR included medications Abilify and Cymbalta for depression and anxiety. It did not include Alprazolam or Lamictal, or behaviors associated with the resident's mental health medications. During an interview on 3/19/25 at 10:21 AM Resident #17 reported talking to social services during her admission regarding her mental health including PTSD. Further discussion revealed staff had spoken to the resident about some of her actions and behaviors since she moved in. She felt her medications were stable, but also revealed she continued to experience anxiety and stress related to her diagnoses. During an interview on 03/19/25 at 09:21 AM Staff A, Licensed Practical Nurse (LPN) stated she did not know a lot about Resident #17's mental health diagnoses. She reported behaviors of being manipulative, saying things that were untrue, yelling at staff, needing to be right no matter what, and scratching herself. She thought the PASRR would be reviewed and/or completed by social services or the Director of Nursing (DON). On 03/19/25 at 09:52 AM the DON indicated the facility would complete a new PASRR if a resident had a new diagnosis and maybe for new medications. She reported that social services would complete a PASRR form review on admission. The DON acknowledged they missed that there was not a PTSD diagnosis and some of the medications on the initial form, and stated they needed to start a new PASRR for this resident. On 03/20/25 at 01:09 PM the facility Administrator stated the facility had gotten better with PASRRs but didn't see PTSD wasn't addressed on the PASRR the hospital submitted for this resident. She acknowledged they didn't catch it and stated they try to look at the PASRRs during the referrals process. During a follow up on 03/20/25 at 01:34 PM the Administrator stated the facility did not have a PASRR policy and just followed the regulations.

Based on resident and staff interviews, clinical record review, and facility policy review, the facility failed to ensure interventions for pain management provided resident with effective pain relief following a fall with injury to right wrist for 1 of 3 resident reviewed for pain management (Resident #8). The facility reported a census of 38 residents. Findings include: The Care Plan revealed Resident #8 had been at risk for falling related to decreased safety awareness and impulsiveness with an intervention initiated on 2/13/25 for pain evaluation to be completed with Primary Care Provider, elastic bandage wrap (ACE wrap), and ice to be applied to right wrist for swelling and pain control. The Care Plan revealed Resident #8 had impaired cognition related to a traumatic brain injury that affected short term and long term memory. The Care Plan lacked a focused area for pain management, goals for pain, or identification of ongoing pain symptoms following the fall on 2/11/25 with injury to the right wrist. Review of Nursing Notes revealed the following entries: 1. On 2/11/25 at 6:10 AM, Resident #8 had fallen after self transferring in room and was found sitting on floor against the wall underneath television with blood observed coming from Resident #8's nose. Resident #8 rated pain a 9 on a scale of 1 to 10 (from least pain to worst pain) in right wrist. Resident was transported via ambulance to Emergency Department for possible nasal fracture and a possible right wrist fracture. 2. On 2/11/25 at 9:44 AM, Hospital notified facility that Resident #8 had fractured nose and a soft tissue injury to right wrist. Resident #8 transferred back to facility. 3. On 2/12/25 at 3:32 PM, Resident #8 rated pain 9 out of 10 to right wrist, Nursing Note lacked interventions attempted or follow up assessment. 4. On 2/13/25 at 9:30 AM, Resident #8's right wrist documented as painful and swollen from fall, nursing to review with Primary Care Provider on rounds this day and therapy to evaluate for wrist splint and ice as needed for pain. 5. On 2/14/25 at 2:03 PM, Resident #8's right hand had swelling from previous fall and resident reported pain at 8 out of 10. 6. On 3/05/25 at 8:44 PM, a recommendation received from therapy for ace wrap to the left upper extremity, starting at resident's fingers and up to elbow, on in morning and off at bed time and instructed that once swelling is down, therapy would evaluate a use of cock up wrist splint. Note lacked recommendation for injured right wrist. A Hospital note, dated 2/11/25, revealed an x-ray had been completed on right wrist, indicated for right wrist pain and deformity after fall, findings revealed old fracture deformity in distal right radius without an acute fracture and soft tissues swollen throughout the wrist. A Computed Tomography (CT) scan also completed on Resident #8's face and jaw, revealed a small, comminuted, mildly displaced fracture of the right nasal bone. The Medication Administration Record (MAR), dated February 2025, revealed Resident #8 had the following orders in place for pain: -Gabapentin 300 milligrams (mg) with instructions to give 300 mg by mouth one time per day for pain, order initiated on 1/24/2022. -Acetaminophen (Tylenol) 650 mg with instructions to give 650 mg every 6 hours as needed for pain, order initiated on 1/24/2022. The February MAR revealed Resident #8 had not utilized as needed (PRN) Tylenol 650 mg between 2/01/25 and 2/11/25. Resident #8 required a dose of PRN Tylenol 650 mg for pain on the following dates: 2/11/25 at 7:53 PM, pain rated 8 out of 10, noted with an E, or effective, for pain. 2/12/25 at 2:00 AM, pain rated 9, noted as effective. At 2:29 PM pain rated 8, noted with I, or ineffective, for pain relief. At 8:29 PM, rated 8, noted to be effective. 2/13/25 at 8:14 AM, pain rated 9, noted as ineffective. At 4:53 PM, pain rated 9, noted as effective. 2/14/25 at 9:04 AM, pain rated 9, noted as effective. 2/15/25 at 1:16 PM, pain rated 9, noted as effective. 2/16/25 at 1:00 AM, pain rated 8, noted as effective. At 10:19 AM, pain rated 5, noted effective. At 5:19 PM, pain rated 9, with ineffective relief. 2/17/25 at 6:04 AM, pain rated 3, noted to be ineffective. At 7:10 PM, pain rated 9, noted effective. 2/21/25 at 7:46 PM, pain rated 9, noted to be effective. 2/22/25 at 12:38 PM, pain rated 5, noted as effective. At 6:39 PM, pain rated 9, noted effective. 2/23/25 at 5:21 PM, pain rated 8, noted effective. 2/24/25 at 6:47 PM, pain rated 9, noted effective. 2/25/25 at 12:35 PM, pain rated 7, noted effective. 2/28/25 at 12:43 PM, pain rated 7, noted effective. The MAR lacked a follow up pain number rating following doses noted to be effective or ineffective. The Treatment Administration Record (TAR), dated February 2025, revealed Resident #8 had the following orders in place for wrist pain: -Apply ice to right wrist/hand with instructions to apply for 20 minutes and remove for 20 minutes, every one hour as needed for pain. The February TAR indicated as needed ice order utilized 8 times, each noted to provide effective pain relief. The MAR, dated March 2025, revealed no changes made to Resident #8's pain medication regimen. The March 2025 MAR revealed Resident #8 required a dose of as needed Tylenol 650 mg for pain on the following dates: 3/01/25 at 6:41 PM, pain rated 9 out of 10, Tylenol noted with a U or unknown pain relief. 3/02/25 at 7:52 AM, pain rated 8, noted to be effective. At 5:06 PM, pain rated 9 with unknown effectiveness. 3/03/25 at 9:10 AM, pain rated 9, noted effective. At 5:10 PM, pain rated 6 with unknown effectiveness. 3/04/25 at 12:27 PM, pain rated 8, noted effective. 3/06/25 at 2:36 PM, pain rated 7, noted effective. 3/07/25 at 12:20 PM, pain rated 7, noted effective. 3/14/25 at 6:25 PM, pain rated 9 with unknown effectiveness. 3/15/25 at 6:56 PM, pain rated 9, noted effective. 3/17/25 at 6:32 PM, pain rated 9, noted effective. 3/18/25 at 2:34 PM, pain rated 9, no documentation of effectiveness charted. Resident #8's Electronic Health Records (EHR) lacked documentation of physician notification related to pain rated 9 out of 10 or ineffective pain relief following pharmacological intervention. On 3/18/25 at 2:33 PM, Resident #8 sat in recliner in their room, noted to have cloth sleeve (tubigrip) covering right wrist and forearm. Resident #8 reported right wrist still painful after fall and requested pain medicine from surveyor. Staff A, Licensed Practical Nurse (LPN) gave Resident #8 dose of as needed pain medicine. On 3/19/25 9:18 AM, Staff B, Certified Nursing Assistant (CNA), reported Resident #8 wears a right wrist splint at night and cloth sleeve during the day. Staff B stated Resident #8 had not recently complained of wrist pain and informed that resident had been improving with transfers using the walker since fall. Staff B reported that Resident #8 would request pain medicine if she needed and stated the Tylenol or ice had been effective in providing resident with pain relief. Staff B claimed Resident #8's sleep and day to day activities had not been affected by wrist pain. On 3/19/25 at 9:25 AM, Staff A, Licensed Practical Nurse (LPN), confirmed as needed Tylenol 650 mg had been given to Resident #8 on 3/18/25 at 2:33 PM upon request of pain medicine for pain rated 9 out of 10. Staff A stated Resident #8 would always ask for pain medicine when needed and informed that resident's pain typically was related to right wrist. Staff A reported she would follow up with Resident #8 about 45 minutes after giving Tylenol by verbally asking if pain had improved, Staff A denied documentation of verbal follow up assessment for Resident #8's pain but stated the MAR would reflect if Tylenol had been effective. On 3/20/25 at 1:30 PM, Facility Administrator stated Resident #8 had shown symptoms of pain such as guarding of right wrist with swelling and tenderness following fall with injury to the area which has since improved. Administrator acknowledged that nursing documentation was needed to take credit for the work they do, but did feel they were adequately managing Resident #8's pain. The facility policy, titled Pain Policy, dated 9/2023, revealed the purpose of the policy is to ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences. The policy instructed staff to assess the resident for effectiveness of pain medication following as needed (PRN) pain medication and if pain is unrelieved despite pharmacologic and nursing measures, the resident's physician will be notified.

Based on observation, record review, resident interview, staff interview, and policy review the facility failed to account for a resident's experiences, preferences, and potential triggers that might cause re-traumatization for 1 of 3 residents diagnosed with PTSD (Post Traumatic Stress Disorder) (Resident #17). The facility reported a census of 38 residents. Findings include: Resident #17's Social History, dated 09/23/24 at 12:34 PM for an admission on 09/20/25, documented the resident suffered a lot of abuse as a child. She indicated she didn't like to sleep with her door closed, was nervous around people, had difficulty trusting others, felt sadness, lost family connection, and had a lot of traumatic experiences as an adult. The document included recognition of her PTSD diagnosis. The Minimum Data Set (MDS) for Resident #17 dated March 3, 2025 included diagnoses of depression, anxiety disorder, and PTSD. The Brief Interview for Mental Status indicated the resident scored 15/15 which indicated intact cognition. The Care Plan for Resident #17, admitted [DATE], did not address her mental health diagnoses, mental health medications, triggers, goals, focus areas, or interventions. During an observation on 03/17/25 at 02:01 PM the resident was sitting in her recliner next to her roommate. She was scratching at her right shoulder, put her hand down, and started scratching her calf. She answered a few questions and asked for a return visit for her interview. During the follow up interview on 3/19/25 at 10:21 AM observed the resident lounging in her recliner, scratching at the top of her leg. She reported talking to Social Services during her admission regarding past trauma and some of her mental health triggers. Further discussion regarding her mental health revealed staff had spoken to her about some of her actions and behaviors since she moved in. She recalled a couple of times she yelled at staff if she thought they were rushed or in a bad mood. She reported she felt more down and frustrated, and needed more attention, when her health changed including when staff 'made me use' the sit to stand lift to get up. The resident stated staff didn't really talk to her about health changes affecting her mental health, and she thought she needed more support at those times. An interview with Staff B, Certified Nurses Aide (CNA) on 03/19/25 at 09:05 AM revealed she was not aware of the resident's diagnoses or triggers. She stated she knew the resident didn't like male caregivers but didn't know if that was written anywhere. She didn't know if her scratching was medical or behavioral. Her primary non-pharmacological intervention was talking to the resident, and she reported she would tell the nurse if Resident #17 needed more support. During an interview with Staff B, Licensed Practical Nurse (LPN) at 09:21 AM on 03/19/25 she stated she did not know a lot about the resident's mental health diagnoses. She stated the resident could be manipulative and had said things that were not true, and reported the staff just knew that, said okay, and moved on. She reported the resident had a lot of behaviors including scratching herself, yelling at staff, and had to be right no matter what. On 03/18/25 at 1:52 PM Staff C, Social Services, stated she started trauma informed care discussions with residents at admission as part of the resident's social history. They would discuss triggers and non-pharmacological interventions. Sometimes the DON would assist with this as well. One of them would make sure new information would get into the Care Plan. During an interview on 03/19/25 at 09:52 AM with the Director of Nursing (DON) she reported Staff C would assess trauma triggers as part of admission and usually put mental health information into resident Care Plans. She was not sure why the diagnoses, triggers, medications, and non-pharmacological interventions were not in the Care Plan. She stated adding triggers was a 'new one' they were working on and needed to be added to the Care Plan. The DON expected non-pharmacological interventions in Care Plans to include things such as repositioning, pain management, toileting, addressing hunger, walking, activities, hydration, addressing potential overstimulation. She reported some behaviors for Resident #17 were related to declines in functional status and acknowledged that could impact mental health. On 03/20/25 at 01:09 the Administrator reported there was not a policy for trauma informed care and stated the facility followed regulations.

Based on staff interview, clinical record review, and facility policy review, the facility failed to provide bed hold notice to resident or resident representative prior to transferring 2 of 3 residents to the hospital (Resident #35 and Resident #27). The facility reported a census of 38 residents. Findings include: 1. Resident #35: The Minimum Data Set (MDS), dated [DATE], revealed the most recent reentry to facility dated 1/26/25 from acute/short-term general hospital. The Electronic Health Records (EHR) census tab informed that on 1/22/25 Resident #35 had a hospital paid leave and on 1/26/25 Resident #35 readmitted to facility. Review of the Nursing Notes revealed the following entries: On 1/22/25 at 3:11 AM, Resident #35 had unwitnessed fall with head injury and vital signs out of normal range. Resident #35 transferred to the hospital via ambulance. Family, physician, and Director of Nursing notified of transfer. On 1/22/25 at 3:57 AM, Nursing Note included reason for transfer and personal belongings sent but lacked documentation for the questions: -Does resident and/or resident representative want to hold the bed? -Was the Bed Hold notice sent with resident representative or to the hospital? In a Hospital History and Physical, dated 1/22/25, revealed Resident #35 presented to the hospital with a mechanical, unwitnessed, fall from her Nursing Home with head trauma, unknown if loss of consciousness. In Emergency Department Resident #35 found to be hypertensive with blood pressure 180/70 and unable to provide any history regarding fall. In a Hospital Discharge Summary, dated 1/26/25, revealed Resident #35 admitted to the hospital for unwitnessed fall, found to have fever due to pneumonia human metapneumovirus positive, required oxygen and antibiotics. Resident #35 improved and stable, discharged back to facility. Facility provided document, titled Private Pay Reserved Bed Form, dated 1/25/25, identified an amount to be charged rate per day to reserve the bed for Resident #35. Resident #35 signed and dated form on 1/27/25 in request for bed to be reserved during absence from facility and agreed to pay the rate identified per day. 2. Resident #27: The Minimum Data Set (MDS), dated [DATE], revealed the most recent reentry to facility on 1/18/25 from acute/short-term general hospital. The Electronic Health Records (EHR) census tab revealed on 1/12/25, Resident #27 had a hospital paid leave and on 1/18/25, Resident #27 returned to the facility. Review of Nursing Notes revealed the following entries: 1. On 1/12/25, Resident #27 experienced change of condition when nursing documented assessment of adventitious lung sounds, bilateral lower extremity edema, wet sounding non-productive cough, and decrease in appetite. Family and physician notified of condition with order received from physician to send Resident #27 to the hospital for evaluation and treatment. 2. On 1/18/25, Resident #27 returned to the facility following acute hospitalization for viral pneumonia. In a hospital History and Physical Note, dated 1/13/25, Resident #27 diagnosed with acute hypoxemia secondary to human metapneumovirus infection with shortness of breath and cough for 1 week. In a hospital Discharge Summary, dated 1/12/25 through 1/18/25 for meta-pneumovirus infection. The facility lacked documentation of a Bed Hold notice provided to Resident #27 or resident representative prior to hospitalization [DATE]. On 3/19/25 at 10:30 AM, Facility Administrator confirmed that facility lacked documentation of notice of Bed Hold for Resident #35 or Resident #27 provided prior to transfer, or within 24 hours of transfer to hospital. The facility policy, titled Bed Hold and Return Policy, dated 10/2023, revealed the purpose of policy is to ensure that residents are made aware of facility's bed hold and return policy before and upon transfer or when taking a therapeutic leave of absence from the facility. The policy instructed staff to provide bed hold notice to residents and/or resident representative upon admission and at the time of transfer or within 24 hours of transfer if the transfer is emergent/urgent. The policy additionally instructed the facility to inform the resident and/or resident representative in writing in a language and manner they understand prior to transferring a resident to a hospital or the resident going on therapeutic leave of the bed hold and return policy.

Based on MDS (Minimum Data Set) review, resident census data, the Resident Assessment Instrument (RAI) manual, staff interview, and policy review the facility failed to submit a discharge MDS for 1 of 1 residents reviewed (Resident #25). The facility reported a census of 38 residents. Findings include: The MDS for resident #25 dated 01/02/25 documented the resident admitted to the facility 11/01/24, discharged from the facility on 01/02/25 to the community, and return was not anticipated. The census tab of the electronic health record indicated the facility stopped billing on 01/02/25. The MDS Summary screen documented the facility completed the MDS with a note that read 'Do not submit to CMS (Centers for Medicare and Medicaid Services)'. During and interview on 03/19/25 at 12:57 PM the Director of Nursing (DON) stated the MDS should have been submitted. She was not sure what happened to trigger the do not submit indicator or how this had been missed. The DON reported that based on the resident's insurance and discharge status they had to submit the discharge MDS and confirmed it would be late. On 03/18/25 at 1:39 PM the Administrator reported the facility did not have a policy for MDS or Care Plan assessments. She stated they followed the RAI manual. The RAI manual dated October 2024, page 2-45 with a section titled Tracking Records and Discharge Assessments Reporting, indicated tracking records and discharge assessment reporting was required for all residents in skilled nursing facilities. The section further documented the discharge assessment must be submitted within 14 days after the completion date.

Based on observation, staff interviews, and policy review, the facility failed to ensure food items covered, dated, and stored to prevent possible cross-contamination. The facility reported a census of 40 residents. Findings include: During an observation on 05/19/24 at 9:30 AM, initial tour of the kitchen revealed the walk-in refrigerator with a four wheeled cart, on top glasses of various poured drinks included, 3 white milks, 2 chocolate milks, 3 apple juices, and 3 orange juices. The glasses were uncovered. The cart had two opened milk jugs without open dates. Another larger tiered cart contained two trays of individual plated pies slices, also uncovered, without a label or date. During an interview on 5/19/24 at 9:32 AM dietary Staff B, stated the pies were to be served for lunch today, did not know when they were cut. Staff B revealed the four wheeled cart in the refrigerator was used for breakfast and pushed into the refrigerator after the breakfast meal. On 5/20/24 at 11:54 AM Certified Dietary Manager, Staff A relayed was not sure why the cart was in the refrigerator with the poured juice cups, acknowledge the drinks on the cart should have been discarded. On 5/21/24 at 3:00 PM the Administrator relayed the four wheeled cart is put in the refrigerator after the meal service to keep the milk cold. The Administrator acknowledged the milk jugs were not dated. The Administrator voiced the other cups on the cart would have been disposed of and relayed the pies were discarded. The Administrator acknowledged the pies should have been covered. Policy titled, Refrigerated Food Storage dated 4/15/05 documented food will be stored, properly labeled, and dated per the regulatory requirements and maintenance of food quality.

Based on clinical record review, staff interview, and state designated authority direction for Preadmission Screening and Resident Review (PASRR) the facility failed to complete a follow-up PASRR screening for one out of one resident reviewed in the current sample who had a change in mental health status (Resident #17). The facility reported a census of 40 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] did not reveal a completed score for the Brief Interview for Mental Status (BIMS). The MDS recorded Resident #17 with Psychiatric/Mood disorders that included anxiety disorder, depression, and bipolar disorder. The MDS revealed antipsychotics received by Resident #17 on a routine basis. The Care Plan, revised date 5/8/24 documented for Resident #17 psychotropic medication used, included potential for adverse reactions related to psychotropic, antidepressant and antipsychotic medications due to obsessive-compulsive disorder, anxiety, depression, post-traumatic stress disorder, and bipolar disorder interventions. On 05/21/24 at 02:32 PM the Administrator relayed some mental health diagnoses were not discovered until after Resident #17 admitted to the facility, they did not resubmit for a new PASRR and acknowledged that should have been done. The Administrator relayed the facility used the guidelines provided by the state verses a facility policy. The Notice of PASRR Level 1 screen outcome, dated 8/5/2016 from state contracted company for screening documented Resident #17 does not have a major mental illness included does not have bipolar or major depression. The Level 1 screen relayed no psychotropic medications have been prescribed. The document directed the nursing facility to submit a status change for further evaluation with changes.

Based on record review, interviews, and facility policy review, the facility failed to ensure pneumococcal vaccines were offered to 2 (Resident #21 and Resident #38) of 5 sampled residents reviewed for immunizations. Findings included: A review of a facility policy titled, Influenza and Pneumococcal Pneumonia Vaccines, updated 08/29/2022, revealed, 1. Upon admission, determine when the resident last received the influenza and pneumococcal vaccines by assisting the resident/responsible party with completing the Admission Influenza and Pneumococcal Vaccination Information form. The policy also indicated, ii. If previously vaccinated with a pneumococcal vaccine, determine which one(s) were given and include the date administered if known. If the resident received the pneumococcal vaccine prior to September 2014 then they probably received only the PPSV [pneumococcal polysaccharide vaccine] 23 vaccine and will be eligible to receive the PCV [pneumococcal conjugate vaccine] 15 or PCV20 vaccine - if desired - once 12 months have passed. Additionally, the policy indicated, e. The need for pneumococcal vaccination will be assessed upon admission and administered following an order from the medical provider for the type of pneumococcal vaccination needed. Further review of the policy revealed, 12. Those who have received PCV13 with or without PPSV23 b. Adults [AGE] years of age i. Give PPSV23 at least one year after PCV13 to those who have no underlying medical conditions or risk factors or have medical conditions or risk factors excluding cochlear implants, cerebral spinal leak or immunocompromising in 5ci above. The policy also indicated, 5.11. Those who have only received PPSV23 a. May give 1 dose of PCV15 or PCV20 at least 1 year from the last dose of PPSV23 administered. 1. A review of the Admission Record for Resident #21 indicated the facility admitted the resident in January 2018 with diagnoses which included congestive heart failure, type 2 diabetes mellitus without complications, stage 3 chronic kidney disease, and obesity. The record indicated the resident was greater than [AGE] years of age. An annual Minimum Data Set (MDS) dated [DATE] revealed Resident #21 had a Brief Interview for Mental Status (BIMS) score of 14 which indicated the resident was cognitively intact. According to the MDS, Resident #21 was not up to date on the pneumococcal vaccine and the vaccine was not offered. A review of Resident #21's immunization record in the electronic health record (EHR) revealed the resident had a PCV13 pneumococcal vaccine on 01/04/2016. There was no documentation in the resident's medical record to indicate the facility had offered Resident #21 the PPSV23 vaccine upon or since admission to the facility. During an interview on 03/07/2023 at 2:04 PM, the Director of Nursing (DON) stated there was no documentation which indicated Resident #21 had been offered a second pneumococcal vaccine upon or since admission to the facility. The DON stated residents were generally offered the pneumococcal vaccine upon admission. During an interview on 03/08/2023 at 11:21 AM, Licensed Practical Nurse (LPN) #1 stated the Admission Influenza and Pneumococcal Vaccination Information form was completed prior to a resident's admission. She stated she had never reviewed the immunization form. LPN #1 stated she did not know how Resident #21's second pneumococcal vaccine had been missed. During an interview on 03/08/2023 at 11:40 AM, the Administrator stated no Admission Influenza and Pneumococcal Vaccination Information form could be found for Resident #21. She stated the failure to offer a second vaccine to the resident was an oversight. 2. Review of an Admission Record revealed the facility admitted Resident #38 in October 2022 with diagnoses which included chronic obstructive pulmonary disease and stage 3 chronic kidney disease. According to the admission record, Resident #38 was greater than [AGE] years of age. A review of an Order Summary Report revealed Resident #38 had a physician's order dated 10/24/2022 for a pneumococcal vaccine to be administered. A quarterly Minimum Data Set (MDS) dated [DATE] indicated Resident #38 had severely impaired cognitive skills per a staff assessment for mental status. According to the MDS, the resident was up to date on the pneumococcal vaccine. Review of Resident #38's immunization record in the electronic health record (EHR) indicated the resident received a pneumococcal vaccine on 08/07/2009. There was no documentation in the resident's medical record to indicate the facility had offered the resident a second pneumonia vaccine upon or since admission to the facility. During an interview on 03/07/2023 at 2:04 PM, the Director of Nursing (DON) stated there was no documentation which indicated Resident #38 had been offered a second pneumococcal vaccine upon or since admission to the facility. The DON stated residents were generally offered the pneumococcal vaccine upon admission. During an interview on 03/08/2023 at 11:21 AM, Licensed Practical Nurse (LPN) #1 stated the Admission Influenza and Pneumococcal Vaccination Information form was completed prior to a resident's admission. She stated she had never reviewed the immunization form. LPN #1 stated she did not know how Resident #38 had been missed for a second pneumococcal vaccine. During an interview on 03/08/2023 at 11:40 AM, the Administrator stated no Admission Influenza and Pneumococcal Vaccination Information form could be found for Resident #38. She stated the failure to offer a second pneumococcal vaccine to the resident was an oversight.

Based on record review and staff interview, the facility failed to conduct and document Care Conferences completed on a quarterly basis for three of four residents reviewed (Residents #5, #27 and #29). The facility reported a census of 38 residents. Findings Include: 1. Resident #5's Minimum Data Set (MDS) dated [DATE] identified the resident as cognitively intact with a Brief Interview for Mental Status (BIMS) of 15. The MDS also identified the resident required extensive staff assistance with most activities of daily living excluding eating and personal hygiene. The MDS documented the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . The Care Plan with the goal target date of 4/17/22 identified the resident with the following problems: a. At risk for complications of diabetes mellitus. b. Use of antidepressant medication. c. Acute and chronic pain. d. At risk for pressure injuries. e. Bladder incontinence. A review of the Care Conference Progress Notes for the past year revealed conferences documented as held on the following dates: 1/25/21, 6/11/21, 1/17/22. 2. Resident #27's MDS dated [DATE] identified the resident as cognitively impaired with a BIMS of 3. The MDS also identified the resident required extensive staff assistance with most activities of daily living. The Face Sheet documented the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Care Plan with the goal target date of 3/23/22 identified the resident with the following problems: a. Altered nutrition related to subarachnoid hemorrhage. b. At risk for falls. c. At risk for complications from incontinence. d. Potential for pressure ulcers. e. At risk for impaired communication. f. Impaired cognition. g. Impaired ADL (activities of daily living) performance. h. Chronic lower back pain. A review of the Care Conference Progress Notes for the past year revealed conferences were documented as held on the following dates: 3/26/21, 7/5/21, 9/29/21 and 11/24/21. 3. Resident #29's MDS dated [DATE] did not identify the resident as cognitively intact or impaired. The MDS also identified the resident required extensive staff assistance with most activities of daily living. The MDS documented the resident had the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Care Plan with the goal target date of 3/15/22 identified the resident with the following problems: a. Period of [CONDITION(S)]. b. At risk for increased behaviors related to dementia. c. Uses hospice services. d. Potential for falls. e. Potential for adverse side effects of medication related to use of psychoactive medications. f. Mental health diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] g. At risk for additional pain/discomfort. h. At risk for pressure ulcer development. A review of the Care Conference Progress Notes for the past year revealed conferences were documented as held on the following dates: 1/25/21, 5/3/21 and 7/15/21. In an interview on 1/20/22 at 8:24 AM, the Social Worker reported Care Conferences are scheduled once every 3 months or whenever a significant change occurs. Documentation is completed in the Care Conference Notes in the Electronic Medical Record (EMR). She also reported she had started working at the facility in September 2021 and could not explain why Conferences did not occur quarterly prior to her hire date. In an interview on 1/20/22 at 8:28 AM, the Director of Nursing (DON) reported she would have to check the regulations to see how often Care Conferences should be held as she had just started working there last month. In an interview on 1/20/22 at 8:30 AM, the Administrator reported Care Conferences are to be held every 3 months, sometimes residents' families refuse to come in and we will have remote Conferences by phone. If they refuse to attend, it should be documented in the Progress Notes or sometimes in e-mail correspondence. The Administrator also reported the facility did not have a policy related to Care Conferences.

Based on observation, document review and interview, the facility failed to prevent pressure ulcers for 1 of 1 resident ' s reviewed with pressure ulcers (Resident #3). The facility reported a census of 39 residents. Findings include: Resident #3's Minimum Data Set (MDS) 30 day assessment completed 8/28/15 documented short and long term memory deficits to include severely impaired cognitive skills and decision making. According to the MDS Resident #3, required extensive assistance of two staff members for bed mobility, transfers, dressing, toilet use and bathing. Resident #3 utilized a wheelchair for mobility. The MDS listed Resident #3 as always incontinent of urine and frequently incontinent of bowel. The MDS for Resident #3 ' s [DIAGNOSES REDACTED]. The MDS identified Resident #3 exhibited 3 Stage 1 pressure ulcers and at risk for development of pressure ulcers. An admission nursing assessment completed by the director of nursing (DON) on 7/30/15 revealed Resident #3's skin was intact without open areas. The nursing admission assessment only listed a bruise located to the back of Resident #3 ' s left hand. Braden scale for predicting pressure sore risk completed 7/30/15 identified Resident #3 with a score of 11 that indicated Resident #3 as high risk for developing pressure sores. The interim care plan dated as initiated 7/30/15 lacked interventions to prevent pressure ulcers until 8/4/15. Physical therapy note dated 8/4/15 revealed the following documentation: blisters noted on both heels and left great toe which appear to be pressure or shear/friction related, possible sources of blisters; yesterday was the first day Resident #3 wore shoes in a while. Assessment of the shoes revealed harder back to the shoe and slip on type shoes. At this time recommend use of slippers or grip socks and limit ambulation to allow for heels to heal and decrease pain. Care plan with the target date of 11/16/15 identified Resident #3 with 2 stage 2 pressure ulcers to both heels and 1 stage 1 pressure ulcer to the left great toe and directed staff to: a. Place a bed cradle on the bed b. [MEDICATION NAME] foam wrapped with gauze to areas and change every 3 days c. Place Prafo heel float boots on except when transferring resident during which moccasins will be worn d. Wound clinic to manage the pressure ulcers e. Assess impaired skin for signs and symptoms of infection with daily cares and dressing changes, report changes to the wound clinic as needed Review of the weekly pressure ulcer progress report (completed on 9/15/15) for the left heel revealed the following: Date identified: 8/4/15, Stage 2 Measurements: on 8/4/15 length 3 cm (centimeters), width 4.5 cm, fluid filled blister On 9/10/15, now area with 3 open areas identified as #2 which measured 0.2 cm by 0.2, #3 which measured 0.3 by 0.3 and #4 which measured 0.3 by 0.4 cm (new forms had not been initiated to identify the location and if the measurements were length by width and no documentation of depth). During an interview on 9/15/15 at 9:00 a.m., the DON reported she would expect nurses to start a new sheet for each new open area identified to show the location and assessment for each area. On 9/17/15 the weekly pressure ulcer progress report for the left heel had only 1 measurement documented as 5 x 6 cm and failed to address the other areas identified the previous week. Nurse's notes on 9/10/15 failed to include documentation of the blister opening and failed to have a description or the location of the three new areas identified and failed to have an assessment of any amount of drainage if present. During an interview on 9/17/15 at 11:25 a.m., the DON verified Resident#3 ' s orders written on 9/3/15 for the wound clinic to evaluate and treat the pressure sores and verified the chart failed to contain documentation of the assessments completed by the wound clinic. At that time, the DON provided a copy of a weekly pressure ulcer progress report, which showed 3 wounds #2, #3 and #4 all documented on the left heel, however, the record lacked documentation that showed, on the diagram of the body, where each area was identified. Staff documented the first assessment on 9/17/15 with wounds #3 and #4 identified as healed. Observation of a dressing change to Resident #3's left heel (with the DON present) on 9/17/15 at 8:58 a.m. revealed Staff A, licensed practical nurse, (LPN) removed the soiled dressings, removed gloves, washed hands and donned new gloves, cleansed Resident #3 ' s left heel with saline soaked dressings, measured the open area as 1.0 cm long and 0.5 cm wide. No other open area was noted. Staff A reported the measurement of the outer area as 5 cm long by 6 cm wide.