Every finding on record at Harrison Nursing and Rehabilitation Center

Based on observation, interview, review of a guideline from the Centers for Disease Control and Prevention (CDC), and review of the facility's policies, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent and control the development and transmission of communicable diseases. The facility failed to identify and correct problems relating to infection prevention practices such as improper hand hygiene and glove use, storage of contaminated and clean supplies together, lack of a hand-washing sink in a shower room, identifying a resident with a multi-drug resident organism (MDRO) as requiring Enhanced Barrier Precautions (EBP), storage of medical supplies and clean laundry that exposed them to contamination, and lack of nonpermeable aprons or disposable gloves available for staff use when handling contaminated laundry. This deficient practice had the potential to affect all 50 current residents. The findings include: Review of the CDC's guideline's Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs), dated 04/02/2024, revealed the CDC targeted epidemiologically important MDROs including extended-spectrum beta-lactamase (ESBL), as requiring EBP to reduce transmission in nursing home settings.Review of the facility's policy titled, Infection Control Policy (General), dated 10/2020, revealed the facility was expected to develop and implement an infection control program to prevent, detect, investigate, and control infections. The policy revealed infection control practices applied to all staff, residents, and visitors, included implementation of standard and transmission based precautions, and required staff training, monitoring, and oversight by the quality assurance and performance improvement committee.Review of the facility's policy titled, Enhanced Barrier Precautions Standard of Practice, revised 3/2026, revealed EBPs were implemented during high contact care activities for residents with chronic wounds, indwelling devices, or identified multidrug resistant organisms when contact precautions did not otherwise apply. The policy revealed the facility was responsible for identifying residents requiring enhanced precautions and ensuring staff implemented appropriate measures, including use of gowns and gloves.Review of the facility's policy titled, Hand Hygiene Protocol, undated, revealed staff was expected to perform hand hygiene using soap and water or alcohol-based hand rubs at key times, including before and after resident contact, after exposure to contaminated surfaces, after glove use, and before and after personal protective equipment (PPE) removal. The policy further revealed gloves were not a substitute for hand hygiene and required hand hygiene after removal.Review of the facility's policy titled, Linen Storage, dated 4/2025, revealed clean linens were required to be stored separately from contaminated linens and maintained in a manner to prevent contamination. The policy revealed linens were to be stored in covered carts or designated areas, linen carts were to remain closed when not in use, and access to clean linens was limited to authorized staff.Review of the facility's policy titled, Housekeeping (General), dated 10/2020, revealed housekeeping and maintenance services were expected to maintain a sanitary, orderly, and comfortable environment through routine cleaning of resident rooms, care areas, and common areas. The policy revealed the environment should not pose a safety risk and infection control practices were to be utilized during daily housekeeping activities.1. Observation on 03/31/2026 at 9:25 AM revealed Hospitality Aide (HA) 1 and HA2 were passing ice on the 200 Hall. Both aides were wearing gloves in the hallway. The aides failed to remove gloves or perform hand hygiene or change gloves between resident rooms. Further observation revealed the hospitality aides wore the same pair of gloves while obtaining ice from multiple residents. HA1 and HA2 picked up the ice scoop with gloved hands, held resident water pitchers over the ice bin, placed the ice scoop into its holder, and covered the pitcher, delivering it to the resident's room and returning to repeat the process. Further observation inside room [ROOM NUMBER], revealed HA2 handled the resident's water pitcher, including picking up the pitcher, opening the lid, discarding the contaminated straw and discarding the remaining water in the resident's sink. She then exited the room to refill the pitcher with ice without performing hand hygiene or changing gloves.During an interview with HA2 on 03/31/2026 at 9:30 AM, she stated she was educated to wear gloves during the ice pass. When asked by the State Survey Agency (SSA) Surveyor why she did not remove her gloves after each resident and perform hand hygiene and after handling individual water pitchers and touching residents' personal belongings, she stated, I did use hand-hygiene. She stated she received infection control training in orientation.During an interview with HA1 on 03/31/2026 at 9:35 AM, she stated she was educated to wear gloves during the ice pass. When asked by the SSA Surveyor why she did not remove her gloves after each resident and perform hand hygiene and after handling individual water pitchers and touching residents' personal belongings, she stated, I did. She stated she received infection control training in orientation.During an interview with the Assistant Director of Nursing (ADON) 2 on 03/31/2026 at 10:57 AM, she stated nursing leadership performed random audits of staff to ensure they followed infection control policies. She stated there was no documentation of the audits conducted. The ADON2 stated if she witnessed a breach in protocol, she would stop the staff member and provide reeducation. She stated she had no concerns and had not observed any issues related to infection control deficiencies.During an interview with the Infection Preventionist/Assistant Director of Nursing 1 (IP/ADON1) on 04/01/2026 at 3:25 PM, she stated Hospitality Aides were trained to wear gloves while passing ice; however, she stated they were also educated to remove the gloves and perform hand hygiene after each ice pass. The IP/ADON1 stated staff might not have received detailed or situation-specific training. She stated orientation included infection control training, hand hygiene, and personal protective equipment (PPE) education; however, these practices were not consistently implemented2. Observation of the 200 Hall Biohazard Room on 03/31/2026 at 1:45 PM revealed the presence of four red biohazard containers and storage boxes containing unused sharps containers. There were also six boxes of gloves, including one opened box, on the shelf in the room.During an interview with IP/ADON1 on 04/01/2026 at 3:25 PM, she stated clean supplies should not be stored in soiled utility areas, including shower rooms, and should be brought in as needed. She stated storing clean items with dirty items created a risk of contamination and transmission of infection.3. Observation on 03/31/2026 at 1:50 PM of the 200 Hall Shower Room revealed clean items including towels, linens, and briefs were stored on the shelf near the shower stall. Further observation revealed there was no hand-washing sink located in the shower room. Additionally, a strong fecal odor was present in the room.During an interview with IP/ADON1 on 04/01/2026 at 3:25 PM, she stated clean supplies should not be stored in the shower rooms and should be brought in as needed. She stated storing clean items in the shower room created a risk of contamination and transmission of infection. She stated housekeeping was responsible for cleaning the shower rooms daily and as needed. However, IP/ADON1 stated if a resident experienced an incontinent episode or other soiling event, the staff member providing care to the resident was responsible for immediately cleaning the area with housekeeping notified for additional cleaning or follow up as needed. She stated the sink in the Shower Room had fallen off the wall and was being replaced.3. a. Observation of the Laundry Room on 03/31/2026 at 2:00 PM revealed the laundry folding area was cluttered with supplies, resident items, and staff personal belongings, including an insulated water bottle and a fast-food wrapper. Staff personal items were stored directly on the floor and additional clothing items were stacked underneath the folding table. Storage containers were located beside the folding table with stacks of clean clothes stored on top of the containers. Additionally, these items were located directly by an exit door used to access the back of the building and supplies.b. Observation of the Laundry Room on 04/02/2026 at 10:11 AM revealed the area was accessed through a door from the Dirty Utility Room, leading directly into a small, enclosed space. The room contained one washing machine, one dryer, and an approximately 4 x 4-foot folding counter. Observation revealed staff personal items, including drinks, were stored on top of the folding table alongside resident belongings. A plastic laundry basket of clean clothing and personal items were also stored beneath the folding counter directly on the floor. A door within the laundry room provided direct access to the exterior of the building. Staff was observed to frequently pass through the laundry room during the observation period to access an outdoor medical supply storage shed. The area was used multiple times daily by multiple staff as a pathway to the shed.Further observation revealed a secondary door within the laundry room led to a narrow L-shaped walkway. This area was used for storage of clean linen and for hanging mechanical lift slings and resident clothing. It was full, making it difficult to pass through without brushing up against the hanging clothing. Further observation of the laundry storage closet revealed two boxes of supplies were stored directly on the floor. There were no nonpermeable aprons or disposable gloves available for staff use when handling contaminated laundry. Additionally, there was no disinfectant available in the laundry area to clean the nonpermeable aprons used by staff when handling contaminated laundry.During an interview with the Environmental Services (EVS) Director on 04/02/2026 10:11 AM, she stated she had not been informed that the folding area should be separate from the washing machine area. She further stated the facility layout did not allow for separation. She stated staff usually had disinfectant spray to clean the nonpermeable aprons, but there were none available in the area for staff to use. She further stated supplies should not be stored on the floor, and staff drinks or food should not be on the folding table. Additionally, she stated residents' clothing and laundry should be handled in a safe and sanitary manner to prevent cross contamination.C. Observation of the Dirty Utility Room on 04/02/2026 at 10:40 AM revealed five linen receptacles were overfilled with bagged and unbagged soiled linen and clothing piled above the rim of the linen barrels. There were no lids in place covering the receptacles.During an interview with the EVS Director on 04/02/2026 10:40 AM, she stated linen receptacles should not be overfilled, and soiled linen and clothing should be placed in bags prior to disposal in the receptacles. The EVS Director stated the receptacles should be maintained with lids in place to ensure they remain covered. When asked by the SSA Surveyor why they were not covered, she stated she did not have any lids for the receptacles. She further stated a staff member had called in the night before and they were trying to catch up on laundry, and the facility had only one washer and one dryer. The EVS Director stated implementing infection control practices was important to prevent the spread of disease and control cross-contamination by contaminated items. 4. Observation of Licensed Practical Nurse (LPN) 3 perform a blood glucose fingerstick on 03/31/2026 at 4:00 PM revealed, after the procedure, LPN3 removed contaminated gloves multiple times without performing hand hygiene between glove removal and reapplication. Additionally, LPN3 brought in an entire bottle of test strips into the room and placed the bottle on the barrier along with a contaminated glucometer.During an interview with LPN3 on 04/01/2026 at 8:30 AM, she stated hand hygiene was important after removal of PPE to prevent the spread of contamination and reduce the risk of infection transmission. She stated, after contaminating gloves, they should be removed and hand hygiene should be completed prior to putting on a new pair of gloves to maintain infection control and protect the resident's safety. She further stated taking medical supplies into a resident's room created the potential for contamination. She stated only the supplies needed for the procedure should be taken into a resident's room, or any items brought into the room should be cleaned and disinfected in accordance with the facility's policy prior to reuse.5. Observation on 04/02/2026 at 8:34 AM revealed Resident (R) 2, who was colonized with ESBL in the urine, had no EBP signage in place on or near her room's door.Review of the admission Face Sheet, found in R2's electronic medical record (EMR), revealed the facility admitted the resident on 01/20/2026, with diagnoses which included urinary tract infection with ESBL, chronic kidney disease, and adult failure to thrive. Review of R2's admission Minimum Data Set [MDS], with an Assessment Reference Date (ARD) of 02/04/2026, revealed the facility assessed the resident to have a Brief Interview for Mental Status [BIMS] score of 15 out of 15, which indicated the resident was cognitively intact. Review of R2s Comprehensive Care Plan [CCP], dated 02/09/2026, revealed a focus for infection related to urinary tract infection with ESBL. An intervention initiated on 02/09/2026, indicated the resident should be placed in contact precautions until 02/18/2026. There were no interventions for EBP placed after 02/18/2026.During an interview with IP/ADON1 on 04/01/2026 at 3:25 PM, she stated residents colonized with multidrug-resistant organisms including those identified by the CDC as targeted MDROs, such as ESBL, should be placed on EBP for the safety of the resident and staff and to prevent the spread of infection. The IP/ADON1 was unable to provide an explanation as to why R2 was not in EBP. 6. Observation of the Medical Supply Storage Shed on 04/02/2026 at 10:25 AM revealed the shed contained medical supplies such as incontinence products, disposable resident supplies, personal protective equipment (PPE), wound care items, and miscellaneous medical supplies. There was excessive clutter with disorganized, exposed supplies stacked irregularly on shelving and directly on the bare floor. The number of supplies on the floor impeded movement, causing contact and cross contamination with the supplies. Items were stored directly on the floor and stacked up to the ceiling, in contact with the roof. The flooring was visibly soiled with dirt, dust, and stains, with accumulation of packing materials, trash, and debris. Rodent droppings were observed in the storage area. Further observation revealed opened wound dressing boxes, ace bandages, opened disposable cloth gowns, and a bag of loose plastic PPE gowns. Disposable cloth gowns were unboxed and not maintained in protective packaging and were stored directly on the floor and on top of other boxes. Plastic gowns were observed falling out of the bag onto the floor and onto boxes stored on the floor. A box of disposable suction machine supplies was opened, exposed, and stored directly on the floor.Further observation of the Medical Supply Storage Shed on 04/02/2026 at 10:25 AM revealed an air conditioning unit with visible accumulation of dust and debris along the vents and interior components. The unit appeared unclean and was not maintained in a sanitary manner. Medical supplies were stored on both sides of the unit and directly in front of the unit, impeding airflow. Observation of the shed's exterior revealed structural damage, including openings and rotting wood. The shed door was visibly deteriorated; when closed, there was an approximately six-inch gap at the bottom where the barn type doors joined. Further observation revealed the exterior area was not maintained in a clean and sanitary manner. The shed was located directly adjacent to a wooded area with dense foliage and overgrowth. The ground consisted of dirt, gravel, and debris, with clutter including trash receptacles, loose lids, and an opened cardboard box containing packing materials stored directly on the ground.During an interview with the Central Supply Supervisor (CSS) on 04/02/2026 at 10:25 AM, conducted at the time of the observation, she stated she had been tasked with cleaning the shed, organizing the supplies, and ensuring an adequate egress in and out of the shed. She stated supplies should not be stored directly on the floor to keep supplies clean and to prevent contamination. She stated the facility had limited storage, and the shed was designated for storage and medical supplies. The CSS stated multiple staff accessed the shed repeatedly throughout the day to obtain supplies. She stated they entered through the clean side of the Laundry Room, exited the rear of the building, and returned through the same pathway. She stated the frequency of staff traffic resulted in the shed door being opened repeatedly throughout the day, creating ongoing exposure to outside environmental elements. The CSS stated the storage shed had evidence of rodent activity. Additionally, she stated she had found rodent droppings and nesting materials inside storage boxes containing medical supplies. During an interview with IP/ADON1 on 04/01/2026 at 3:25 PM, she stated she had served as the facility's IP since 2020; however, she also fulfilled multiple roles, including staff nurse and ADON. She stated competing responsibilities across multiple roles impeded her ability to perform and oversee infection prevention activities effectively. The IP/ADON1 stated it was her expectation that staff followed infection control guidelines to ensure a safe, sanitary environment for residents, staff, and visitors. She stated it was important to prevent the spread of disease and infection. During an interview with the Director of Nursing (DON) on 04/02/2026 at 11:30 AM, she stated the facility followed CDC guidelines for infection control. The DON stated nursing staff was trained and aware of infection control policies. She further stated staff was expected to follow infection control practices, including hand hygiene and appropriate use of PPE. The DON stated hand hygiene should be performed after resident care and after glove removal, and failure to perform hand hygiene or use appropriate PPE could result in the spread of infection. She stated it was her expectation that all nursing staff followed standards of care and implemented standard precautions during all resident care. During additional interview on 04/02/2026 at 4:29 PM, the DON stated she had concerns regarding the potential daily spread of infection due to sanitation practices and contamination of linens. She stated laundry should not pile up and any receptacle should be closed with a lid. Additionally, she stated medical and resident supplies stored in the outdoor shed should be maintained in a clean, sanitary, and protected environment. She initially stated she had no concerns regarding the storage of supplies in the shed, including potential exposure to environmental contaminants and improper storage conditions that could impact the integrity of supplies intended for resident use. However, upon further interview she stated the storage conditions were not optimal and stated the area could be better. During an interview with the Administrator on 04/02/2026 at 5:02 PM, she stated staff followed guidance from the CDC and the facility's policies and procedures for infection control. She stated the nursing staff was expected to implement transmission-based precaution or enhanced-barrier precautions (EBP) for residents as indicated. She further stated medical supplies should be stored in a clean and sanitary manner to preserve integrity and prevent contamination. The Administrator stated all laundry should be handled in a safe and sanitary manner, and the laundering process should prevent cross-contamination. Furthermore, the Administrator stated the facility needed to improve oversight to ensure compliance with infection control practices and appropriate medical supply storage. She stated it was her expectation that all staff followed CDC guidelines for infection prevention and surveillance.During an interview with the Medical Director on 04/01/2026 at 4:10 PM, he stated staff was expected to follow infection control policies, including performing hand hygiene upon entering and exiting resident rooms. He stated failure to follow the facility's policies and infection control guidelines could result in the spread of infection. He stated it was important for the health, safety, and well-being of residents and staff.

Based on interview, record review, and review of the facility's policy, the facility failed to meet at least quarterly and have the required attendees present. The findings include: Review of the facility's policy titled, QAPI [Quality Assurance Performance Improvement] Plan Standard of Practice, revised 04/2025, revealed the facility was to conduct ongoing quality reviews and monitor action plans monthly to evaluate effectiveness and identify the need for revision. Further review revealed that the QAPI committee, at a minimum, consisted of the Medical Director or designee, Director of Nursing (DON), Infection Preventionist (IP), and at least three additional staff members, including the Administrator.Review of the facility's QAPI meeting minutes, dated 05/15/2025, revealed the Medical Director or designee was not in attendance. Review of the facility's QAPI meeting minutes, dated 12/24/2025, revealed the Medical Director and the IP were not in attendance. Further review revealed there was a lapse of six months and nine days between meetings.During an interview with the IP on 04/02/2026 at 11:57 AM, she stated in the last year she may have missed one or two of the QAPI meetings if she had to work the floor the night before. During an interview with the DON on 04/02/2026 at 4:21 PM, she stated she had been at the facility since January. She further stated that if the QAPI meeting sheet was not signed by her, she did not attend.During an interview with the Medical Director on 04/02/2026 at 4:10 PM, he acknowledged involvement in prior QAPI meetings, but he was unable to provide further information regarding the lack of meetings occurring. During an interview with the Administrator on 04/01/2026 at 3:09 PM, she stated she had been at the facility for two weeks but had yet to review the QAPI minutes or set up a QAPI meeting.

Based on interview, record review, review of the facility's policy, and review of the facility's Plan of Correction (PoC) for the survey completed on 03/08/2025, with a compliance date of 03/28/2025, the facility failed to have an effective system to address systemic failures through the Quality Assurance Performance Improvement (QAPI) process.The facility failed to sustain compliance and implement effective corrective actions following a deficiency cited on the previous standard survey under 42 CFR S483.80 Infection Prevention and Control; 42 CFR S483.80 Influenza and Pneumococcal Immunizations; and 42 CFR S483.80 COVID-19 Immunization. This systemic failure placed residents at increased risk for preventable infectious diseases, including influenza, pneumococcal infections, and COVID-19. This deficient practice had the potential to affect all residents residing in the facility.The findings include:Review of the facility's policy titled, QAPI Plan Standard of Practice, revised 04/2025, revealed the facility was to conduct ongoing quality reviews and monitor action plans monthly to evaluate effectiveness and identify the need for revision. Further review revealed that the QAPI committee, at a minimum, consisted of the Medical Director or designee, Director of Nursing (DON), Infection Preventionist (IP), and at least three additional staff members, including the Administrator.Review of the facility's policy titled, Infection Control Policy (General), dated 10/2020, revealed the facility was expected to develop and implement an infection control program to prevent, detect, investigate, and control infections. The policy stated it required monitoring and oversight by the QAPI committee.Review of the facility's PoC related to 42 CFR S483.80 Infection Prevention and Control, for the 03/08/2025 survey, with a compliance date of 03/28/2025, revealed interventions for deficient practice in infection control included conducting QAPI team meetings monthly instead of quarterly for 12 months. Additionally, the PoC stated audits on QAPI performance would be conducted monthly for 12 months and reviewed monthly by the QAPI committee. According to the PoC, audits would be conducted by either the Administrator or the DON, including logs of audits of any active Performance Improvement Plan (PIP). Review of the facility's PoC related to 42 CFR S483.80 Influenza and Pneumococcal Immunizations, for the 03/08/2025 survey, with a compliance date of 03/28/2025, revealed the facility would offer the vaccines and would document each vaccine offering, including provision of education and whether the resident consented or declined. Additional review of the PoC revealed audit findings were reviewed by the QAPI committee, with identified issues addressed, staff reeducation provided, and determinations made regarding ongoing monitoring or additional interventions. The documentation further revealed audit results were to be presented to the QAPI committee, with disciplinary action taken against staff who failed to comply with facility policies.Review of the facility's PoC related to 42 CFR S483.80 COVID-19 Immunization, for the 03/08/2025 survey, with a compliance date of 03/28/2025, revealed the facility would offer the vaccine and would document each vaccine offering, including provision of education and whether the resident consented or declined. Additional review of the PoC revealed audit findings were reviewed by the QAPI committee, with identified issues addressed, staff reeducation provided, and determinations made regarding ongoing monitoring or additional interventions. The documentation further revealed audit results were to be presented to the QAPI committee, with disciplinary action taken against staff who failed to comply with facility policies.Review of the facility's QAPI meeting minutes, dated 05/15/2025, revealed the Medical Director or designee was not in attendance. Review of documentation provided by the facility revealed no evidence that the QAPI committee identified or implemented actions to address ongoing deficiencies related to infection prevention and control, influenza and pneumococcal immunizations, or COVID-19.Review of QAPI documentation provided by the facility revealed another QAPI meeting was not conducted until 12/24/2025, a lapse of six months and nine days. Further review revealed no evidence the QAPI committee identified or implemented actions to address ongoing deficient practices related to infection prevention and control, influenza and pneumococcal immunizations, or COVID-19.Review of the facility's QAPI meeting minutes, dated 12/24/2025, revealed the Medical Director and the IP were not in attendance. Further review revealed no evidence the QAPI committee identified or implemented actions to address ongoing deficiencies related to infection prevention and control, influenza and pneumococcal immunizations, or COVID-19.During an interview with the IP on 04/01/2026 at 3:25 PM, she stated multiple system breakdowns, including a lack of dedicated time to complete infection prevention responsibilities, a lack of proactive monitoring, unclear roles and responsibilities, and gaps in implementation and oversight of infection control practices, were responsible for the continued and repeated deficient practices related to infection control. She further stated changes in ownership and turnover in administrative staff, including the Administrator and DON, contributed to repeated deficient practice.In continued interview with the IP on 04/02/2026 at 11:57 AM, she stated her attendance at the QAPI meeting was affected when she was scheduled to work the floor the night prior to a meeting. She stated she could not say if she was provided with meeting minutes to review.During an interview with the DON on 04/02/2026 at 4:21 PM, she stated she began employment at the facility on 01/20/2026. When asked about her attendance at QAPI meetings, she stated if she did not sign the QAPI meeting attendance sheet, she did not attend. The DON further stated she could not speak as to why there were repeated deficiencies in infection control. During an interview with the Medical Director on 04/02/2026 at 4:10 PM, he acknowledged involvement in prior QAPI activities related to the facility's PoC; however, he was unable to provide detailed information regarding current monitoring or follow up processes. The Medical Director stated he could not speak as to why there were repeated deficiencies in infection control. During an interview with the Administrator on 04/01/2026 at 3:09 PM, she stated she had been employed at the facility for two weeks. She revealed, prior to identification by the State Survey Agency (SSA) surveyors, she was unaware of any current issues with the facility regarding infection control. The Administrator further stated she had not yet reviewed QAPI meeting minutes or scheduled a QAPI meeting. She stated it was her responsibility to ensure all processes established in the facility were maintained, including the QAPI program. She further stated she could not speak as to why there were repeated deficiencies in infection control.

Based on interview, record review, and review of the Centers for Medicaid and Medicare Services (CMS) recommendations, the facility failed to ensure each resident was offered the COVID-19 vaccine and that each resident or resident's representative received education regarding the benefits, potential risks, and side effects associated with the COVID-19 vaccine. Additionally, the facility failed to ensure the resident's medical record included documentation that, at a minimum, the resident or resident's representative was provided education regarding the benefits and potential risks of the COVID-19 vaccine, each dose of the COVID-19 vaccine administered to the resident, or that the resident did not receive the vaccine due to medical contradictions or refusals for 5 of 5 sampled residents, Residents (R) 16, R22, R35, R37, and R41.The findings include:Review of CMS's Center for Clinical Standards and Quality/Quality, Safety & Oversight Group's QSO-23-10-NH Memo, dated 07/25/2025, revealed Long-term Care facilities (LTC) must offer residents vaccination against COVID-19 when vaccine supplies were available to the facility. Additionally, LTC facilities must screen residents prior to offering the vaccination for prior immunization, medical precautions, and contraindications to determine whether they were appropriate candidates for vaccination.A request was made on 03/31/2026 at 9:52 AM to the Infection Preventionist (IP) by the State Survey Agency (SSA) Surveyor for all of the facility's policies and procedures regarding COVID-19 vaccination. The facility failed to provide a copy of the COVID-19 policy related to residents for review.1. Review of the admission Face Sheet, found in R16's electronic medical record (EMR), revealed the facility admitted the resident on 07/09/2025, with diagnoses which included acute and chronic respiratory failure, chronic obstructive pulmonary disease (COPD), and congestive heart failure.Review of R16's quarterly Minimum Data Set [MDS], with an Assessment Reference Date (ARD) of 01/14/2026, revealed the facility assessed the resident to have a Brief Interview for Mental Status [BIMS] score of 12 out of 15, which indicated the resident had moderate cognitive impairment.Review of R16's Immunization Report, with the current report ending on 01/04/2026, revealed there were no documented COVID-19 vaccinations or documented declinations during the 2025-2026 vaccination period.Review of R16's facility-provided Informed Consent for COVID-19 Vaccine revealed the consent form was dated and signed on 03/31/2026, the same date the State Survey Agency (SSA) Surveyor requested the information. Review of the form revealed the resident declined the vaccination.Review of R16's EMR revealed no COVID-19 vaccination, documented declinations, and no documentation of education regarding the benefits and potential risks of the COVID-19 vaccine during the 2025 vaccination period.During an interview with R16 on 03/31/2026 at 9:25 AM, she stated she did not remember being offered the vaccine or signing a consent form. She stated she did not receive a vaccine information sheet providing education about the vaccine.2. Review of the admission Face Sheet, found in R22's EMR, revealed the facility admitted the resident on 12/10/2024, with diagnoses which included acute and chronic respiratory failure with hypoxia, acute kidney failure, and congestive heart failure.Review of R22's quarterly MDS, with an ARD of 01/28/2026, revealed the facility assessed the resident to have a BIMS score of 15 out of 15, which indicated the resident was cognitively intact.Review of R22's Immunization Report, with the current report ending on 01/04/2026, revealed there was a history of refusal for the COVID-19 vaccine. However, there were no documented COVID-19 vaccinations or documented declinations during the 2025-2026 vaccination period.Review of R22's facility-provided Informed Consent for COVID-19 Vaccine revealed the consent form was dated and signed on 03/31/2026, the same date the SSA Surveyor requested the information. Review of the form revealed the resident was not administered the vaccination, even though she consented to receive the vaccine.During an interview with R22 on 03/31/2026 at 11:15 AM, she stated she agreed to receive the vaccine. However, she stated she did not receive the vaccine at the time she signed the consent, and she was not provided with education on the vaccine.3. Review of the admission Face Sheet, found in R35's EMR, revealed the facility admitted the resident on 01/25/2024, with diagnoses which included atherosclerotic heart disease, asthma, and COPD.Review of R35's annual MDS, with an ARD of 01/22/2026, revealed the facility assessed the resident to have a BIMS score of 15 out of 15, which indicated the resident was cognitively intact.Review of R35's Immunization Report, with the current report ending on 01/04/2026, revealed there were no documented COVID-19 vaccinations or documented declinations during the 2025-2026 vaccination period.Review of R35's facility-provided Informed Consent for COVID-19 Vaccine revealed the consent form was dated and signed on 03/31/2026, the same date the SSA Surveyor requested the information. Further review revealed the resident's initials were on the signature line, and the resident did not document acknowledgement of receiving vaccine information, understanding risks and benefits, or was given the opportunity to ask questions. The form showed the resident was not administered the vaccination.Review of R35's EMR revealed no documentation of provided education regarding the benefits and potential risks of the COVID-19 vaccine.During an interview with R35 on 03/31/2026 at 10:15 AM, she stated the facility approached her previously to sign an informed consent for the COVID-19 vaccine, and she agreed to receive the vaccine. However, she stated she did not receive the vaccine at that time, and she was not provided with education on the vaccine.4. Review of the admission Face Sheet, found in R37's EMR, revealed the facility admitted the resident on 10/02/2014, with diagnoses which included chronic viral hepatitis C, emphysema, and cerebral infarct with right-sided hemiplegia.Review of R37's quarterly MDS, with an ARD of 01/22/2026, revealed the facility assessed the resident to have a BIMS score of five out of 15, which indicated the resident was severely cognitively impaired.Review of R37's Immunization Report, dated 04/01/2026, revealed there was no COVID-19 vaccination or documented consent or declination during the 2025 vaccination period.Review of R37's facility-provided Informed Consent for COVID-19 Vaccine revealed a verbal informed consent for the COVID-19 vaccination was obtained via telephone from the resident's representative (RR) on 03/31/2026, the same date the SSA Surveyor requested the information. R37's RR declined the vaccination on the resident's behalf.Review of R37's EMR revealed no documentation of provided education regarding the benefits and potential risks of the COVID-19 vaccine.R37 was not interviewed due to his cognition. Attempted telephone interview with R37's representative on 04/01/2026 at 2:10 PM, revealed no opportunity to leave a voicemail message.5. Review of the admission Face Sheet, found in R41's EMR, revealed the facility admitted the resident on 10/15/2024, with diagnoses which included anemia, chronic peripheral venous insufficiency, and adrenocortical insufficiency.Review of R41's quarterly MDS, with an ARD of 03/05/2026, revealed the facility assessed the resident to have a BIMS score of 15 out of 15, which indicated the resident was cognitively intact.Review of R41's Immunization Report, with the current report ending on 01/04/2026, revealed there were no documented COVID-19 vaccinations or documented declinations during the 2025-2026 vaccination period.Review of R41's facility-provided Informed Consent for COVID-19 Vaccine revealed a verbal informed consent for the COVID-19 vaccination was obtained via telephone from the RR on 03/31/2026, the same date the SSA Surveyor requested the information. Further review revealed R41's representative declined the vaccination.In an attempted telephone interview with R41's representative on 04/01/2026 at 2:20 PM, a voicemail was left; however, no callback was received.Review of R41's EMR revealed no documentation of provided education regarding the benefits and potential risks of the COVID-19 vaccine.R41 was unavailable for interview.During an interview with the Infection Preventionist (IP) on 04/01/2026 at 3:25 PM, she stated she had served as the facility's IP since 2020; however, she also fulfilled multiple roles, including staff nurse and Assistant Director of Nursing. She stated competing responsibilities across multiple roles impeded her ability to perform and oversee infection prevention activities effectively. When asked why residents had not received the COVID-19 vaccination during the 2025-2026 vaccination period, she stated COVID-19 vaccines had previously been provided to the facility through the state's public health program until this vaccination period. However, she stated once state-supplied vaccines were no longer available, she requested direction from the former Administrator on ordering vaccines. She stated she was informed the facility would not cover the cost, and residents would be responsible for payment. She stated she expressed concern regarding residents' ability to pay and confirmed no further action was taken. Furthermore, the IP stated she had contacted local pharmacies to establish a partnership to provide on-site COVID-19 vaccination clinics at the facility. She stated outside pharmacies could directly bill residents' insurance for vaccine administration, which the facility was unable to do. The IP stated consent documentation was initiated during the survey, and some COVID-19 consent forms were obtained on 03/31/2026 to determine the number of residents consenting to a COVID-19 vaccination for submission to a pharmacy. However, the IP stated the facility had not made a formal determination regarding when the COVID-19 clinic would be held or who would conduct the clinic.During continued interview with the IP on 04/01/2026 at 3:25 PM, she stated the facility had been cited in prior surveys for failure to ensure appropriate immunization practices, including COVID-19 vaccinations. The IP further stated the facility did not sustain compliance following the plan of correction due to multiple system breakdowns. When presented with examples of residents lacking documentation of COVID-19 vaccine consent, declination, and education, the IP stated the documentation was incomplete. She stated she attributed the breakdown to staffing changes, role confusion, and lack of clear responsibility. She stated there had been a whole breakdown of the team. She stated the responsibility for immunization oversight had not been clearly assigned during the transition to new ownership and administrative leadership. She stated the facility provided Centers for Disease Control and Prevention (CDC) Vaccine Information Sheets (VIS) for education; however, this was not documented in the residents' electronic medical records. When asked why appropriate documentation, including consent and education, was not maintained, she stated following changes in administration and ownership, she had been directed to discontinue use of the previous forms and was subsequently provided new documentation forms, which she had only recently begun to implement. Additionally, she stated accurate immunization documentation was important for resident safety. She stated it ensured each resident received the appropriate vaccines and prevented missed or duplicate vaccinations. Furthermore, the IP stated COVID-19 vaccinations were important in reducing infection risk and should be administered and documented in accordance with CDC guidelines.During an interview with the facility's Account Representative for the facility's contracted pharmacy on 04/01/2026 at 3:45 PM, he stated the pharmacy did not provide resident-specific COVID-19 vaccines billed to individual residents. He stated vaccines were supplied as house stock, and the facility would be billed directly for the vaccine. The representative stated the pharmacy did not bill individual residents' insurance, and the facility would be responsible for the cost of the vaccines.During an interview with the Director of Nursing (DON) on 04/02/2026 at 4:29 PM, she stated the IP was responsible to ensure all residents received education regarding the COVID-19 vaccination and were offered the opportunity to consent or decline the vaccination. She stated when a resident lacked capacity, family members or responsible parties should be informed to enable informed decision-making. The DON stated the resident's EMR should accurately reflect current and completed documentation of all vaccinations and immunizations, including administration, education provided, and any consent or declination in accordance with the facility's policy and regulatory requirements. She stated COVID-19 vaccinations were important in reducing infection risk and should be administered in accordance with CDC guidelines.During an interview with the Administrator on 04/02/2026 at 5:02 PM, she stated it was important that the facility maintained appropriate documentation to demonstrate it provided the required COVID-19 vaccine education to residents to comply with CDC recommendations and adhere to the facility's infection control program. The Administrator stated the IP Nurse was responsible for infection control oversight. She stated following policy and CDC guidelines was important for the safety of residents and staff.During an interview with the Medical Director on 04/01/2026 at 4:10 PM, he stated it was his expectation that staff would follow CDC guidelines for the administration of immunizations, including COVID-19. He stated immunizations were important to reduce the risk of infection.

Based on interview, record review, the Centers for Disease Control and Prevention (CDC) guidance, and review of the facility's policy, the facility failed to ensure each resident was offered influenza and pneumococcal immunizations, and each resident or resident representative received education on the benefits, potential risks, and side effects associated with influenza and pneumococcal immunizations. Additionally, the facility failed to ensure the resident's medical record included documentation, at a minimum, the resident or resident representative was provided education regarding the benefits and potential risks of the influenza and pneumococcal immunizations, each dose of the influenza and pneumococcal immunizations vaccine administered to the resident, or the resident did not receive the immunizations due to medical contraindications or refusals for 5 of 5 sampled residents, Resident (R) 16, R22, R35, R37, and R41.The findings include:Review of CDC guidance Prevention and Control of Seasonal Influenza with Vaccines: Recommendations of the Advisory Committee on Immunization Practices (ACIP), dated 09/05/2024, revealed the CDC recommended routine annual influenza vaccination for all individuals aged six months and older, unless contraindicated, as immunity declined over time and vaccine formulations were updated each season.Review of CDC guidance ACIP Recommendations: Pneumococcal Vaccine, dated 01/08/2025, revealed pneumococcal vaccination was based on age and risk factors, with vaccination recommended for adults age [AGE] and older and those with certain high-risk conditions, utilizing a one-time dose or series depending on prior vaccination status.Review of the facility's policy titled, Pneumonia Vaccine Policy and Procedure, revised 03/21/2023, revealed the facility's policy was to offer and encourage pneumonia vaccination to all residents, when indicated, to prevent the spread of pneumonia. The policy revealed residents were assessed upon admission for pneumonia vaccination history. According to the policy, the immunization was documented in the individual's medical record. Furthermore, the policy stated residents or their representatives had the right to decline vaccination.1. Review of the admission Face Sheet, found in R16's electronic medical record (EMR), revealed the facility admitted the resident on 07/09/2025 with diagnoses which included acute and chronic respiratory failure, chronic obstructive pulmonary disease (COPD), and congestive heart failure.Review of R16's quarterly Minimum Data Set [MDS], with an Assessment Reference Date (ARD) of 01/14/2026, revealed the facility assessed the resident to have a Brief Interview for Mental Status [BIMS] score of 12 out of 15, which indicated the resident had moderate cognitive impairment.Review of R16's Immunization Report, with the current report ending on 01/04/2026, revealed the resident refused the influenza and pneumococcal vaccinations.Review of R16's electronic medical record (EMR) revealed no documentation of influenza or pneumococcal vaccine consent or declination, and no documentation of education provided on the benefits and potential risks of the vaccinations.During an interview with R16 on 03/31/2026 at 9:25 AM, she stated she did not remember being offered the vaccines or signing consent forms. She stated she did not receive a vaccine information sheet providing education about the influenza and pneumococcal vaccinations.2. Review of the admission Face Sheet, found in R22's EMR, revealed the facility admitted the resident on 12/10/2024, with diagnoses which included acute and chronic respiratory failure with hypoxia, acute kidney failure, and congestive heart failure.Review of R22's quarterly MDS, with an ARD of 01/28/2026, revealed the facility assessed the resident to have a BIMS score of 15 out of 15, which indicated the resident was cognitively intact.Review of R22's Immunization Report, dated 04/01/2026, revealed no documented evidence of pneumococcal immunization, and no documented evidence of a current influenza immunization.Additionally, review of a second Immunization Report, provided by the facility, revealed the report reflected a date range of 01/01/2000 through 01/01/2999 and indicated it was printed on 01/04/2026 at 2:52 PM. The report documented administration of the Prevnar 20 (pneumococcal vaccination) on 11/26/2025; however, there was no recorded note documenting the manufacturer, lot number, or expiration date of the vaccine. According to the record, R22 received the influenza vaccine on 12/01/2025.During an interview with R22 on 03/31/2026 at 11:15 AM, she stated she agreed to all her vaccinations. She stated she did not remember if she signed a pneumococcal immunization consent or received education.3. Review of the admission Face Sheet, found in R35's EMR, revealed the facility admitted the resident on 01/25/2024, with diagnoses which included atherosclerotic heart disease, asthma, and chronic obstructive pulmonary disease.Review of R35's annual MDS, with an ARD of 01/22/2026, revealed the facility assessed the resident to have a BIMS score of 15 out of 15, which indicated the resident was cognitively intact.Review of R35's Immunization Report, dated 04/01/2026, revealed documentation indicated only an historical record of pneumococcal and influenza vaccinations, with no specific dates provided to verify administration and no clear documentation supporting current pneumococcal or influenza vaccination. Additionally, review of a second Immunization Report, provided by the facility, revealed the report reflected a date range of 01/01/2000 through 01/01/2999 and indicated it was printed on 01/04/2026 at 2:52 PM. The report documented administration of Prevnar 20 on 01/21/2026; however, there was no note recording the manufacturer, lot number, or expiration date of the vaccine, consistent with previous vaccination documentation. The report also indicated R35 received the influenza vaccine on 01/20/2026. For both immunizations, the documented administration date was after the report print date, creating a discrepancy in the record's accuracy and reliability.Review of R35's EMR revealed there was no documentation of an influenza or pneumococcal vaccine consent or declination, and no documentation of education provided regarding the benefits and potential risks of the vaccinations.During an interview with R35 on 03/31/2026 at 10:15 AM, she stated she had received influenza and pneumococcal immunizations in the past but was unable to provide a specific date for either vaccination. She stated she did not remember signing a consent form for either vaccination. R35 further stated she was not provided with education regarding the benefits and potential risks of the vaccinations.4. Review of the admission Face Sheet, found in R37's EMR, revealed the facility admitted the resident on 10/02/2014, with diagnoses which included chronic viral hepatitis C, emphysema, and cerebral infarct with right-sided hemiplegia.Review of R37's quarterly MDS, with an ARD of 01/22/2026, revealed the facility assessed the resident to have a BIMS score of five out of 15, which indicated the resident was severely cognitively impaired.Review of R37's EMR revealed there was no documentation of a pneumococcal vaccine consent or declination, and no documentation of education provided regarding the benefits and potential risks of the pneumonia vaccine for the resident's pneumococcal vaccination dated 03/17/2023.R37 was not interviewed due to his cognition. Attempted telephone interview with R37's representative on 04/01/2026 at 2:10 PM, provided no opportunity to leave a voicemail message.5. Review of the admission Face Sheet, found in R41's EMR, revealed the facility admitted the resident on 10/15/2024, with diagnoses which included anemia, chronic peripheral venous insufficiency, and adrenocortical insufficiency.Review of R41's quarterly MDS, with an ARD of 03/05/2026, revealed the facility assessed the resident to have a BIMS score of 15 out of 15, which indicated the resident was cognitively intact.Review of R41's Immunization Report, with the current report ending on 01/04/2026, revealed the resident refused the pneumococcal vaccination. Review of R41's EMR revealed no documentation of a pneumococcal vaccine consent or declination, and no documentation of education provided on the benefits and potential risks of the vaccination.Attempted telephone interview with R41's representative on 04/01/2026 at 2:20 PM, with a voicemail left, produced no return call.R41 was unavailable for interview.During an interview with the Infection Preventionist (IP) on 04/01/2026 at 3:25 PM, she stated she had served as the facility's IP since 2020; however, she also fulfilled multiple roles, including staff nurse and Assistant Director of Nursing. She stated competing responsibilities across multiple roles impeded her ability to perform and oversee infection prevention activities effectively, including vaccinations and immunizations, as well as required documentation. She stated the facility had been cited in prior surveys for failure to ensure appropriate immunization practices. She stated the facility did not sustain compliance following the plan of correction due to multiple system breakdowns. When presented with examples of residents lacking documentation of pneumococcal and influenza vaccine consent, declination, and education, the IP stated the documentation was incomplete. She stated she attributed the breakdown to staffing changes, role confusion, and lack of clear responsibility, and there had been a whole breakdown of the team. She stated responsibility for immunization oversight had not been clearly assigned during the transition to new ownership and administrative leadership. During an interview with the IP on 04/01/2026 at 3:25 PM, she stated the facility provided CDC Vaccine Information Sheets (VIS) for resident education; however, this was not documented in the residents' electronic medical records (EMR). When asked why appropriate documentation, including consent and education, was not maintained, she stated following changes in administration and ownership, she had been directed to discontinue use of the previous forms. She stated she was subsequently provided new documentation forms which she had only recently begun to implement. When asked by the State Survey Agency (SSA) Surveyor to explain the discrepancy between the immunization report printed on 01/04/2026 at 2:52 PM and the documented pneumococcal vaccine administration date on 01/21/2026, she was unable to explain how the report reflected a vaccination date occurring after the report print date and did not clarify the accuracy or reliability of the documentation. She stated R35 received the pneumococcal vaccination, and she believed the vaccination occurred on the date listed in the report. However, she stated she was unable to explain how the report reflected a vaccination date after the report's print date and could not provide additional documentation to verify the vaccine's administration. Additionally, the IP stated accurate immunization documentation was important for resident safety. She stated it ensured each resident received the appropriate vaccines and prevented missed or duplicate vaccinations. Furthermore, the IP stated pneumococcal and influenza vaccinations were important for reducing infection risk and should be administered and documented in accordance with CDC guidelines.During an interview with the Director of Nursing (DON) on 04/02/2026 at 4:29 PM, she stated the IP was responsible to ensure all residents received education regarding influenza and pneumococcal vaccinations and were offered the opportunity to consent or decline the vaccinations. She stated when a resident lacked capacity, family members or responsible parties should be informed to enable informed decision-making. The DON stated the resident's EMR should accurately reflect current and completed documentation of all vaccinations and immunizations, including administration, education provided, and any consent or declination in accordance with the facility's policy and regulatory requirements. She stated influenza and pneumococcal vaccinations were important in reducing infection risk and should be administered in accordance with CDC guidelines.During an interview with the Administrator on 04/02/2026 at 5:02 PM, she stated it was important the facility maintained appropriate documentation to demonstrate it provided the required influenza and pneumococcal vaccine education to residents to comply with CDC recommendations and adhere to the facility's infection control program. The Administrator stated the IP nurse was responsible for infection control oversight. She stated following policy and CDC guidelines was important for the safety of residents and staff.During an interview with the Medical Director on 04/01/2026 at 4:10 PM, he stated it was his expectation that staff would follow CDC guidelines for the administration of immunizations. He stated immunizations were important to reduce the risk of infection.

Based on interview, facility policy review, and review of the Facility Assessment, the facility failed to provide staffing numbers in the facility assessment based on the resident population and their needs for care and support to ensure there was sufficient staff to meet the needs of the residents at any time. There was also no plan in the facility assessment for recruitment and retention. Additionally, the lack of staffing minimums in the facility assessment contributed to complaints of slow call light response time for 7 of 41 sampled residents, Resident (R) 2, R16, R19, R30, R34, R45, and R52.The findings include:Review of the document titled, Facility Assessment Tool Record, [NAME] Nursing and Rehabilitation Center, dated 03/18/2026, revealed no documented evidence the Facility Assessment contained staffing numbers indicating the number of licensed nurse providing care, nurse aides providing care, and other nursing personnel needed to meet the needs of the residents. Additionally, the Facility Assessment did not contain information related to maintaining a plan to maximize recruitment and retention of direct care staff.Review of the document titled, Resident Rights, A Guide for Kentucky's Nursing Facility Residents, no date, revealed residents have the right to dignity, respect and freedom to be treated with consideration, respect, and dignity. All residents have the right to be addressed how they want to be addressed and the right to be clothed and groomed consistent with their gender identity. Additionally, residents have the right to be free from mental and physical abuse, corporal punishment, involuntary seclusion, and physical and chemical restraints. Facility staff cannot refuse to provide care due to resident's sexual orientation nor can staff harass a resident due to his/her gender identity.1.Review of R2's Face Sheet revealed the facility admitted R2 on 01/20/2026 with admitting diagnoses including chronic kidney disease, stage 2 (mild), difficulty in walking, not elsewhere classified, and adult failure to thrive. The admission Minimum Data Set [MDS], with an Assessment Reference Date (ARD) of 01/25/2026, revealed the facility assessed R2 with a Brief Interview for Mental Status [BIMS] score of 15 of 15, indicating R2 was cognitively intact.Review of R2's Care Plan titled, At Risk for Falls, dated 02/16/2026, revealed R2 was care planned for impulsive behavior, poor safety awareness, and unsteady gate. Interventions for R2 included assess for falls and place call light and frequently used items within reach.During an interview on 03/30/2026 at 1:41 PM with R2 she stated she had to wait over an hour and a half for staff to come and change her at night. R2 stated, I get upset having to wait that long when I am dirty. I am not able to get up and use the bathroom by myself. R2 also stated she was not changed from 7: 00 AM to 11:00 AM one day when staff was busy.2. Review of R 16's Face Sheet revealed the facility admitted R16 on 02/21/2026 with admitting diagnoses including chronic obstructive pulmonary disease (COPD), unspecified, acute and chronic respiratory failure with hypercapnia, and acute respiratory failure with hypoxia. The admitting MDS assessment was incomplete, and the BIMS was not available at time of survey.Review on 04/01/2026 at 10:52 AM of R16's Care Plan titled, ADLI Rehab (self-care), dated 03/09/2026 revealed R16 had problems described as self care deficit, need for assistance with activities of daily living (ADLs), goals including R16 will be clean, dressed and out of bed (OOB) daily as R16 will allow through next review date, and interventions including incontinent care as needed (PRN); adult briefs as indicated. Interview on 03/31/2026 at 10:06 AM with R16 she stated she often has to sit in a wet brief. She stated she had been wet since 7:00 AM, and staff did not change her until State Surveyor (SSA) came down the hall and staff rushed to get her changed. R16 stated Certified Nursing Assistant (CNA)2 was rude because she had to ask for ice three times before she got some ice.3. Review of R19's Face Sheet revealed the facility admitted R19 on 03/23/2026 with admitting diagnoses including type II diabetes mellitus with diabetic neuropathy, unspecified, chronic kidney disease, stage 3 unspecified, and dependence on wheelchair. The admitting MDS assessment, with an ARD of 03/20/2026, revealed the facility assess R19 to have a BIMS score of 15 of 15, indicating R19 was cognitively intact. Review on 04/01/2026 at 12:56 PM of R19's Care plan titled, Impaired Bowel/Bladder Elimination, dated 10/23/2025 revealed R19 was at risk for complications related to bowel/bladder incontinence and impaired renal function related to chronic kidney disease stage 3, interventions included incontinence care PRN; adult briefs and barrier cream as indicated. Additional Care Plan titled, Skin Integrity revealed R19 was at risk for altered skin integrity/pressure ulcer development related to immobility, incontinence, obesity, and skin to skin contact in groin area, interventions included monitor skin integrity every one weeks and moisture barrier cream to buttocks and peri area as needed with incontinence care. During an interview on 03/31/2026 at 10:42 AM with R19 she stated staff generally assisted with her needs; however, response times to her call light could be prolonged. She reported that it sometimes takes up to one to two hours for staff to respond, noting that delays were more common during the second shift. She further stated that she has experienced extended wait times for assistance with changing a soiled brief. The resident expressed feelings of neglect during these instances, stating she feels abandoned when help is delayed.4. Review of R30's Face Sheet revealed the facility admitted R30 on 02/20/2026 with admitting diagnoses including heart failure, unspecified, cellulitis of right lower limb, morbid (severe) obesity due to excess calories, and unsteadiness on feet. The MDS assessment, with an ARD of 02/25/2026, revealed the facility assessed R30 to have a BIMS score of 15 of 15, indicating R30 was cognitively intact.Review of R30's Care Plan titled, Skin Integrity, revealed R30 had unspecified open wound to scrotum and testes, evidenced by presence of skin breakdown or at high risk for skin breakdown related to moisture associated skin damage (MASD) with monitor skin integrity one time a week. Additional Care Plan titled, Impaired Bowel/Bladder Elimination, dated 01/20/2026 revealed R30 had alteration in elimination as evidenced by incontinence of bowel and bladder with interventions including incontinence care PRN; and adult briefs and barrier cream as indicated.During an interview on 03/31/2026 at 1:45 PM with R30's Power of Attorney (POA) she stated she telephoned R30 the day before, 03/30/2026 at 4:25 PM and he was waiting for assistance in changing his brief. The POA stated she spoke with R30 again on 03/31/2026 at 7:13 PM and R30 was still waiting for assistance with his soiled brief.5. Review of R34's Face Sheet, revealed the facility admitted R34 on 04/26/2023 with admitting diagnoses including chronic obstructive pulmonary disease, unspecified, dependence on wheelchair, and atherosclerosis of renal artery. The quarterly MDS, with an ARD of 01/05/2026, revealed the facility assessed the resident to have a BIMS score of 15 of 15, indicating R34 was cognitively intact.Review of R34's Care Plan titled, ADL rehab (self-care) dated 03/02/2026 revealed R34 had muscle weakness, generalized and dependence on wheelchair, related to self-care deficit, with interventions including incontinent care PRN; adult briefs as indicated. Review of the Care Plan titled, Skin Integrity dated 03/02/2026 revealed R34 was at risk for skin breakdown and interventions including monitoring skin integrity one time a week, moisture barrier cream to buttocks and peri area as needed with incontinence care. Review of the Care Plan titled, Bowel/Bladder Incontinence, revealed R34 had bladder incontinence related to impaired mobility, generalized weakness and chronic pain. Interventions for R34 including apply incontinence briefs/pads, provide emotional support when incontinent, provide privacy and maintain dignity during incontinence care and toileting, and toilet resident upon request.During an interview on 03/31/2026 at 9:50 AM with R34, she stated, A lot of people are scheduled but they don't come, especially the aides. R34 stated sometimes the call light is not answered in a timely manner. R34 reported it took an hour for staff to come one time. She stated she would time it with her watch but was unable to determine if it happened at night or on the weekends.6. Review on 03/31/2026 at 3:37 PM of R45's Face Sheet revealed the facility admitted R45 on 12/23/2025 with admitting diagnoses including acute and chronic respiratory failure unspecified whether with hypoxia or hypercapnia, morbid (severe) obesity due to excess calories, and muscle weakness, generalized. Review of the quarterly MDS, with an ARD of 01/09/2026, revealed the facility assessed the resident to have a BIMS score of 15 of 15, indicating R45 was cognitively intact.Review of R45's Care Plan titled, Urinary Incontinence and Indwelling Catheter, dated 12/30/3035 revealed R45 was at risk for alteration in bladder elimination related to use of Foley Catheter, with interventions including change catheter and drainage bag as needed, indwelling catheter care, inspect skin for any sign of skin breakdown, and ask R45 weekly if staff can replace catheter.During an interview on 03/30/2026 at 1:53 AM, R45 stated night shift staff were slow about providing care after a bowel movement. R45 stated it took staff from 30 to 45 minutes to answer call lights at night and early in the morning. R45 stated it was awful to sit and wait for staff to come and change them.7. Review of R52's Face Sheet, revealed the facility admitted R52 on12/31/2025 with admitting diagnoses including pressure ulcer of sacral region, stage 3, age related physical debility, and muscle weakness, generalized. Review of the admission MDS, with an ARD of 01/05/2026, revealed the facility assessed the resident with a BIMS score of 14 of 14, indicating R52 was cognitively intact. Review of R52's Care Plan titled, Urinary Incontinence and Indwelling Cather, dated 01/10/2026 revealed R52 had benign prostatic hyperplasia (BPH), neuromuscular dysfunction of bladder and required the following interventions including indwelling catheter care, inspect skin for any sign of skin breakdown, keep skin and dry, and provide appropriate assistance with toileting needs. During an interview on 03/31/2026 at 9:21 AM with R52's son he stated it would take staff 35 to 40 minutes to answer call lights especially at night. R52's son also stated R52 had a catheter but required help getting to the bathroom to use the commode. R52 told his son he would have to wait a long time for help to get off the commode.During an interview on 04/01/2026 at 2:29 PM with CNA4 she stated she worked every other weekend and two to three nights a week. CNA4 stated out of the four nights she worked there was only one out of the four where there were three CNA's for the facility, the other nights there were two for 46 residents. CNA4 stated she does not have time to get her job done and she feels rushed every shift. CNA4 stated residents have to wait a ridiculous amount of time for us to help them when they use their call lights.During an interview on 04/01/2026 at 2:57 PM with CNA5 she stated she worked night shift and there were two CNA's for the entire building. CNA5 stated she feels exhausted at the end of her shift. CNA5 stated residents have to wait an average of 20 to 30 minutes for one of the CNA's to answer the call light at night. CNA5 stated the rounds overlap and we are physically not able to get to each resident.During an interview on 04/02/2026 at 3:10 PM with the Assistant Director of Nursing (ADON) and Staff Development Coordinator she stated she attended Quality Assurance Project Improvement (QAPI) meetings, and her role was to assist with audits and gathering information together for the meeting. ADON/SDC stated she had not been involved with the Facility Assessment.During an interview on 04/02/2026 at 3:53 PM with the Director of Nursing (DON) she stated it was her expectations that residents received care when their call light was turned on. The DON stated she was not familiar with the Facility Assessment. She stated the staffing numbers were based on the hours per patient day (HPPD) for the building. The DON stated if there were no staffing numbers in the facility assessment, she would go to the Administrator and the scheduler. The DON stated she would participate in QAPI at the next meeting.During an interview on 04/02/2026 at 5:21 PM with Administrator she stated she had worked with the regional person in developing the Facility Assessment. State Surveyor (SSA) asked the Administrator if she was aware the staffing numbers were absent from the Facility Assessment and the retention and recruitment plan for the facility. The Administrator stated she had been at the facility for two and a half weeks and had not had time to look over the Facility Assessment. The Administrator stated it was her expectation the facility would be appropriately staffed to meet the residents' needs. She stated the facility ran at 3.50 HPPD [Hours Per Patient Day]. The SSA informed Administrator on 03/30/2026, the HPPD was calculated at 2.97 HPPD according to the posted staffing; on 03/31/2026, the HPPD was calculated at 3.15 HPPD according to the posted staffing; and on 04/01/2026 the HPPD was calculated at 3.25 HPPD according to the posted schedule. The Administrator stated she would get with the scheduler to make sure the staffing numbers meet the residents' needs and would need to adjust the Facility Assessment.

Based on observation, interview, review of the Centers for Disease Control and Prevention's (CDC) document, review of vaccine package inserts, and review of the facility's policy, the facility failed to ensure medications and biologicals were stored in accordance with CDC guidelines, manufacturers' recommendations, and professional standards of practice, and failed to ensure appropriate environmental controls were used to preserve their integrity. 1) Observation on [DATE] at 3:55 PM of the medication storage refrigerator revealed the temperature was at 48 F, exceeding the recommended upper limit. Review of the medication refrigerator temperature logs revealed multiple instances of temperatures falling below the minimum required range for proper medication storage (36 F to 46 F). During the month of [DATE], temperatures were documented below 36 on 13 out of 31 days. 2) Observation on [DATE] at 3: 55 PM revealed that the medication storage refrigerator revealed 58 single-dose Afluria influenza vaccines were stored tightly packed together inside a refrigerator drawer with no space between the vaccines to allow for proper circulation. At the time of the observation. The temperature was at 48 F.3) Resident 30's insulin was labeled as opened on [DATE] and expired on [DATE] according to the manufacturer's recommendations but was still being used for the resident. The findings include:Review of the CDC's Vaccine Storage and Handling Toolkit, dated [DATE], revealed vaccines must be stored to maintain potency and effectiveness through strict adherence to cold chain requirements. The guidance revealed vaccines requiring refrigeration must be maintained at temperatures between 36 and 46 degrees (F). It must not be exposed to temperatures outside of this range, including freezing or elevated temperatures, as such exposure may result in reduced potency and loss of effectiveness. The CDC further revealed vaccines must be stored in a refrigerator, which allows for proper air circulation and maintains consistent temperature control to ensure stability.Review of the manufacturer's package insert for Afluria (an inactivated influenza vaccine), no date, revealed the pre-filled syringes must be stored refrigerated at temperatures between 36 and 46 degrees (F), must not be frozen, and must not be exposed to high temperatures. The package insert further revealed any vaccine exposed to freezing temperatures should be discarded and the vaccine must be maintained under proper storage conditions to preserve potency and effectiveness until administration. Manufacturer recommendations further support storing vaccines with adequate spacing and air circulation to maintain consistent temperatures and prevent temperature fluctuations that may compromise vaccine integrity.Review of the facility's policy titled Medication Storage, no date, revealed medications must be stored to maintain integrity, resident safety, and comply with regulatory guidelines. Further review of the policy revealed medications must be stored according to the manufacturer's guidelines. Medications requiring refrigeration will be maintained between 36 and 46 degrees (F). Additionally, temperatures will be checked daily to ensure they are within the specified range, and the refrigerator should be defrosted regularly.1) Observation on [DATE] at 3:55 PM of the medication refrigerator revealed it was a small dormitory-style Unit equipped with two shelves, a bottom door, and an open freezer compartment. The thermometer reading inside the refrigerator was observed at 48 degrees (F), which exceeded the acceptable range for refrigeration medication storage. The freezer compartment revealed approximately two inches of accumulated ice and non-defrosted buildup.2) Observation of the medication refrigerator's storage drawer on [DATE] at 3:55 PM, revealed 58 single doses of Afluria influenza vaccines in boxes were stored tightly packed, on top of each other, inside the drawer at the bottom of the refrigerator with no space between the boxed vaccines to allow for proper circulation.3) Observation and review of the Refrigeration Checklist, dated 03/2026, revealed according to the documented instructions, temperatures must be maintained at or below 41degrees (F). The Refrigeration Checklist included a section to document corrective actions when temperatures were at or above 41 degrees (F). Documentation revealed multiple instances in which the medication refrigerator temperature fell below the minimum acceptable range of 36 to 46 degrees (F) for proper vaccine and medication storage. In [DATE], temperatures were recorded below 36 degrees (F) on 13 of 31 days. Review of the medication refrigerator temperature logs revealed temperatures falling below the required range of 36 to 46 degrees (F) during [DATE]. Specifically, temperatures were documented as follows: [DATE] at 34 degrees (F); [DATE] at 34 degrees (F); [DATE] at 34 degrees (F); [DATE] at 32 degrees (F); [DATE] at 30 degrees (F); [DATE] at 34 degrees (F); [DATE] at 32 degrees (F); [DATE] at 34 degrees (F); [DATE] at 34 degrees (F); [DATE] at 35 degrees (F); [DATE] at 31 degrees (F); [DATE] at 31 degrees (F); and [DATE] at 34 degrees (F). Further review revealed corrective action was documented on [DATE], [DATE], and [DATE], including an increase in the refrigerator temperature, but no follow-up temperature readings were documented. For all other identified dates, no documented corrective action was taken to ensure the refrigerator temperature remained within the required range.During an interview with Licensed Practical Nurse (LPN) 3 on [DATE] at 4:45 PM, she stated she wasn't sure of the proper temperature range for refrigerated medications per facility policy guidelines. She stated she believed the temperature log indicated medication and vaccines should be stored at approximately 41 degrees (F). LPN 3 stated that if she found the temperature to be at or below 41 degrees (F), it would be acceptable. She was unable to state what temperature was too low for proper storage. Furthermore, she stated if the temperature exceeded 41 degrees (F), she would take corrective action, which would include increasing the temperature of the refrigerator. She was unsure what follow-up action to take when the temperature was out of range. LPN3 stated proper storage ensures medications and vaccines remain stable, maintain their potency, and were suitable for safe administration.During an interview with the Infection Preventionist/Assistant Director of Nursing (IP/ADON1) on [DATE] at 4:15PM, she stated the night shift was responsible for taking and documenting refrigerator temperatures daily. She further stated the freezer should be defrosted and the refrigerator maintained within the correct temperature range. She stated the facility followed CDC guidelines for medication and infection control policies. When asked by the State Survey Agency (SSA) surveyor about appropriate refrigerator storage temperatures for medications and biologicals, she was unable to identify the recommended temperature range. She was also unable to describe current CDC recommendations for proper vaccine storage and handling, including temperature-monitoring requirements and the need to maintain appropriate spacing to allow adequate air circulation. The IP/ADON1 stated it was important to store medications and vaccines the right way because if they get too hot or too cold, they can stop working the way they should. She stated improperly stored medications may not treat medical conditions properly, and vaccines may not protect residents from disease. The IP/ADON1 stated proper storage helped ensure medications and vaccines were safe, effective, and were able to do what they were intended to do.During an interview with the Assistant Director of Nurses (ADON) 2 on [DATE] at 1:30 PM, she stated the refrigerator should be checked once daily to ensure appropriate temperatures were maintained. She stated the acceptable temperature range was between 36 and 46 degrees (F), and staff should routinely monitor and adjust the unit as needed to maintain consistent temperatures. She further stated the refrigerator should be maintained in good working order and defrosted routinely to prevent ice buildup. She stated she was unaware of certain CDC recommendations for vaccine storage. ADON 2 stated it was important to ensure medications and vaccines were stored properly to maintain their potency and to protect residents' safety by reducing the risk of preventable disease.During an interview with the Regional Quality Nurse (RQN) on [DATE] at 5:10 PM, she stated it was her expectation staff follow national guidelines for the refrigeration of medications and vaccinations. She stated vaccines should not be stored with other refrigerated medications to maintain their efficacy and stability. She further stated the temperature log should include the acceptable temperature range so staff could readily determine when the refrigerator was out of range. She stated it was important all medications were stored at appropriate refrigeration temperatures and in accordance with manufacturers' guidelines to preserve their potency and intended therapeutic effects.During an interview with the Director of Nurses (DON) on [DATE] at 11:30 AM, she stated refrigerated vaccines and medications should be stored according to guidelines. The DON stated nursing staff were expected to monitor and document refrigerator temperatures daily and take corrective action when the temperatures fell outside acceptable ranges. She stated it was important medications and vaccines were stored properly to maintain their safety and effectiveness for resident use. During an interview with the Administrator on [DATE] at 5:02 PM, she stated it was her expectation all nursing staff followed the facility policy regarding medication and vaccine storage. She stated it was important for the residents' health and safety.

Based on observation, interview, record review, review of the controlled substance log titled Controlled Medication Shift Change Log, and review of the facility's policies, the facility failed to ensure proper documentation of the narcotic card count at each change of shift in accordance with professional standards of practice for 3 of 4 medication carts.1) Review of the 100 Hall back medication cart on 04/01/2026 at 8:30 AM, revealed the oncoming nurse failed to sign the Controlled Medication Shift Change Log on the following dates 04/01/2026, 03/24/2026, and 03/10/2026.2) Review of the 100 Hall split medication cart on 04/01/2026 at 9:45 AM, revealed the oncoming nurse failed to sign the Controlled Medication Shift Change Log on 03/24/2026 and 03/10/2026.3) Review of the 200 Hall split medication cart on 04/01/2026 at 10:00 AM, revealed on 03/16/2026, the oncoming nurse failed to sign the log. On 02/26/2026 and 01/27/2026, the outgoing nurse failed to sign the Controlled Medication Shift Change Log. The findings include:Review of the facility's policy titled Inventory Control of Drugs, no date, revealed controlled drugs are inventoried and documented under proper conditions with regard to security and state and federal regulations. Scheduled II (controlled medications that have high abuse potential but are legally prescribed for medical use) medications are countered by the oncoming nurse and outgoing nurse at least once a day at the change of shift and documented on a controlled drug count verification sheet.1) Observation and review of the 100 Hall back medication cart on 04/01/2026 at 8:30 AM, revealed the oncoming nurse failed to sign the Controlled Medication Shift Change Log on the following dates 04/01/2026, 03/24/2026, and 03/10/2026.During an interview with Licensed Practical Nurse (LPN) 3 on 04/01/2026 at 8:45 AM, she stated it was the facility's policy and procedure to count controlled medications. She stated the outgoing and oncoming nurses performed the count of the controlled drug cards at each shift change to ensure the count was accurate and reconciled. LPN3 stated she had not signed the Controlled Medication Shift Change Log on 04/01/2026 at change of shift because she wanted to wait to sign the log after the pharmacy delivered new inventory. LPN3 stated it was important to sign the log at the time of shift change to prevent potential diversion.2) Review of the 100 Hall split medication cart on 04/01/2026 at 9:45 AM, revealed the oncoming nurse failed to sign the Controlled Medication Shift Change Log on 03/24/2026 and 03/10/2026.During an interview with the Assistant Director of Nurses (ADON) 2 on 04/02/2026 at 1:30 PM, she stated that her assigned responsibilities included management and oversight of the 100 Hall. She stated controlled medications were expected to be counted at each shift change by both ongoing and oncoming nurses, with both nurses signing the Controlled Medication Shift Change Log when the count was completed. Additionally, she stated she was not aware of the reason the shift change count documentation had not been completed. ADON2 stated she did not conduct routine audits of the medication carts or the shift change logs to verify the accuracy or completeness of the documentation. She stated following policy and procedures related to controlled medications was important to help prevent drug diversion and to ensure accurate accountability of all controlled substances. 3) Review of the 200 Hall split medication cart on 04/01/2026 at 10:00 AM, revealed on 03/16/2026, the oncoming nurse failed to sign the log. On 01/27/2026 and 02/26/2026, the outgoing nurse failed to sign the Controlled Medication Shift Change Log.During an interview with ADON1 on 04/01/2026 at 3:25 PM, she stated her assigned responsibility included management and oversight of the 200 Hall. She stated controlled medications should be counted at each shift change by both the outgoing and oncoming nurses, and that the count should be documented with two signatures on the Controlled Medication Shift Change Log. Additionally, she stated she was not aware of any routine audits being done to check the shift change logs. ADON1 stated without regular review, missing signatures or errors might not be caught. She stated further it was important to follow facility policy to prevent the potential for drug diversion and to ensure the accuracy of the controlled medication count.During an interview with the Director of Nurses (DON) on 04/02/2026 at 11:30 AM, she stated nursing staff was expected to sign the Controlled Medication Shift Change Log at the time they assumed responsibility for the medication cart and again when relinquishing responsibility. She stated that documentation should occur at the time of the count to ensure accountability and to clearly identify responsible staff in the event a discrepancy related to controlled drugs was identified.During an interview with the Administrator on 04/02/2026 at 5:02 PM, she stated it was her expectation that all nursing staff followed the facility policy regarding the counting and documentation of controlled drugs. The Administrator stated that completing controlled medication counts at the start of each shift was necessary to maintain accurate accountability and reduce the risk of drug diversion.

Based on interview, record review, and review of the facility's policy, the facility failed to ensure that residents were informed of and able to exercise their rights regarding advance directives. Specifically, there was no documented evidence that the facility educated the residents and/or their representative on advance directives. This failure had the potential to result in residents making uninformed decisions regarding their care and treatment preferences for 7 of 41 sampled residents reviewed, Resident (R) 12, R16, R22, R33, R35, R37 and R41.The findings include:Review of the facility's policy titled, Advance Directive Standard of Practice, reviewed 3/2026, revealed it is the resident's right to formulate an advance directive. Further review revealed the facility will inquire about the existence of any advance directives, and should the resident indicate they issued advance directives about their care and treatment, documentation must be recorded in the medical record of such directive, and a copy of such directive should be included in the resident's medical record. Additional review revealed the facility will periodically assess the resident's decision-making abilities and approach their health care proxy or legal representative if the resident is determined to not have decision making capacities regarding advance directives and/or treatment provision. Further review revealed during the care planning process, the facility will identify, clarify, and review with the residents or legal representatives whether they have the desire to make any changes to the advance directives. Review of the facility's sample Resident admission Packet revealed that the document titled, Advance Directive Policy and Record, undated, referenced the facility's policy. Further review revealed the document permits the facility to note the status of the resident's advance directive along with a place for a date and initials. 1. Review of R12's Face Sheet revealed the facility admitted the resident on 10/27/2025 with diagnoses to include congestive heart failure (CHF), diabetes mellitus, and depression. Review of R12's admission Minimum Data Set [MDS], with an Assessment Reference Date (ARD) of 02/12/2026, revealed the resident had a Brief Interview for Mental Status [BIMS] score of eight out of 15, indicating the resident was moderately cognitively impaired.In an interview with R12 on 04/01/2026 at 2:15 PM, she stated she had an advance directive in place and was not certain if she had provided the paperwork to the facility. She further stated she did not remember being asked about it in her care plan meeting. Review of R12's Advance Directive Policy and Record, undated, revealed an incomplete record that indicated the .documents were not yet received, but center was informed. The only information filled in on the form was the resident's name, the representative name, and their relationship to the resident. Further review revealed no documented evidence the opportunity to formulate or decline an advance directive was explained to the resident in a manner she understood, only the date 10/27 with no year was included along with the initials of a staff member. 2. Review of R16's Face Sheet revealed the facility admitted the resident on 07/09/2025 with diagnoses to include depression, coronary artery disease, and bipolar disorder. Review of R16's admission MDS, with an ARD of 01/16/2026, revealed the resident had a BIMS score of 13 out of 15, indicating the resident was cognitively intact.Review of R16's Advance Directive Policy and Record, undated, revealed an incomplete record that indicated Resident or representatives states that the resident has no written AD [advance directive]. The only information filled in on the form was the resident's name and the date, 7/9/25, along with the initials of a staff member. Further review revealed no documented evidence the opportunity to formulate or decline an advance directive was explained to the resident in a manner she understood.3. Review of R22's Face Sheet revealed the facility admitted the resident on 12/10/2024 with diagnoses to include heart failure, diabetes mellitus, and chronic obstructive pulmonary disease (COPD).Review of R22's admission MDS, with an ARD of 02/12/2026, revealed the resident had a BIMS score of 15 out of 15, indicating the resident was cognitively intact.Review of R22's Advance Directive Policy and Record, undated, revealed an incomplete record that indicated the Resident or representatives states that the resident has no written AD. The only information filled in on the form was the resident's name and the date, 3/31/26, along with the initials of a staff member. Further review revealed no documented evidence the opportunity to formulate or decline an advance directive was explained to the resident in a manner she understood.4. Review of R33's Face Sheet revealed the facility admitted the resident on 02/11/2026 with diagnoses to include benign prostatic hyperplasia, renal insufficiency, and diabetes mellitus. Review of R33's admission MDS, with an ARD of 02/25/2026, revealed the resident had a BIMS score of 11 out of 15, indicating the resident was cognitively intact.Review of R33's Advance Directive Policy and Record, undated, revealed an incomplete record that indicated the .documents were not yet received, but center was informed. The form included the resident's name; however, the representative name/relationship was blank, and it was not indicated if R33 had a legal representative, and if R33 did not have a legal representative, it was not applicable. Further review revealed no documented evidence the opportunity to formulate or decline an advance directive was explained to the resident in a manner she understood, only the date, 2/11 with no year, was included along with the initials of a staff member. 5. Review of R35's Face Sheet revealed the facility admitted the resident on 01/25/2024 with diagnoses to include coronary artery disease (CAD), thyroid disorder, and arthritis. Review of R35's admission MDS, with an ARD of 02/04/2026, revealed the resident had a BIMS score of 15 out of 15, indicating the resident was cognitively intact.Review of R35's Advance Directive Policy and Record, undated, revealed an incomplete record that indicated the .resident or representative states the resident has no written AD. The form included the resident's name; however, the representative name/relationship was blank, and it was not indicated if R35 had a legal representative, and if R35 did not have a legal representative, it was not applicable. Further review revealed no documented evidence the opportunity to formulate or decline an advance directive was explained to the resident in a manner she understood, only the date, 1/16/26, with the initials of a staff member. 6. Review of R37's Face Sheet revealed the facility admitted the resident on 10/02/2014 with diagnoses to include stroke, hemiplegia, and malnutrition. Review of R37's admission MDS, with an ARD of 01/26/2026, revealed the resident had a BIMS score of five out of 15, indicating the resident was significantly impaired cognitively.Review of R37's Advance Directive Policy and Record, undated, revealed an incomplete record that indicated the .resident or representative states the resident has no written AD. The form included the resident's name; however, the representative name/relationship was blank, and it was not indicated if R37 had a legal representative, and if R37 did not have a legal representative, it was not applicable. Further review revealed no documented evidence the opportunity to formulate or decline an advance directive was explained to the resident in a manner he understood, only the date, 3/31/26, with the initials of a staff member. 7. Review of R41's Face Sheet revealed the facility admitted the resident on 10/15/2024 with diagnoses to include malnutrition (protein or calorie), depression, and scoliosis. Review of R41's admission MDS, with an ARD of 03/16/2026, revealed the resident had a BIMS score of 15 out of 15, indicating the resident was cognitively intact.Review of R41's Advance Directive Policy and Record, undated, revealed an incomplete record that indicated the .resident or representative states the resident has no written AD. The form included the resident's name; however, the representative name/relationship was blank, and it was not indicated if R41 had a legal representative, and if R41 did not have a legal representative, it was not applicable. Further review revealed no documented evidence the opportunity to formulate or decline an advance directive was explained to the resident in a manner she understood, only the date, 3/31/26, with the initials of a staff member. During an interview with the Admissions Director on 04/02/2026 at 11:57 AM, she stated she got the verbal report of whether a resident has an advance directive during admission, but Social Services obtained all the hard copies for the electronic medical record (EMR). She stated that the residents' wishes could be carried out in a way that did not align with their preferences if an accurate advance directive was not in place. During an interview with Social Services Director on 04/02/2026 at 11:57 AM, she stated she collected documents related to current advance directives upon admission and she assisted with completing the form from the admissions packet. She stated the interdisciplinary team (IDT) did not consistently review the advance directive status during care plan meetings. During an interview with the Director of Nursing (DON) on 04/02/2026 at 4:22 PM, she stated it was important for the residents to have an opportunity to select advanced directives, so that their wishes would be respected. During an interview with the Administrator on 03/31/2026 at 3:21 PM, she stated she expected staff to follow all facility policies and procedures related to advance directives.

Based on observation, interview, record review, and review of the facility's procedure resource, Lippincott Nursing Procedures, the facility failed to ensure that a resident who needed respiratory care was provided with such care, consistent with physician orders and professional standards of practice for 3 out of 3 sampled residents, Resident (R) 16, R22, and R38.The findings include: Review of the facility's procedure resource, [NAME] Nursing Procedures ninth edition manual, copyright 2023 Wolters Kluwer revealed, Hypoxemia (low oxygen) causes pulmonary vasoconstriction and subsequently pulmonary hypertension, which increases workload in the right side of the heart. For implementation, the manual stated to verify the practitioner's order for oxygen therapy. Review of the admission Face Sheet, found in R38's electronic medical record (EMR) revealed the facility admitted R38 on 10/26/2025 with diagnoses to include heart failure, obesity, and shortness of breath. Review of R38's Minimum Data Set [MDS], with an Assessment Reference Date of 03/05/2026, revealed the facility assessed the resident to have a Brief Interview for Mental Status [BIMS] score of zero (00), indicating R38 was severely cognitively impaired. Review of R38's Monthly TAR [Treatment Administration Record], for 03/2026, revealed an order ID #88/23369307 which started on 03/24/2026 for oxygen at 3 liters per minute (LPM) via nasal cannula. Observation on 03/30/2026 at 4:49 PM revealed R38 with a nasal cannula in his nose to deliver oxygen. However, the oxygen concentrator beside the bed was set at zero. The State Survey Agency (SSA) Surveyor requested Licensed Practical Nurse (LPN) 2 check the order for R38's oxygen in the computer. She opened the EMR and found the order for R38's oxygen which stated it was to be set at 3 Liters Per Minute (LPM). At this time, the Assistant Director of Nursing (ADON) 1 was at the nurse's station and stated she was going to check R38's oxygen level. The SSA Surveyor walked to R38's room with ADON1 along with Licensed Practical Nurse (LPN) 1. LPN1 stated R38's oxygen concentrator was to be set at 1.5 LPM. ADON1 checked R38's oxygen level by pulse oximetry, and it was 88 percent, a low reading. LPN1 said the concentrator was unplugged, so she plugged in the concentrator and set the level to 1.5 LPM. The resident's oxygen level increased to 94 percent. Review of R38's Progress Note, dated 03/30/2026 at 6:51 PM, written by ADON1 revealed Guardianship was notified and the Advanced Practice Registered Nurse (APRN) was aware of the incident. Review of R38's Treatment Administration Record [TAR], revealed on 03/30/2026 the resident's oxygen was set at 3 LPM via nasal cannula and acknowledged with a check mark. During an interview with LPN1 on 03/30/2026 at 4:58 PM, she stated she was the nurse on the unit caring for R38. When asked, she stated R38's oxygen was to be set at 1.5 LPM. When asked how she knew what a resident's oxygen order was, she stated she had a sheet that she wrote the oxygen setting on when she started working. The SSA Surveyor asked LPN1 to look at the sheet and let the SSA Surveyor know what R38's oxygen setting was supposed to be. She looked at the sheet and stated R38's oxygen setting was to be at 3 LPM. LPN1 then went to R38's room and increased the resident's oxygen setting on the concentrator to 3 LPM. During an interview with ADON1 on 03/31/2026 at 7:26 AM, she stated there were orders in the computer to find the resident's oxygen setting. She further stated the facility had 12-hour shifts, and the setting was checked twice a day and documented on the treatment administration record (TAR). She further stated it was important for the resident to have the correct oxygen setting, so the oxygen saturation of the resident was adequate. She also stated if the correct setting was not provided, the resident could become short of air and become confused. She then stated Certified Nurse Aide (CNA) 1 had unplugged R38's oxygen to plug in a bed. She further stated CNA1 was educated on the spot to never unplug an oxygen concentrator without checking with the nurse. During an interview with CNA1 on 03/31/2026 at 7:36 AM, she stated R38's oxygen tubing was not in his nose, so she thought he did not need the oxygen. She stated she needed to plug in a bed, so she unplugged the oxygen concentrator. She further stated she was educated by ADON1 and now knew to check with the nurse before unplugging a resident's oxygen concentrator. During an interview with CNA2 on 03/31/2026 at 7:44 AM, she stated she knew a resident was on oxygen by looking at the care profile (computer site for CNAs). When asked to show the SSA Surveyor where R38's oxygen was documented on the CNAs care profile, CNA2 could find where R38 needed oxygen. During an interview with ADON2 on 03/31/2026 at 10:51 AM, she stated she was assigned to R38's unit. She also stated she was working on progress notes in the office during the incident. She stated from what she understood, R38's oxygen concentrator was unplugged, and as soon as staff was aware, she stated she notified the doctor and family. She also stated the CNAs knew a resident was on oxygen because it was on the resident care profile. She stated the importance of having the correct oxygen setting was to keep the resident from having shortness of breath. She further stated if the oxygen setting was too low, a resident might need to go to the hospital from a decreased oxygen saturation level. During an interview with Registered Nurse (RN) 1 on 04/02/2026 at 11:49 AM, she stated she made sure the oxygen was at the correct setting by checking the order. She stated she looked at the oxygen concentrator and verified the setting. She stated she then looked at the resident. She stated R38's oxygen was set on 2 LPM. She stated she knew that because she went into the room and looked at the machine this morning. She stated the importance of following the provider's order was to keep a resident from getting into respiratory distress. She also said if the setting was too high, the resident could get dizzy. During an interview with the Director of Nursing (DON) on 03/31/2026 at 7:38 AM, she stated she heard about the incident. She further stated the doctor and family were notified, and the resident was not harmed. The DON stated the nurse knew the resident needed oxygen because of the provider's order in the computer. She further stated the CNA knew by the care profile. She stated the residents' oxygen setting was also discussed in morning report. She stated the importance of keeping oxygen at the correct setting was to keep the resident's cells oxygenated and for the resident's comfort. During additional interview with the DON on 04/02/2026 at 4:21 PM, she stated she expected staff to follow the physician's orders for oxygen. She stated, if the resident refused oxygen, she expected staff to notify the physician. She further stated after the episode where R38's oxygen was turned off; the facility did an audit of all residents on oxygen. During an interview with the Administrator on 04/02/2026 at 5:23 PM, she stated she was not notified about R38's oxygen being turned off. She further stated she would expect the staff to notify her if there was an issue with oxygen. During an interview with the Medical Director on 04/02/2026 at 4:10 PM, he stated he was not notified that R38's oxygen had been turned off. He stated another provider might have been notified. He further stated a resident could develop respiratory distress if the oxygen orders were not followed. 2. Review of the admission Face Sheet, found in R16's EMR, revealed the facility admitted the resident on 07/09/2025, with diagnoses that included chronic obstructive pulmonary disease (COPD), congestive heart failure, and iron deficiency anemia. Review of R16's quarterly MDS, with an ARD of 01/14/2026, revealed the facility assessed the resident to have a BIMS score of 12 out of 15, which indicated the resident had moderate cognitive impairment. Review of the Physician's Order Form, dated 03/2026, found in R16's EMR, revealed R16 may have oxygen at 3 LPM via nasal cannula. Review of the Treatment Administration Record (TAR), dated 03/31/2026, found in R16's EMR, revealed nursing staff had documented on the TAR at 7:00 AM that oxygen was being administered at 3 LPM via nasal cannula. Review of R16's Comprehensive Care Plan [CCP], initiated on 03/09/2026, revealed a focus for alteration in respiratory status, with a goal for the resident to remain free from signs and symptoms of respiratory distress through the next review date. An intervention dated 02/21/2026, indicated the resident was to receive oxygen at 3 LPM via nasal cannula, delivered by an oxygen concentrator. Observation on 03/31/2025 at 8:00 AM, revealed R16 was in bed with her eyes closed and appeared to be sleeping. Oxygen was in place via nasal cannula at 1.5 LPM. Continued observation on 04/04/2026 at 11:00 AM revealed R16's oxygen concentrator remained set at 1.5 LPM. 3. Review of the admission Face Sheet, found in R22's EMR, revealed the facility admitted the resident on 12/10/2024, with diagnoses which included acute and chronic respiratory failure with hypoxia, acute kidney failure, and congestive heart failure. Review of R22's quarterly MDS, with an ARD of 01/28/2026, revealed the facility assessed the resident to have a BIMS score of 15 out of 15, which indicated the resident was cognitively intact. Review of R22's Physician's Orders, dated 03/2026, revealed R22 was to receive continuous oxygen at 2 LPM via nasal cannula at the hour of sleep, and as needed, every shift. Review of the TAR, dated 03/31/2026, revealed nursing staff had documented at 7:00 AM that oxygen was being administered at 2 LPM via nasal cannula. Review of R22's CCP, initiated 10/30/2025, revealed a focus for alteration in respiratory status, with a goal for the resident to have no complication related to shortness of air through the next review date. An intervention dated 09/21/2025 indicated the resident could receive oxygen at 2 LPM via nasal cannula, delivered by an oxygen concentrator. Observation on 03/31/2026 at 8:30 AM, revealed R22 was in bed with her eyes closed and appeared to be sleeping. Her oxygen was in place via nasal cannula at 2.5 LPM. Continued observation on 03/31/2026 at 11:52 AM revealed her oxygen remained set at 2.5 LPM. During an interview with LPN2 on 03/31/2026 at 9:00 AM, she stated she assessed each resident's respiratory status every shift and ensured oxygen was delivered at the prescribed liters per minute. According to the LPN, she checked both R16's and R22's oxygen at the correct flow rate during start of shift rounding and confirmed the flow rate was correct. LPN2 stated it was important to verify the oxygen concentrator was set to the correct flow rate, as settings could change. She further stated an incorrect flow rate for a resident with COPD or respiratory failure could result in complications, including worsening of the resident's condition. During additional interview with ADON1 on 03/31/2026 at 10:57 AM, she stated nurses were responsible to ensure oxygen flow rates were consistent with physician orders. ADON1 stated nurses were expected to assess residents during medication administration and perform respiratory assessments each shift for residents who received oxygen. During additional interview with the DON on 04/02/2026 at 4:29 PM, she stated nursing staff was expected to follow the physician's orders for oxygen administration. The DON stated staff received education regarding oxygen administration which emphasized the importance of adhering to physician orders, as an incorrect oxygen concentration could result in complications, including worsening of the residents' respiratory status. During additional interview with the Administrator on 04/02/2026 at 5:02 PM, she stated it was her expectation that all clinical staff followed the physician's orders as written to prevent complications and ensure the residents' safety and well-being. During a continued telephone interview with the Medical Director on 04/02/2026 at 4:10 PM, he stated it was his expectation that nursing staff would follow physician orders. The Medical Director further stated when a resident had an order for oxygen, and it was not administered as ordered, this could cause problems, including shortness of breath. He again stated failure to follow oxygen orders could negatively impact the resident's respiratory status.

Based on observation, interview, record review, review of the facility's procedure manual, Lippincott Nursing Procedures, and the staff's Skill Competency sheets, the facility failed to ensure residents had their urinary collection bags secured properly below the bladder for 1 of 2 residents assessed for urinary catheters, Resident (R) 33. The findings include:Review of the facility's procedure manual revealed the facility used Lippincott Nursing Procedures, ninth edition, copyright 2023 Wolters Kluwer, which stated, Keep the drainage bag below the level of the patient's bladder to prevent backflow of urine into the bladder, which increases the risk of catheter urinary tract infection.Review of the staff's Skill Competency sheet given to CNAs and nurses in orientation revealed there was no mention of the importance of keeping the urinary catheter collection bag below the resident's bladder.Review of the admission Face Sheet, found in R33's electronic medical record (EMR, revealed the facility admitted the resident on 02/11/2026 with diagnoses to include end stage renal disease, diabetes, and Alzheimer's dementia.Review of R33's admission Minimum Data Set [MDS], found in R33's EMR, with an Assessment Reference Date (ARD) of 02/25/2026, revealed the facility assessed the resident to have a Brief Interview for Mental Status [BIMS] score of nine of 15, which indicated R33 had moderate cognitive impairment.Review of R33's Care Plan found in the resident's EMR and dated 02/12/2026, revealed there was no intervention to educate the resident on the risks of urinary tract infection when the urinary collection bag was on the side of the wheelchair.Observation on 03/30/2026 at 1:56 PM, 04/01/2026 at 8:22 AM, 04/02/2026 at 12:16 PM and 3:07 PM revealed R33's urinary catheter bag on the side of the chair above the resident's bladder. During an interview on 03/31/2026 at 3:13 PM with Certified Nurse Aide (CNA) 2, she stated R33 liked the urinary catheter bag on the side of the wheelchair.During an interview with CNA9 on 04/02/2026 at 12:04 PM, she stated she placed the urinary collection bag below the bladder so it could drain instead of urine backing up into the bladder.During an interview with Licensed Practical Nurse (LPN) 1, she stated the importance of keeping the urinary catheter bag below the bladder was to prevent urinary tract infections. She further stated R33 liked the urinary bag on the side of the wheelchair. She also stated R33 was care planned to have the urinary collection bag on the side of the chair. She stated she did not know if he had been educated on the risks of a urinary tract infection when the urinary collection bag was on the side of the chair and below his bladder. During an interview with Registered Nurse (RN) 1 on 04/02/2026 at 11:49 AM, she stated the urinary catheter collection bag should be positioned to the resident's preference. She further stated for a resident who was in a wheelchair, the urinary collection bag should be lower than the bladder. She also stated if it was not positioned below the bladder, it would not flow correctly and could cause a urinary tract infection.During an interview with the Director of Nursing (DON) on 04/02/2026 at 4:21 PM, she stated if a catheter collection bag was above the bladder, urine could flow back into the bladder. She stated staff should be taught that the urinary collection bag should be below the bladder.During an interview with the Administrator on 04/02/2026 at 5:23 PM, she stated she would expect staff development to do education on urinary catheters. She further stated she was not sure if this was in the current education.

Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs for 2 of 13 sampled residents, Residents (R) 16 and R35.1. During an interview with R16 on 03/31/2026 at 9:45 AM, she stated she had chronic back pain. However, review of R16's care plan revealed no non-pharmacological interventions were developed or implemented to address the resident's chronic pain.2. During an interview with R35 on 03/31/2026 at 10:15 AM, she stated she had chronic bilateral lower extremity and left knee pain. However, review of R35's care plan revealed no non-pharmacological intervention was developed or implemented to address the resident's chronic pain.The findings include:A request on 04/02/2026 at 3:50 PM for the facility's policy titled Care Plan Policy was made by the State Survey Agency (SSA) Surveyor; however, the facility failed to provide the policy for review.1. Review of the admission Face Sheet, found in R16's electronic medical record (EMR), revealed the facility admitted the resident on 07/09/2025, with diagnoses which included low back pain, osteoarthritis, and chronic obstructive pulmonary disease (COPD).Review of R16's quarterly Minimum Data Set [MDS], with an Assessment Reference Date (ARD) of 01/14/2026, revealed the facility assessed the resident to have a Brief Interview for Mental Status [BIMS] score of 12 out of 15, which indicated the resident had moderate cognitive impairment. Further review revealed the resident had impairment in her bilateral upper and lower extremities. The MDS stated she required substantial/maximal assistance (helper does half of the effort) to roll left to right, sitting to lying down, and lying to sitting on the side of the bed.Review of R16's Comprehensive Care Plan [CCP], dated 03/09/2026, revealed a focus for pain, with a goal for the resident to verbalize adequate relief of pain or ability to cope with incompletely relieved pain through the next review date. An intervention initiated on 10/31/2025 indicated staff was to administer pain medications as ordered. Additionally, an intervention dated 10/31/2025 indicated staff was to notify the physician if interventions were unsuccessful or with a significant change from baseline. There were no non-pharmacological interventions developed to address R16's chronic pain.Review of the Physician's Order Form, dated 03/2026, found in R16's EMR, revealed orders for acetaminophen (analgesic) 500 milligrams (mg), two tablets by mouth four times daily as needed for pain; Aspercreme (analgesic) external lotion 10 percent, apply to both shoulders every 12 hours as needed (PRN) for pain; gabapentin (analgesic) 300 mg one capsule by mouth twice daily for insomnia; and hydrocodone-acetaminophen (narcotic analgesic) 7.5-325 mg, one tablet by mouth three times daily for unspecified displaced fracture, second cervical vertebra, subsequent encounter for fracture with routine healing.During an interview with R16 on 03/31/2026 at 9:45 AM, she stated she had chronic back pain from a motor vehicle accident, a history of fractures, and osteoarthritis. She stated she experienced constant pain and at times rated her pain between eight and 10 on a zero to 10 pain scale, with 10 being the worst pain. She stated she received both scheduled and PRN pain medications. She further stated she also received physical therapy to help with mobility and pain. She stated she was aware her pain would never go away, but it was managed with treatment. R16 stated nursing staff did not offer non-pharmacological interventions to assist with her pain management. She stated she believed her pain would be better managed if she were offered non-pharmacologic interventions. R16 stated repositioning, application of heat or cold, and use of supportive devices would help provide additional comfort.2. Review of the admission Face Sheet, found in R35's EMR, revealed the facility admitted the resident on 01/25/2024, with diagnoses which included primary osteoarthritis of left ankle and foot, chronic pain, and chronic obstructive pulmonary disease.Review of R35's annual MDS, with an ARD of 01/22/2026, revealed the facility assessed the resident to have a BIMS score of 15 out of 15, which indicated the resident was cognitively intact. Further review revealed she was dependent (helper does all the effort) for assistance to roll left to right, sitting to lying down, and lying to sitting on the side of the bed.Review of R35's CCP, dated 01/27/2026, revealed a focus for pain, with a goal for the resident to verbalize adequate relief of pain through the next review date. An intervention initiated on 01/16/2026 indicated staff was to monitor pain every 12 hours. Additionally, an intervention initiated on 03/16/2026 directed staff to administer pain medications as ordered. There were no non-pharmacological interventions developed to address R35's chronic pain.Review of the Physician's Order Form, dated 03/2026, found in R35s EMR, revealed orders for acetaminophen 500 mg by mouth every six hours PRN for pain; pregabalin (analgesic) 150 mg by mouth twice daily for chronic pain; and acetaminophen (analgesic) 500 milligrams (mg) by mouth three times daily for pain.During an interview with R35 on 03/31/2026 at 10:15 AM, she stated she had chronic pain in her bilateral lower extremities and left knee. She stated she took scheduled pain medications. R35 stated nursing staff did not offer non-pharmacological interventions to assist with pain management. She stated she believed adding non-pharmacological interventions, especially frequent repositioning and the application of heat or cold, would make her more comfortable and decrease her pain.During an interview with the MDS Nurse on 03/31/2026 at 3:11 PM, she stated she did not necessarily put in non-pharmacological interventions for residents with chronic pain. She stated appropriate interventions to provide comfort would include repositioning, use of supportive devices, and application of heat or cold. The MDS Nurse stated nursing staff should monitor the effectiveness of interventions and adjust care based on the resident's response. She stated adding non-pharmacological interventions to the plan of care was important for improving the resident's comfort and reducing pain.During an interview with Licensed Practical Nurse (LPN) 3 on 04/01/2026 at 8:55 AM, she stated the care plan served as a guide for staff to deliver consistent and appropriate care. LPN3 stated interventions such as repositioning and other comfort measures could help reduce pain and should be implemented in addition to pain medications as appropriate. She further stated non-pharmacological interventions were important for supporting pain management, enhancing comfort, and improving residents' overall well-being.During an interview with the Director of Nursing (DON) on 04/02/2026 at 4:29 PM, she stated it was her expectation that residents with chronic pain would have a care plan that included appropriate interventions. She stated pain medications should be administered as ordered, both scheduled and as needed. She stated if pain was not relieved by pharmacological interventions, nursing staff was expected to notify the physician and implement non-pharmacological interventions, including repositioning, use of supportive devices, application of heat or cold as appropriate, range-of-motion exercises, distraction techniques, and provision of sensory and comfort measures. Additionally, she stated staff should provide emotional support and reassurance to address anxiety or fear related to pain, assess pain routinely using a standardized scale, monitor the effectiveness of interventions, and revise the care plan as needed. The DON further stated non-pharmacological interventions were effective and should be included in the care plan to guide ongoing care. The DON stated it was important that care plans were individualized to reflect each resident's needs, including pain management to enhance their quality of life and overall well-being.During an interview with the Administrator on 04/02/2026 at 5:02 PM, she stated it was her expectation that all clinical staff followed the physician's orders as written to prevent complications and ensure the residents' safety and well-being.During a telephone interview with the Medical Director on 04/02/2026 at 4:10 PM, he stated it was his expectation that the nursing staff would follow the physician's orders. He stated including non-pharmacological interventions in the plan of care promoted safety, enhanced well-being, and helped relieve pain. The Medical Director further stated it was his expectation staff would follow the physician's orders and the resident's plan of care. The Medical Director stated adherence to it was essential to providing appropriate care in a rehabilitation setting.

Based on interview, record review, and review of the facility's policy, the facility failed to notify the resident of the transfer in writing and maintain a copy of the notice in the resident's medical record. The facility failed to ensure the transfer or discharge was documented in the resident's medical record. The facility failed to send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman for 1 of 1 sampled residents, Resident (R) 16.Record review and interviews revealed R16 was not notified in writing of her 07/19/2025 transfer to the hospital, to include the reason for the transfer, the duration of the bed hold, and the facility's policies regarding bed holds. There was no written transfer or bed hold documented in the resident's medical record. Furthermore, the facility did not notify the State Long-Term Care Ombudsman, either verbally or in writing, of R16's transfer to the hospital. The findings include:Review of the facility's policy titled, Admission, Transfer, and Discharge Standards of Practice, reviewed 03/2026, revealed prior to transfer or discharge of a resident, the facility was to notify the resident and/or the resident's representative of the reason for the transfer or discharge. The policy further revealed a copy of the discharge notice was to be sent to the State Ombudsman's office, and the medical record was to reflect the reason for the transfer or discharge. Additionally, the policy revealed at the time of a resident's transfer for hospitalization, written notice of the facility's bed hold policy was to be provided.Review of R16's electronic medical record (EMR) revealed no written transfer notice or a copy of the transfer notice/bed hold documented in her medical record.Review of the admission Face Sheet, found in R16's EMR, revealed the facility admitted the resident on 07/09/2025, with diagnoses which included chronic obstructive pulmonary disease (COPD), congestive heart failure, and iron deficiency anemia.Review of R16's quarterly Minimum Data Set [MDS], with an Assessment Reference Date (ARD) of 01/14/2026, revealed the facility assessed the resident to have a Brief Interview for Mental Status [BIMS] score of 12 out of 15, which indicated the resident had moderate cognitive impairment.During an interview with R16 on 03/31/2026 at 8:30 AM, she stated at the time of her transfer to the hospital she was not informed of the facility's transfer or discharge policy or bed hold policy. She stated she did not sign any paperwork related to the transfer notice and had no knowledge of a bed hold policy.During an interview with the Social Services Director (SSD) on 04/02/2026 at 1:27 PM, she stated when a resident was transferred to the hospital, the facility sent a face sheet, vital signs, medication list, and pertinent nursing notes with the resident. She stated if a transfer and bed hold form was completed, copies of those documents should be maintained in the electronic medical record. She further stated the resident and resident's representative or power of attorney (POA) were provided verbal notification of the transfer. She stated R16 was her own POA. Furthermore, she stated she was not aware of whether a written notice of transfer or discharge was provided to R16, whether documentation was mailed, or whether documentation was retained to provide evidence compliance with written notification requirements.During an interview with the Admissions Coordinator on 04/02/2026 at 1:38 PM, she stated when a resident was transferred to the hospital, the process was for Admissions to document the transfer and send a notification to the Business Office Manager (BOM) via email. She stated the e-mail served as a record of the transfer and was maintained in the electronic medical record. Furthermore, she stated the transfer and bed hold notice was only provided to the resident or resident's representative if a copy was requested. The Admissions Coordinator was unable to provide documentation regarding R16's transfer to the hospital on [DATE]. She further stated she was unaware if the facility had notified the State Long-Term Care Ombudsman's office of a resident's transfer to the hospital.During an interview with the BOM on 04/02/2026 at 1:39 PM, she stated a transfer and bed hold notice was provided only to the resident or resident's representative if a copy was requested. She stated a copy of an e-mail document from the Admissions Coordinator was maintained in the electronic medical record; however, she was unable to provide documentation related to R16's transfer to the hospital on [DATE]. The BOM further stated the facility did not notify the State Long-Term Care Ombudsman's office of a resident's transfer to the hospital.During an interview with the Director of Nursing (DON) on 04/02/2026 at 4:29 PM, she stated she was not aware of a process requiring completion of a transfer or discharge form, obtaining signatures from the resident or the resident's representative, or mailing a hard copy of the notice of transfer to the resident or resident's representative and the State Long-Term Care Ombudsman's office. The DON stated when a resident was transferred from the facility to the hospital, the physician was notified, and the facility notified the resident's family or the resident's representative.During an interview with the Administrator on 04/02/2026 at 5:02 PM, she stated she had been employed at the facility for approximately two weeks and was not yet familiar with the facilities transfer, discharge and bed hold process. She stated it was her expectation that the facility followed all applicable guidelines to ensure that residents and their representatives were notified in accordance with regulatory requirements, including the transfer or discharge process and bed hold provisions.

Based on observation, interview, record review, and review of facility's policies, the facility failed to ensure accommodation of needs and preferences for 2 of 3 sampled residents related to room accommodation and activity preferences, Resident (R) 7 and R8.The findings include: Review of the facility's policy titled, Quality of Life, dated 10/2020, revealed the facility shall provide, and each resident will receive, the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, consistent with the resident's comprehensive assessment and plan of care. Review of the facility's policy titled, Activities of Daily Living, dated 10/2020, revealed the facility will provide care and services to residents that are person-centered, and honor and support each resident's preferences, choices, values, and beliefs. Review of the facility's policy titled, Housekeeping Services, dated 10/2020, revealed housekeeping and maintenance services shall maintain a sanitary, orderly, and comfortable interior. 1. Observation on 03/31/2026 at 1:35 PM revealed R8 was sitting in her wheelchair midway down the 100 hall, crying, with no staff present in the hallway. The State Survey Agency (SSA) Surveyor requested for Certified Nursing Assistant (CNA) 2 to assist R8 to try and understand why R8 was upset. In an immediate interview, CNA2 stated R8 was probably upset because her television was not working, and the television was one of the only types of entertainment the resident enjoyed. Further observations on 04/01/2026 at 1:35 PM, 04/01/2026 at 3:19 PM, and 04/02/2026 at 10:09 AM, revealed R8 in her wheelchair in the hallway, by the nurses' station, or in her room by herself. No staff was observed interacting with R8. Review of R8's Face Sheet revealed the facility admitted the resident on 09/05/2025 with diagnoses to include active primary progressive multiple sclerosis, abnormal posture, and dysphasia, oropharyngeal phase. Review R8's quarterly Minimum Data Set [MDS], with an Assessment Reference Date (ARD) of 12/05/2025, revealed the facility assessed the resident to have a Brief Interview for Mental Status [BIMS] score of 14 out of 15, indicating R8 was cognitively intact. Review of R8's Care Plan revealed the resident required staff assist and encouragement to go to activities and she liked to watch television in her room. During an interview with the Maintenance Assistant on 04/01/2026 at 1:48 PM, he stated he had been switching R8's television back and forth trying to get the cable to come back on. He stated there had been an issue at the facility over the past few months with the cable going off and the internet lagging or shutting down. He further stated the cable provider had been to the facility and could not find any issues with the cable feed from the provider. The Maintenance Assistant stated R8's cable had been going out frequently and he had tried to re-boot the cable box and that would help occasionally. Other times, he had to wait for the cable to reset and come back on. He stated R8 would become upset when it stopped working, as she had to wait until the cable came back on. During an interview with CNA2 on 04/02/2026 at 2:55 PM, she stated the internet froze quite often. She stated it could be down from 60 seconds to two to three minutes. CNA2 stated residents complain about the cable going off, and the outage may not affect an entire section of the building, but only a few rooms. During an interview with the Activities Director on 04/01/2026 at 3:34 PM, she stated R8 liked to sit in the sun on days when it was nice out. She stated R8 liked to watch television, especially sports shows and some of the crime shows on cable. She stated R8 did become upset when the cable was not working. During an interview with the Director of Nursing (DON) on 04/02/2026 at 3:53 PM, she stated it was her expectation for staff to meet the activity needs for each resident. She stated she was familiar with R8, and she would expect staff to talk with R8 and understand what made her upset and try to correct the situation. During an interview with the Administrator on 04/02/2026 at 5:21 PM, she stated it was her expectation for staff to provide activities specifically designed to meet residents' needs. She stated the cable company had contacted her about updating the system and modem. 2. Observation on 04/01/2026 at 3:05 PM revealed the bed across from R7 had several boxes stored underneath, and on top of an empty bed, from a previous resident. The previous resident had left the faciity on [DATE] and items had been left in the room since then. R7 felt bad that previous residents' items had been left behind. During an interview with Licensed Practical Nurse (LPN) 3 on 04/01/2026 at 2:55 PM, she stated the items in R7's room had been left there for a few weeks and that social services were responsible for taking care of the previous resident's belongings. She further stated she believed the items were still in the room due to a guardianship issue. During an interview with the Social Services Director on 04/01/2026 at 3:12 PM, she stated the family of the previous resident in R7's room had told the facility they could donate the items left behind. She further stated she would contact them again to see what to do with the items. During an interview with the DON on 04/02/2026 at 3:54 PM, she stated the discharged resident's belongings should be followed up with by social services. She further stated she would give families one to two weeks to take discharged belongings. During an interview with the Administrator on 04/02/2026 at 5:22 PM, she stated she felt the discharged resident's belongings should have been placed in the social services office right away. She further stated she felt the current residents could be affected negatively by the items staying in the room.

Based on observation, interviews, and review of the facility's policies, the facility failed to ensure the area around the two outside dumpsters was free of trash, and the elimination of debris prevented the potential for vermin and pest attraction. This had the potential to affect all 50 residents who resided in the facility.The findings include:Review of the facility policy titled, Housekeeping Services (General), reviewed March 2026, and provided by the facility, revealed, Housekeeping and maintenance services shall maintain a sanitary, orderly, and comfortable. The facility reported that they do not have a specific policy for Food-Related Garbage and/or Refuse Disposal. Review of the facility policy titled, Pest Control, reviewed March 2026, and provided by the facility, revealed, The facility shall maintain a safe and sanitary environment to mitigate potential pest concerns. Observation made on 03/31/2026 at 8:00 AM, of the outdoor dumpster area in a corner of the facility parking lot, revealed cigarette butts, straws, soda cans, medical gloves, papers, plastics and plastic utensils on the ground near the dumpster area. Observation made on 03/31/2026 at 9:32 AM, of the outdoor dumpster area in a corner of the facility parking lot, revealed cigarette butts, straws, soda cans, medical gloves, papers, plastics and plastic utensils on the ground near the dumpster area. During an interview with Maintenance/Housekeeping Director on 03/31/2026 at 4:27 PM, he stated that Housekeeping was responsible for taking out the trash and was also responsible for keeping the dumpster area clean. He confirmed the trash around the dumpster area was unacceptable. During an interview with the Kitchen Supervisor (KS) on 03/31/2024 at 10:11 AM, she stated that garbage should be contained when being transported from the kitchen to the dumpster area and that the dietary aides are assigned that task. She further stated that Housekeeping empties trash in the rest of the building and they are responsible for maintaining the dumpster area in a sanitary condition. KS stated that if the area is not maintained rodents could be attractive for rodents. During an interview with the Director of Nursing (DON) on 04/02/2026 at 2:05 PM, she stated that she did not go to the area where the dumpsters were located but said that animals could come if there were trash or debris on the ground.During an interview with the Administrator on 03/31/2026 at 3:21 PM, she stated housekeeping staff were responsible for maintaining the trash/dumpster area and her expectation was for the dumpster's lids to be closed with no trash on the ground. She stated that an unsanitary area could attract things such as pests.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure all drugs used in the facility were labeled in accordance with professional standards. Observation revealed undated, opened, and expired medications in 3 of 4 medication carts and 1 of 1 treatment carts. Those medications included inhalers, an insulin vial, insulin pens, laxatives, antifungal powder, and topical creams. The findings include: Review of the facility's policy titled, Medication Storage, dated 08/22/2024, stated, Drug containers that have missing, incomplete, improper, or incorrect labels are returned to the pharmacy for proper labeling before storing. Discontinued, outdated, or deteriorated drugs are returned to the dispensing pharmacy or destroyed. Review of the facility's dispensing pharmacy's form Medication Expiration Dating stated, The following medications must be dated once they are opened. The form listed insulin vials and insulin pens. 1. a. During observation on 01/22/2025 at 8:44 AM of the 200-Hall split medication cart revealed one Trelegy Ellipta inhaler (triple combination medication used to treat adult chronic obstructive pulmonary disease (COPD) and asthma) with an expiration date of 01/08/2025, which LPN1 instructed the staff member at the nurses' station to immediately order another for the resident. Additional observation revealed one opened and undated bottle of Acid Gone (an over the counter antacid) with no opened date. Continued observation revealed albuterol single packets in an opened foil package with no opened date. Furthermore, there were medications observed such as tiotropium bromide (a bronchodilator used to treat COPD and asthma) not in an original pharmacy package with no name; albuterol two vials not stored in a protective bag and no opened date; and one bottle of Robafen DM Cough Syrup not in the original packaging, with no label or opened date. b. Observation on 01/22/2025 at 10:00 AM of the medication cart for Rooms 206-212 revealed an opened multi-use vial of insulin lispro (used to treat diabetes mellitus) with an expired date of 01/16/2025 written on the vial; a bottle of lactulose (used to treat constipation) 10 grams with an expired date of 01/02/2025 written on the label; an albuterol inhaler (a bronchodilator) opened and undated; a fluticasone inhaler (a corticosteroid used to treat asthma) opened and undated; and five insulin pens opened and unbagged in the same compartment together. Further observation revealed unwasted narcotics found in the narcotic box for a resident who had expired on 01/19/2025. c. Observation on 01/22/2025 at 10:25 AM of the medication cart for Rooms 200 through 205 revealed three opened insulin pens in the same compartment and unbagged. During an interview on 01/22/2025 at 10:00 AM with Licensed Practical Nurse (LPN) 3, she stated she was unaware the insulin was expired, and it should have been discarded by the expiration date. She stated expiration dates should be checked prior to administering any medication. 2. Observation on 01/22/2025 at 10:18 AM of the treatment cart revealed the Pharmacy Technician was going through the cart with a lot of medications on top of it. When asked what she was doing, she stated she went through the cart once a month and paired the medications out of bags with the correct empty bag, placing the medication back in the bag. Observation 01/22/2025 at 10:20 AM of the treatment cart revealed nystatin powder with no label, and unbagged and opened tubes of antifungal cream, clotrimazole cream, miconazole cream, and ketoconazole cream (all anti-fungal medications). Further observation revealed a tube of MediHoney (used to treat wounds and burns) was also unbagged and opened. During an interview on 01/24/2025 at 10:43 AM with LPN 4, she stated medication should be dated upon opening, and the date checked before every administration. She stated medication without opened or expired dates should be removed from the medication cart and discarded. She stated this was important to decrease the risk of medication errors. During an interview on 01/24/2025 at 9:36 AM with Staff Development, she stated the process when opening and administering medications included to date the medication with the date it was opened so staff would know when to discard it. She stated weekly audits were performed on the medication carts on Mondays. She stated any expired or undated medication should be removed from the carts and replaced. She stated narcotics were removed and wasted by the Director Of Nursing (DON). She stated any home medications brought in for resident use should be discussed with the facility pharmacy. She stated keeping the medication carts free from expired medication was important to prevent harm to residents. During an interview on 01/24/2025 at 10:20 AM with the Director of Nursing (DON), she stated it was her expectation that medications be dated upon opening. She stated carts were checked weekly for insulin expiration dates. She stated no medication should be in the cart and in use if unlabeled because staff would not know which resident it belonged to. The DON stated narcotics were kept in the cart and included in the count until she wasted the narcotic. She stated wasting narcotics was usually done as soon as possible. When asked about the narcotics for the expired resident, she stated she was told about the medications, and she forgot about them. The DON stated it was important to keep the medications dated and unnecessary medication removed from the cart to decrease the risk of medication errors. During an interview on 01/24/2025 at 4:30 PM with the Administrator, she stated it was her expectation that medications be put back in the proper packaging/bags when they were placed back into the medication cart, and they needed to be dated. She stated her expectation was that the dates should be checked every time the medication was used. She stated if a medication had no label or an expired date, then it should be removed from the cart. She stated any narcotic that needed to be wasted should be reported to the DON. She stated it was important so residents did not receive wrong or expired medications. 51417

Based on observation, interview, record review, review of the facility's job descriptions, and review of the facility's plan of correction (PoC), dated 03/12/2024, the facility failed to have an effective Quality Assurance Performance Improvement (QAPI) process. The facility failed to develop, implement, and maintain an effective, comprehensive, data-driven QAPI program that focused on indicators of the outcomes of care and quality of life that were achieved and sustained. Observation on 01/22/2025 at 10:00 AM revealed insulin lispro was opened, in use, and dated with an expiration date of 01/16/2025. Review of the previous survey, dated 01/07/2024 to 01/11/2024, revealed a repeat issue was found with the expired insulin being used. This affected all 49 current residents residing in the facility. Refer to F761 The findings include: Review of the facility's Director of Nursing job description, dated 06/17/2023, revealed the tasks included but were not limited to: maintaining compliance with state and federal regulations; being an active member of the QAPI Committee; coordinating and/or developing on-going QAPI activities or nursing services to monitor nursing compliance with standards and regulatory requirements through rounds, interviews, and record reviews; compiling summary of findings of the QAPI Committee; and participating in the preparation of the PoC response to an inspection survey and implementing any follow-up QAPI required for any nursing allegations. Review of the facility's Nursing Home Administrator job description, undated, revealed the Administrator was to oversee QAPI and other facility committees and ensure the facility operates in compliance with all local, state, and federal regulations. Review of the facility's acceptable PoC, for the Standard Recertification/Abbreviated/Extended Survey, concluded on 01/11/2024, revealed the facility was to implement the PoC to ensure the facility achieved substantial compliance by 03/06/2024. However, the facility had a repeat deficiency following the latest survey, concluded on 01/24/2025. Further review of the facility's PoC, for the survey with an exit date of 01/11/2024, revealed the Director of Nursing (DON) or Licensed Practical Nurse (LPN) 6 would monitor compliance regarding labeling and storage of medications. Furthermore, the PoC stated the weekly, monthly, and random audits would be performed by either the DON or LPN6. The weekly audits were performed by LPN6 monthly, and random audits were performed by the pharmacy technician. Review of the facility's Audits revealed the facility would perform weekly audits for four weeks, monthly audits for two months, then random through the QAPI process to ensure medications were dated as indicated, and no expired medications were in the medications carts. The review of Audits performed by LPN6 revealed audits were completed on 02/20/2024, 02/26/2024, 03/07/2024, and 03/15/2024. Review of the Quality Improvement: Quality Assurance RX LTC Tech Summary Report, of audits performed by the pharmacy technician for expired and undated insulin revealed on 03/18/2024 there was expired glucose solution and undated glargine; on 04/10/2024 there was expired humulin R, glargine, and lispro, also undated; on 05/15/2024 there was expired aspart; on 06/12/2024 there was expired glargine and undated novolin R; on 08/14/2024 there was expired glargine and novolin 70/30; on 09/18/2024 there was expired glargine and undated lantus; and on 10/14/2024 there was expired novolog. Observation on 01/22/2025 at 10:00 AM revealed insulin lispro was opened, in use, and dated with an expiration date of 01/16/2025. (Refer to F761) The State Survey Agency (SSA) Surveyor was unable to interview the DON regarding QAPI because she was unavailable, unreachable, and out of the facility on 01/24/2025. During an interview on 01/24/2025 at 4:30 PM with the Administrator, she stated it was the responsibility of the DON to monitor QAPI audits. She stated this was important to ensure compliance.

Based on observation, interview, record review, review of the Centers for Disease Control and Prevention (CDC) guidelines, review of the manufacturer's instructions for use, and review of the facility's policies, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 26 sampled and supplemental residents, Residents (R) 44 and R21. Additionally, the failed to assess and monitor the building's water system for Legionella and other opportunistic waterborne pathogens affecting the total census of 49. 1. Observation on 01/22/2025 at 11:40 AM with Licensed Practical Nurse (LPN) 3 revealed she did not don (put on) personal protective equipment (PPE) in an enhanced-barrier precaution (EBP) room before she provided direct care. Further observation revealed LPN3 failed to prevent contamination of surfaces and clean the glucometer according to the Environmental Protection Agency (EPA) registered disinfectant manufacturer's instructions. 2. Observation on 01/23/2025 at 12:20 PM with Registered Nurse (RN) 1 after administering medication to R21 revealed RN1 cleaned the stethoscope while still wearing dirty gloves. 3. Review of the facility's documentation related to water management and Legionella prevention and detection revealed there was no documentation that control measures to include visible inspections, disinfection, and temperature controls were monitored, documented, and audited. Furthermore, the facility failed to provide documentation of a process flow diagram for the facility's water flow to include identified areas where Legionella could grow and spread. The findings include: Review of the CDC's guideline, provided by the facility, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated 09/10/2021, revealed reusable medical equipment should be cleaned and disinfected according to manufacturer's instructions or the facility's policies before and after use. The guidelines stated facilities should maintain separation between clean and soiled equipment to prevent cross-contamination. Further review of the guidelines revealed staff should be trained in the correct steps for cleaning and disinfection of shared equipment. Review of the facility's policy titled, Infection Control Policy and Procedure/Surveillance Plan, reviewed 09/14/2024, revealed the facility maintained an infection prevention and control program designed to provide a safe sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections per accepted national standards and guidelines. Continued review revealed annual skill checkoffs would be performed by the Infection Preventionist (IP) and would cover the use of PPE, isolation precautions, and the safe handling of contaminated equipment. Review of the facility's policy titled, Enhanced Barrier Precautions, revised 11/17/2024, revealed it was the facility's policy to implement enhanced barrier precautions (EBP) for the prevention of transmission of multidrug resistant organisms [MDRO]. Furthermore, the policy stated that EBP reduced transmission of MDROs through gown and glove use during high resident care activities. Review of the facility's policy titled, Shared Equipment, reviewed 08/22/2024, revealed it was the facility's policy to attempt to decrease the risk of spreading infection and disease through infection control standards for cleaning medical equipment before and after each individual resident use and follow the direction for dwell times (the amount of time a disinfectant must remain visibly wet to kill a pathogen). Review of the facility's policy titled, Glucometer Cleaning Policy and Procedure, reviewed 03/30/2024, revealed it was the facility's policy to ensure each resident was provided with a clean and non-infectious glucometer. Further review revealed nursing staff would clean the glucometer with SaniCloth wipes and allow the glucometer to sit and dry for three minutes before and after each use. Review of the cleaning and disinfecting instructions for the Assure Prism Multi-Blood Glucose Monitoring System, no date, revealed to minimize the risk of transmitting bloodborne pathogens, the exterior of the glucometer should be cleaned of all dirt, blood, and bodily fluids before performing the disinfection procedure, which would prevent the transmission of bloodborne pathogens. Per the instructions, the exterior of the glucometer should remain wet for the appropriate dwell time according to the disinfectant's instructions. Review of the cleaning and disinfecting instructions for SaniCloth wipes revealed if visibly soiled use one or more wipes as necessary to wet surfaces sufficiently and to thoroughly clean the surface. According to the instructions, all surfaces must remain visibly wet for a two-minute dwell time to assure complete disinfection of all pathogens. 1. Review of R44's Face Sheet, located in the resident's electronic health record (EHR), revealed the facility admitted the resident on 05/03/2024 with diagnoses to include chronic obstructive pulmonary disease (COPD), type 2 diabetes mellitus, and unstageable wound with dressing to right foot. Review of R44's quarterly Minimum Data Set [MDS], with an Assessment Reference Date (ARD) of 12/03/2024, revealed the facility assessed the resident to have a Brief Interview for Mental Status [BIMS] score of 11 out of 15, which indicated R44 had moderate cognitive impairment. Review of R44's Physician Orders, dated 01/24/2025, located in the resident's EHR, revealed there was an order for EBP for a wound with a dressing. Observation of LPN3 on 01/22/2025 at 11:40 AM revealed she gathered a glucometer, lancet, testing strips, and alcohol wipes, and placed them into a plastic tray before taking them into R44's room. She set the tray on a barrier cloth on the bedside table and performed a finger stick test. LPN3 did not put on a gown before performing the finger stick on R44. After completing the procedure, LPN3 discarded the barrier sheet from under the tray and placed the tray on an unclean surface. She returned the tray to the medication cart without placing a barrier sheet underneath the contaminated tray. LPN3 then cleaned the contaminated glucometer using one disinfectant wipe and wiping it for 24 seconds. She then placed the device inside the contaminated tray. Furthermore, LPN3 did not adhere to the required dwell time of two-minutes as specified in the wipe's instructions. During an interview on 01/22/2025 at 11:50 AM, LPN3 stated each medication cart had at least one glucometer that was shared among residents. When asked what the dwell time for the wipes was, LPN3 stated, Two minutes. However, she could not articulate the definition of dwell time. She stated any equipment taken into a resident's room must be cleaned and disinfected before being used on another resident to prevent the spread of infection or bloodborne pathogens. LPN3 stated further that she did not wear a gown because she believed that performing a fingerstick did not meet the EBP requirements for high-risk direct care. Additionally, LPN3 stated she had received infection prevention and control practice (IPCP) education upon hire and had also received education through in-service trainings provided by the Infection Preventionist/Wound Care Nurse (IP/WCN). She stated the importance of following infection control protocols and EBP requirements was to prevent the spread of infection among staff and residents. After the interview, LPN3 retrieved the glucometer and plastic tray from the medication cart and cleaned them according to facility protocols before using them on a different resident. During interview with the IP/WCN on 01/23/2025 at 12:00 PM, she stated the facility followed CDC guidelines and recommendations related to IPCP. She stated she provided education to all staff related to IPCP, and all staff was trained on the use of PPE and isolation precautions to include EBP. She stated gowns and gloves must be worn whenever staff entered an EBP room if high-contact care was provided. She stated high contact care included the use of devices. Per the interview, the IP/WCN stated she had not observed any concerns related to staff's failure to follow IPCP or EBP protocols. She stated it was her expectation that all staff followed IPCP. The IP/WCN stated it was important for the safety of residents and staff and to prevent the spread of infection. She also stated nursing staff was trained to clean and disinfect the glucometer after each use using SaniCloth cleaning and disinfectant wipes with a two-minute dwell time. She stated contaminated glucometers should be placed on a barrier cloth to prevent the spread of infection and cleaned, then disinfected for the appropriate time and stored separately to keep clean. 2. Review of R21's Face Sheet, located in the resident's EHR, revealed the facility admitted the resident on 10/16/2020 with diagnoses including esophageal obstruction, acute pancreatitis, congenital stenosis, and stricture of the esophagus. Review of R21's quarterly MDS, with an ARD of 11/25/2024, revealed the facility assessed the resident to have a BIMS score 15 out of 15, indicating the resident had intact cognition. Observation on 01/23/2025 at 12:20 PM with RN1 after administering medication to R21 revealed RN1 cleaned the stethoscope with an alcohol wipe while still wearing the gloves that she wore when she provided physical contact and medication administration to R21. After cleaning the stethoscope, the dirty gloves were doffed (removed) and discarded, and RN1 washed her hands. During an interview on 01/24/2025 at 10:17 AM with the Director of Nursing (DON), she stated she expected staff to remove dirty gloves, use proper hand hygiene, and re-glove to clean a piece of equipment. During additional interview with the DON on 01/24/2025 at 10:30 AM, she stated all staff received IPCP training upon hire and periodically throughout the year. In addition, the DON stated staff was updated on current CDC guidelines when they changed. She stated the Unit Managers audited staff for compliance. However, she stated there was no documentation of staff IPCP audits. Per interview, it was the DON's expectation that all staff maintained IPCP guidelines at all times to decrease the potential spread of infection. During an interview on 01/24/2025 at 4:25 PM with the Administrator, she stated common sense told one to clean equipment with clean gloves. She stated she expected her staff to use clean gloves after patient care when encountering equipment. 3. Review of the facility's policy titled, Legionella Prevention Policy and Procedure, dated 10/13/2024, revealed the facility would attempt to decrease the risk of exposure to Legionella bacteria to residents, staff, and visitors. Policy review revealed weekly water temperature checks, empty room faucet and eyewash station flushes, and cleaning of the ice machines would be performed and logged. Review of the CDC's Guideline Developing a Legionella Water Management Program, revealed a key component of the water management program (WMP) was a flow diagram used to describe the facility's water systems and identify areas at risk for Legionella growth and spread. Review of the facility's documentation related to their water management revealed there was no documentation that control measures to include visible inspections, disinfection, and temperature controls were monitored, documented, and audited. Furthermore, the facility failed to provide documentation of a process flow diagram for the facility's water flow to include identified areas where Legionella could grow and spread. Review of the facility's WMP revealed the facility did not include a flow diagram to describe the facility's water system or identify where in the facility there were areas at risk for Legionella or other waterborne pathogens to grow and spread. During an interview with the Maintenance Director on 01/22/2025 at 9:11 AM, he stated he did not know about the facility's WMP. He stated he checked water temperatures throughout the building and documented them on a sheet of paper. During an interview with the Administrator on 01/22/2025 at 9:40 AM, she stated she was responsible for water management in the facility. She stated she performed in-house monitoring of the water supply quarterly using a testing kit. The Administrator stated the facility did not have a flow diagram to describe the water system and identify areas where Legionella could grow. She stated she was familiar with the CDC's tool kit to help facilities development of a WMP. She stated further that she had not completed a Legionella Environmental Assessment Form (LEAF) to help identify areas at risk for Legionella growth and spread. She stated the Maintenance Director performed water monitoring and flushing. During an interview with the Infection Preventionist (IP) on 01/22/2025 at 1:37 PM, she stated the Administrator was responsible for the WMP. During an interview with the Administrator on 01/24/2025 at 4:20 PM, she stated it was her expectation that staff followed the facility's IPCP policies and procedures to prevent the spread of infection to residents and staff. During an interview with the Medical Director on 01/24/2024 at 4:15 PM, he stated the facility followed CDC guidelines and recommendations. The Medical Director stated it was his expectation that the facility followed all its policies and procedures, and he further expected the DON and the IP to oversee and implement infection prevention and control policies. 51417

Based on interview and review of the facility's policy, the facility failed to ensure all residents had the right to send and receive mail on Saturdays. This affected all 49 current residents residing in the facility. The findings include: Review of the facility's policy titled, Residents Rights, revised 12/15/2024, revealed the resident had the right to privacy in written communications, including the right to send and promptly receive mail. During the Resident Council meeting on 01/22/2025 at 2:00 PM, it was stated by all 12 residents in attendance that residents did not receive or send mail on Saturdays at the facility, and they did not receive packages unopened the day they were delivered to the facility. In an interview with the Social Services Director (SSD) on 01/24/2025 at 10:38 AM, she stated mail was not delivered on Saturdays. The SSD stated the Activities Director was responsible for delivering mail on Saturdays. However, she stated she had received many complaints about the Activities Director delivering mail and decided she would be responsible for delivering mail. The SSD stated her work schedule was Monday through Friday, and she did not work on the weekends. The SSD stated she was aware mail should be delivered to residents every day of the week that residents' mail was received by the facility. In an interview with the Activities Director on 01/24/2025 at 2:25 PM, she stated she did not work on the weekend; therefore, she was not available to deliver mail to the residents. The Activities Director stated the SSD told her residents had complained about not receiving a newspaper that was delivered on a Thursday until the following Monday. The Activities Director stated she came to work the next day after being off and was told by the Business Office Manager that the SSD would be delivering the mail to residents. In an interview with the Director of Nursing (DON) on 01/24/2025 at 4:35 PM, she stated she was unsure who got the mail from the mailbox, who was responsible for documenting how many pieces the facility received each day, and who was responsible for distributing the mail and packages to the residents. The DON stated she was unaware the residents were not receiving mail or packages on Saturdays. The DON stated residents not receiving their mail or packages on any day of the week that there were deliveries to the facility was a violation of their rights. In an interview with the Administrator on 01/24/2025 at 4:10 PM, she stated she expected residents to receive their mail upon delivery to the facility.

Based on interview, record review, review of the Centers for Disease Control and Prevention (CDC) document, and review of the facility's policy, the facility failed to ensure the medical record included documentation of the resident's or resident representative's (RR) education regarding the benefits and potential side effects of immunizations for 5 of 5 residents sampled for immunizations (Resident (R) 6, R9, R16, R21, and R44). The findings include: Review of the facility's policy titled, Immunization/Vaccination Policy and Procedure, dated 11/09/2024, revealed the facility would educate and offer residents available immunizations against infections to minimize the risk of acquiring or transmitting disease. Per the policy, residents would be assessed for medical contraindications of immunizations and receive education regarding the benefits and potential side effects of the immunizations. Review of the documentation provided to residents regarding vaccine education showed the facility stated they offered residents the CDC's Vaccine Information Sheets (VIS) for the COVID-19 and Respiratory Syncytial Virus (RSV) vaccines, both dated 10/19/2023. The facility did not offer residents current 2024-2025 VIS sheets. 1. Review of R6's Face Sheet, located in the resident's electronic health record (EHR), revealed the facility admitted the resident on 05/07/2024 with diagnoses to include debility, asthma, and seizure disorder. Review of R6's quarterly Minimum Data Set [MDS], with an Assessment Reference Date (ARD) of 12/30/2024, revealed the facility assessed the resident to have a Brief Interview for Mental Status [BIMS] score of five out of 15, which indicated R6 had severe cognitive impairment. Review of R6's Immunization Record, located in the resident's EHR, revealed R6 received his RSV vaccine on 10/03/2024. He received his influenza vaccine on 10/07/2024. For both immunization records, No was answered to the question about whether education was provided by the nurse. There was no documentation that the RR was provided updated vaccine information. Other vaccine information was historical. R6 was non-interviewable, and his RR was not contacted. 2. Review of R9's Face Sheet, located in the resident's EHR, revealed the facility admitted the resident on 11/17/2022 with diagnoses to include obstructive uropathy, protein calorie malnutrition, and ventral hernia. Review of R9's quarterly MDS, with an ARD of 12/09/2024, revealed the facility assessed the resident to have a BIMS score of 5 out of 15, which indicated R9 had severe cognitive impairment. Review of R9's Immunization Record, located in the resident's EHR, revealed R9 received her RSV vaccine on 10/03/2024. She received her last influenza vaccine on 11/17/2022. For both immunization records, No was answered to the question about whether education was provided by the nurse. There was no documentation the RR was provided updated vaccine information. Other vaccine information was historical. Resident 9 was non-interviewable, and her RR was not contacted. 3. Review of R16's Face Sheet, located in the resident's EHR, revealed the facility admitted the resident on 08/07/2024 with diagnoses to include acute on chronic respiratory failure, encephalopathy, and non-compliance with medical regimen. Review of R16's quarterly MDS, with an ARD of 12/26/2024, revealed the facility assessed the resident to have a BIMS score of 15 out of 15, which indicated R16 was cognitively intact. Review of R16's Immunization Record, located in the resident's EHR, revealed R16 received her RSV vaccine on 10/03/2024. She received her influenza vaccine on 10/14/2024. For both immunization records, No was answered to the question about whether education was provided by the nurse. There was no documentation the resident was provided updated vaccine information. Other vaccine information was historical. During an interview with R16 on 01/23/2025 at 9:34 AM, she stated she was not provided a VIS to read or sign prior to administration of her last vaccines. She stated education regarding the benefits and risks and potential side effects associated with the vaccine was good information to have to make an informed decision. 4. Review of R21's Face Sheet, located in the resident's EHR, revealed the facility admitted the resident on 10/16/2020 with diagnoses to include esophageal obstruction, acute pancreatitis, and congenital stenosis and stricture of the esophagus. Review of R21's quarterly MDS, with an ARD of 12/26/2024, revealed the facility assessed the resident to have a BIMS score of 15 out of 15, which indicated R21 was cognitively intact. Review of R21's Immunization Record, located in the resident's EHR, revealed R16 received his RSV vaccine on 10/03/2024. He received his Influenza vaccine on 10/14/2024. For both immunization records, No was answered to the question about whether education was provided by the nurse. There was no documentation the resident was provided updated vaccine information. Other vaccine information was historical. During an interview with R21 on 01/23/2025 at 9:55 AM, he stated he did not remember any education about the vaccines or that he was given a VIS to read or sign prior to administration of his last vaccines. He stated he was just asked if he wanted the vaccine. 5. Review of R44's Face Sheet, located in the resident's EHR, revealed the facility admitted the resident on 05/03/2024 with diagnoses to chronic obstructive pulmonary disease (COPD), type 2 diabetes mellitus, and unstageable wound to right foot. Review of R44's quarterly MDS, with an ARD of 12/03/2024, revealed the facility assessed the resident to have a BIMS score of 11 out of 15, which indicated R44 had moderate cognitive impairment. Review of R44's Immunization Record, located in the resident's EHR, revealed R44 declined the influenza vaccination for this season. He had also declined the pneumococcal vaccination. For both immunization records, No was answered to the question about whether education was provided. There was no documentation the resident was provided updated vaccine information. During an interview with R44 on 01/22/2025 at 11:52 AM, he stated he declined both immunizations when offered. He stated he was not provided a VIS to read or sign. During an interview with the Infection Preventionist (IP) on 01/23/2025 at 12:00 PM, she stated the facility followed the CDC's recommendation for all immunizations and vaccines. She stated the facility provided vaccine education to residents. The IP stated she did not know why the sampled resident files did not have vaccine education documentation. The IP did not answer why the facility was using outdated VIS sheets from 2023 for the 2024-2025 vaccines. The IP stated it was important for the facility to educate and offer residents recommended vaccines and follow CDC's recommendations for vaccines and immunizations to prevent the spread of diseases and infections. During an interview with the Director of Nursing (DON) on 01/24/2025 at 10:30 AM, she stated the facility followed CDC recommendations for resident and staff immunizations and vaccines. She stated it was important for residents to be educated about and offered all recommended immunizations and vaccines. She stated the IP provided updated VIS information to educate staff and residents. Furthermore, she stated immunization or declination of the vaccine should be documented in resident files as part of a comprehensive infection control program. During an interview with the Administrator on 01/24/2025 at 4:20 PM, she stated it was important the facility maintained the appropriate documentation to reflect that it provided the required COVID-19 vaccine education to employees to comply with CDC recommendations and adhere to the facility's infection control program. The Administrator stated the IP Nurse was responsible for infection control oversight, but everyone must follow policies. She stated further that following policy and CDC guidelines was important for the safety of residents and staff. During an interview with the Medical Director on 01/24/2024 at 4:15 PM, he stated the facility followed CDC guidelines and recommendations. The Medical Director stated it was his expectation that the facility followed all its policies and procedures, and he further expected the DON and the IP to oversee and implement infection prevention and control policies.

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to implement the intervention of the use of a mechanical lift for one (1) of three (3) sampled residents, Resident #39. The facility assessed Resident #39 and care planned the resident to require the use of a mechanical lift (an assistance device used to transfer residents from one (1) surface to another who required support more than the manual support provided by caregivers alone) with two (2) staff assisting. However, on 02/06/2024, State Registered Nurse Aide (SRNA) #8 and Licensed Practical Nurse (LPN) #1 transferred Resident #39 from the bed to the Geri chair (geriatric, a large padded chair with a wheeled base designed to assist patients with limited mobility) then later from the Geri chair to the bed without the use of the mechanical lift. The following day, LPN #2 assessed Resident #39 to have external rotation to his/her right lower extremity, and the resident was subsequently found to have a femur and vertebra fracture. The findings include: Review of the facility's policy, Comprehensive Care Plans, last reviewed 11/30/2021, revealed the facility must develop and implement a comprehensive person-centered care plan (CCP) for each resident, consistent with residents' rights, that included measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the resident's comprehensive assessment. Further review revealed the care planning process would include an assessment of the resident's strengths and needs and incorporate the resident's personal and cultural preferences in developing goals of care. Additional review revealed that qualified staff responsible for carrying out interventions specified in the care plan would be notified of their roles and responsibilities for carrying out the interventions, initially and when changes were made. Review of the facility's policy titled, Care Plan Policy & Procedure, reviewed 01/31/2024, revealed care plans were put in place to ensure safety, quality, and individual care for residents. Per policy review, staff members were expected to follow the resident's care plan when providing care. Review of Resident #39's Admission Record revealed the facility admitted the resident on 10/05/2022 with diagnoses including unspecified sequelae of cerebral infarction, muscle weakness, and unspecified dementia. Review of Resident #39's most recent Minimum Data Set (MDS) assessment was a Significant Change Assessment, dated 02/01/2024, and indicated that the resident was dependent for chair/bed-to-chair transfers. Review of Resident #39's Quarterly Minimum Data Set (MDS) Assessment, dated 01/04/2024, revealed chair/bed-to-chair transfer was rated as not attempted due to medical condition or safety concerns. Review of Resident #39's Comprehensive Care Plan history revealed the Minimum Data Set (MDS) Coordinator updated the care plan interventions for transfers on 01/22/2024 to total care with a two (2) staff assist with mechanical lift and Geri chair. Review of Resident #39's Kardex, or nurse aide care plan, revealed it was undated and included the requirement for total care with two (2) staff assistance with a mechanical lift and Geri chair. Review of Resident #39's Progress Note, dated 02/07/2024 at 10:45 AM, revealed the Hospice State Registered Nurse Aide (SRNA) asked LPN #2 to look at Resident #39's right leg because it looked abnormal. Further review revealed LPN #2 stated she went immediately to the room, performed an assessment, and noted Resident #39 had facial grimacing and moaning when his/her right leg was moved. Continued review revealed the resident's right leg appeared to be rotated outwardly. Additional review revealed LPN #2 notified the Advanced Practice Registered Nurse (APRN), who gave an order to obtain x-rays. The facility transferred Resident #39 to the local hospital via Emergency Medical Services. Review of Resident #39's Discharge Summary from the local hospital, dated 02/07/2024, revealed Resident #39 had sustained an intertrochanteric comminuted fracture (bone was broken in at least two (2) places) to the right proximal femur and a thoracic eleven (T11) vertebral fracture. Further review revealed the age of the T11 fracture was indeterminate, although it was new since the last imaging he/she had undergone. However, there was no reference given for that date. Further review revealed Resident #39 was discharged back to the facility. During interview with SRNA #8 on 02/20/2024 at 2:34 PM, she stated for a resident transfer, she asked the aide from the previous shift, she would receive that instruction from the nurse, or she would check the care plan. In further interview, she stated most residents required either a one (1) or two (2) person assist. SRNA #8 stated there had never been an issue with the care plan not being clear. During additional interview with SRNA #8 on 02/20/2024 at 5:10 PM, she stated she got Resident #39 up with Licensed Practical Nurse (LPN) #1. The SRNA stated they did not use a mechanical lift on 02/06/2024 because the resident's room was being deep cleaned. She also stated she and another aide transferred Resident #39 back to bed the same way. SRNA #8 stated she later learned Resident #39 was supposed to be transferred by using the mechanical lift. During interview with LPN #1 on 02/20/2024 at 3:13 PM, she stated when determining a resident's transfer status, she looked at the Kardex, the aide care plan, because it was a quick view. During additional interview with LPN #1 on 02/20/2024 at 5:47 PM, she stated SRNA #8 came to her for help with transferring Resident #39 on 02/06/2024, and they just picked the resident up from the bed by his/her pants and moved the resident over to the chair. She stated she and the aide bore the weight. LPN #1 stated Resident #39 did not fall during the transfer nor was he/she dropped. During additional interview with LPN #1 on 02/21/2024 at 11:52 AM, she stated Resident #39 had been transferred with a lift before but then was changed to extensive assist with two (2) staff. She stated she was told after the incident that the care plan was changed to mechanical lift for transfers in late January 2024, but she had not been aware of this. During interview with Registered Nurse (RN) #3 on 02/21/2024 at 10:50 AM, she stated she saw Resident #39 on the Monday prior to the incident, and his/her status remained at baseline, with no evidence of pain or external rotation. During interview on 02/22/2024 at 9:09 AM with Occupational Therapist (OT) #1, she stated if a resident was being transferred from the bed to a Geri chair, it should be done using a mechanical lift device or some type of a slider board for assistance to ensure the safety of the residents. During interview with the Minimum Data Set (MDS) Coordinator on 02/22/2024 at 10:59 AM, she stated Resident #39 had been placed on Hospice care in January 2024 and that led to the Significant Change assessment on 02/01/2024. She stated the expectation was that any changes on the MDS assessment from the previous one would be updated on the care plan. During interview with the Director of Nursing (DON) on 02/21/2024 at 3:16 PM, she stated newly admitted residents received therapy screening and that helped determine their activities of daily living (ADL) abilities. She also stated safe transfers could be based on nursing judgment as well. The DON stated nurses built the baseline care plan at admission, and the ADLs transferred automatically from the care plan to the Kardex if the nurse tagged it. The DON stated her expectation was that staff reviewed care plans prior to a shift. She stated the care plan was key to providing guidance on care, and the care plan should be updated with changes. The DON stated SRNA #8 knew he/she was supposed to use the mechanical lift. She also stated her expectation was that staff would check the Kardex to confirm transfer status prior to transferring. During interview with the Administrator on 02/21/2024 at 3:51 PM, she stated nurses used their judgment in assessing residents' needs, such as transfers. She stated it was possible for staff to print the Kardex to one (1) page in order to have a reference in hand. The Administrator stated she expected nurses to update care plans in real time and add an intervention that staff reviewed the next day in morning meeting. She stated the bottom line was nursing staff members were expected to look at the care plan. The Administrator stated updates to the care plan went to the Kardex immediately, if the nurse tagged the update. She stated the elements marked with a K in the care plan had been tagged for the Kardex. She stated following the care plan was important because it protected the residents. During subsequent interview with the Administrator on 02/22/2024 at 8:43 AM, she stated the shower sheet or hall sheet listed transfer status and other ADL requirements. She stated there were separate sheets for aides and nurses, and they could use the sheets but were supposed to go to the care plan or Kardex. Also, she stated nurses could run a multiple day report on their residents, and the aides had a dashboard on Point Click Care (PCC, a software program) and could print those. She stated aides could also print their task sheets to have a paper guide as well as the computer.

Based on observation, interview, record review, and review of the facility's policies, it was determined the facility failed to ensure the use of assistance devices to prevent injury for one (1) of three (3) sampled residents (Residents #39). On 02/06/2024 staff transferred Resident #39 from the bed to chair then back to bed without using a mechanical lift (an assistance device used to transfer residents from one (1) surface to another who required support more than the manual support provided by caregivers alone). Resident #39 sustained an intertrochanteric comminuted fracture (the bone was broken in at least two (2) places) to the right proximal femur and a fracture to the thoracic (T)11 vertebrae. The findings include: Review of the facility's policy, untitled, revised 12/17/2023, revealed it was the facility's policy to assess and help to accommodate residents with activities of daily living (ADL). Further review revealed ADLs would be assessed and documented according to the needs of the individual resident, and ADLs would be care planned and updated as needed. Continued review revealed staff would accommodate the resident with ADLs based on needs. Review of the facility's policy titled, Care Plan Policy & Procedure, reviewed 01/31/2024, revealed care plans were put in place to ensure safety, quality, and individual care for residents. Per policy review, staff members were expected to follow the resident's care plan when providing care. Review of Resident #39's Admission Record revealed the facility admitted the resident on 10/05/2022 with diagnoses including unspecified sequelae of cerebral infarction, muscle weakness, and unspecified dementia. Review of Resident #39's Quarterly Minimum Data Set (MDS) Assessment, dated 01/04/2024, Section GG, Functional Abilities and Goals, Subsection E Mobility, revealed chair/bed-to-chair transfer was rated as not attempted due to medical condition or safety concerns. Review of Resident #39's Significant Change in Status MDS Assessment, dated 02/01/2024, Section GG, Functional Abilities and Goals, Subsection E Mobility, revealed chair/bed-to-chair transfer was rated dependent. Review of Resident #39's care plan revealed transfers required total care with a two (2) staff assist with a mechanical lift to the Geri-chair (geriatric, a large padded chair with a wheeled base designed to assist patients with limited mobility). The intervention was added by the Minimum Data Set (MDS) Coordinator on 01/22/2024. Review of Resident #39's Kardex (nurse aide care plan) revealed under Transferring, that transfers required total care with a two (2) staff assist with a mechanical lift to the Geri-chair. This intervention was tagged to the Kardex from Resident #39's care plan intervention added by the MDS Coordinator on 01/22/2024. Review of Resident #39's Point Click Care (PCC, a software program used for charting) record, dated 02/06/2024 at 3:37 PM, revealed documentation that Resident #39 was transferred with total dependence-full staff performance. Review of Resident #39's Progress Note, dated 02/07/2024 at 10:45 AM, revealed the Hospice State Registered Nurse Aide (SRNA) asked Licensed Practical Nurse (LPN) #2 to look at the resident due to the resident's right leg looking abnormal during his/her bath. LPN #2 stated she went immediately to the room and performed an assessment and noted Resident #39 had facial grimacing and moaning when the right leg was moved. Per the note, the resident's right leg appeared to be rotated outwardly. The nurse stated she notified the Advanced Practice Registered Nurse (APRN), obtained instructions to send the resident to the emergency department for X-Rays if the family was agreeable. The note stated the Director of Nursing (DON) notified Resident #39's family, and Emergency Medical Services (EMS) transported the resident to the hospital. Further review of Resident #39's Progress Note, dated 02/07/2024 at 3:32 PM and written by LPN #2, stated the hospital had informed LPN #2 that Resident #39 had a right femur fracture and was awaiting a treatment decision from the family. Continued review of a note, dated 02/07/2024 at 5:16 PM, revealed the ED staff called report to the facility, which included Resident #39 had a T11 (thoracic eleven) vertebral compression fracture and a comminuted intertrochanteric fracture of the right proximal femur. In addition, a note, dated 02/07/2024 at 5:48 PM, revealed Resident #39 was returned to the facility by ambulance. Review of Resident #39's Emergency Department Discharge Summary, dated 02/07/2024, revealed he/she had sustained an intertrochanteric comminuted fracture to the right proximal femur and a T11 fracture. Further review revealed the age of the T11 fracture was indeterminate, although it was new since the last image (no date) he/she had undergone. In an interview with State Registered Nurse Aide (SRNA) #8 on 02/20/2024 at 2:34 PM, she stated she started at the facility in January 2024. She stated in the beginning of employment she would ask the previous aide how a resident transferred. SRNA #8 stated she would be told by the nurse, or she would check the care plan for information on what the resident required for transfers. She stated most residents were either a one (1) or two (2) person assist. She stated she would ask another aide if there was a question about how to care for a resident. In another interview with SRNA #8 on 02/20/2024 at 5:10 PM, she stated she got Resident #39 up with Licensed Practical Nurse (LPN) #1 on 02/06/2024. She further stated they got the resident up on the side of the bed, and the Geri-chair was pulled up to the side of the bed. She stated she could not say they stood the resident up with the resident bearing weight. She stated she did not think Resident #39 moved his/her feet. The SRNA stated they lifted under Resident #39's arms and by his/her pants, with up, over, and turn movements. SRNA #8 stated it was like stand and pivot, but she and LPN #1 bore the weight. She stated they did not use a gait belt. The SRNA denied that Resident #39 was dropped or hit his/her leg on anything. She stated she and the Quality Assurance Manager transferred Resident #39 back to bed the same way. SRNA #8 stated the Quality Assurance Manager was passing by the room and tried to help her situate Resident #39 with pillows, then they reported the discomfort to LPN #1 at the nurse's station. SRNA #8 stated she later learned Resident #39 was supposed to be transferred by the mechanical lift. In an interview with Licensed Practical Nurse (LPN) #1 on 02/20/2024 at 3:13 PM, She stated when determining a resident's transfer status, she looked at the Kardex. She stated on admission she did an assessment and got a Physical Therapy (PT) consult. In additional interview with LPN #1 on 02/20/2024 at 5:47 PM, she stated SRNA #8 came to her for help with transferring Resident #39 on 02/06/2024. She stated Resident #39 was being moved out of the room so the room could be deep cleaned. She stated Resident #39 was prone to lean and did not ambulate, and Resident #39 used the Geri chair when out of bed. She stated that day, they just picked him/her up from the bed by his/her pants and moved the resident over to the chair. She stated she and the aide bore the resident's weight. She stated she frequently used the Kardex because it was a quick view. She stated Resident #39 was not fussy or agitated until going to the dining room later that day. She stated the agitation occurred after Resident #39 was sat up vertically to eat. She stated once the resident was taken out of the dining room and tilted back in the chair, he/she was quiet as a mouse and did not seem to be in pain. She stated she thought the resident did not want to eat in the dining room, as he/she normally took meals in his/her room. She stated Resident #39 did not fall during the transfer nor was he/she dropped. In additional interview with LPN #1 on 02/21/2024 at 11:52 AM, she stated Resident #39 had been transferred with a lift before and then was changed to extensive assist with two (2) staff. She stated she was told after the incident that the care plan had been changed to requiring a mechanical lift for transfers in late January 2024, but she had not been aware of this. In an interview with the Hospice Registered Nurse (RN) on 02/21/2024 at 10:50 AM, she stated she saw Resident #39 on the Monday prior to the incident, and all Resident #39's assessments remained baseline, with no evidence of pain or external rotation of the right leg. The Hospice RN further stated Resident #39 was frequently agitated during any care, and they had a conference about interventions for this incident but had not had evidence of chronic pain or anxiety aside from that. Observation of Resident #39's skin on his/her right side with the Hospice Nurse on 02/21/2024 at 10:50 AM, revealed no signs of new or healing bruising. In an interview with the Occupational Therapist (OT) on 02/21/2024 at 12:38 PM, she stated she had been an OT for seventeen (17) years and had worked at the facility since April 2023. She stated all residents got an evaluation upon admission, depending on the admission criteria and the discharging facility. The OT stated if the family was in the room, she would ask them the residents. She stated the OT determined if they needed a walker, wheelchair, bedside commode, raised toilet seat, a reacher, and how many assists they needed to move. She stated if the residents needed equipment, the OT could get the equipment for them immediately if it was in the supply shed. She stated she also made recommendations on the assist level. During the interview, the OT stated that she evaluated how many assists the residents needed and if they needed cueing. The OT stated she scored the residents on each section evaluated. She stated extensive assist meant the resident could only assist twenty-five percent (25%) to help move him/her or complete the activity; moderate assist was fifty percent (50%). The OT stated if the residents were a maximum assist with two (2) staff, then they needed a mechanical device because they could not help or complete at all without totally relying on aid. In another interview with the OT on 02/22/2024 at 9:09 AM, she stated there had been a few instances where the OT would recommend a Geri chair for a resident's use. The OT stated the determination for need was based on how dependent the resident was; if the resident was having difficulty sitting up or could not use his/her arms to push up; and if the resident had rigidity in his/her lower body. She stated the resident must be dependent on assistance to have a Geri chair recommended. The OT stated, in her opinion as an OT, if a resident was being transferred from the bed to a Geri chair, it should be done using a mechanical lift device or some type of a slider board for assistance. In an interview with the Minimum Data Set (MDS) Coordinator on 02/22/2024 at 10:59 AM, she stated she had been the MDS Coordinator for about a month. She stated Resident #39 had been placed on Hospice care in January 2024, but the Significant Change in Status Assessment had not been completed by staff. She stated the Regional MDS Nurse and the facility's Director of Nursing (DON) had informed her it was missed in January 2024, so she completed it on 02/01/2024. In an interview with the Emergency Department Physician on 02/20/2024 at 2:35 PM, he stated he felt Resident #39's fractures were not from physical abuse as there was no bruising. He stated the ED's call to Adult Protective Services (APS) was because the resident was non-ambulatory, bedridden, and sustained a hip fracture. He stated his best guess was that somebody was trying to transfer the resident and just dropped him/her on the hip; or, he/she slipped, based on the hip fracture and thoracic spine fracture. He stated an acute axial load on the pelvis/bottom went straight up the spine and was the most common source of a vertebral thoracic fracture. In an interview with the Medical Director on 02/20/2024 at 4:06 PM, he stated he had talked to the Hospice Nurse, who found Resident #39 with a shortened right leg, and the Director of Nursing (DON), whom the nurse/aide told that they had the resident stand and pivot rather than use the lift. He stated he did not know if there was any withheld information, but Resident #39 did sustain a compression fracture. He stated Resident #39's fracture looked more like a high energy impact, but the resident was frail, and there was no other evidence of a fall. In an interview with the Director of Nursing (DON) on 02/21/2024 at 3:16 PM, she stated newly admitted residents received therapy screening and that helped determine activities of daily living (ADL) abilities. She also stated what defined a safe transfer could be based on nursing judgment as well. The DON stated SRNA #8 knew he/she was supposed to use the lift. The DON stated she suspected when staff members transferred Resident #39 that the resident's right leg did not pivot. She also stated her expectation was that staff would check the Kardex to confirm transfer status prior to transferring the resident. In an interview with the Administrator on 02/21/2024 at 3:51 PM, she stated nursing judgment was used for assessing residents' needs, such as transfers. She stated therapy conducted screening for newly admitted residents, and therapy might bring evaluations to the interdisciplinary team (IDT) to make a recommendation for a resident to use a lift for transfers. She stated the IDT included the Administrator, Director of Nursing, Quality Assurance Manager, Social Services Director, and Minimum Data Set Coordinator. In additional interview with the Administrator on 02/22/2024 at 8:43 AM, she stated the shower sheet/hall sheet would list things like transfer status, whether residents required feeding assistance or other ADL requirements. She stated leaders used these for training new employees. She stated active employees used the sheet but were supposed to go to the care plan/Kardex for information on resident care. The Administrator stated there was a different sheet for aides or nurses that they could make notes on and carry with them. She stated the nurses' sheet was kept on the medication cart, as well as the 24 hour report. Also, she stated nurses could run a multiple day report on their residents, and the aides had a dashboard on Point Click Care (PCC) and could print those. She stated aides could also print their task sheets to have a paper guide as well as the computer. The Administrator stated staff could not use mechanical lifts with residents until they had taken and passed a skill competency.

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to maintain acceptable parameters of nutritional status for one (1) of thirty-seven (37) sampled residents (Resident #39). Resident #39 lost greater than ten percent (10%) of his/her body weight in the past six (6) months and over twenty percent (20%) in a year. The facility failed to ensure that interventions were implemented timely to prevent the weight loss. The findings include: Review of the facility's policy, Weight Monitoring Procedure, dated 12/03/2023, revealed the facility weighed residents once per month, unless the resident unexpectedly lost greater than five percent (5%) of his/her body weight in one (1) month; greater than seven and a half percent (7.5%) in three (3) months; or greater than ten percent (10%) in six (6) months. Review of Resident #39's Face Sheet revealed the facility admitted the resident on 10/05/2022 with diagnoses that included unspecified dementia and major depressive disorder. Further review revealed the facility updated the diagnosis list to include cerebral infarction (stroke) and aphasia (inability to speak) on 12/02/2022. Review of Resident #39's Quarterly Minimum Data Set (MDS) Assessment, dated 07/13/2023, revealed the facility assessed the resident as having lost ten percent (10%) or more of his/her body weight in the last six (6) months while not on an intended weight-loss program. Review of Resident #39's Annual Minimum Data Set (MDS) Assessment, dated 10/05/2023, revealed the facility assessed the resident as not able to be understood and assessed the resident's memory, decision making, and attention to be severely impaired. Further review revealed the facility assessed Resident #39 as being dependent on staff for eating and as requiring a mechanically altered diet. Review of Resident #39's Care Plan, dated 04/19/2023, revealed the facility identified that Resident #39 lost eighteen percent (18%) of his/her body weight in the previous six (6) months and set a goal of no further significant weight loss. Further review of the care plan revealed the facility identified further weight loss of 10.9% in six (6) months on 07/13/2023, and on 01/03/2024 a loss of 10.5% of his/her body weight in the past six (6) months. Continued review revealed the interventions listed included: provide diet and supplements per physician's order; assist the resident with meal tray as needed; obtain meal preferences; encourage food and fluids; and monitor weights as needed. Additional review revealed the facility did not date the interventions. Per review of the section of the care plan describing Activities of Daily Living (ADLs), the intervention for eating described Resident #39 as able to feed himself/herself after the tray was set up. However, the resident was no longer able to perform this activity. Review of the facility's document Weight Summary, dated 01/01/2024, revealed Resident #39 weighed one hundred one (101) pounds on 01/01/2024, down from one hundred thirteen (113) pounds on 07/02/2023, for a loss of over ten percent (10.6%) in six (6) months. Further review revealed Resident #39 weighed one hundred twenty-eight (128) pounds on 01/02/2023, for a loss of over twenty-one percent (21.1%) of his/her body weight in one (1) year. Review of the facility's document Progress Note-NAR (Nutrition at Risk), dated 05/17/2023, revealed the dietician discharged Resident #39 from the NAR focus group, despite noting a four percent (4%) weight loss during the four (4) weeks the facility was following the resident for significant weight loss. Review of Resident #39's Physician's Order for nutrition, dated 10/10/2023, revealed the resident was prescribed a fortified foods diet with pureed texture. Review of the facility's document Nutrition: Amount Eaten, dated 12/12/2023 through 01/10/2024, revealed Resident #39 ate fifty percent (50%) or less of sixty (60) of the ninety-one (91) meals documented. Review of the facility's document Nutrition: Snacks, dated 12/14/2023 through 01/10/2024, revealed the facility failed to offer snacks to Resident #39 during daytime hours. Record of Resident #39's food preferences was requested by the State Survey Agency (SSA) on 01/10/2024 at 1:45 PM and on 01/11/2024 at 2:30 PM. However, the facility failed to provide this documentation by the time of exit on 01/11/2024 at 7:30 PM. Observation of the meal service on 01/10/2024 at 12:35 PM revealed State Registered Nurse Aide (SRNA) #4 assisted Resident #39 with eating, starting with the mashed potatoes. Observation revealed Resident #39 ate fifty percent (50%) of the mashed potatoes and pureed chicken in gravy and drank twenty-five percent (25%) of the sweet tea. Further observation revealed SRNA #4 had not opened the fortified pudding container. Observation on 01/08/2024 between 1:15 PM and 2:15 PM and on 01/09/2024 between 9:30 AM and 11:45 AM revealed staff failed to offer snacks and drinks throughout the day. In an interview on 01/09/2024 at 6:03 PM, Resident #39's resident representative stated the facility never asked her what Resident #39's food preferences were. However, the representative stated she told several aides that Resident #39 disliked sweet tea, which the facility continued to serve Resident #39 at every lunch and dinner. The resident's representative stated Resident #39 liked coffee with sweetened creamer and fruit juice, which could be a source of calories, but she did not see those offered to the resident consistently. Further, the resident's representative stated she had visited after a meal service and observed Resident #39 asleep in bed without any food being disturbed on the tray left at the bedside. Per interview, Resident #39 ate when the resident's representative fed her, and some staff members told her that Resident #39 ate well when they fed the resident. The resident's representative stated she believed when the resident did not eat the majority of a meal served, it was because his/her food preferences were not honored or the staff member assisting with feeding lacked skill in feeding. In interview on 01/10/2024 at 12:35 PM, SRNA #4 stated she did not know what Resident #39's food preferences were and was not aware if anyone had asked the resident's representative about Resident #39's food preferences. Further, SRNA #4 stated she attempted to feed the resident each meal, and if the resident started to refuse bites, she stopped trying to feed him/her and documented the amount eaten. SRNA #4 stated she did not regularly offer Resident #39 snacks. She stated she tried to offer him/her drinks through the day, but the resident would often refuse. In an interview on 01/11/2024 at 10:07 AM, the Registered Dietician (RD) stated she was aware Resident #39 had lost a significant amount of weight, and the resident was included in the Nutrition at Risk (NAR) intervention group. Per interview, the RD followed residents in the NAR program when they had lost more than five percent (5%) of their body weight in one (1) month or more than ten percent (10%) in six (6) months. The RD further stated Resident #39 had been part of the NAR program earlier in the year but was discharged when his/her weekly weights were stable for four (4) weeks. The RD stated that a stable weight was defined as within two and one-half percent (2.5%) of the previous weight; though if the weight slowly decreased over that amount of time, she considered it appropriate to continue to monitor the resident closely. The RD stated she made recommendations for Resident #39, such as adding fortified oats and/or pudding, when Resident #39 lost weight. However, she stated she was only in the facility one (1) day per week and did not know what foods Resident #39 was actually eating, nor had she identified if the technique of the aides feeding Resident #39 had contributed to his/her weight loss. Per interview, the RD stated she had not educated staff on techniques to use in assisting residents with eating, such as offering higher calorie foods first. Additionally, the RD stated she put her recommendations in her notes in the electronic medical record. However, she stated she did not know if those recommendations went on the resident's care plan. She further stated she did not assess resident's food preferences as a potential cause for a resident's weight loss as she believed that was the role of the Dietary Manager. In an interview on 01/11/2024 at 2:37 PM, the Dietary Manager (DM) stated each resident's food preferences were documented in the dietary computer system and could be obtained from interviewing the resident about his/her preferences or even from observing returned meal trays to see what the resident had eaten. Per interview, the DM stated she believed Resident #39 liked butterscotch flavored fortified pudding, but she did not know if that preference was documented in the computer system or if it was written on the resident's care plan. In an interview on 01/11/2024 at 4:08 PM, the Director of Nursing (DON) stated she was aware Resident #39 had been losing weight and that he/she had poor intake at meals. She further stated her expectations were for the facility to assess resident food preferences on admission and during quarterly care planning meetings. However, she stated she did not know when Resident #39's food preferences were updated due to the facility not communicating with the resident's representative due to difficulty contacting her via phone. Per interview, the facility had talked to the resident's representative about Resident #39's weight loss and that administration of an appetite stimulant might have increased the resident's food intake, but the DON stated she did not know if the resident's food preferences had been discussed at that time. In an interview on 01/11/2024 at 5:30 PM, the Administrator stated her expectations were for residents who had lost weight to have interventions implemented as recommended by the Dietician. Per interview, she did not conduct audits to ensure staff were implementing interventions and to try to identify any barriers to implementing recommendations. In further interview, the Administrator stated she was aware Resident #39 had lost weight over many months due to poor intake. She stated she did not believe the facility had tried to offer Resident #39 smaller, more frequent meals in an attempt to increase his/her caloric intake.

Based on interview and record review it was determined the facility failed to revise the Care Plan for two (2) of thirty-seven (37) residents (Residents #5 and #39). Resident #39 was care planned to be nutritionally at risk. However, care plan interventions were not updated following a significant weight loss. Resident #5 experienced nine (9) falls from 01/12/2023 through 11/02/2023. One fall resulted in a fractured wrist. There was no evidence that interventions following the falls were placed on the care plan or dated. (See F689 and F692) The findings include: Review of the facility's policy, Care Plan Policy and Procedure, dated 08/13/2023, revealed the Interdisciplinary Team (IDT), which included the Dietician, Dietary Manager, nursing staff, and the Director of Nursing, or Licensed Nurse were responsible for updating the resident's care plan when there were changes in the resident's care needs. 1. Review of Resident #39's Face Sheet revealed the facility admitted the resident on 10/05/2022 with diagnoses that included unspecified dementia and major depressive disorder. Further review revealed the facility updated the diagnosis list to include cerebral infarction (stroke) and aphasia (inability to speak) on 12/02/2022. Review of Resident #39's Annual Minimum Data Set (MDS) Assessment, dated 10/05/2023, revealed the facility assessed the resident as not able to be understood and assessed the resident's memory, decision making, and attention to be severely impaired. Further review revealed the facility assessed Resident #39 as dependent on staff for eating and requiring a mechanically altered diet. Review of Resident #39's Quarterly MDS Assessment, dated 07/13/2023, revealed the facility assessed the resident as having lost ten percent (10%) or more of his/her body weight in the last six (6) months while not on an intended weight-loss program. Review of Resident #39's Care Plan, dated 04/19/2023, revealed the facility identified that Resident #39 lost eighteen percent (18%) of his/her body weight in the previous six (6) months and set a goal of no further significant weight loss. Further review of the care plan revealed the facility identified further weight loss on 07/13/2023 of ten and nine-tenths percent (10.9%) in six (6) months; and on 01/03/2024 a loss of ten and one-half percent (10.5%) of his/her body weight in the past six (6) months. Continued review revealed the interventions listed were to provide diet and supplements per physician's order, to assist the resident with the meal tray as needed, to obtain meal preferences, encourage food and fluids, and monitor weights as needed. Per review, the facility failed to date the interventions and failed to make the interventions resident specific. In the section of the care plan describing Activities of Daily Living (ADL), the intervention for eating described Resident #39 as able to feed himself/herself after the tray was set up. However, the resident was no longer able to perform this activity. Review of Resident #39's nutrition orders, dated 10/10/2023, revealed the facility prescribed a fortified foods diet with pureed texture for Resident #39. Observation of the meal service on 01/10/2024 at 12:35 PM revealed State Registered Nurse Aide (SRNA) #4 assisted Resident #39 with eating. Per observation, Resident #39 ate fifty percent (50%) of the mashed potatoes and pureed chicken in gravy and drank twenty-five percent (25%) of the sweet tea. Further observation revealed SRNA #4 had not opened the fortified pudding container. In an interview on 01/09/2024 at 6:03 PM, Resident #39's resident representative stated the facility never asked her what Resident #39's food preferences were. However, the representative told several aides that Resident #39 disliked sweet tea, which the facility continued to serve Resident #39 at every lunch and dinner. In interview on 01/10/2024 at 12:35 PM, SRNA #4 stated she did not know what Resident #39's care plan contained about Resident #39's dietary needs such as food preferences. She further stated she was not aware if anyone had asked the resident's representative about Resident #39's food preferences or if staff members documented their observations about which foods Resident #39 demonstrated preferences for based on his/her consumption. In an interview on 01/11/2024 at 10:07 AM, the Registered Dietician (RD) stated she made recommendations for Resident #39 and gave them to the nursing management team to enter as orders in the electronic medical record. She further stated she did not know if those interventions also went on the resident's care plan. In an interview on 01/11/2024 at 4:08 PM, the Director of Nursing (DON) stated she was aware the facility had failed to keep resident care plans up to date with resident specific interventions. Per interview, it was the DON's expectation that resident-specific interventions to address a resident's unplanned weight loss were up-to-date and followed. In an interview with the Director of Nursing (DON) on 01/11/2024 at 1:25 PM, she stated there had not been a process in place to review or revise care plans. In an interview with the Administrator on 01/11/2024 at 5:10 PM, she stated the care plans were a mess and that they failed to be resident-specific. She stated the new DON had implemented a process to improve care plans including that the nurses could now place immediate interventions after an incident. She stated her expectation for a care plan was it should be updated as needed with specific interventions to reflect resident care needs. She stated staff should be able to look at a care plan and know the plan of care. She added the former DON had created care plans but had not done anything about them. 45990 2. Review of Resident #5's medical record revealed the facility admitted the resident on 03/04/2022 with diagnoses to include muscle weakness, reduced mobility, dementia, and difficulty in walking. Continued review revealed the facility assessed Resident #5 on 12/18/2023 to be severely cognitively impaired with a score of three (3) of fifteen (15) on the Brief Interview for Mental Status (BIMS). Review of Resident #5's Annual Minimum Data Set (MDS) Assessment, dated 12/18/2023, revealed the resident required moderate to partial assistance with Activities of Daily Living (ADL) and utilized a walker as an assistive device. Review of Resident #5's Care Plan, no date given for creation, revealed a focus as a fall risk related to confusion, gait and balance problems, incontinence, and impaired safety awareness. Further review revealed a goal included the resident was to be free of falls with a resolved date of 11/23/2022. Continued review revealed Resident #5 would not sustain further serious injury through the review date given as 04/07/2024. Further review revealed interventions placed were to have a safe environment with a resolved date of 02/13/2023. Additional interventions included: signage on walker as a reminder to use; bed to be at appropriate height; encourage to use call light; wear appropriate footwear; and encourage to toilet every day at 6:00 AM and 4:00 PM. However, there was no date given for revisions or creations. Additional review revealed a resolved date of 01/12/2023 for observation of appropriate use of walker with frequent reminders to use it. Additional review of Resident #5's Care Plan revealed a focus of impaired cognitive function/dementia/impaired thought processes related to dementia. Interventions placed included the resident required verbal cues, reminders, and redirection for safety with a resolved date of 01/07/2024. However, no creation or revision date was given. Review of Resident #5's Progress Notes, revealed nine (9) falls from 01/12/2023 through 11/02/2023. 1a. On 01/12/2023 at 6:20 AM, Resident #5 was found sitting on the bathroom floor. The facility assessed Resident #5 to have no injuries. b. On 01/30/2023 at 11:10 AM, Resident #5 was found lying on his/her back in his/her room. Resident #5 was assessed without any injuries noted. c. On 02/11/2023 at 4:56 PM, Resident #5 was found sitting in the bathroom doorway. Resident #5 was assessed with no injuries noted. d. On 02/24/2023 at 8:08 AM, Resident #5 was found in his/her room on the floor to the right side of the chair. An assessment revealed Resident #5 complained of right foot pain without bruising or redness noted. e. On 03/21/2023 at 11:13 PM, Resident #5 was found sitting on the floor in his/her room between the bed and the chair. Resident #5 was assessed without any injuries noted. f. On 05/30/2023 at 7:46 PM, Resident #5 was ambulating behind staff in the hallway without using a walker. Staff left Resident #5 to get the walker from the dining room, but before they returned, Resident #5 had fallen in the hallway. An assessment was performed revealing a reddened area noted to the right elbow and knee and no complaint of pain. g. On 08/24/2023 at 2:35 PM, Resident #5 was found leaning against the wall in front of the lounge. An assessment was performed with moderate swelling to the resident's left wrist; the resident had complaints of pain to that area. The facility transferred Resident #5 to a local hospital per Emergency Services. Per Resident #5's hospital record, dated 08/24/2023, the resident sustained a left distal radial (wrist) fracture. In an interview with Licensed Practical Nurse (LPN) #2 on 01/11/2024 at 8:10 AM, she stated, after the 08/24/2023 fall, she added a small basket to Resident #5's walker for his/her stuffed cats to cue the resident not to leave the walker since he/she was so fond of stuffed cats. However, review of Resident #5's care plan revealed it did not include this intervention. h. On 09/18/2023 at 1:21 AM a notation was made in the medical record for follow-up on fall. However, no notation was found for this fall other than entry for no injuries. i. On 11/02/2023 at 5:40 PM, Resident #5 was found on the bathroom floor. Resident #5 was assessed without injuries noted. However, review of Resident #5's care plan revealed no dates for the interventions or revision dates. Observation on 01/07/2024 at 1:15 PM revealed Resident #5 sitting at a table in the dining room with two (2) other residents. Resident #5's walker was sitting to the right of him/her within reach. No signage for a reminder to use the walker was observed. Further observation revealed a small white plastic basket was attached to the top frame of the walker with two (2) stuffed cats inside the basket. In an interview with State Registered Nurse Aide (SRNA) #2 on 01/11/2024 at 8:45 AM, she stated, when asked how she knew if any new interventions were placed for a resident on the care plan, she stated staff got information in report from the nurses. She added that the facility's system did not transfer any new information about a resident. In an interview with SRNA #5 on 01/11/2024 at 8:30 AM, she stated she was providing care for Resident #5 today and knew he/she was a fall risk. She stated she got that information from shift report and did not look at the Care Plan or Kardex. In an interview with SRNA #4 on 01/09/2024 at 3:40 PM, she stated she would refer to the Care Plan Book for any new information for any resident. However, upon observation SRNA #4 was unable to locate the book. In an interview on 01/11/2024 at 9:20 AM with the Director of Nursing (DON), she stated she had held that title since November of 2023. The DON stated the nurses should be placing immediate interventions to care plans when there was an incident including falls. She stated if there were no interventions placed on the care plans after a fall, staff should be passing information on in report to the next shift. During the interview, the DON stated she had identified problems with the whole care plan process saying there was no process for nurses to place immediate interventions after a fall. The DON stated, at this time, nurses were not allowed to add interventions to care plans. When asked whose responsibility that was, she said that she, the DON was responsible. She stated she was putting a Process Improvement Plan (PIP) program in place for falls and care plans. She stated the process should be when a resident fell , an assessment should be done and immediate interventions placed at that time by that nurse. When asked to find the interventions placed in the medical record/care plan for Resident #5's falls, the DON replied she could not locate them.

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to ensure adequate supervision and assistance devices to prevent falls for two (2) of thirty-seven (37) sampled residents (Residents #29 and #12). Resident #29 sustained a laceration to the chin requiring six (6) sutures on 02/21/2023 when the bed the resident was in was not locked and rolled causing the resident to fall while receiving care with only one (1) person assistance when the facility had assessed and care planned Resident #29 to require the assistance of two (2) person for toileting and bed mobility. Resident #12 sustained nine (9) documented falls from 09/24/2023 to 01/05/2024, none with injuries. The findings include: Review of the facility's policy, Resident Fall Protocol, dated 09/01/2023, revealed it was the policy of the facility to attempt to eliminate falls from occurring and/or to prevent residents from falls with major injuries. Review of the procedure section of the policy revealed the facility was to include interventions as indicated. Further review of the policy, under the note section, revealed a neuro/cranial check assessment was to be initiated by the nurse at the time of the fall, had to be done if the fall was unwitnessed, or the resident hit his/her head. It stated this assessment was to be done for twenty-four (24) hours. 28707 1. Review of Resident #29's Electronic Health Record (EHR) revealed the facility admitted the resident on 03/04/2022 with diagnoses to include unspecified dementia without behavioral disturbance, need for assistance with personal care, and other reduced mobility. The facility assessed Resident #29, in a Quarterly Minimum Data Set (MDS) Assessment, dated 07/20/2023, as severely cognitively impaired and requiring extensive assist of two (2) with bed mobility and with incontinence care. Review of Resident #29's Comprehensive Care Plan, last reviewed 10/17/2023, revealed the resident was care planned for two (2) person assist with toileting and bed mobility, but these interventions were undated. Resident #29 was also care planned for transfers with a mechanical lift, which was also undated. Review of Resident #29's Fall Report, dated 12/21/2023, revealed Resident #29 had a fall with injury on 12/21/2023 at 7:00 PM while a State Registered Nurse Aide (SRNA) was assisting the resident with incontinence care. Per the report, the resident rolled out of bed before the SRNA could stop the resident. The report stated Resident #29 was sent to the emergency room and required six (6) stitches repair a laceration to his/her chin. Review of Resident #29's Root Cause Analysis document, not dated, revealed Resident #29 would be changed with the assist of two (2) with bed mobility/incontinence care to prevent the resident from rolling out of bed in the future. However, review of the MDS and Comprehensive Care Plan revealed the facility had already assessed and care planned the resident to require two (2) person assist with toileting and bed mobility. Interview on 01/11/24 at 8:01 AM with SRNA #6 revealed she was working on 12/21/2023 with Resident #29. She stated she was going to give Resident #29 care and had never had any problem changing him/her before. She stated she was changing Resident #29 and did not realize the bed was not locked. She stated in her four (4) years working at the facility, nothing like that had ever happened. She stated the bed rolled while she turned to get wipes, Resident #29 became unstable, and the resident fell too fast for SRNA #6 to prevent the fall. SRNA #6 stated Resident #29 immediately became a two (2) person assist after that. She also stated she now always checked to ensure beds were in the locked position before providing any kind of care. In an interview on 01/10/2024 at 1:13 PM with State Registered Nurse Aide (SRNA) #4, she thought Resident #29 was a one (1) person assist with care prior to the fall on 12/21/2023. In another interview on 01/10/2024 at 1:15 PM with SRNA #4, she stated she had been at the facility for almost eleven (11) years. SRNA #4 stated resident care plans or the Kardex were not documented in the SRNA care plans on the computer, and usually the nurses just told the SRNAs about resident care during shift change report. She further stated she did not necessarily hear of a new intervention for each fall. In an interview with SRNA #5 on 01/10/2024 at 2:48 PM, she thought Resident #29 was a one (1) person assist prior to the fall on 12/21/2023. In an interview on 01/10/2024 at 10:10 AM with SRNA #3, she stated she had been at the facility for two (2) years. SRNA #3 stated if she had questions about how a resident transferred or toileted, she either asked the other SRNAs or the charge nurse. She stated there was an aide Kardex on the computer where she did her charting, but she admitted she had never seen it but knew where to look for it. She stated she mainly got her resident information on rounds from the previous shift staff, In an interview on 01/10/2024 at 3:32 PM with Licensed Practical Nurse (LPN) #2, she stated she believed Resident #29 was a one (1) person assist with changing but had not worked with the resident recently. In an interview with the Director of Nursing (DON) on 01/11/2024 at 4:18 PM, she stated she would expect staff to ensure care plan interventions were implemented and care plans would be referenced by all staff before providing care. She went on to state, she would expected staff to ensure the bed was locked prior to providing resident care. She stated when she conducted a fall investigation, she noted the intervention for two (2) person assistance in the notes section and SRNA #6 should have asked for assistance prior to providing toileting care and bed mobility for Resident #29. 46651 2. Review of Resident #12's medical record revealed the facility admitted the resident on 08/08/2023 with diagnoses of unspecified dementia with muscle weakness, unsteadiness on feet, and chronic obstructive pulmonary disease. Review of Resident #12's Admission Minimum Data Set (MDS) Assessment, dated 08/08/2023 and the Quarterly MDS Assessment, dated 11/15/2023, section GG revealed Resident #12 used a walker and a wheelchair for mobility and needed assistance with bathing, dressing, using the toilet, and eating. Resident #12 also needed assistance with walking from room to room (with or without a device such as cane, crutch, or walker). Further review of the MDS, section C for cognition dated, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of five (5) of fifteen (15) which indicated severe cognitive impairment. Review of the Facility Resident Matrix dated 01/07/2024 revealed Resident #12 was coded for falls. Review of Resident #12's Comprehensive Care Plan (CCP) for falls, last reviewed 11/16/2023, revealed Resident #12 was at risk for and had falls related to gait and balance problems, psychoactive drug use, decreased safety awareness, and cognitive impairment. The documented goal was for Resident #12 to be free of injury from falls through the target date of 02/14/2024. Documented active interventions, all undated, included: encourage resident to use the call light for assistance as needed, encourage resident to wear non-skid footwear when ambulating as the resident allowed, encourage resident to toilet before/after meals, encourage use of assistive device, walker to promote independence when ambulating, physical therapy as ordered, and Resident #12 needed a safe environment with floors free from spills and/or clutter, adequate glare free lighting, a working and reachable call light, the bed in low position at night, and personal items within reach. Three (3) additional undated interventions were follow facility fall protocol; encourage Resident #12 to participate in activities that promoted exercise and physical activity for strengthening and improved mobility such as Sittercise; and Resident #12 needed activities that minimized the potential for falls while providing diversion and distraction. These were marked as resolved on 12/10/2023. Review of Resident # 12's Comprehensive Care Plan (CCP) for Activities of Daily Living, last review date 11/16/2023, revealed Resident #12 required assistance with activities of daily living related to dementia, impaired balance, and limited mobility. The documented goal, undated, was Resident #12 would maintain his/her current level of function in bed mobility, transfers, eating, dressing, toilet use, and personal hygiene through the target date of 02/14/2024. Documented active interventions, all undated, included encourage Resident #12 to use the call bell for assistance, make sure shoes were comfortable and fit properly, assist with eating as needed, and Resident #12 required cueing, encouragement, and limited assist with transferring. Review of the facility's document, Incidents by Incident Type, printed on 01/09/2024, revealed Resident #12 sustained a fall on the following dates: 09/24/2023 at 10:58 PM, 09/24/2023 at 11:53 PM, 10/15/2023 at 7:28 PM, 10/28/2023 at 8:25 AM, 12/05/2023 at 5:55 PM, 12/30/2023 at 2:04 AM, 01/01/2024 at 9:44 AM, 01/03/2024 at 7:45 AM, and 01/05/2024 at 1:05 PM. a. Review of Resident #12's Fall Incident Report, dated 09/24/2023 at 10:58 PM and written by Licensed Practical Nurse (LPN) #4, revealed staff (not identified) was called to the room where Resident #12 was found kneeling at the bedside. Resident #12 was documented to have stated he/she was trying to get up and here I am on the floor. No injuries were observed, and it was documented no witnesses to the fall could be identified. Review of Resident #12's Health Status Note, dated 09/24/2023 at 10:58 PM and written by LPN #4, revealed she was called to the room by staff, and Resident #12 was found kneeling on the floor beside the bed and had stated he/she fell out of the bed. An assessment was documented as completed, and Resident #12 was transferred to the bed with no injury noted. However, there was no documented evidence the facility performed neuro/cranial check assessment, initiated by the nurse at the time of the fall as the fall was unwitnessed, and continued for twenty-four (24) hours as per the facility's policy. b. Review of Resident #12's Fall Incident Report, dated 09/24/2023 at 11:53 PM by LPN #4, revealed she was called to the room by staff, and Resident #12 was found sitting on the floor in front of the sink and had stated he/she was walking to the sink to empty a pitcher of water, lost his/her balance, and fell hitting the wall with his/her left arm. An assessment was documented as completed, and Resident #12 was assisted up by staff and ambulated back to bed. No injury was documented, and no witnesses to the fall were identified. Review of Resident #12's Health Status Note, dated 09/24/2023 at 11:53 PM and written by LPN #4, revealed she was called to the resident's room by staff, and Resident #12 was found sitting on the floor in front of the sink. LPN #4 further documented an assessment was done per the nurse, Resident #12 was able to move his/her extremities on his/her own. Staff lifted the resident to his/her feet. The resident was able to ambulate to bed, and a bruise was noted to the resident's posterior left upper arm. However, there was no documented evidence the facility performed a neuro/cranial check assessment, initiated by the nurse at the time of the fall as the fall was unwitnessed, and continued for twenty-four (24) hours as per the facility's policy. c. Review of Resident #12's Fall Incident Report, dated 10/15/2023 at 7:28 AM by LPN #5, revealed a SRNA, unidentified, observed Resident #12 on the floor beside the bed and documented the resident had stated he/she rolled out of bed. LPN #5 documented a small abrasion was noted to the back and left side of Resident #12's head, and Resident #12 denied pain. LPN #5 further documented range of motion to all extremities and neurological checks were within normal limits. Review of Resident #12's Incident Note, dated 10/15/2023 at 10:43 AM, revealed an SRNA observed Resident #12 lying on the floor beside the bed. LPN #5 documented Resident #12 stated he/she rolled out of bed. LPN #5 assessed Resident #12, and noted a small abrasion to the back of Resident #12's head on the left side. Continued review revealed Resident #12 denied any pain to any extremities, and range of motion to all extremities was within normal limits. LPN #5 further noted a skin assessment was completed and vital signs and neurological checks were obtained and were also within normal limits. However there was no documented evidence the facility continued to performed neuro/cranial check assessment for twenty-four (24) hours as the fall was unwitnessed and the resident had an abrasion to the head. d. Review of Resident #12's Fall Incident Report, dated 10/28/2023 at 7:28 AM by LPN #5 revealed she was in the hallway administering medications and heard Resident #12 yell out, Help Me. She documented she turned to observe Resident #12 with his/her head on a pillow on the floor, and the resident's waist/legs remained on the bed. LPN #5 documented Resident #12 stated he/she had leaned over and rolled off the bed. The LPN documented no apparent injury was visualized; range of motion was normal for all four (4) extremities; a skin assessment and neurological checks were completed and were within normal limits. Per the report, Resident #5's fall was unwitnessed. Review of Resident #12's Incident Note dated 10/28/2023 at 10:01 AM, revealed the same information as Resident #12's Fall Incident Report, dated 10/28/2023 at 7:28 AM, but it added that no new orders were received from the APRN. However, there was no documented evidence the facility performed neuro/cranial check assessment, as the fall was unwitnessed, and continued for twenty-four (24) hours as per the facility's policy. e. Review of Resident #12's Fall Incident Report, dated 12/05/2023 at 5:55 PM by LPN #5, revealed she observed Resident #12 sitting on the floor beside the bathroom door, and Resident #12 stated he/she was coming from the bathroom and lost his/her balance. LPN #5 documented Resident #12 denied hitting his/her head, no injury was noted, and Resident #12's roommate stated Resident #12 slid down the wall to the floor. LPN #5 further documented range of motion to all extremities and a skin assessment and vital signs were all within normal limits. Resident #12 denied pain or discomfort, and LPN #5 observed Resident #12 had his/her walker nearby but did not have shoes on. Review of Resident #12's Incident Note dated 12/05/2023 at 6:03 PM, detailed the same information about the fall as the Fall Incident Report, dated 12/05/2023 at 5:55 PM. However, there was no documented evidence the facility performed a neuro/cranial check assessment, initiated by the nurse at the time of the fall as the fall was unwitnessed, and continued for twenty-four (24) hours as per the facility's policy. f. Review of Resident #12's Fall Incident Report, dated 12/30/2023 at 2:04 PM by the MDS Nurse revealed Resident #12 was laying on the floor next to the bed with his/her head toward the foot of the bed and facing the wall. The report stated it appeared his/her feet were tangled up in the blanket, and the resident stated he/she was just trying to get up. The MDS Nurse documented the bed was in the lowest position. Resident #12 was alert and oriented to person which was normal, and a head-to-toe assessment was completed with no injury found. The MDS Nurse further documented neurological checks were initiated as the fall was unwitnessed, vital signs were stable, and Resident #12's daughter and the APRN were notified. Review of Resident #12's Incident Note dated 12/30/2023 at 4:21 PM by the MDS Nurse, revealed the same information as Resident #12's Fall Incident Report, dated 12/30/2023 at 2:04 PM. However, there was no documented evidence the facility performed neuro/cranial check assessment, as the fall was unwitnessed, were continued for twenty-four (24) hours as per the facility's policy. g. Review of Resident #12's Fall Incident Report, dated 01/01/2024 at 9:44 AM by LPN #6, revealed Resident #12 attempted to get out of bed without assistance, did not use the call light, had regular socks on with the bed in the lowest position. The resident stated he/she slid out of the bed. LPN #6 documented she assisted Resident #12 back to bed, completed a full skin assessment, put shoes on the resident, and brought him/her to the nurses' station in a wheelchair. LPN #6 further documented Resident #12 denied pain, no injuries were observed at the time of the incident, with no witnesses to the fall were identified. Review of Resident #12's Health Status Note, dated 01/01/2024 at 10:01 AM, revealed Resident #12 slid out of bed that morning with the bed in the lowest position and the call light in easy reach, but he/she did not use it. LPN #6 further documented no injuries were noted and Resident #12 was sitting at the nurses' station. However, there was no documented evidence the facility performed neuro/cranial check assessment, initiated by the nurse at the time of the fall as the fall was unwitnessed, and continued for twenty-four (24) hours as per the facility's policy. h. Review of Resident #12's Fall Incident Report, dated 01/03/2024 at 7:45 AM by LPN #7, revealed she was called to Resident #12's room by an unidentified SRNA. Per the report, upon entering the room, LPN #7 observed Resident #12 lying on the floor next to the bed on his/her left side. The report stated Resident #12 denied pain, no injuries were noted, vital signs were stable, and Resident #12 was unable to give a description of what happened. Per the report no witnesses to the fall were identified. Review of Resident #12's Health Status Note, dated 01/03/2024 at 8:00 AM, revealed Resident #12 was found by an SRNA lying on the floor next to his/her bed. The note stated an assessment was completed, vital signs were stable, and no injuries were noted. Continued review revealed Resident #12 denied pain or discomfort, the bed was in the lowest position and the call light was in reach. LPN #7 further documented Resident #12 was encouraged to use the call light for assistance, to continue to wear non slip socks, and that he/she voiced understanding at the time. However, there was no documented evidence the facility performed neuro/cranial check assessment, initiated by the nurse at the time of the fall as the fall was unwitnessed, and continued for twenty-four (24) hours as per the facility's policy. i. Review of Resident #12's Fall Incident Report, dated 01/05/2024 at 1:05 PM by LPN #3, revealed Resident #12 was found lying on the floor in front of the nurses' station on his/her right side with his/her right arm at a natural angle behind his/her head and both legs bent at the knees. Per the report, Resident #12 stated, I fell I don't know. LPN #3 documented a head to toe assessment was completed, and Resident #12 complained of neck, right arm, and right hip pain. Resident #12's head and neck were stabilized to prevent movement, neurological checks were completed, and Resident #12 was assessed to be at his/her baseline for orientation. The facility assessed Resident #12 as being able to move all extremities, hand grasps were equal and strong, speech was clear, but pupils measured four (4) millimeters with sluggish reaction. Vital signs were stable with no obvious injuries noted. Per the report, 911 was called for transport to the hospital for evaluation. No witnesses to the fall were identified. Further review of Resident #12's Fall Incident Report dated 01/05/2024, in the notes section dated 01/08/2024, revealed Resident #12 was noted lying on his/her right side on the floor by the nurses' station on 01/05/2024. The facility assessed Resident #12 and noted the resident had no obvious injury. However, the resident was sent to the hospital emergency department (ED) for evaluation related to complaints of neck pain and returned with no new orders or acute injuries notes. Review of Resident #12's Health Status Note dated 01/05/2024 at 1:30 PM, revealed the intervention to be put in place when Resident #12 returned to the facility would be proper footwear, shoes or nonskid socks to be in place. Review of Resident #12's Health Status Note dated 01/06/2024 at 4:32 AM, revealed Resident #12 returned from the ED on 01/05/2024 at 8:10 PM with no new orders and diagnostic tests negative for acute injuries. In an interview on 01/10/2024 at 10:10 AM with SRNA #3, she stated for Resident #12, he/she was very forgetful and needed frequent redirection. She further stated it seemed to her when Resident #12 got up he/she was either trying to get to the bathroom or stated he/she was looking for a little white dog. When asked if staff had tried providing him/her with a stuffed white dog to see if that helped at all, she stated not that she was aware of. In an interview with SRNA #4 on 01/09/2024 at 3:40 PM, she stated she would refer to the Care Plan Book for any new information for any resident. However, upon observation SRNA #4 was unable to locate the book. She stated if a resident fell she would get the nurse immediately. In another interview on 01/10/2024 at 1:15 PM with SRNA #4, she stated she had been at the facility for almost eleven (11) years. She stated she knew Resident #12 had fallen several times because he/she kept trying to get up. She stated in order to try and keep Resident #12 from trying to stand up, they placed him/her behind the nurses' station for the whole shift, basically doing one-to-one (1:1) supervision with the resident. She further stated that even then, staff had to keep reminding Resident #12 to sit down. SRNA #4 stated residents' care plans or the Kardex were not documented in the SRNA care plans on the computer, and usually the nurses just told the SRNAs about resident care during shift change report. She further stated she did not necessarily hear of a new intervention for each fall. She stated Resident #12 used to walk with a walker when he/she first came to the facility, and staff tried to use distraction and redirection with Resident #12, but it did not always work. In an interview on 01/10/2024 at 2:48 PM with SRNA #5 she stated she had worked at the facility since October 2023. SRNA #5 stated Resident #12's most recent fall was last week and he/she used to use a walker and was now in a wheelchair when up. She stated she did not know if Resident #12 had certain behaviors that were repeating like looking for something or going to the bathroom. SRNA #5 stated a resident's method of toileting and mobility were on the care plan/Kardex, and she could see that where she charted in the computer. She stated the resident information was also relayed in the morning report or rounds. SRNA #5 further stated she did not hear of specific interventions added for each resident's fall during report. She stated she just heard the resident fell and was okay. In an interview on 01/10/2023 at 12:55 PM with LPN #3, she stated she had worked at the facility on an as needed basis for sixteen (16) years. She stated after a resident fell , and after the resident was assessed and safe, she would fill out an incident report. However, she stated the Director of Nursing (DON) finished the report and filled in the intervention on the resident's care plan. She stated she did not attend Interdisciplinary Team (IDT) meetings. In an interview on 01/10/2023 at 3:31 PM with LPN #2, she stated she had worked for the facility from 2012 to 2021, left, and returned in August 2023. She stated an intervention was put in place after each fall on the resident's care plan and asked, isn't that an MDS kind of thing? When asked if she knew how to tell if a resident was care planned as a fall risk she stated she would have to look that up. LPN #2 stated nurses were made aware of resident care needs through verbal report and through the care plans which were on the computer. She stated if something changed with a resident's care, she communicated that to the staff on the floor verbally. LPN #2 stated Resident #12 was confused and required frequent redirection, had an unsteady gait, had a walker and a wheelchair which he/she frequently forgot to use, his/her bed was kept in low position, and staff tried to ensure he/she was assisted with toileting and getting up. She also stated Resident #12 was rounded on more frequently than the standard every two (2) hours, and his/her room was located closer to the nurses' station. LPN #2 further stated her job was safety, and she did not touch care plans. She stated she filled out the incident report, and when her part was done, there was a spot where she could put an immediate intervention in. The LPN stated the incident report stayed open until the DON completed and closed it during the Interdisciplinary Team (IDT) meeting. LPN #2 stated she did not know when IDT met or how often and that she had never been to an IDT meeting. When asked what her expectation was for residents with multiple and repeated falls, she stated if she was in charge, she would utilize pressure alarms for the high-risk residents, so she would know if a resident was trying to get up. In an interview on 01/11/2024 at 3:30 PM with the MDS Nurse, she stated she had been the MDS Nurse since Monday but had been with the facility as a floor nurse since 01/17/2023. She stated she was scheduled for MDS training in February 2024 and had just begun working on care plan updates. She stated she was aware care plans needed to be updated with each new intervention as soon as possible. However, she was not aware the system did not date the care plan entries. She stated it was her expectation every resident's fall be investigated and the cause addressed to promote resident safety. In an interview on 01/10/2024 at 8:10 AM with the DON (Director of Nursing) she stated when she did a fall investigation, she typically put the investigation, interventions, and the Root Cause Analysis under the notes section of the investigation report. She stated she did not know how they were doing it prior to her coming to the facility. The DON stated she currently had a process improvement plan in progress for fall investigations and care plans because she saw that there were concerns in those areas. She also stated typically fall investigations were covered under Quality Analysis, and she thought the previous DON, who was no longer at the facility, had been doing Quality Analysis. The DON stated she had done education with floor staff members in December 2023 with interventions for falls when they occurred, their role in determining the root cause, and trying to gather all the information they could at the time. She stated she started as DON at the facility on the first Monday in November 2023, and her process would be the IDT team would be involved in the investigation and root cause analysis of a fall, and all falls would be reviewed weekly on Fridays. The DON stated her expectation would be a new fall intervention would placed on the resident's care plan, which she had explained to floor staff, and the investigation would also be checked to ensure a new intervention was placed there. In continued interview on 01/11/2024 at 9:20 AM with the DON, she stated her tasks included offering oversight of the nursing clinical area, assuring staff members were performing their tasks including nurse aides. The DON added the nurses should be placing immediate interventions to care plans when there was an incident including falls and a neuro/cranial check assessment was to be initiated by the nurse at the time of the falL. She stated neuro checks had to be done if the fall was unwitnessed, or if the resident hit his/her head. The DON stated this should be done for twenty-four (24) hours as per the facility's policy. She added she had identified problems with the whole care plan process, saying there was no process for nurses to place immediate interventions after a fall. The DON stated, at this time, nurses were not allowed to add interventions to care plans. When asked whose responsibility that was, she said the DON. She added that she was putting in place a Process Improvement Plan (PIP) program for falls and care plans. She stated the process should be when a resident fell , an assessment should be done and immediate interventions placed at that time by the nurse. She also stated that nurse would fill out an incident report, which right now was not always performed. In an interview on 01/11/2024 at 8:25 AM with the Administrator, she stated the facility's fall process was the nurse on duty assessed the resident and the situation and responded with an intervention. She stated the doctor and the resident's representative were notified, but the DON was not notified unless it was a fall with a major injury. Then, she stated in the morning meeting/stand up, the fall was reviewed. She stated the appropriateness of the intervention should also be should reviewed and changes should be made as appropriate. She stated the root cause of the fall was determined in the weekly IDT meeting (she stated the members were nursing leadership, MDS Nurse, the Dietician via phone, the Infection Preventionist, the Quality/Staff Development Nurse, and sometimes the Social Services Director). She stated she did not typically attend the weekly IDT meeting. The Administrator further stated the floor/charge nurses did not add interventions on the care plan and that sometimes the DON did it. She stated it had been the MDS Nurse's responsibility but going forward it would be a team effort. The Administrator stated it was her expectation every employee do their job and that included investigating falls, updating care plans, and ensuring every resident's safety. In another interview with the Administrator on 01/11/2024 at 5:10 PM, she added that the facility had identified falls were occurring at mealtimes, and the process was to have a staff member in the hallway during mealtimes. She stated that had decreased incidents for awhile but did not say if the process was ongoing.

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident's rights set forth that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs for three (3) of thirty-seven (37) sampled residents (Residents #29, #12, and #26). Resident #29 sustained a laceration to the chin requiring six (6) sutures on 02/21/2023 when the bed the resident was in was not locked and rolled causing the resident to fall while receiving care per one (1) persons assistance when the resident was assessed and care planned for two (2) person assist. Resident #12 sustained nine (9) documented falls from 09/24/2023-01/05/2024 with six (6) documented active interventions on his/her fall care plan, none of which were dated. There was no care plan for monitoring psychotropic medications for side effects. Resident #26's care plan was not specific regarding how often staff should round. Resident #26 was ordered and care planned a splint for his/her left hand, which was not observed, and the resident reported it had not been applied in months. The findings include: Review of the facility's policy, Care Plan Policy and Procedure, dated 08/13/2023, revealed the facility would maintain an up-to-date plan of care on each resident with a procedure to include the Interdisciplinary Team (IDT) or Licensed Nurse to be responsible for updating the plan of care as changes in individual care needs occurred. Further review revealed the care plan was the primary instrument used to meet the objectives for each resident, and the focused approach sought favorable outcomes. 1. Review of Resident #29's Electronic Health Record (EHR) revealed the facility admitted the resident on 03/04/2022 with diagnoses that included unspecified dementia without behavioral disturbance, need for assistance with personal care, and other reduced mobility. The facility assessed Resident #29, in a Quarterly Minimum Data Set (MDS) Assessment, dated 07/20/2023, as severely cognitively impaired and requiring extensive assist of two (2) with bed mobility and with incontinence care. Review of Resident #29's Comprehensive Care Plan, last reviewed 10/17/2023, revealed the resident was care planned for two (2) person assist with toileting and bed mobility, but these interventions were undated. Resident #29 was also care planned for transfers with a mechanical lift, which was also undated. Review of Resident #29's Fall Report, dated 12/21/2023, revealed Resident #29 had a fall with injury on 12/21/2023 at 7:00 PM while a State Registered Nurse Aide (SRNA) was assisting the resident with incontinence care. Per the report, the resident rolled out of bed before the SRNA could stop the resident. The report stated Resident #29 was sent to the emergency room and required six (6) stitches to repair a laceration to his/her chin. Interview on 01/11/2024 at 8:01 AM with SRNA #6, she stated she was working on 12/21/2023 with Resident #29. She stated she was going to give Resident #29 care and had never had any problem changing him/her before. SRNA #6 stated she was changing Resident #29 and did not realize the bed was not locked. She stated in her four (4) years working at the facility, nothing like that had ever happened. The SRNA stated the bed rolled when she turned to get wipes, Resident #29 became unstable, and the resident fell too fast for her to prevent the fall. SRNA #6 stated Resident #29 immediately became a two (2) person assist after that. She also stated she now always checked to ensure beds were in the locked position before providing any kind of care. SRNA #6 was unaware of Resident #29 being assessed as requiring extensive assist of two (2) with bed mobility and with incontinence care previously. In an interview with SRNA #4 on 01/10/2024 at 1:15 PM, she stated resident care plans or the Kardex were not documented in the SRNA care plans on the computer, and usually the nurses just told the SRNAs about resident care during shift change report. SRNA #4 stated she had been informed Resident #29 was a one (1) person assist, and was unaware of Resident #29 being assessed and care planned as two (2) assist prior to the 12/21/2023 fall. In an interview with SRNA #23 on 01/10/2024 at 2:48 PM, she stated if she had questions about how a resident transferred or toileted, she either asked the other SRNAs or the charge nurse. She stated there was an aid Kardex on the computer where she did her charting. However, she stated she had never seen it but knew where to look for it. She stated she mainly got her resident information on rounds from the previous shift staff. During an interview with Licensed Practical Nurse (LPN) #2 on 01/10/2024 at 3:32 PM, she stated she believed Resident #29 was a one (1) person assist with changing, but was not certain as she had not worked with Resident #29 recently. In interview with the Director of Nursing (DON) on 01/11/2024 at 4:18 PM, she stated she would expect staff to ensure care plan interventions were implemented and care plans would be referenced by all staff before providing care. She state, she noted the intervention for two (2) person assistance in the notes section and SRNA #6 should have asked for assistance prior to providing toileting care and bed mobility for Resident #29. 2. Review of Resident #12's Face Sheet revealed the facility admitted the resident on 08/08/2023 with diagnoses of unspecified dementia with agitation, muscle weakness, and unsteadiness on his feet. Review of Resident #12's Admission Minimum Data Set (MDS) Assessment, section C for cognition, dated 08/15/2023, revealed a Brief Interview for Mental Status (BIMS) score of five (5) of fifteen (15), indicating severe cognitive impairment. Review of Resident #12's Admission MDS Assessment, dated 08/08/2023, section GG, revealed Resident #12 used a walker and a wheelchair for mobility; and needed assistance with bathing, dressing, using the toilet, and eating prior to the current illness, exacerbation, or injury. Resident #12 also needed assistance with walking from room to room (with or without a device such as cane, crutch, or walker) prior to the current illness, exacerbation, or injury; and as needing assistance with internal or external stairs (with or without a device such as cane, crutch, or walker) prior to the current illness, exacerbation, or injury. Review of Resident #12's Quarterly MDS Assessment, section C for cognition, dated 11/15/2023, revealed a Brief Interview for Mental Status (BIMS) score of six (6) of fifteen (15), indicating severe cognitive impairment. Review of Resident #12's Quarterly MDS Assessment, dated 11/15/2023, section GG, revealed there were no changes to Resident #12's functional ability since the Admission MDS Assessment, dated 08/08/2023. Review of Resident # 12's Comprehensive Care Plan (CCP) for falls, last reviewed 11/16/2023, revealed Resident #12 was at risk for and had falls related to gait and balance problems, psychoactive drug use, decreased safety awareness, and cognitive impairment. The documented goal was for Resident #12 to be free of injury from falls through the target date of 02/14/2024. Documented active interventions, all undated and unclear as to which fall the interventions were in response to, included encourage resident to use the call light for assistance as needed, encourage resident to wear non-skid footwear when ambulating as the resident allowed, encourage resident to toilet before/after meals, encourage use of assistive device, walker to promote independence when ambulating, physical therapy as ordered, and Resident #12 needed a safe environment with floors free from spills and/or clutter, adequate glare free lighting, a working and reachable call light, the bed in low position at night and personal items within reach. Three (3) additional undated interventions included: follow the facility's fall protocol, encourage Resident #12 to participate in activities that promoted exercise, physical activity for strengthening and improved mobility such as Sittercise. Resident #12 needed activities that minimized the potential for falls while providing diversion and distraction were marked as resolved on 12/10/2023. Review of Resident #12's Clinical Orders, dated 08/08/2023, revealed an active order for Seroquel (an antipsychotic medication which side effects included dizziness and faintness and lightheadedness when getting up from a lying or a sitting position). The order was for a Seroquel twenty-five milligram (25 mg) tablet to be given by mouth two (2) times a day and a Seroquel three-hundred milligrams (300 mg) tablet to be given by mouth at bedtime. Review of Resident #12's CCP revealed no care plan had been developed for the use of a psychoactive medication and the monitoring for adverse side effects. Review of the facility's document Incidents by Incident Type, printed on 01/09/2024, revealed Resident #12 sustained nine (9) falls on the following dates: 09/24/2023 at 10:58 PM, 09/24/2023 at 11:53 PM, 10/15/2023 at 7:28 PM, 10/28/2023 at 8:25 AM, 12/05/2023 at 5:55 PM, 12/30/2023 at 2:04 AM, 01/01/2024 at 9:44 AM, 01/03/2024 at 7:45 AM, and 01/05/2024 at 1:05 PM. a. Review of Resident #12's Fall Incident Report, dated 09/24/2023 at 10:58 PM, revealed Resident #12 was found kneeling at the bedside. Resident #12 was documented to have stated he/she was trying to get up and here I am on the floor. No injuries were observed, and it was documented no witnesses were found. No immediate intervention was identified to place on the CCP. b. Review of Resident #12's Fall Incident Report, dated 09/24/2023 at 11:53 PM, revealed Resident #12 was found sitting on the floor in front of the sink and had stated he/she was walking to the sink to empty a pitcher of water, lost his/her balance, and fell hitting the wall with his/her left arm. No injury was documented, and it was documented no witnesses were found. No immediate intervention was identified to place on the care plan. c. Review of Resident #12's Fall Incident Report, dated 10/15/2023 at 7:28 AM, revealed Resident #12 was found on the floor beside the bed, and the resident stated he/she rolled out of bed. A small abrasion was noted to the back, left side of Resident #12's head. No immediate intervention was identified to place on the care plan. d. Review of Resident #12's Fall Incident Report, dated 10/28/2023 at 7:28 AM, revealed Resident #12 was found with his/her head on a pillow on the floor, and the resident's waist/legs remained on the bed. Resident #12 stated he/she leaned over and rolled off the bed. No injuries were noted. No immediate intervention was identified to place on the care plan. e. Review of Resident #12's Fall Incident Report, dated 12/05/2023 at 5:55 PM, revealed Resident #12 was found sitting on the floor beside the bathroom door. Resident #12 stated he/she was coming from the bathroom and lost his/her balance. Resident #12 had his/her walker nearby but did not have shoes on. No injuries were noted. No immediate intervention was identified to place on the care plan. f. Review of Resident #12's Fall Incident Report, dated 12/30/2023 at 2:04 PM, revealed Resident #12 was lying on the floor next to the bed with his/her head toward the foot of the bed and facing the wall, and it appeared his/her feet were tangled up in the blanket. No injuries were noted. No immediate intervention was identified to place on the care plan. g. Review of Resident #12's Fall Incident Report, dated 01/01/2024 at 9:44 AM, revealed Resident #12 attempted to get out of bed without assistance, did not use the call light, had regular socks on, and stated he/she slid out of the bed. No injuries were noted. No immediate intervention was identified to place on the care plan. h. Review of Resident #12's Fall Incident Report, dated 01/03/2024 at 7:45 AM, revealed Resident #12 was found lying on the floor next to his/her bed on his/her left side. Resident #12 was unable to give a description of what happened. No injuries were noted. No immediate intervention was identified to place on the care plan. Further review of Resident #12's Fall Incident Report, the notes section dated 01/04/2024, revealed Resident #12's recent increase in falls was discussed and therapy would assess and adjust the plan of care accordingly to decrease the risk of future falls. However, no adjustments to the plan of care were observed on Resident #12's CCP for Falls. i. Review of Resident #12's Fall Incident Report, dated 01/05/2024 at 1:05 PM, revealed Resident #12 was found lying on the floor in front of the nurses' station on his/her right side with his/her right arm at a natural angle behind his/her head and both legs bent at the knees. Resident #12 stated that he/she did not know why he/she fell . Further review of Resident #12's Fall Incident Report, the notes section dated 01/08/2024, revealed Resident #12 was sent to the hospital emergency department for evaluation related to complaints of neck pain and returned with no new orders or acute injury notes. The note further documented, upon review of Resident #12's fall history, it was noted the majority of his/her falls occurred during or within an hour or two (2) of mealtimes, so staff would encourage Resident #12 to toilet before/after meals in an attempt to decrease falls. This intervention appeared on Resident #12's CCP but was undated and unclear as to which fall it was in response to. In an interview on 01/10/2024 at 3:31 PM with Licensed Practical Nurse (LPN) #2, she stated an intervention was put in place after each fall on the resident's care plan and asked, Isn't that an MDS kind of thing? When asked if she knew how to tell if a resident was care planned as a fall risk, she stated she would have to look that up. LPN #2 stated nurses were made aware of resident care needs through verbal report and through the care plans which were on the computer. She stated if something changed with a resident's care, she communicated that to the staff on the floor verbally. In an interview on 01/11/2024 at 3:30 PM with the MDS Nurse, she stated she had been in that role since Monday but had been with the facility as a floor nurse since 01/17/2023. The MDS Nurse stated she was scheduled for MDS training in February 2024 and had just begun working on care plan updates. She stated she was aware care plans needed to be developed/updated after each fall with a new intervention as soon as possible. The MDS Nurse stated she was not aware the system did not date the care plan entries. In an interview on 01/10/2024 at 8:10 AM with the Director of Nursing (DON), she stated she currently had a process improvement plan in progress for fall investigations and care plans because she saw that there were concerns in those areas. The DON stated her expectation would be a new fall intervention would be placed on the resident's care plan, which she had explained to floor staff. In an additional interview on 01/10/2024 at 12:40 PM with the DON, she stated the Seroquel was being used off label (the practice of using a drug for a different purpose then what the Food and Drug Administration (FDA) approved) to manage Resident #12's dementia with agitation, and there was no approved diagnosis for the use of this medication for Resident #12. She further stated it was her expectation the use of any psychoactive medication be on the resident's care plan. 46710 3. Review of Resident #26's Face Sheet revealed the facility admitted the resident on 07/02/2020 with diagnoses including hemiplegia (paralysis) of left side of the body, chronic kidney disease, and type 2 diabetes. Review of Resident #26's Quarterly MDS Assessment, dated 11/30/2023, revealed the facility assessed the resident's cognition with a BIMS score of fifteen (15) of fifteen (15), indicating the resident was cognitively intact. a. Review of Resident #26's Care Plan, dated 12/03/2023, revealed the facility assessed the resident as having left sided paralysis and listed interventions including: reposition as tolerated with every care round and encourage the resident to be up in a chair daily. Observation on 01/09/2024 from 9:30 AM to 11:45 AM revealed no staff entered Resident #26's room during this time to reposition Resident #26. Observation on 01/07/2024 at 2:43 PM of Resident #26's room revealed there was no chair available for the resident to sit in. In an interview on 01/07/2024 at 2:43 PM, Resident #26 stated staff did not routinely reposition him/her, but occasionally a staff member would place a pillow in different positions for offloading. Per interview, Resident #26 stated he/she did not refuse repositioning as long as he/she could still reach his/her personal items. In further interview, Resident #26 stated he/she would like to sit in a recliner on the days he/she did not go to dialysis, but the facility told him/her that he/she could not have a recliner due to not having enough space in his/her room. b. Review of Resident #26's Care Plan, dated 12/03/2023, revealed the facility identified the resident had a left hand contracture and listed the intervention to place a splint to the left hand for up to four (4) hours per day as tolerated. Review of the facility's document Nursing Rehab, dated 12/13/2023 through 01/11/2024, revealed staff members charted they applied the splint on three (3) occasions during that time frame. The rest of the days, staff marked not applicable for this task. Observation on 01/07/2024 at 2:43 PM revealed the splint was available on Resident #26's bedside table. In an interview on 01/07/2024 at 2:43 PM, Resident #26 stated staff had only applied the splint to his/her left hand contracture two (2) or three (3) times in the last month. In an interview on 01/10/2024 at 1:15 PM, State Registered Nurse Aide (SRNA) #4 stated she did not know Resident #26 had a splint that staff members were to apply to his/her contracted hand every day. In an interview on 01/10/2024 at 3:31 PM, LPN #2 stated she was not aware of Resident #26's need for a splint and had not applied it to the resident at any time. In an interview on 01/11/2024 at 4:08 PM, the DON stated Resident #26 reported to her on 01/09/2024 that staff had not applied his/her brace to his/her contracture. Per interview, the DON stated she believed staff members needed additional education to ensure they knew how to access residents' care plans. In an interview on 01/11/2024 at 5:30 PM, the Administrator stated she did not know why staff failed to apply the splint as described in Resident #26's Care Plan but stated she did expect staff to implement care planned interventions.

Based on interview, record review and review of the facility's policy, it was determined the facility failed to ensure the Comprehensive Care Plan was revised for two (2) of fourteen (14) sampled residents (Resident #8 and #6). Resident #8 was assessed by the facility on 01/29/14, to require the assistance of two (2) staff for bed mobility. However, review of the Comprehensive Care Plan revealed no documented evidence it was revised to include this information until 03/06/14, when Resident #8 experienced a fall from his/her bed while being assisted by only one (1) staff person. Resident #8 sustained a Right Patella (Kneecap) Fracture as a result of the fall. Also, at the time of the survey, staff caring for Resident #8 were not aware the resident was to have two (2) staff assist with bed mobility. Additionally, Resident #6's Comprehensive Care Plan was not revised in regards to discontinuing weights as per a family request and written physician's orders [REDACTED]. The findings include: Review of the facility's policy titled, "Individual and Interdisciplinary Plan of Care", undated, revealed it was the policy of the facility to maintain an up to date care plan for each resident. The Care Plan was to be comprehensive and reflect the needs of the residents. According to the Policy, it was the intent of the facility to achieve and maintain each resident's highest practicable physical, psychosocial, and functional status. 1. Review of Resident #8's medical record revealed [DIAGNOSES REDACTED]. Review of Resident #8's Quarterly Minimum Data Set (MDS) Assessment, dated 01/29/14, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of thirteen (13) which indicated the resident was not cognitively impaired. Further review of the MDS revealed the facility assessed Resident #8 to require extensive two (2) staff assist for bed mobility and as being frequently incontinent of bowel and bladder. Review of the Comprehensive Care Plan dated 05/22/13, revealed Resident #8 an Activities of Daily Living (ADL's) care plan related to the resident's [DIAGNOSES REDACTED]. Continued review of the ADL care plan revealed an intervention dated 05/22/13 which was revised 10/20/13 that stated Resident #8 required limited assist of one (1) staff to turn and reposition in bed. Further review of the ADL care plan revealed an intervention which was undated, that stated Resident #8 was to have the extensive assist of two (2) to turn and reposition in bed. In addition, review of the Comprehensive Care Plan revealed a risk for falls care plan revised 05/15/13, revealed a goal which stated Resident #8 would not sustain serious injury. Further review of the risk for falls care plan revealed an intervention dated 03/06/14, the date of the resident's fall, which stated Resident #8 was to have two (2) staff members assistance for bed mobility. Review of the Resident #8's "Nurse Aide Daily Care Plan Record" dated March 2014, which was utilized by State Registered Nursing Assistants (SRNAs) to inform them of residents' care needs, revealed bed mobility was marked as extensive assist of one (1) staff, highlighted as changed on 03/06/14, and marked as assist of two (2) staff. Review of the Nurse's Notes revealed a "late entry, dated 03/06/14 at 8:45 AM, written by the DON. Continued review of the "late entry" Note revealed it was documented in regards to an incident which occurred on 03/06/14 at 6:00 AM, where a SRNA reported she was assisting Resident #8 to turn in the bed when the resident rolled out of bed and fell to the floor. Further review of the "late entry" Note revealed Resident #8 reported he/she rolled close to the edge of the bed and rolled out of the bed. Review of the Nurse's Notes/Condition Change Form, dated 03/06/14 at 10:00 AM, revealed the resident complained of right leg pain after rolling out of bed that morning. The Physician ordered an x-ray; x-ray results were received; and, sent to the Physician with no new orders received. Review of the Nurse's Note, dated 03/06/14 at 7:10 PM, revealed the Advanced Practice Registered Nurse, (APRN) called with new orders regarding the x-ray results and staff was to obtain a orthopedics consult for Resident #8. Continued review of the Nurse's Notes/Condition Change Forms, revealed on 03/07/14 at 10:05 AM, Resident #8 complained of right leg pain and a call was placed to the APRN with an order received to transfer Resident #8 to the hospital emergency room (ER). Review of the Hospital ER Note dated 03/07/14, revealed Resident #8 was diagnosed with [REDACTED]. Interview, on 05/14/14 at 12:10 PM, with Resident #8 revealed a SRNA was providing perineal care and he/she was trying to help with rolling over so the SRNA cleanse him/her. Resident #8 stated he/she was being assisted by only the one (1) SRNA at the time, and rolled too close to the edge of the bed, and ended up rolling out onto the floor. Phone interview, on 05/14/14 at 4:40 PM, with State Registered Nursing Assistant (SRNA) #4, revealed she was often assigned to Resident #8. SRNA #4 explained SRNA's referred to the "nurse aide care plan" (Daily Care Plan Record) at the nurse's station to know what care residents' needed. She stated when she was in a resident's room she had nothing to refer to related to the resident's care. She stated sometimes it was hard to remember all the interventions listed on the Daily Care Plan Record, and reported she was unsure what the care plan said regarding bed mobility for Resident #8. She stated on 03/06/14, she was providing incontinence care for Resident #8 when the resident rolled over too far in the bed and fell to the floor. Continued interview revealed she was never questioned about the incident or educated by the DON or by administrative staff related to the incident. She reported she was still turning and repositioning Resident #8 by herself at that time and the resident still tried to help and often rolled over too far. SRNA #4 stated other staff were also turning and positioning the resident in the bed without assistance of two (2) staff. Phone interview on 05/14/14 at 5:05 PM, with Registered Nurse (RN) #2 who was assigned to Resident #8 at the time of the fall on 03/06/14, revealed SRNA #4 reported the resident had rolled out of bed and had landed on the floor, but had not hit his/her head. She stated she was never questioned about the incident or educated by the DON or administration. She indicated she thought Resident #8 was a one (1) person assist with bed mobility at the time of the fall. Continued interview revealed she thought Resident #8 was still a one (1) person assist for bed mobility and did not think that had changed after the fall on 03/06/14. RN #2 further stated staff referred to the Nurse Aide Care Plan or the Comprehensive Care Plan for a reference for care. Interview, on 05/14/14 at 5:15 PM and 5:45 PM, with the MDS Coordinator, revealed she obtained information needed to completed the MDS's by interviewing staff about the residents care needs and functional abilities. She stated she also had the SRNAs' complete the seven (7) days of Activities of Daily Living (ADL) Tracker which specified what type of assistance residents required, and how many staff was required to assist the residents with bed mobility, eating, transfers and toileting. The MDS Coordinator stated she also observed staff during care to see how much assistance the residents required. Further interview revealed the MDS Coordinator generated the Comprehensive Care Plans and the Daily Care Plan Record from the MDS Assessments. Continued interview with the MDS Coordinator revealed the DON, Social Services (SS) and the Activities Coordinator worked together as a team to develop and revise care plans in the care plan meetings. After reviewing the MDS dated [DATE], and the Comprehensive Care Plan and Daily Care Plan Record, the MDS Coordinator stated the Comprehensive Care Plan and Daily Care Plan Record was not revised until after Resident #8's fall on 03/06/14 to include the required two (2) staff assist for bed mobility. However, she stated the intervention for the two (2) staff assist with bed mobility should have been added to the Care Plans after she completed the 01/29/14 MDS. Interview, on 05/14/14 at 4:10 PM and 7:00 PM and 05/15/14 At 3:45 PM, with the Director of Nursing (DON), revealed the MDS Coordinator completed the Comprehensive Care Plans which were reviewed for accuracy in the care plan meetings by her and the other interdisciplinary staff, which consisted of SS, the MDS Coordinator and sometimes therapy staff. She stated the care plan information was then put on the Nurse Aide Care Plan/Daily Care Plan Record by the MDS Coordinator. Per interview, the DON revealed the last MDS completed, prior to the fall on 03/06/14, was a Quarterly MDS completed on 01/29/14, which stated Resident #8 required two (2) staff to assist with bed mobility. However, the DON stated both the Comprehensive Care Plan and the SRNA's Daily Care Plan Record were not updated until after Resident #8's fall on 03/06/14, for two (2) staff to assist him/her with bed mobility. According to the DON, the Comprehensive Plan of Care and the Daily Care Plan Record should have been updated at that time to reflect Resident #8 required two (2) staff assist with bed mobility as the Care Plan was generated from the MDS Assessment. The DON revealed the interdisciplinary team met the morning after any fall to discuss causes for the falls and need for any new interventions. She stated for Resident #8's 03/06/14 fall she felt the root cause was the resident being assisted by only one (1) staff instead of two (2) for bed mobility. The DON revealed she had not re-educated the staff involved at the time of Resident #8's fall, and stated staff were not always informed of changes in the care plan. The DON explained SRNA's were to review the Daily Care Plan Record which was kept at the nurse's station, daily at the beginning of their shift to know what care residents required. She further stated the only communication to staff for any changes made in reference to care of residents, was by them reviewing the Daily Care Plan Record or Comprehensive Care Plan. Interview, on 05/14/14 at 6:35 PM, with the Quality Assurance (QA) Nurse revealed revisions made to the Comprehensive Care Plans or the Daily Care Plan Record (nurse aide care plan) were not communicated verbally to staff. The QA Nurse stated however, the SRNA's were expected to read the Daily Care Plan Record at the beginning of each shift and should recognize any changes then to residents' care. 2. Review of Resident #6's medical record revealed [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed Resident #6 as having a BIMS score of nine (9) indicating moderate cognitive impairment. Additional review revealed the facility assessed Resident #6's weight as two hundred and fifty-four (254) pounds. Review of the May 2014 physician's orders [REDACTED].#6's weight assessments as requested by Resident #6's family due to the resident's Chronic Back Pain. Review of the Comprehensive Plan of Care dated 06/06/13, revealed a care plan related to nutritional status in regards to the family bringing in full meals at least three (3) times a week for Resident #6. Continued review of the care plan revealed a goal for the resident not to develop complications related to Obesity. Further review revealed no documented evidence the Comprehensive Care Plan was revised to discontinue Resident #6's weights as per the physician's orders [REDACTED]. Interview, on 05/14/14 at 5:15 PM and 05/15/14 at 5:00 PM, with the MDS Coordinator revealed Resident #6's Comprehensive Care Plan was not revised to discontinue the resident's weight measurements. She stated if the facility weighed Resident #6 because the request was not care planned, it could have contributed to increasing the resident's back pain or caused emotional distress for him/her. The MDS Coordinator stated she was responsible for ensuring the care plans were revised; however, it was also a team approach and the care plans were reviewed by the DON, Social Services and the Activities staff during care plan meetings. She stated revisions of care plans was supposed to be automatic when the physician's orders [REDACTED]. The MDS Coordinator reported when she completed residents' MDS Assessments she was supposed to go through the care plan updates forms and transcribe the pertinent information to the Comprehensive Care Plan. Further interview revealed Resident #6's Comprehensive Care Plan should have been revised to include the intervention to discontinue the weights as the original order was dated 08/26/13, and the last MDS was completed 03/04/14.

Based on interview, record review and review of the facility's policy, it was determined the facility failed to ensure each resident received adequate supervision and assistance to prevent accidents for one (1) of fourteen (14) sampled residents (Resident #8). Resident #8 was assessed by the facility to require the assistance of two (2) staff for bed mobility per the Minimum Data Set (MDS) assessment dated [DATE]; however, the Comprehensive Care Plan revised 10/29/13 revealed the resident required limited assist of one (1) staff to turn and reposition in the bed. The Daily Care Plan Record, a reference State Registered Nursing Assistants (SRNAs) used to indicate residents' care needs, dated March 2014, revealed Resident #8 required extensive assistance of one (1) staff member for bed mobility. On 03/06/14, Resident #8 was being assisted by one (1) staff member with bed mobility during incontinence care, even though he/she had been assessed to require two (2) staff for this. Resident #8 fell off the bed and sustained a Right Patella (Kneecap) Fracture. In addition, there was no documented evidence of a Nurse's Note written in the medical record by the nurse who assessed the resident at the time of the fall which occurred on 03/06/14 at 6:00 AM, to include an assessment and notifications to the Physician and the Responsible Party. Also, there was no documented evidence staff who was assigned to Resident #8's care at the time of the fall were questioned to try and determine the root cause of the fall. Additionally, the facility failed to ensure the residents' environment remained as free of accident hazards as possible as evidenced by a hanging ceiling vent cover over the toilet in a resident bathroom which staff indicated could cause harm to the resident if it fell . The findings include: Review of the facility's policy titled, "Falls Management Program", revised 10/16/12, revealed it was the policy of the facility to safeguard residents while promoting the highest possible level of independence and quality of life. The Policy stated this would be accomplished through: assessment of all residents to establish their risk for falls; care planning; and implementing appropriate interventions to minimize falls and injuries related to falls; and, tracking and trending patterns. Review of Resident #8's medical record revealed [DIAGNOSES REDACTED]. Review of Resident #8's Quarterly Minimum Data Set (MDS) Assessment, dated 01/29/14, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of thirteen (13) out of fifteen (15), indicating he/she was cognitively intact. Continued review revealed the facility assessed Resident #8 as requiring extensive assistance of two (2) persons for bed mobility and as being frequently incontinent of bladder and bowel. Review of the seven (7) day Activities of Daily Living (ADL's) Tracking form dated 01/23/14 through 01/29/14, for the MDS dated [DATE], revealed Resident #8 required two (2) staff to assist with bed mobility. Review of the Comprehensive Care Plan dated 05/22/13, revealed Resident #8 required assistance with Activities of Daily Living (ADL's) related to [DIAGNOSES REDACTED]. Continued review of the ADL care plan revealed the goal stated Resident #8 would maintain the current level of function related to bed mobility, transfers, toilet use, and personal hygiene. The interventions dated 05/22/13 and revised 10/20/13, revealed Resident #8 required limited assist of one (1) to turn and reposition in bed. Further review of the ADL care plan revealed an undated intervention which stated Resident #8 was to have extensive assist of two (2) to turn and reposition in bed. Continued review of the Comprehensive Care Plan revealed a risk for falls care plan, revised 05/15/13, related to Resident #8 being unaware of his/her safety needs. Review of the risk for falls care plan revealed a goal which stated the resident would not sustain serious injury. Further review of the risk for falls care plan revealed a new intervention added on 03/06/14, after the resident's fall that day, which stated Resident #8 was to have two (2) staff members for bed mobility. Review of the "Daily Care Plan Record" for March 2014, revealed bed mobility was marked as extensive assist of one (1) staff, and highlighted as changed on 03/06/14 to indicate Resident #8 required assist of two (2) staff. Interview, on 05/14/14 at 4:10 PM and 7:00 PM and 05/15/14 At 3:45 PM, with the DON revealed the Comprehensive Care Plan and the Daily Care Plan Record should have also reflected Resident #8's assessed need for two (2) to assist with bed mobility, as the Care Plan was generated from the MDS. However, she stated both the Comprehensive Care Plan and the Daily Care Plan Record were not updated until 03/06/14 after Resident #8's fall to include the intervention for two (2) staff to assist with bed mobility. Review of the facility's Fall Risk Evaluation form, dated 01/28/14 which was the last Fall Risk Evaluation completed before Resident #8's fall on 03/06/14, revealed when all the scores on the form were added the total score equaled sixteen (16) which indicated the resident was a high risk for falls. The Evaluation form stated a total score of ten (10) or above represented a high risk for falls. However, further review of the Fall Risk Evaluation revealed the total score documented on the form for Resident #8 was noted to be six (6), instead of sixteen (16) which would not indicate the resident was a high risk for falls. Continued review of the Fall Risk Evaluation revealed the parameters evaluated included Resident #8's status or condition related to disorientation, chair bound, not able to perform gait/balance, current medications and three (3) or more predisposing diseases. Interview, on 05/14/14 at 5:15 PM and 5:45 PM, with the MDS Coordinator revealed she completed Fall Risk Evaluations on all residents on admission, quarterly, yearly and with a significant change. She stated she had inadvertently written a six (6) instead of a sixteen (16) on the Fall Risk Evaluation completed on 01/28/14 for Resident #8 and she clarified the resident was at high risk for falls. Review of the Nurse's Notes revealed no documented evidence a Nurse's Note was written at the time of Resident #8's fall on 03/06/14 at 6:00 AM. However, review of the Nurse's Notes dated 03/06/14 at 8:45 AM, noted as a late entry for 03/06/14 at 6:00 AM, which had been completed by the Director of Nursing (DON) revealed a SRNA reported assisting Resident #8 to turn in the bed, and the resident continued to roll, and rolled out of bed. Continued review revealed vital signs were documented as: blood pressure as 123/63, pulse as 78, respirations as 18, and temperature as 98.2. Continued review of the late entry Note revealed Resident #8 stated he/she had rolled close to the bed edge and rolled out of the bed. The late entry Note stated the Physician was notified with no new orders at that time, and the resident's family was also notified. Review of the Nurse's Notes/Condition Change Form, dated 03/06/14 at 10:00 AM, revealed Resident #8 complained of right leg pain after rolling out of bed in the "AM" (morning). Per the Note, an x-ray was ordered by the Physician and Radiology and the family was notified. Review of the Nurse's Notes, dated 03/06/14 at 5:00 PM, revealed x-ray reports were received and sent to the Physician with no new orders received. Review of the Nurse's Notes, dated 03/06/14 at 7:10 PM, revealed the Advanced Practice Registered Nurse (APRN) called with new orders regarding the results of the x-rays and staff was to obtain a orthopedics consult. Review of the Nurse's Notes dated 03/07/14 9:00 AM, revealed Resident #8 was encouraged to stay in bed and not put weight on the right knee, and the resident denied complaints of pain or discomfort. Review of the Nurse's Notes/Condition Change Form, dated 03/07/14 10:05 AM, revealed Resident #8 complained of right leg pain, a call was placed to the APRN, and new orders received to send Resident #8 to the hospital emergency room (ER). Review of the Nurse's Notes, dated 03/07/14 at 10:20 AM, revealed Emergency Medical Services (EMS) was notified for transport and the resident was transported on 03/07/14 at 10:35 AM. Review of the Hospital ER Note dated 03/07/14, revealed Resident #8 had a Fracture of the right Patella. Continued review of the Hospital ER Note revealed Resident #8 was to be non-weight bearing and was to keep an ace wrap on the right leg for support. Interview, on 05/14/14 at 12:10 PM, with Resident #8 revealed he/she was trying to assist an SRNA with completing his/her perineal care in bed and had rolled over so the SRNA could finish washing him/her. Resident #8 stated he/she was being assisted by only one (1) SRNA at the time, and rolled too close to the edge of the bed and ended up rolling out onto the floor. The resident stated he/she "yelled" and five (5) other staff arrived after that. Resident #8 stated he/she had hurt his/her right leg. Phone interview, on 05/14/14 at 4:40 PM, with SRNA #4 revealed she was frequently assigned to Resident #8. She stated on 03/06/14, she was providing incontinence care for Resident #8 which included perineal care and applying a new brief. SRNA #4 stated Resident #8 rolled over too far in the bed and fell to the floor landing on her/his buttocks with her/his back against the dresser and wall. She reported she went to get the nurse who assessed Resident #8 by obtaining vital signs and checking the resident's arms and legs for movement. Continued interview revealed Resident #8 denied pain, and she and the nurse assisted the resident to a standing position and back on the bed. SRNA #4 stated she was never questioned or educated by the DON or by administrative staff related to the incident, and was still turning and repositioning Resident #8 by herself, although the resident still tried to help when being turned and often rolled over too far. SRNA #4 stated other staff were also turning and positioning Resident #8 in the bed without assistance. However, review of the Daily Care Plan Record used by SRNAs when providing resident care, revealed Resident #8's was revised on 03/06/14 for the resident to have two (2) person assistance with bed mobility. Further interview with SRNA #4 revealed SRNA's were to refer to the "nurse aide care plan" (Daily Care Plan Record) at the nurse's station when providing care for residents; however, she had nothing to reference for care needs while she was in residents' rooms and had to try to remember all interventions for the residents. She stated she was unsure what the care plan said regarding bed mobility for Resident #8. Phone interview, on 05/14/14 at 5:05 PM, with Registered Nurse (RN) #2 who was assigned to Resident #8 at the time of the fall on 03/06/14, revealed SRNA #4 came to her and reported the resident had rolled out of bed and had landed on the floor but had not hit his/her head. She stated she assessed Resident #8 by obtaining vital signs, and assessed for range of motion and pain. RN #2 stated she and SRNA #4 assisted the resident back to bed and she did not remember if they used a mechanical lift for transfer or stood the resident up. She stated she had filled out an Incident Report and also written the fall incident on the Twenty-Four (24) Hour Report. RN #2 reported she thought she had documented the incident and her assessment of the resident in the Nurse's Notes. She stated she was never educated related to the incident or questioned by the DON or administration. RN #2 stated she thought Resident #8 was still to have only a one (1) person for bed mobility and did not think that had changed. However, review of the Comprehensive Care Plan and SRNAs "Daily Care Plan Record" revealed they were revised 03/06/14 for Resident #8 to have assistance of two (2) staff with bed mobility. Further interview with RN #2 revealed staff were to refer to the "Nurse Aide Care Plan" or the Comprehensive Care Plan as a reference for care needs for residents. Continued interview on 05/14/14 at 5:15 PM and 5:45 PM, with the MDS Coordinator revealed she obtained information needed to complete the MDS's by interviewing staff about residents' care needs and functional abilities. She stated she also had the SRNAs' complete the seven (7) days of the ADL Tracker form which specified what type of assistance the resident required and how many staff was required to assist the resident in bed mobility, eating, transfers and toileting. The MDS Coordinator stated she also observed staff during care to see how much assistance residents required. She stated she generated the Comprehensive Care Plans and the Daily Care Plan Record from the MDS Assessments. According to the MDS Coordinator, she completed the Daily Care Plan Record at the beginning of each month. Continued interview revealed for Resident #8 she should have noted on the Comprehensive Care Plan and the Daily Care Plan Record, the resident was to have assist of two (2) for bed mobility, after she completed the 01/29/14 MDS, which had revealed the resident needed two (2) for bed mobility. Further interview with the MDS Coordinator revealed the DON, Social Services (SS) and the Activities Coordinator worked together as a team to develop and revise care plans in the care plan meetings. Interview, on 05/14/14 at 4:10 PM and 7:00 PM and 05/15/14 at 3:45 PM, with the DON revealed the facility could not share Incident Reports or fall investigations as they were part of the facility's Quality Assurance. However, during the interview, she allowed the Surveyor to briefly glance at the investigation information to check for a nursing assessment and notifications to the Physician and Responsible Party after the fall. She stated Resident #8's fall occurred on 03/06/14 at 6:00 AM, and she had written the late entry related to the fall on 03/06/14 at 8:45 AM. She further stated she had taken information from the Incident Report, completed by RN #2, to document the late entry including vital signs. The DON revealed the nurse, RN #2, who assessed Resident #8 should have documented her assessment in the Nurse's Notes because the Incident Report and fall investigation were not a part of the permanent record. She stated her expectation was for the nurse to assess for pain, skin condition, range of motion, vital signs, and document this assessment, as well as, document notifications to the Physician and responsible party. Continued interview revealed her investigation of the fall consisted of reading the Incident Report and fall investigation completed by RN #2 and interviewing Resident #8. According to the DON, the last MDS completed prior to the fall on 03/06/14, was a Quarterly MDS completed on 01/29/14, which stated the resident required two (2) to assist with bed mobility. She stated the Comprehensive Care Plan and the Daily Care Plan Record should have also reflected Resident #8's assessed need for two (2) to assist with bed mobility, as the Care Plan was generated from the MDS. The DON reported normally the MDS Coordinator completed the Care Plans which were reviewed for accuracy in the Care Plan meeting by her and the interdisciplinary staff, which consisted of the Social Worker, the MDS Coordinator and sometimes therapy staff. She stated this information was then placed on the Nurse Aide Care Plan/Daily Care Plan Record by the MDS Coordinator. The DON revealed the interdisciplinary team met as a group the next morning after any fall to discuss the reasons for the fall and any new interventions needed. She stated in regards to Resident #8's fall she felt the root cause of the fall was the resident being assisted with one (1) staff, instead of two (2) as assessed for bed mobility. She stated both the Comprehensive Care Plan and the Daily Care Plan Record was updated on 03/06/14 for two (2) staff to assist with bed mobility. Further interview with the DON, revealed she had not performed interviews or re-education with the staff involved at the time of the resident's fall, and confirmed changes in the care plan were not necessarily verbalized to staff. The DON stated the SRNA's were to review the Daily Care Plan Record daily, at the beginning of each shift. She further stated all communication to staff for any changes made in reference to care of the resident, was by review of the Daily Care Plan Record or Comprehensive Care Plan, as there was not necessarily verbal communication to staff when a change was made. Interview, on 05/14/14 at 6:35 PM, with the Quality Assurance Nurse revealed changes made to the Comprehensive Care Plans or the Daily Care Plan Record were not communicated verbally to staff; however, the SRNA's were expected to read the Daily Care Plan Record at the beginning of each shift and should recognize any changes then. 2. Observation on initial tour of Room 211 on 05/13/14 at 11:27 AM revealed a hanging ceiling vent cover over the toilet seat in the resident bathroom. Interview with SRNA #1 on 05/13/14 at 11:34 AM, revealed the ceiling vent cover had been like that "for awhile". She stated the vent cover should have been reported to maintenance, especially since it could have fallen and hit a resident in the head and caused injury. Interview with the Quality Assurance Nurse on 05/13/14 at 11:44 AM, revealed the ceiling vent cover should not hang from the ceiling, as it held the possibility of injury to a resident if it fell on their head. She stated the loose vent cover should have been reported to maintenance for repair. Observation on 05/15/14 at 5:44 PM with the Maintenance Director, revealed the bathroom vent cover was still loose from the ceiling in Room 211. Interview, during the observation, with the Maintenance Director revealed a loose ceiling vent cover could be a safety hazard, as it could fall on a resident.