Every finding on record at Hilltop Nursing & Rehabilitation Center

Based on interview and record review the facility failed to ensure that a resident maintained acceptable parameters of nutritional status for 1 (Resident #11) of 3 residents reviewed for nutrition/weight loss. The facility failed to provide dietary interventions for a resident with significant weight loss. Findings:Review of the undated facility Nutrition/Hydration Management Policy revealed in part .It is the goal of the ID team, with participation by the RD consultant, that residents of this facility maintain acceptable parameters of nutritional status to the extent medically possible. At a minimum, the following residents will be referred to the High Risk committee: Significant weight change (5% or greater in 30 days or less, 10% or greater in 180 days or less). Review of Resident #11's medical record revealed an admission date of 12/29/2025 with a re-entry date of 02/05/2026 with diagnoses that included in part .Hemiplegia and Hemiparesis following Cerebral Infarction affecting Right Dominant Side, Deficiency of Other Vitamins, and Muscle Wasting. Review of Resident #11's 02/2026 physician orders revealed in part.Weekly Weights (initiated 12/30/2025), Resident is at high risk of malnutrition related to GERD, Hyperlipidemia, Hypertension, Anxiety, Pain, and Hypothyroidism (initiated 12/31/2025). Review of Resident #11's admission MDS with an ARD of 01/02/2026 revealed a BIMS score of 14, which indicated intact cognition. Resident #11 required set-up assistance with eating. Review of Resident #11's Significant Change MDS with an ARD of 02/09/2026 revealed Resident #11 had weight loss of 5% or more in the last month and was not on a prescribed weight loss regimen. Review of Resident #11's Weekly Weights Summary Report revealed:12/31/2025-108.001/01/2026-108.201/06/2026-100.0 01/13/2026-101.201/20/2026-101.8 (-5.0% change over 30 days Comparison Weight 12/31/2025, 108.0 lbs, -5.6%, -6.0 lbs)01/27/2026-100.0 (-7.5% change, Comparison Weight 01/01/2026, 108.2 lbs, -7.6%, -8.2 lbs)02/05/2026-101.8 (-5.0% change over 30 days, Comparison Weight 01/01/2026 108.2 lbs, -5.6%, -6.0 lbs) Review of Resident #11's Care Plan with a review date of 03/30/2026 read in part.Focus: High risk for malnutrition and dehydration related to poor appetite secondary to diagnoses of GERD, Hypothyroidism, Vitamin Deficiency, Anxiety, Pain, Nausea. Intervention: Weigh weekly, Report significant weight loss to MD/NP. Review of Resident #11's medical record revealed no evidence of dietary interventions to address Resident #11's significant weight loss. In an interview on 02/10/2026 at 4:00 p.m., S3 DON stated Resident #11 had a stroke recently, was sent out to the hospital on [DATE], and returned on 02/05/2026. S3 DON reviewed Resident #11's weights with this surveyor and confirmed Resident #11 had significant weight loss. S3 DON stated she was responsible for charting residents' weights into the computer. S3 DON stated anytime the weight triggered as weight loss she would notify the physician and S11 RD to receive a house supplement for the residents. S3 DON confirmed that there was no evidence or documentation of any dietary interventions to address Resident #11's significant weight loss prior to Resident #11's hospitalization but should have been. In a telephone interview on 02/11/2026 at 9:35 a.m., S11 RD revealed she was not notified of Resident #11's significant weight loss. S11 RD stated her first time seeing Resident #11 was on 02/10/2026 in which she made new recommendations to address the significant weight loss. S11 RD stated if she had been contacted by the facility in January 2026 of Resident #11's significant weight loss she would've implemented interventions to address the weight loss at that time.

Based on observation and interview the facility failed to maintain a clean and sanitary kitchen in accordance with professional standards for food service safety. This deficient practice had the potential to affect all 9 residents who received a puree diet. The facility failed to ensure staff were wearing a beard restraint during meal preparation.Findings:Observation on 02/09/2026 at 11:15 a.m., revealed S13 [NAME] with a hair net on and a full beard/goatee with no beard restraint while preparing the puree recipe for all 9 residents. S13 [NAME] stated he always prepared the puree meals for the residents in the facility.In an interview on 02/09/2026 at 12:45 p.m., S4 Dietary Manager confirmed, S13 [NAME] did not have on a beard restraint net to cover his beard during puree meal preparation and should have.

Based on observation and interview, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents and staff by failing to provide an adequate number of clean washcloths and towels. This deficient practice had the potential to affect all 89 residents residing in the facility.Findings:On 02/09/2026 at 1:30 p.m., the Resident Council Meeting was conducted, and it was revealed that two of the residents expressed concerns over not having enough towels or washcloths available in the clean linen storage on the hall to properly clean and dry themselves.Interview with S7 Laundry on 02/10/2026 at 8:58 a.m. revealed that linens, towels, and washcloths are delivered to the halls between 8:00 a.m. and 9:00 a.m.Observation of linen closets on 02/10/2026 at 12:10 p.m. revealed that Hall X had six towels and no washcloths.Observation of linen closets on 02/10/2026 at 3:02 p.m. revealed that Hall V had no towels and four washcloths and Hall W had one towel and four washcloths.Interview with S8 Laundry on 02/10/2026 at 3:45 p.m. revealed that linens, towels, and washcloths are picked up during her 3:00 p.m. to 11:00 p.m. shift and washed, dried, and placed back in the hall clean linen storage. However, after 11:00 p.m. there is no laundry service until the morning workers come into work.Observation of linen closets on 02/11/2026 at 7:32 a.m. revealed Hall V had no towels or washcloths, Hall W had no towels and one washcloth, Hall X had six towels and one washcloth, Hall Z had no towels or washcloths.Interview with S7 CNA, S8 CNA, and S9 CNA on 02/11/2026 at 7:37 a.m. revealed that not having an adequate amount of towels and washcloths for resident care had been an ongoing issue. All three CNAs reported that they do not have towels or washcloths in the clean linen storage on their halls. S7 CNA, S8 CNA, and S9 CNA reported that they had to search the facility to find towels or washcloths.Interview with S12 CNA on 02/11/2026 at 7:48 a.m. revealed that upon arrival to work that morning, there were no towels or washcloths available for resident care. She reported that towels and washcloths are routinely used when providing peri- and ADL care to residents.Interview with S9 Laundry on 02/11/2026 at 7:45 a.m. revealed that the facility only used towels and washcloths to provide peri- and ADL care for the residents in the facility.Interview with S2 Assistant Admin on 02/11/2026 at 9:31 a.m. confirmed there was an inadequate number of towels and washcloths for all residents in the facility.

Based on interviews and record review, the facility failed to ensure residents received mail on Saturdays. This has the potential to affect all 89 residents residing in the facility.Findings:Review of the facility admission packet dated 02/2023, revealed in part- under the Mail section of Resident Rights .The resident has the right to- (1) Send and promptly receive mail that is unopened.On 02/09/2026 at 1:30 p.m., the Resident Council Meeting was conducted, and it was revealed that the residents did not receive mail on Saturdays. The Resident Council were in agreement that if resident mail was delivered on a Saturday, they would like to received their personal mail on the same day as it was delivered to the facility. During this same Resident Council meeting, the S5 SSD stated that the residents do not receive mail on Saturdays and that she received all of the weekend mail on Monday mornings to then sort and distribute to the residents on Monday.In an interview on 02/11/2026 at 9:31 a.m., S2 Assistant Admin stated that the Weekend Activity Director should distribute resident mail on Saturdays, when it is received and not wait until Monday morning.In a telephone interview on 02/11/2026 at 10:00 a.m., S6 Weekend SSD revealed she had been working as the Weekend Activity Director since 03/2024 and was never trained or instructed to procure, sort, or deliver mail to the residents on Saturdays. The Weekend Activity Director confirmed that no mail had been delivered to the residents on Saturday since her hiring in March 2024.

Based on interview and record review, the facility failed to implement a comprehensive person-centered care plan consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 (Resident #11) residents of 3 sampled residents reviewed for nutrition. The facility failed to ensure the Physician and Registered Dietician was notified of significant weight loss for Resident #11, who was at high risk for malnutrition according to their plan of care.Findings: Review of the undated facility Nutrition/Hydration Management Policy revealed in part .It is the goal of the ID team, with participation by the RD consultant, that residents of this facility maintain acceptable parameters of nutritional status to the extent medically possible. At a minimum, the following residents will be referred to the High Risk committee: Significant weight change (5% or greater in 30 days or less, 10% or greater in 180 days or less). Review of Resident #11's medical record revealed an admission date of 12/29/2025 with a re-entry date of 02/05/2026 with diagnoses that included in part .Hemiplegia and Hemiparesis following Cerebral Infarction affecting Right Dominant Side, Deficiency of Other Vitamins, and Muscle Wasting. Review of Resident #11's 02/2026 physician orders revealed in part.Weekly Weights (initiated 12/30/2025), Resident is at high risk of malnutrition related to GERD, Hyperlipidemia, Hypertension, Anxiety, Pain, and Hypothyroidism (initiated 12/31/2025). Review of Resident #11's admission MDS with an ARD of 01/02/2026 revealed a BIMS score of 14, which indicated intact cognition. Resident #11 required set-up assistance with eating. Review of Resident #11's Significant Change MDS with an ARD of 02/09/2026 revealed Resident #11 had weight loss of 5% or more in the last month and was not on a prescribed weight loss regimen. Review of Resident #11's Weekly Weights Summary Report revealed:12/31/2025-108.001/01/2026-108.201/06/2026-100.0 01/13/2026-101.201/20/2026-101.8 (-5.0% change over 30 days, Comparison Weight 12/31/2025, 108.0 lbs, -5.6%, -6.0 lbs)01/27/2026-100.0 (-7.5% change, Comparison Weight 01/01/2026, 108.2 lbs, -7.6%, -8.2 lbs)02/05/2026-101.8 (-5.0% change over 30 days, Comparison Weight 01/01/2026 108.2 lbs, -5.6%, -6.0 lbs) Review of Resident #11's Care Plan with a review date of 03/30/2026 read in part.Focus: High risk for malnutrition and dehydration related to poor appetite secondary to diagnoses of GERD, Hypothyroidism, Vitamin Deficiency, Anxiety, Pain, Nausea. Intervention: Weigh weekly, Report significant weight loss to MD/NP. In an interview on 02/10/2026 at 4:00 p.m., S3 DON stated the floor nurses would conduct weekly weights on the residents. S3 DON stated they would then bring the weights to her and she would put the weights into the computer and it would trigger a warning if there was significant weight loss for a resident. S3 DON revealed that Resident #11 had significant weight loss and stated the facilities process is to notify the physician and S11 RD of significant weight loss. S3 DON reviewed Resident #11's Electronic Health Record with this surveyor and stated if it's not charted then the physician or S11 RD wasn't notified. S3 DON confirmed that she did not notify the physician or S11 RD of Resident #11's significant weight loss but should have. In a telephone interview on 02/11/2026 at 9:35 a.m., S11 RD revealed she was not notified of Resident #11's significant weight loss. S11 RD stated her first time seeing Resident #11 was on 02/10/2026 in which she made new recommendations to address the significant weight loss. S11 RD stated if she had been contacted by the facility in January 2026 of Resident #11's significant weight loss she would've implemented interventions to address the weight loss at that time.

Based on observation, record review and interviews the facility failed to ensure residents who are unable to carry out Activities of Daily Living (ADL) received the necessary services to maintain bed mobility. The facility failed to provide bed mobility/repositioning as ordered for 1 (Resident #5) of 2 sampled residents reviewed for ADLs. Findings:Review of undated policy on 02/11/2026 at 2:15 p.m. titled, Positioning (Movement in Bed) revealed the following on page 6.4) Change position at least every 2 hours if resident is unable to move in bed without assistance, base frequency decisions on the resident's age, size, weight, circulatory and integumentary status and medical diagnosis. Review of Resident #5's medical record revealed an admit date of 03/21/2022 and a re-entry date of 11/04/2024 with diagnoses that included in part.Parkinson's Disease without Dyskinesia, Other Persistent Atrial Fibrillation, Bipolar Disorder, Generalized Anxiety Disorder, Other Specified Depressive Disorder, Alcohol Abuse, and Other Hypotension. Review of Resident #5's Quarterly MDS with an ARD date of 10/10/2025 revealed a BIMS of 9, which indicated moderate cognition. Resident #5 required supervision or touching assist with repositioning. Review of Resident #5's care plan revealed in part .Intervention: Turning and repositioning program: turn and/or reposition every 2 hours and prn while in bed/chair. On 02/10/2026 at 8:00 a.m. an observation of Resident #5's room revealed an over bed signage located on the resident's bedside wall and easily visible. Observed the over bed signage stating Resident #5 required the following repositioning clock image times: 12:00 a.m./p.m. R (right side); 2:00 a.m./p.m. L (left side); 4:00 a.m./p.m. B (back side); 6:00a.m./p.m. R (right side); 8:00 a.m./p.m. L (left side); and 10:00 a.m./p.m. B (back side).On 02/10/2026 at 9:40 a.m. an observation of S14 CNA and S17 CNA revealed the CNAs enter Resident #5's room to reposition him. Observed the CNAs exit Resident #5's room. At the time of observation, S14 CNA revealed Resident #5 required repositioning every 2 hours.In an interview on 02/10/2026 at 9:43 a.m., S14 CNA revealed that she and S17 CNA had assisted Resident #5 with repositioning while in bed. On 02/10/2026 from 8:30 a.m. - 12:30 p.m. an observation revealed Resident #5 was not repositioned every 2 hours and still positioned on his back side. In an interview on 02/10/2026 at 2:02 p.m., S14 CNA stated residents are repositioned every 2 hours. S14 CNA confirmed she did not reposition Resident #5 every 2 hours but should have.In an interview on 02/10/2026 at 2:06 p.m., S3 DON stated that staff were to reposition/turn residents every 2 hours. S3 DON confirmed the above findings. S3 DON confirmed Resident #5 required turning and repositioning every 2 hours and S14 CNA should have repositioned him but did not.

Based on observation, interview, and record review the facility failed to ensure that a resident received adequate supervision to prevent incidents and accidents. The facility failed to ensure a resident received supervision while smoking for 1 (Resident #34) of 1 resident reviewed for smoking. Findings: Review of the facility's undated policy on 02/11/2026 at 9:59 a.m. titled Smoking Policy read in part . Residents and Visitors: Do Not Allow residents who have been classified as non-responsible to smoke alone. Review of Resident #34's medical record revealed she was admitted to facility on 06/06/2011 and had diagnoses that included in part Primary Generalized Osteoarthritis, Lack of Coordination, Anxiety Disorder, and Drug Induced Subacute Dyskinesia. Record review of Resident #34's Quarterly MDS with an ARD of 01/09/2026 revealed Resident #34 had a BIMS of 12, and was a current tobacco user. Record review of Resident #34's 02/2026 physician orders revealed in part.Resident is an unsafe smoker. Smoking plan is as follows: Resident will receive only 1 cigarette at a time at designated smoke times in designated areas with staff supervision. Record review of Resident #34's Smoking Safety assessment dated [DATE] revealed Resident #34 was determined to be an unsafe smoker. Resident #34 was to receive 1 cigarette at a time at designated smoke times in designated smoke times with staff supervision. Review of Resident #34's Care plan revealed in part.Resident is an unsafe smoker. Smoking plan is as follows: resident will resident will receive only 1 cigarette at a time at designated smoke times in designated areas with staff supervision. Observation on 02/09/2026 at 12:15 p.m. revealed Resident #34 was being wheeled outside to designated smoking area by a staff member. Staff member provided Resident #34 with 1 cigarette, lit the cigarette, and walked away leaving Resident #34 unsupervised while she smoked. Observation on 02/09/2026 at 12:20 p.m. revealed Resident #34 sitting in designated smoking area smoking a cigarette unsupervised. Observation on 02/10/2026 at 8:31 a.m. revealed Resident #34 sitting outside in designated smoking area unsupervised. At 8:37 a.m. S10 Charge RN along with this surveyor observed Resident #34 sitting outside in designated smoking area smoking unsupervised. S10 Charge RN revealed that Resident #34 was an unsafe smoker. In an interview on 02/10/2026 at 8:45 a.m. S3 DON stated if a resident is deemed as an unsafe smoker and requires staff supervision then the resident should be supervised while smoking. S3 DON confirmed that Resident #34 was an unsafe smoker and should have been supervised when smoking but was not.

Based on observation, interview, and record review, the facility failed to ensure that the residents received a mechanically altered diet as ordered by the physician for 3 (#4, #49, #50) of 3 residents reviewed. This deficient practice had the potential to affect 9 residents receiving pureed diets. Findings: Resident #4 Review of Resident #4's medical record revealed an admit date of 09/26/2025.with diagnoses that included in part.Generalized Anxiety Disorder, Essential (Primary) Hypertension, Chronic Embolism and Thrombosis of Other Specified Veins, and Localized Edema. Review of Resident #4's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) date of 01/09/2026 revealed a Brief Interview for Mental Status (BIMS) of 11, which indicated moderate cognitive impairment. Resident #4 required setup or clean-up assist with eating. Review of Resident #4's physician orders dated 01/26/2026 revealed an order for Regular NSOT (no salt on tray) diet, pureed texture, and Regular/thin consistency liquids. Review of Resident's #4's care plan revealed in part. Intervention: regular NSOT (no salt on tray) diet, pureed texture, regular/thin consistency liquids. On 02/10/2026 at 8:15 a.m., an observation was conducted inside of Resident #4's room during his breakfast. Resident #4's breakfast tray consisted of scrambled eggs and ground sausage. The food items were not of pureed consistencies. Review of Resident #4's meal ticket revealed: Regular NSOT diet, pureed texture, regular/thin consistency liquids. Resident #49 Review of Resident #49's electronic health record revealed an admission date of 07/18/2023 with diagnoses which included: Atherosclerotic Heart Disease, Hypertension, Congestive Heart Failure, and Severe Protein Calorie Malnutrition. Review of Resident #49's Quarterly MDS with an ARD of 01/23/2026 revealed a BIMS score of 99, indicating Resident #49 was unable to complete the interview. Resident #49 received a mechanically altered diet that required modification of food texture. Review of Resident #49's Physician's Order dated 07/15/2025 read in part. Regular diet, pureed texture, regular/thin (liquids). Review of Resident #49's comprehensive care plan with a revision date of 03/31/2025 read in part.Resident #49 was at risk for a nutritional problem. An intervention dated 07/15/2025 included Resident #49's diet changed to puree to allow for better tolerance. On 02/09/2026 at 8:47 a.m., observation of Resident #49's meal ticket for breakfast revealed Resident #49 was ordered a regular diet with pureed texture. Observation of Resident #49's breakfast tray revealed sausage that was ground in texture rather than pureed as ordered. On 02/10/2026 at 8:38 a.m., observation of Resident #49's meal ticket for breakfast revealed Resident #49 was ordered a regular diet with pureed texture. Observation of Resident #49's breakfast tray revealed sausage that was ground in texture rather than pureed as ordered. Resident #50 Review of Resident #50's electronic health record revealed an admission date of 01/15/2025 with diagnoses which included: Diffuse Traumatic Brain Injury, Nutritional Deficiencies, Hypertension, Chronic Obstructive Pulmonary Disorder, Dysphagia following other Cerebrovascular Disease, and Cognitive Communication Disorder. Review of Resident #50's Quarterly MDS with an ARD of 12/26/2025 revealed a BIMS score of 7, indicating moderate cognitive impairment. Resident #50 received a mechanically altered diet that required modification of food texture. Review of Resident #50's Physician's Order dated 12/06/2024 read in part. Regular diet, pureed texture, nectar/mildly thick (liquids). Review of Resident #50's comprehensive care plan with a revision date of 12/19/2025 read in part.Resident #50 had alteration in nutrition and was at risk for malnutrition. Interventions included: Regular diet, pureed in texture, nectar/mildly thick consistency and double portions with all meals. On 2/10/2026 at 8:32 a.m., observation of Resident #50's meal ticket for breakfast revealed Resident #50 was ordered a regular diet with pureed texture. Observation of Resident #50's breakfast tray revealed sausage that was ground in texture rather than pureed as ordered. On 2/10/2026 at 8:56 a.m., observation of Resident #49's breakfast tray was conducted in the presence of the S4 Dietary Manger. S4 Dietary Manager confirmed Resident #49 was ordered a pureed diet but received ground meat. S4 Dietary Manager further acknowledged that Resident #4 and Resident #50, who were ordered pureed diets, received ground meat.

Based on observations and staff interviews the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment. The facility failed to ensure personnel stored and processed linens so as to prevent the spread of infection by not drying and storing laundered lift slings, privacy curtains, mattress protectors, and Geri-chair cushions in a sanitary manner. This deficient practice had the potential to affect the 89 residents living in the facility. On 02/10/2026 at 3:45 p.m. and on 02/11/2026 at 7:45 a.m., an observation was conducted of an area outside the laundry room door which revealed lift slings and a privacy curtain draped on a metal rack. These items were piled on top of each other and open to outside air and elements.In an interview on 02/11/2026 at 7:45 a.m. with S9 Laundry revealed this was how lift slings and privacy curtains were dried and stored because the laundry had nowhere else to dry or store large items.On 02/11/2026 at 1:00 p.m., an observation was conducted of the area outside the laundry room door which revealed a metal hanging rack with 6 lift slings, 1 privacy curtain, and a geri-chair cushion piled on top of each other and draped over the rack. The privacy curtain was hanging down, touching the concrete, and had debris on it.An interview on 02/11/2026 at 1:00 p.m. with S9 Laundry revealed laundry workers wash lift slings, privacy curtains, and geri-chair cushions. S9 Laundry stated they hang them on the metal rack to dry and they stay there until someone picks them up. S9 Laundry confirmed the privacy curtain was touching the concrete and had debris on it, but should not have.On 02/11/2026 at 1:30 p.m. an observation and interview was conducted with S16 Laundry Supervisor which confirmed the above findings. S16 Laundry Supervisor revealed the CNAs remove the slings from the lifts at night, take them to the laundry where they are washed and hung to dry on the metal hanging rack. S16 Laundry Supervisor stated CNAs should come get the slings each morning. S16 Laundry Supervisor removed the curtain from the rack and noticed debris and rust marks on the curtain where it was in contact with the metal rack. S16 Laundry Supervisor confirmed the lift slings, privacy curtain, and the Geri-chair pad on the rack should have been clean, but they were not.

Based on record review and interview, the facility failed to ensure a resident's right to be free from neglect by failing to provide the necessary care and services to 1 (Resident #1) of 3 (Resident #1, Resident #2 and Resident #3) sampled residents. Findings:The deficient practice resulted in an Immediate Jeopardy situation for Resident #1 on 07/24/2025 at approximately 2:30 a.m. when Resident #1 was found on the floor by S3 LPN and complained of neck pain. Resident #1 was placed back into bed and S3 LPN failed to notify the Physician of Resident #1's fall and failed to medicate Resident #1 for complaints of pain. Resident #1 sustained a second fall on 07/24/2025 at 4:30 a.m. and then complained of neck, back, and head pain at that time. Resident #1 was transported to the hospital on [DATE] at 7:40 a.m. and was diagnosed with a fracture of his C-4, C-5 and C-6. Pain medications that were ordered and available for Resident #1 were not administered.S1 Administrator was notified of the Immediate Jeopardy situation on 08/27/2025 at 2:45 p.m.This deficient practice continued at a potential for more than minimal harm for all residents in the facility that had the potential to fall or required the need for pain medications. The census was 89.Findings: On 08/25/2025, a review of the facility's policy titled Abuse-Neglect Prevention Manual with a revision date of 04/03/2025, revealed in part., Definitions: (G). Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional stress. On 08/25/2025, a review of the facility's policy titled Falls, with no revision date, revealed in part.Procedure: 3. Ascertain extent and type of injury.4. Make resident as comfortable as condition permits.5. Notify physician for further orders. Follow nursing interventions if required.6. Notify family or guardian.7. Document details in nurses' notes. (All shifts will complete a follow-up note for at least 72 hours.)8. Fill out incident/accident formReview of Resident #1's medical record revealed an admit date of 07/21/2025 with diagnoses that included in part.Heart Disease Unspecified, Dementia in other Diseases, Mood Disturbance, Anxiety and Type II Diabetes Mellitus. Review of Resident #1's Discharge MDS with an ARD of 07/26/2025 revealed a BIMS score of 5 indicating severe cognitive impairment. Review of Resident #1's MDS revealed he required supervision or touching assistance with oral hygiene, personal hygiene; partial/moderate assistance with toileting hygiene, bathing and set-up or clean up assistance with eating. Resident #1 used a manual wheelchair for mobility had no impairments to upper/lower extremities. Review of Resident #1's care plan with a target date of 10/19/2025 revealed in part.1. Physical mobility impaired with interventions that included to assist with bed mobility, transfers, locomotion as necessary or requested, monitor for decline in mobility and notify physician of changes.2. Self-care deficit with interventions that included for resident to receive person-centered care; needs with assist with bathing, hygiene, dressing, and grooming.3. High Risk for falls related to Cerebrovascular Accident and Heart Disease with interventions that included turn bars on bed times two to assist with mobility, assist with transfers as needed, keep assistive devices in reach, keep bed in lowest position with wheels locked, and keep call light in reach. Review of an incident report dated 07/24/2025 at 4:30 a.m. by S4 LPN revealed in part .Nursing Description: This nurse was notified by CNA that resident was lying on the floor. As this nurse entered the room this nurse observed resident lying on the floor on his back between the bed and the air conditioner. Resident stated he didn't know what happened or how he got on the floor. No injuries noted anywhere to residents body upon full body assessment. Range of Motion within normal limits. Resident stated he was having some back, head and neck pain. Daughter notified of incident and transfer of resident to ER to be evaluated and treated. Immediate Action Taken: Full body assessment, Vital signs taken, pain assessment, assisted back into bed x 3 person assist to wait on ambulance to transfer to hospital. Level of Pain-10. Review of Resident #1's Medication Administration Record and Narcotic Log revealed no documentation of pain medicine administered on 07/24/2025. Review of Resident #1's nursing progress notes dated 07/24/2025 at 7:40 a.m. by S2 DON revealed in part.ambulance here to transport resident to the hospital per stretcher due to pain from fall. Nursing progress note dated 07/24/2025 at 1:20 p.m. revealed in part. report received from the hospital regarding resident. Nurse reports CT of the head clear but neck shows C-4 and C-5 fracture and resident will be coming back to the nursing home in a C-collar and to follow up with neurosurgery in 2 weeks. Family aware and has been at the hospital with resident. Review of Resident #1's x-ray dated 07/24/2025 revealed in part.CT of Cervical Spine without contrast. History: Neck pain, fall. Impression: Osteoporosis, mild anterior subluxation C4-C5 and prior anterior and posterior bony fusion C5-C7. Transverse fracture through the body of C5 with additional transverse fractures extending through the fused posterior elements of C5-C6 and this fracture configuration is felt to be unstable. Fractures through the posterior elements of C-4 non-displaced. Interview on 08/25/2025 at 2:00 p.m. with S2 DON revealed Resident #1 was at the facility for 5 days (07/21/2025 through 07/26/2025), on respite care. S2 DON revealed on 07/23/2025 Resident #1 was agitated and kept trying to get out of his wheelchair to ambulate. S2 DON revealed Resident #1 was becoming more difficult to handle. S2 DON stated on 07/24/2024 at 4:30 a.m. Resident #1 was heard hollering by S5 CNA and was found in his room on the floor. S5 CNA stayed with Resident #1 while S6 CNA summoned S3 LPN and S4 LPN. Resident #1 complained of head and neck pain and was sent to the hospital for evaluation. S2 DON stated Resident #1 was diagnosed with fractures to C-4 and C-5 and returned back to the facility on [DATE] at approximately 3:00 p.m. Telephone interview on 08/26/2025 at 8:20 a.m. with S5 CNA revealed on 07/24/2024 S7 CNA came and got her to help with Resident #1, because he had fallen. S5 CNA stated they called for S3 LPN. S5 CNA stated Resident #1 had been up by the nurse's station earlier in the shift saying he wanted to go home. Telephone interview on 08/26/2025 at 8:24 a.m. with S3 LPN revealed she provided care for Resident #1 on 07/24/2025 for the 7:00 p.m. to 7:00 a.m. shift. S3 LPN stated at approximately 4:30 a.m. S6 CNA came to the nurse's station and stated Resident #1 had fallen. S3 LPN stated when she and S4 LPN entered Resident #1's room he was lying on the floor between the bed and air conditioner. S3 LPN stated she assessed Resident #1 and helped him back to bed with the assistance of S5 CNA and S7 CNA .S3 LPN stated Resident #1 complained of head and neck pain. S3 LPN stated Resident #1 had been restless all night and kept trying to get out of the bed. S3 LPN stated Resident #1 had fallen earlier in the morning on 07/24/2025 at approximately 2:00-2:30 a.m. S3 LPN stated S4 LPN and S6 CNA helped her to put Resident #1 back in the bed after the first fall. S3 LPN stated she did not notify the physician or responsible party that resident #1 had fallen between 2:00-2:30 a.m. on 07/24/2025. S3 LPN stated she did not document the fall or tell S1 DON that Resident #1 had fallen between 2:00-2:30 a.m. on 07/24/2025. S3 LPN confirmed she should have notified the physician and documented that Resident #1 had fallen at 2:00-2:30 a.m. on 07/24/2025. During the interview S3 LPN confirmed the following: Resident #1 complained of neck and head pain rated a 10 after the 4:30 a.m. fall; S3 LPN waited 3 hours to send Resident #1 to the hospital after 2 unwitnessed falls. S3LPN failed to administer Resident #1 pain medications that were ordered and available at the facility.Telephone interview on 08/26/2024 at 8:45 a.m. with S6 CNA revealed she was on Resident #1's hall speaking with S5 CNA when they heard Resident #1 yell for help. S6 CNA stated when they entered Resident #1's room he was lying on the floor. S6 CNA stated S3 LPN, S4 LPN and S5 CNA assisted Resident #1 off the floor onto the bed. S6 CNA stated Resident #1 had complained of back and neck pain at this time and was moaning and groaning.Interview on 08/26/2025 at 9:16 a.m. with S7 CNA revealed she was the CNA assigned to Resident #1 on 07/24/2025 7:00 p.m.-7:00 a.m. shift. S7 CNA stated Resident #1 fell twice on the 7:00 pm to 7:00 a.m. shift on 07/24/2025. S7 CNA stated the first fall was at approximately 2:30 a.m. and the second fall was 4:30 a.m. S7 CNA stated she was outside on break during the first fall and S6 CNA called her cell phone and said your resident (Resident #1) fell. S7 CNA revealed she went back into the facility to Resident #1's room, and S3 LPN, S4 LPN, S5 CNA, and S6 CNA had gotten him off the floor back in the bed. S7 CNA stated she had went to check on Resident #1 after his first fall and he was on the floor hollering. S7 CNA stated she called for S5 CNA and she summoned the S3 LPN. S7 CNA stated Resident #1 complained of his neck hurting and was groaning in pain. S7 CNA stated she told S3 LPN that Resident #1 was complaining of his neck hurting. S7 CNA stated she was told by S3 LPN to be quiet and let Resident #1 say if he was hurting. S7 CNA stated Resident #1 did not go to the hospital until much later, but continued to complain of neck pain. Telephone interview on 08/26/2025 at 11:45 a.m. with S4 LPN revealed Resident #1 had fallen twice on the 7:00 pm to 7:00 am shift on 07/24/2025. S4 LPN stated she did not remember the time of the first fall. S4 LPN revealed S3 LPN was the nurse for Resident #1 and she assisted her with the first fall. S4 LPN revealed she did not assist with the second fall that occurred at 4:30 a.m., but did complete the incident report. Interview on 08/26/2025 at 1:05 p.m. with S1 Administrator, S2 DON and S8 Corporate Nurse revealed they were unaware that Resident #1 had fallen twice on the 7:00 pm to 7:00 am shift on 07/24/2025. S1 Administrator, S2 DON and S8 Corporate Nurse confirmed the following: S3 LPN should have notified the physician and the responsible party of both falls, documented the first fall; and called the ambulance promptly and administered pain medications as necessary to Resident #1.Telephone interview on 08/26/2025 at 2:36 p.m. with S9 Hospice CNA revealed she arrived to the facility at 6:30 a.m. on 07/24/2025. S9 Hospice CNA stated she was getting ready to bathe Resident #1 and Resident #1 was grimacing and said his neck was hurting. S9 Hospice CNA stated a nurse came in the room and said Resident #1 had fallen. Interview and record review on 08/26/2025 at 1:05 p.m. with S2 DON of Resident #1's 07/2025 Medication Administration Record and Narcotic Log confirmed no documentation of pain medication given on 07/24/2025. The Immediate Jeopardy was removed on 08/28/20205 at 3:25 p.m. The facility implemented and acceptable Plan of Removal as confirmed through onsite observations, interviews and record reviews prior to exit. Plan of Removal: Actions the facility will take:S3 LPN was suspended from work on 08/27/2025 due to the following reasons: neglecting to notify the MD of the fall, neglecting to document on the incident and neglecting to send the resident to the ER promptly. To establish a baseline a pre-test has been developed for each nurse to complete prior to the in-service. This pre-test contains questions related to documentation of falls in the medical record, notification of MD of regarding falls and sending residents to the ER immediately, if indicated. The pre-test also addresses administration of prn pain medications, if indicated.Education/Training Plan-In-services were initiated for all nurses by the DON and/or ADON on 08/27/2025 and will be completed by 08/28/2025. The in-service covers the following:-The requirements to notify the MD of each and every fall, regardless of injury. This notification should be documented in the medical record.-The requirements to document each and every fall in the medical record. The documentation should include a description of the incident and assessment of the resident.-The importance of promptly sending the resident to the emergency room, when indicated based on the assessment, or as ordered by the MD.-The importance of assessing for pain with falls and administering prn pain medication, if ordered and indicated.-Nurses were reminded to always notify the DON or ADON with any questions or concerns. They were also instructed to immediately notify the DON or ADON with any injury requiring and emergency room visit.To ensure understanding of the in-service, a post-test has been developed for each nurse to complete following the in-service. This post-test also contains questions related to documentation of falls in the medical record, notification of MD of regarding falls and sending residents to the ER immediately, if indicated. The post-test also addresses administration of prn medications, if indicated.Additional in-services will be initiated for all nurses by the DON and/or ADON beginning on 08/28/2025. This in-service will address the following:-The definition of neglect-examples of neglect will be reviewed, which will include the following, at a minimum; Failing to notify the MD of a fall with injury, failing to document a fall, failing to document as assessment following a fall, and failing to promptly send the resident to the ER.Nurses will not be allowed to work until they have been in-serviced. Monitoring of Implemented Actions:To ensure residents are promptly cared for following a fall and no neglect has occurred, a QAPI Monitor had been implemented and will begin on 08/28/2025 to ensure the MD was notified, an assessment was documented, the resident was sent to the ER in a timely manner, if ordered or required, and pain medication was administered, if ordered and indicated. This monitor will be completed by the DON or designee on each fall that occurs 3 times a week for 6 weeks, and then monthly thereafter until compliance is reached.To ensure residents are promptly cared for, falls are addressed and no neglect has occurred, and additional QAPI Monitor has been created. The DON or designee will randomly interview 5 CNA's and 3 nurses, questioning their knowledge of any recent falls. If the staff member recalls a fall, this information will be reconciled with the medical record for compliance. This monitor will be completed 3 x week for 6 weeks, and then monthly thereafter until compliance is reached.To ensure continued understanding of the in-service related to neglect, the DON or designee will interview a random sample of at least 3 nurses 3 x a week for 6 weeks, and them monthly thereafter until compliance is reached. This interview will contain questions related to neglect, notification of MD with falls, documentation of falls in the medical record, documentation of assessments related to falls and sending a resident to the ER promptly when ordered or as required.The effectiveness of the corrective actions will be discussed weekly for 6 weeks at the Quality Assurance and Performances Improvement Meeting with findings added to the QAPI minutes. Additional in-services and/or corrective actions will be implemented as needed.

Based on record review and interview the facility failed to provide care and services that met professional standards of quality for 1 (Resident #1) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents, by failing to ensure physician orders were followed timely for the management of pain, and timely hospital transfer after a fall.Findings:The deficient practice resulted in an Immediate Jeopardy situation for Resident #1 on 07/24/2025 at approximately 2:30 a.m. when Resident #1 complained of neck pain after being found on the floor by S3 LPN. S3 LPN failed to notify the physician of the fall and failed to administer pain medications that were ordered and available to give. Resident #1 sustained a second fall on 07/24/2025 at 4:30 a.m. and complained of neck, back, and head pain at a 10 out of 10 on the pain scale at that time. Resident #1 was not transferred to the hospital for evaluation until 3 hours after transfer orders had been given to S3 LPN. On 07/24/2025 at 1:20 p.m. the hospital notified the facility that Resident #1 had a fracture of his C-4, C-5 and C-6.S1 Administrator was notified of the Immediate Jeopardy situation on 08/27/2025 at 2:45 p.m.This deficient practice continued at a potential for more than minimal harm for all residents in the facility. The census was 89.Findings: Review of a facility's policy titled Code of Ethics with no revision date, revealed in part.2. Facility maintains accurate and reliable clinical documentation to insure that all patient care services are medically necessary and conform with all requirements for the delivery of quality patient care services. Review of a facility's policy titled Code of Conduct, with no revision date, revealed in part.The Code of Conduct is in effect at this facility to protect the rights and safety of all employees and patients. Any employee guilty of any of the following will be subject to immediate dismissal: (21). Inefficiency, inability and/or gross or repeated negligence in the performance of assigned duties. Review of Resident #1's medical record revealed an admit date of 07/21/2025 with diagnoses that included in part.Heart Disease Unspecified, Dementia in other Diseases, Mood Disturbance, Anxiety and Type II Diabetes Mellitus. Review of Resident #1's Discharge MDS with an ARD of 07/26/2025 revealed a BIMS score of 5 indicating severe cognitive impairment. Review of Resident #1's MDS revealed he required supervision or touching assistance with oral hygiene, personal hygiene; partial/moderate assistance with toileting hygiene, bathing and set-up or clean up assistance with eating. Resident #1 used a manual wheelchair for mobility had no impairments to upper/lower extremities. Review of Resident #1's care plan with a target date of 10/19/2025 revealed in part.1. Physical mobility impaired with interventions that included to assist with bed mobility, transfers, locomotion as necessary or requested, monitor for decline in mobility and notify physician of changes.2. Self-care deficit with interventions that included for resident to receive person-centered care; needs with assist with bathing, hygiene, dressing, and grooming.3. High Risk for falls related to Cerebrovascular Accident and Heart Disease with interventions that included turn bars on bed times two to assist with mobility, assist with transfers as needed, keep assistive devices in reach, keep bed in lowest position with wheels locked, and keep call light in reach. Review of an incident report dated 07/24/2025 at 4:30 a.m. by S4 LPN revealed in part .Nursing Description: This nurse was notified by CNA that resident was lying on the floor. As this nurse entered the room this nurse observed resident lying on the floor on his back between the bed and the air conditioner. Resident stated he didn't know what happened or how he got on the floor. No injuries noted anywhere to residents body upon full body assessment. Range of Motion within normal limits. Resident stated he was having some back, head and neck pain. Daughter notified of incident and transfer of resident to ER to be evaluated and treated. Immediate Action Taken: Full body assessment, Vital signs taken, pain assessment, assisted back into bed x 3 person assist to wait on ambulance to transfer to hospital. Level of Pain-10. Review of Resident #1's Medication Administration Record and Narcotic Log revealed no documentation of pain medicine administered on 07/24/2025. Resident #1 had Tramadol HCL 50 Milligrams by mouth every 12 hours as needed for moderate to severe pain ordered and available. Review of Resident #1's nursing progress notes dated 07/24/2025 at 7:40 a.m. by S2 DON revealed in part.ambulance here to transport resident to the hospital per stretcher due to pain from fall. Nursing progress note dated 07/24/2025 at 1:20 p.m. revealed in part. report received from the hospital regarding resident. Nurse reports CT of the head clear but neck shows C-4 and C-5 fracture and resident will be coming back to the nursing home in a C-collar and to follow up with neurosurgery in 2 weeks. Family aware and has been at the hospital with resident. Review of Resident #1's x-ray dated 07/24/2025 revealed in part.CT of Cervical Spine without contrast. History: Neck pain, fall. Impression: Osteoporosis, mild anterior subluxation C4-C5 and prior anterior and posterior bony fusion C5-C7. Transverse fracture through the body of C5 with additional transverse fractures extending through the fused posterior elements of C5-C6 and this fracture configuration is felt to be unstable. Fractures through the posterior elements of C-4 non-displaced. Interview on 08/25/2025 at 2:00 p.m. with S2 DON revealed Resident #1 was at the facility for 5 days (07/21/2025 through 07/26/20205), on respite care. S2 DON stated on 07/24/2024 at 4:30 a.m. Resident #1 was heard hollering by S5 CNA and was found in his room on the floor. S5 CNA stayed with Resident #1 while S6 CNA summoned S3 LPN and S4 LPN. Resident #1 complained of head and neck pain and was sent to the hospital for evaluation. S2 DON stated Resident #1 was diagnosed with fractures to C-4 and C-5 and returned back to the facility on [DATE] at approximately 3:00 p.m.Telephone interview on 08/26/2025 at 8:20 a.m. with S5 CNA revealed on 07/24/2024 S7 CNA came and got her to help with Resident #1, because he had fallen. S5 CNA stated they called for S3 LPN. Telephone interview on 08/26/2025 at 8:24 a.m. with S3 LPN revealed she provided care for Resident #1 on 07/24/2025 for the 7:00 p.m. to 7:00 a.m. shift. S3 LPN stated at approximately 4:30 a.m. S6 CNA came to the nurse's station and stated Resident #1 had fallen. S3 LPN stated when she and S4 LPN entered Resident #1's room he was lying on the floor between the bed and air conditioner. S3 LPN stated she assessed Resident #1 and helped him back to bed with the assistance of S5 CNA and S7 CNA. S3 LPN stated Resident #1 complained of head and neck pain. S3 LPN stated Resident #1 had been restless all night and kept trying to get out of the bed. S3 LPN stated Resident #1 had fallen earlier in the morning on 07/24/2025 at approximately 2:00-2:30 a.m. S3 LPN stated S4 LPN and S6 CNA helped her to put Resident #1 back in the bed after the first fall. S3 LPN stated she did not notify the physician or responsible party that resident #1 had fallen between 2:00-2:30 a.m. on 07/24/2025. S3 LPN stated she did not document the fall or tell S1 DON that Resident #1 had fallen between 2:00-2:30 a.m. on 07/24/2025. S3 LPN confirmed she should have notified the physician and documented that Resident #1 had fallen at 2:00-2:30 a.m. on 07/24/2025. During the interview S3 LPN confirmed the following: Resident #1 complained of neck and head pain rated a 10 after the 4:30 a.m. fall; S3 LPN waited 3 hours to send Resident #1 to the hospital after 2 unwitnessed falls. S3LPN failed to administer Resident #1 pain medications that were ordered and available at the facility. Telephone interview on 08/26/2024 at 8:45 a.m. with S6 CNA revealed she was on Resident #1's hall speaking with S5 CNA at approximately 2:30 a.m. on 07/24/2025 when they heard Resident #1 yell for help. S6 CNA stated when they entered Resident #1's room he was lying on the floor. S6 CNA stated S3 LPN, S4 LPN and S5 CNA assisted Resident #1 off the floor onto the bed. S6 CNA stated Resident #1 had complained of back and neck pain at that time and was moaning and groaning. Interview on 08/26/2025 at 9:16 a.m. with S7 CNA revealed she was the CNA assigned to Resident #1 on 07/24/2025 7:00 p.m.-7:00 a.m. shift. S7 CNA stated Resident #1 fell twice on the 7:00 pm to 7:00 am shift on 07/24/2025. S7 CNA stated the first fall was at approximately 2:30 a.m. and the second fall was 4:30 a.m. S7 CNA stated she was outside on break during the first fall and S6 CNA called her cell phone and said your resident (Resident #1) fell. S7 CNA revealed she went back into the facility to Resident #1's room, and S3 LPN, S4 LPN, S5 CNA, and S6 CNA had gotten him off the floor back in the bed. S7 CNA stated between 3:30 a.m.-4:30 a.m. she had went to check on Resident #1 and he was on the floor hollering. S7 CNA stated she called for S5 CNA and she summoned the S3 LPN. S7 CNA stated Resident #1 had complained of his neck hurting and was groaning in pain. S7 CNA stated she told S3 LPN that Resident #1 was complaining of his neck hurting. S7 CNA stated she was told by S3 LPN to be quiet and let Resident #1 say if he was hurting. S7 CNA stated Resident #1 did not go to the hospital until much later, but continued to complain of neck pain. Telephone interview on 08/26/2025 at 11:45 a.m. with S4 LPN revealed Resident #1 had fallen twice on the 7:00 p.m. to 7:00 a.m. shift on 07/24/2025. S4 LPN stated she did not remember the time of the first fall. S4 LPN revealed S3 LPN was the nurse for Resident #1 and she assisted her with the first fall. S4 LPN revealed she did not assist with the second fall. S4 LPN confirmed she did the incident report on Resident #1 on 07/24/2025 at 4:30 a.m.Interview on 08/26/2025 at 1:05 p.m. with S1 Administrator, S2 DON and S8 Corporate Nurse revealed they were unaware that Resident #1 had fallen twice on 07/24/2025. S1 Administrator, S2 DON and S8 Corporate Nurse confirmed S3 LPN should have notified the physician and the responsible party of both falls, documented the first fall; and administered pain medications as necessary to Resident #1 but had not. Telephone interview on 08/26/2025 at 2:36 p.m. with S9 Hospice CNA revealed she arrived to the facility at 6:30 a.m. on 07/24/2025. S9 Hospice CNA stated she was getting ready to bathe Resident #1 and Resident #1 was grimacing and said his neck was hurting. S9 Hospice CNA stated a nurse came in the room and said Resident #1 had fallen and was complaining of neck pain. Interview and record review on 08/26/2025 at 1:05 p.m. with S2 DON of Resident #1's 07/2025 Medication Administration Record and Narcotic Log confirmed no documentation of pain medication given on 07/24/2025. The Immediate Jeopardy was removed on 08/28/20205 at 3:25 p.m. The facility implemented and acceptable Plan of Removal as confirmed through onsite observations, interviews and record reviews prior to exit. Plan of Removal: Actions the facility will take:S3 LPN was suspended from work on 08/27/2025 due to failing to maintain professional standards of care by not notifying the MD following and unwitnessed fall, not assessing the resident, not administering pain medications that were ordered and available and waiting 3 hours to send the resident to the ER. To establish a baseline a pre-test has been developed for each nurse to complete prior to the in-service. This pre-test contains questions related to documentation of falls in the medical record, notification of MD of regarding falls and sending residents to the ER immediately, if indicated. The pre-test also addresses administration of prn pain medications, if indicated.The DON will complete A Performance Evaluation for each nurse beginning 08/28/2025. Nurses on FMLA will have the Performance Evaluation completed upon return to workEducation/Training Plan-In-services were initiated for all nurses by the DON and/or ADON on 08/27/2025 and will be completed by 08/28/2025. The in-service covers the following:-The requirements to notify the MD of each and every fall, regardless of injury. This notification should be documented in the medical record.-The requirements to document each and every fall in the medical record. The documentation should include a description of the incident and assessment of the resident.-The importance of promptly sending the resident to the emergency room, when indicated based on the assessment, or as ordered by the MD.-The importance of assessing for pain with falls and administering prn pain medication, if ordered and indicated.-Nurses were reminded to always notify the DON or ADON with any questions or concerns. They were also instructed to immediately notify the DON or ADON with any injury requiring and emergency room visit.To ensure understanding of the in-service, a post-test has been developed for each nurse to complete following the in-service. This post-test also contains questions related to documentation of falls in the medical record, notification of MD of regarding falls and sending residents to the ER immediately, if indicated. The post-test also addresses administration of prn medications, if indicated.Additional in-services will be initiated for all nurses by the DON and/or ADON beginning on 08/28/2025. This in-service will address professional standards of practice related to the following: -It is professional standards of practice to notify the MD of falls-It is professional standards of practice, following a fall, to administer pain medications when a resident is in pain and has pain medication ordered. If no pain medication is ordered, the MD should be notified so orders can be obtained. -It is professional standard of practice to promptly send a resident to the ER when ordered or required based on assessment. -Resident Rights will be reviewed with each nurse as well. Nurses will not be allowed to work until they have been in-serviced. Monitoring of Implemented Actions: A QAPI Monitor had been implemented and will begin on 08/28/2025 to ensure Professional Standards are maintained following a fall, by ensuring the MD was notified, an assessment was documented, the resident was sent to the ER in a timely manner, if ordered or required, and pain medication was administered, if ordered and indicated. This monitor will be completed by the DON or designee on each fall that occurs 3 times a week for 6 weeks, and then monthly thereafter until compliance is reached.An additional QAPI Monitor has been created to ensure Professional Standards are maintained following a fall by ensuring that falls have been addressed in the medical record. The DON or designee will randomly interview 5 CNA's and 3 nurses, questioning their knowledge of any recent falls. If the staff member recalls a fall, this information will be reconciled with the medical record for compliance. This monitor will be completed 3 x week for 6 weeks, and then monthly thereafter until compliance is reached.To ensure continued understanding of the in-service related to Professional Standards, the DON or designee will interview a random sample of at least 3 nurse, 3 x a week for 6 weeks, and then monthly thereafter until compliance is reached. This interview will contain questions related to Professional Standards, notification of MD with falls, assessing residents with falls, administering pain medications if needed and available and promptly sending residents to the ER when ordered or required.To further ensure Professional Standards are maintained, the DON or ADON will complete Performance Evaluations on 4 nurses weekly for 6 weeks, and then monthly thereafter until compliance is reached. The Corporate nurse will oversee the plan of removal and plan of correction and will also ensure that follow-up regarding the specific areas will be conducted. The effectiveness of the corrective actions will be discussed weekly for 6 weeks at the Quality Assurance and Performances Improvement Meeting with findings added to the QAPI minutes. Additional in-services and/or corrective actions will be implemented as needed.

Based on observation and interview the facility failed to ensure that the nurse staffing pattern was posted daily. The facility census was 89.Findings: Observation on 08/25/2025 at 11:00 a.m. of the posted facility staffing pattern revealed a date of 08/13/2025. Observation and interview on 08/25/2025 at 2:35 p.m. with S2 DON and S10 RN/Charge Nurse stated the [NAME] Clerk had quit abruptly and she was responsible for the daily posting of the facility's staffing pattern. S2 DON confirmed the posted facility staffing sheet was dated 08/13/2025 and did not reflect the current date or staffing, and it should.

Based on interviews and record reviews, the facility failed to provide quarterly personal funds statements for 3 residents of 3 (Resident #44, Resident #67 and Resident #75) residents review for personal funds. The facility held personal funds for a total of 52 residents. Findings Review of the facility's policy from the Admission Packet dated February 2023 and titled Resident Rights read in part . Resident Rights The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside of the facility. A facility must protect and promote the rights of each resident, including each of the following rights: (c) Protection of resident funds. (4) Accounting and Records (ii) The individual financial record must be available through quarterly statements and on request to the resident or his or her legal representative. Resident #67 Review of Resident #67's records revealed a Resident Fund Authorization form dated 06/07/2024 signed by Resident #67 authorizing the nursing facility to manage all monies received by or for him during his stay in the facility. Review of Resident #67's Financial Report and Statement form signed and dated 06/07/2024 received from S14 BOM revealed in part . I, (Resident #67) make the following choice regarding my financial reports and statements from this facility. (2.) I choose to have all of my financial reports and statements from this facility sent to me at the facility. Interview with Resident #67 on 01/06/2025 at 11:02 a.m. revealed Resident #67 has personal funds held by the facility. Resident #67 stated he does not receive a quarterly statement and is only able to see his balance when he makes a deposit. Interview with Resident #67 on 01/07/2025 at 09:40 a.m. in his room revealed that he has never received a quarterly statement for the funds the facility holds for him and would like to if he could. Resident #44 Review of Resident #44's records revealed a Resident Fund Authorization form dated 08/03/2023 signed by Resident #44 authorizing the nursing facility to manage all monies received by or for him during his stay in the facility. Review of Resident #44's Financial Report and Statement form signed and dated 08/03/2023 received from S14 BOM revealed in part . I, (Resident #44) make the following choice regarding my financial reports and statements from this facility. (2.) I choose to have all of my financial reports and statements from this facility sent to me at the facility. Interview with Resident #44 on 01/06/2025 at 11:38 a.m. revealed he had never received a quarterly statement. Resident #75 Review of Resident #75's records revealed a Resident Fund Authorization form dated 04/19/2022 signed by Resident #75 authorizing the nursing facility to manage all monies received by or for him during his stay in the facility. Review of Resident #75's Financial Report and Statement form signed and dated 04/19/2022 received from S14 BOM revealed in part . I, (Resident #75) make the following choice regarding my financial reports and statements from this facility. (2.) I choose to have all of my financial reports and statements from this facility sent to me at the facility. Interview with Resident #75 on 01/06/2025 at 2:33 p.m. revealed that Resident #75 did not receive a quarterly statement for his personal funds held by the facility and would like to have one. Interview with Resident #75 on 01/07/2025 at 09:01 a.m. revealed that Resident #75 had to ask about his personal funds balance and has never received a quarterly statement and would like to have a statement provided to him quarterly. Interview on 01/08/2025 at 2:57 p.m. with S9 HR and S14 BOM confirmed that Resident #44, Resident #67, and Resident #75 had elected to receive personal funds quarterly statements from the facility but had not received them. S9 HR and S14 BOM revealed there is no system in place to ensure personal funds quarterly statements were provided to residents. S9 HR stated the facility holds personal funds for 52 residents residing in the facility and confirmed that no quarterly statement are given out.

Based on interview and record review, the facility failed to ensure the Quality Assessment and Assurance (QAA) committee meeting was held at least quarterly and included the required staff members. Findings: Review of the facility's undated policy titled Quality Assurance and Performance Improvement and Performance Improvement (QAPI) Guidelines read in part . The committee will identify any issues which negatively affect the quality of care and services provided to residents. *Quarterly-Include Medical Director and Consultants. On a quarterly basis, the Medical Director will review a summary of the Quality Assurance and Performance Improvement activities. Review of the facility's quarterly Quality Assessment and Assurance (QAA) committee sign in sheets revealed the last meeting was conducted on 07/11/2023. Interview on 01/09/2025 at 10:03 a.m. with S2 DON revealed the facility had not conducted quarterly QA committee meetings. Review of the last Quarterly Quality Assurance/Performance Improvement Report and sign in sheet dated 07/11/2023 with S2 DON. S2 DON confirmed that was the last date she recalled having a Quarterly QAA meeting. S2 DON confirmed the medical director nor any governing body member had reviewed any current QAPI data since the last meeting held on 07/11/2023.

Based on observations, interviews and record review the facility failed to ensure the interdisciplinary team assessed and determined if a resident was clinically appropriate for self-administration of medication for 1 resident of 1 (Resident #75) residents reviewed for medication administration. Findings Review of the facility's policy and procedure undated and titled Self-Administration of Medication read in part . Policy: It is the policy of this facility that each resident has the right to self-administer medications, but is the responsibility of the interdisciplinary team to determine that it is safe prior to the resident exercising that right. Procedure: 2. If the resident wishes to self-administer medications, the Interdisciplinary Team must assess the resident's overall ability to safely administer his/her own medications. 3. To assess whether the resident is able to self-administer medications, the criteria on the Assessment for self-administration of medications form will be used . If the right is granted, a specific order to self-administer must be obtained which includes how, when and for what reason the medication can be used. 7. Self- administration of bedside medications must be care planned, including the specific order, granting of approval by IDT, and monitoring for compliance. Review of Resident #75's clinical record revealed an admitted [DATE], with diagnoses which included restlessness and agitation, cataract secondary to ocular disorders, dry eye syndrome of bilateral lacrimal glands and allergic rhinitis. Review of Resident #75's Quarterly MDS with an ARD of 12/23/2024, revealed a BIMS score of 15 indicating intact cognition. Review of Resident #75's 01/2025 Physician Orders revealed in part . Afrin Original Nasal Solution 0.05 % (Oxymetazoline HCl) 2 sprays in each nostril every 12 hours as needed for nasal congestion related to chronic rhinitis with a start date of 08/01/2024. Review of Resident #75's Care Plan revealed Resident #75 was not care planned for self-administration of Afrin (nasal spray). Review of Resident #75's medical record revealed no Self-administration Assessment for Afrin (Nasal spray). Observation and interview on 01/06/2025 at 3:16 p.m. with Resident #75 revealed (Afrin) nasal spray and Carboxymethylcellulose Sod PF Ophthalmic Solution eye drops sitting on the stand next to his bed. Resident #75 revealed the facility knew he was a big boy and could handle self-administering the medications that were observed in his room. Observation in Resident #75's room on 01/07/2025 at 09:01 a.m. revealed one bottle of eye drops and two nasal sprays on the stand by Resident #75's bed. Interview with S15 LPN on 01/08/2025 at 09:35 a.m. revealed that Resident #75 should have had two medicines, the Carboxymethylcellulose Sod PF Ophthalmic Solution eye drops and Afrin Nasal Spray for use at bedside. Review of Resident #75's orders with S15 LPN revealed Resident #75 did not have an order to self-administer the Afrin nasal spray at bedside. S15 LPN confirmed that Resident #75 had been self-administering the nasal spray at bedside but should have had an order for self-administration of the Afrin nasal spray at bedside and Resident #75's Care Plan should have reflected self-administration of the nasal spray, but it did not. Observation of Resident #75's room on 01/08/2025 at 09:40 a.m. revealed one bottle of eye drops and two nasal sprays on the stand next to Resident #75's bed. Interview on 01/08/2025 at 9:48 a.m. with S11 LPN and S12 RN revealed there was no self-administration assessment, physician's order for self- administration, or care plan in place for Resident #75's Afrin nasal spray. S12 RN and S11 LPN confirmed that Resident #75 should not have been self-administering the Afrin nasal spray without a self-administration assessment, physician order, or care plan in place. Interview and observation with S2 DON and S13 RN on 01/08/2025 at 09:50 a.m. confirmed that Resident #75 had Afrin nasal spray in his room on the table next to his bed and it should not have been. S2 DON and S13 RN confirmed that Resident #75 had no physician order or updated care plan for self-administration of the Afrin nasal spray.

Based on observation, interview and record review, the facility failed to ensure a resident received reasonable accommodation of needs. The facility failed to provide reasonable accommodation of needs by failing to ensure call light was accessible by a resident for 1 (Resident #42) of 1 Resident reviewed for Positioning. The total sample size was 44. Findings: Review of facility policy titled Call Light System revealed, in part .each resident, when in their room or in bed, must have the call light placed within reach at all times, regardless of staff assessment of resident ability to use it. When resident is in bed, the call bell should be fastened to the side rail or side of bed he/she is facing. Record Review revealed Resident #42 was admitted on [DATE]. Resident #42 had diagnoses that included, in part . Other Specified Disorders Of The Skin And Subcutaneous Tissue, Other Chronic Pain, Contracture Of Muscle, Other Site, Other Sequelae Of Other Cerebrovascular Disease, Hemiplegia And Hemiparesis Following Cerebral Infarction Affecting Right Dominant Side. Review of Resident #42's Quarterly MDS with ARD of 12/31/2024 revealed BIMS Score of 02, indicating severe cognitive impairment. Resident #42 required extensive one person physical assist with bed mobility and toilet use. Resident #42 was totally dependent, requiring 2 person physical assistance with transfers. Resident #42 required supervised self-performance of eating with one person physical assistance. Review of Resident #42's Care Plan revealed, in part .Keep call light in reach and respond in a timely manner. Observation of Resident #42 on 01/07/2025 at 8:44 a.m. revealed his call light was lying on top of bedding, at the foot of bed. Resident #42 could not reach the call light. Observation of Resident #42 on 01/07/2025 at 9:48 a.m. revealed the call light remained positioned at the foot of bed, and was not in reach of resident. Observation of Resident #42 on 01/08/2025 at 8:42 a.m. revealed the call light was not visible to surveyor. S6 LPN and S7 CNA accompanied to Resident #42's bedside and located the call light behind the bed, near the foot of the bed. Interview with S6 LPN at time of observation confirmed the call light was not within reach of resident, and should have been.

Based on observation, interview and record review, the facility failed to ensure that all alleged violations were reported to the State Survey Agency in accordance with State law through established procedures for 3 (#42, #93, and #96) of 6 (#42, #50, #65, #75, #93, and #96) residents reviewed for Accidents. The total Sample Size was 44. The facility failed to: 1. Ensure serious bodily injury of Resident #42 was reported within 2 hours in accordance with State law through established procedures. 2. Ensure serious bodily injury of Resident #93 was reported within 2 hours in accordance with State law through established procedures. 3. Ensure serious bodily injury of Resident #96 was reported within 2 hours in accordance with State law through established procedures. Findings: Review of the facility policy titled Abuse/Neglect Prevention Program stated, in part . 1.Possible indicators of potential abuse and neglect include: a. Injuries of unknown origin b. Contusions, sprains, lacerations, fractures, strains, scratches and dislocation. 2. A NF must report to HSS incidents of alleged abuse. 3. A NF must report to HSS any suspicious injury of unknown origin to a resident. Injuries of unknown origin include, but not limited to: a. All injuries to cognitively impaired residents not witnessed. b. Injuries that are unexplained. c. Fractures, sprains or dislocations. 4. NF must report to the HSS any incidents and allegations of abuse, neglect .and/or injuries of unknown origin immediately, but not later than 2 hours after the allegation is made, if the event that caused the allegation involves abuse or results in bodily harm or injury. 5. Reporting to be made to HSS in accordance with state law through established procedures. Resident #42 Record Review revealed that Resident #42 was admitted on [DATE]. Resident #42 had diagnoses that included, in part . Other Specified Disorders Of The Skin And Subcutaneous Tissue, Other Chronic Pain, Contracture Of Muscle, Other Site, Other Sequelae Of Other Cerebrovascular Disease, Hemiplegia And Hemiparesis Following Cerebral Infarction Affecting Right Dominant Side. Review of Resident #42's Quarterly MDS with ARD of 12/31/2024 revealed a BIMS Score of 02, indicating severe cognitive impairment. Resident #42 required extensive one person physical assist with bed mobility and toilet use. Resident #42 was totally dependent, requiring 2 person physical assistance with transfers. Resident #42 required supervised self-performance of eating with one person physical assistance. Review of Resident #42's medical record revealed an Injury Incident occurred on 11/08/2024 at 10:28 a.m. Review of Department Progress Notes for Resident #42 revealed an incident note dated 11/08/2024 at 4:43 p.m. that read in part . Nurse Practitioner had performed an assessment and wound care for Resident #42 on 11/07/2024. The NP ordered an x-ray of Resident 42's left lower extremity/tibia/fibula to rule out osteomyelitis on 11/07/2024. The x-ray was performed on 11/08/2024 and revealed an avulsion fracture at the medial femoral condyle with no evidence of osteomyelitis. Interview with S2 DON and S4 Charge Nurse on 01/08/2025 at 12:04 p.m. revealed a consultant wound care NP saw Resident #42 on 11/07/2024 and ordered an x-ray to rule out osteomyelitis. The x-ray showed an avulsion fracture. S4 Charge Nurse stated that S1 Administrator was responsible for reporting injuries to the State Survey Agency. S4 Charge Nurse confirmed that S1 Administrator was notified of Resident 42's fracture. Interview with S1 Administrator and S3 Assistant Administrator on 01/08/2025 at 12:34 p.m. S1 Administrator revealed he was responsible for reporting alleged violations to the State Survey Agency in accordance with State law. S3 Assistant Administrator confirmed the Abuse/Neglect Prevention Program Policy provided on 01/08/2025 was up-to-date and was what was utilized by the facility. S1 Administrator confirmed that the State Survey Agency should be notified of any injury of unknown origin in a cognitively impaired resident. S1 Administrator confirmed on 11/08/2024 the facility was made aware of a major injury for Resident #42. S1 Administrator confirmed Resident #42's fracture should have been reported to the State Survey Agency, but was not. Resident #93 Record review revealed that Resident #93 was admitted to facility on 03/21/2024. Resident #93 had diagnoses that included, in part . Displaced Fracture Of Base Of Neck Of Right Femur, Repeated Falls, Age-Related Physical Debility, Encounter For Other Orthopedic Aftercare, Chronic Pain, Cognitive Communication Deficit, Muscle Wasting And Atrophy, Abnormalities Of Gait And Mobility, Lack Of Coordination, and Displaced Midcervical Fracture Of Right Femur. Record review of Resident #93's Significant Change MDS with ARD of 11/08/2024 revealed a BIMS Score of 07, indicating severe cognitive impairment. Resident #93 required 2 person physical assistance with bed mobility, transfers, and toilet use. Resident #93 required supervised self-performance of eating with setup help only. Review of current Orders for Resident #93 revealed, in part . Resident is high risk for falls dated 03/21/2024. Review of Care Plan for Resident #93 revealed resident was at risk for falls. Review of Resident #93's medical record revealed he had an Un-witnessed Fall on 10/25/2024 at 8:30 a.m. Review of Nurse's Notes for Resident #93 revealed the following, in part . 10/25/2024 at 9:26 a.m. Resident #93 was found on the floor, lying on his right side, with his head and shoulders under the bottom of the bed. Resident #93 complained of pain to his right arm and leg. Resident #93's physician was notified and ordered x-rays of right arm and right leg. 10/25/2024 at 12:31 p.m. x-rays were performed. 10/25/2024 at 4:06 p.m. x-ray results of right tibia/fibula, right elbow, right wrist and right humerus were all negative. 10/25/2024 at 5:28 p.m. x-rays of right hip and pelvis revealed no fracture. 10/29/2024 at 3:27 p.m. resident complained of increased pain to right hip and was unable to move lower extremity. 10/29/2024 at 3:50 p.m. an order was given to repeat x-rays of right hip and right lower extremity. Additional medication for pain was ordered. 10/29/2024 at 4:19 p.m. imaging facility was notified of the order for X-rays. 10/29/2024 at 6:42 p.m. x-rays were being performed. 10/29/2024 at 9:31 p.m. x-rays revealed a right femur neck fracture with impaction. S2 DON and S4 Charge Nurse were interviewed on 01/08/2025 at 12:04 p.m. S4 Charge Nurse stated that S1 Administrator was responsible for reporting injuries to the State Survey Agency. S4 Charge Nurse confirmed that S1 Administrator was notified of Resident #93's fracture on 10/29/2024. Interview with S1 Administrator and S3 Assistant Administrator was conducted on 01/08/2025 at 12:34 p.m. S1 Administrator revealed he was responsible for reporting alleged violations to the State Survey Agency in accordance with State law. S3 Assistant Administrator confirmed the Abuse/Neglect Prevention Program Policy provided on 01/08/2025 was up-to-date and was what was utilized by the facility. S1 Administrator confirmed that the State Survey Agency should be notified of any un-witnessed injury of a cognitively impaired resident. S1 Administrator confirmed that no one witnessed Resident #93's fall/injury. S1 Administrator confirmed Resident #3 was cognitively impaired. S1 Administrator confirmed Resident #93's fracture should have been reported to the State Survey Agency, but was not. 51082 Resident #96 Review of Resident #96's medical record revealed an admitted [DATE] with a re-entry date of 11/13/2024. Resident #96's diagnoses read in part .Metabolic Encephalopathy; Primary Generalized (Osteo) Arthritis; Other Specified Disorders of Bone density and structure; Other Intervertebral Disc Degeneration Lumbosacral Region with Discogenic back pain and lower extremity pain; Other Intervertebral Disc Degeneration Thoracolumbar region; Anxiety disorder; Delusional disorders; History of Falling, and Abnormalities of Gait and Mobility. Review of Resident #96's Quarterly MDS with an ARD of 02/19/2025 revealed a BIMS summary score of 12, indicating moderate cognitive impairment. Resident #96 required partial/moderate assistance with transfers. Review of Resident #96's Care Plan with a target date of 02/19/2025 read in part .Physical mobility impaired related to diagnosis of MWA (muscle wasting atrophy), History of falling; 12/31/2024 X-ray shows fracture at L1. Interventions: 01/01/2025 refer resident to neurosurgeon as soon as appointment is scheduled for compression fracture of L1 superior inplate; 01/01/2025 Back Brace on when out of bed as tolerated for comfort; assist with bed mobility, transfers, and locomotion as necessary or as requested. High risk for falls related to gait/balance problems, psychoactive drug use, Osteopenia, Multilevel degenerative disc disease (spine). Interventions: 12/25/2024-Was called into resident room by roommate stating that resident fell while trying to get out of wheelchair. 12/26/2024-Follow up assessment performed; Assist with transfers as needed; Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. Review of Resident #96's Departmental Progress Notes read in part . 12/31/24 4:26 p.m. General Nurse Note- Received MRI (Magnetic Resonance Imaging) results with results of a compression fracture of L1. Contacted the physician and orders given to send to neurosurgeon as soon as appointment was scheduled for compression fracture of L1 superior in plate. Review of Resident #96's Thoracic MRI revealed in part .Impression subacute compression fractures of T6, T8, and L2; chronic compression fracture of L1. Dated: 12/31/2024 12:33 p.m. Review of Resident #96's Lumbar MRI revealed in part .Impression: acute moderate to severe compression fracture seen superior plate of L1 with mild retropulsion of bone fragment but no canal compromise. Stable old compression fracture T12. Multilevel spondylosis with foraminal stenosis at L4-5 bilaterally. Dated 12/26/2024. Interview on 01/08/2025 at 3:06 p.m. with S2 DON accompanied with S4 Charge Nurse stated S1 Administrator was responsible for initiating SIMS (Statewide Incident Management System) reports. S4 Charge Nurse confirmed the facility became aware of Resident #96's major injury of unknown origin on 12/31/2024 and began an investigation. Interview on 01/08/2025 at 3:41 p.m. with S1 Administrator stated he was made aware of Resident #96's compression fracture on the day of the MRI results, 12/31/2024. S1 Administrator stated he's the only one who initiates a SIMS report. S1 Administrator confirmed a SIMS report was not initiated for Resident #96 but should have been.

Based on interview and record review the facility failed to ensure that required discharge documentation was completed for 1 (#99) out of 1 Residents reviewed for discharge. The total sample size was 44. Findings: Review of the facility's undated policy titled Discharge Planning read in part . It is important to ensure that there is a planned program of continuing care to meet each resident's discharge needs. 3. Once completed the Discharge Planning form becomes part of the permanent clinical record. 5. All transfers/discharges of care are coordinated by the Admissions/Discharge Coordinator and conducted according to the following steps: c. Ensure that the physician is contacted regarding the anticipated discharge and necessary orders are obtained. i. Nursing Department completes transfer form and discharge summary information, including current medical information relative to diagnosis, and rehabilitation potential, summary of source of treatment, physician's orders, and pertinent information. Record Review of Resident #99's Electronic Medical Record (EHR) revealed an admitted [DATE] and a discharge date of [DATE]. Resident #99 had diagnoses that included in part .Anxiety Disorders, Diabetes Mellitus, Cerebral Infarction, Aphasia following Cerebral Infarction, Depressive Episodes, Chronic Pain, and Chronic Obstructive Pulmonary Disease. Record Review of Resident #99's MDS with ARD of 09/08/2024 revealed Resident #99 had a BIMS of 11, indicating moderate cognitive impairment. Record Review of Resident #99's EHR and paper medical record revealed no documentation of the following; the basis for the discharge, physician order for discharge, and information provided to the receiving provider that included at minimum: contact information of the provider responsible for the care of the resident, resident representative information including contact information, Advance Directive information, instructions or precautions for ongoing care, Comprehensive care plan goals, and a copy of the residents discharge summary. Interview on 01/08/2024 at 4:18 p.m. with S2 DON confirmed the facility had not completed a discharge summary for Resident #99, but should have. S2 DON confirmed Resident #99's medical record did not contain any of the above information required for discharge, but should. Interview on 01/08/2024 at 4:57 p.m. with S1 Administrator revealed on 11/07/2024 he assisted in Resident #99's transfer to another facility. S1 Administrator revealed there should be documentation in Resident #99's medical record regarding the discharge, and confirmed there was not.

Based on observation, interview and record review, the facility failed to implement a comprehensive person-centered care plan for a resident. The facility failed to implement a care plan intervention by failing to ensure a hand roll was used for contracture of hand for 1 (Resident #42) of 44 sampled residents. Findings: Record Review revealed Resident #42 was admitted on [DATE]. Resident #42 had diagnoses that included, in part . Other Specified Disorders Of The Skin And Subcutaneous Tissue, Other Chronic Pain, Contracture Of Muscle, Other Site, Other Sequelae Of Other Cerebrovascular Disease, Hemiplegia And Hemiparesis Following Cerebral Infarction Affecting Right Dominant Side. Review of Resident #42's Quarterly MDS with ARD of 12/31/2024 revealed BIMS Score of 02, indicating severe cognitive impairment. Resident #42 required extensive one person physical assist with bed mobility and toilet use. Resident #42 was totally dependent, requiring 2 person physical assistance with transfers. Resident #42 required supervised self-performance of eating with one person physical assistance. Review of Resident #42's current Care Plan revealed, in part .Monitor right hand/hand roll for complications. If complications are present, document in nurses notes and notify MD dated 11/16/2022. Review of current MD Orders for Resident #42 revealed, in part .Monitor skin upon removal of right hand roll. Document any skin complications in the nurse's notes and notify MD every shift. Order dated 10/24/2016. Observation of Resident #42 on 01/06/2025 at 10:20 a.m. revealed contracture of right hand with no hand roll in use. Observation of Resident #42 on 01/06/2025 at 11:20 a.m. revealed no hand roll in use to right hand. Observation of Resident #42 on 01/06/2025 at 12:18 p.m. revealed no hand roll in use to right hand. Observation of Resident #42 on 01/07/2025 at 8:44 a.m. revealed no hand roll in use to right hand. Observation of Resident #42 on 01/08/2025 at 8:42 a.m. revealed no hand roll in use to right hand. Interview with S6 LPN and S7 CNA at time of observation revealed Resident #42 utilized a hand roll for right hand contracture. S7 CNA stated they always used a hand roll for Resident #42's contracted right hand. S6 LPN and S7 CNA were both unable to locate a hand roll in the room of Resident #42. S6 LPN confirmed Resident #42 did not have a hand roll in place for contracted right hand, but should have.

Based on observation, interview and record review, the facility failed to ensure a comprehensive person-centered plan of care was reviewed and revised for 2 residents (Resident #31 and Resident #75) of 44 sampled residents. The facility failed to ensure care plans were updated: 1. To include resident was educated to notify nursing staff of need to increase her oxygen if needed for Resident #31 who required oxygen therapy; and 2. To include physician ordered nasal spray in resident's room to be included with self-administered medications for Resident #75. Findings: Review of Resident #31's medical record revealed an admitted [DATE], with diagnoses that included in part . COPD, Chronic Renal Failure with Hypoxia, Nicotine Dependence, unspecified, Dependence on supplemental Oxygen, Chronic Cough and other specified Anxiety Disorders. Review of Resident #31's Physician's Orders revealed an order dated 12/01/2024 for Oxygen at 2 liters/ nasal cannula while in room every shift for shortness of breath related to COPD, unspecified. Review of Resident #31's Quarterly MDS with an ARD of 11/25/2024, revealed a BIMS score of 15 (indicative of intact cognition) and resident required oxygen therapy. Review of Resident #31's Care Plan with a target date of 03/01/2025 revealed in part . Resident #31 required respiratory therapy related to diagnosis of COPD with Chronic Renal Failure and wears oxygen when needed. Interventions included in part . Administer oxygen therapy as ordered and oxygen at 2 liters via nasal cannula while in room related to diagnosis of COPD. Observation on 01/06/2025 at 10:07 a.m. of Resident #31 awake sitting on side of bed awake with oxygen in progress at 3 liters/minute via nasal cannula. She stated she had a breathing treatment this morning. Observation on 01/07/2025 at 9:25 a.m. of Resident #31 awake lying in bed without facial grimace with oxygen in progress at 3liters/minute per nasal cannula. Resident #31 stated she adjusts her oxygen concentrator and stated it is supposed to be set at 3 liters/minute. Interview on 01/08/2025 at 12:04 p.m. with S10 LPN in Resident #31's room verified that her oxygen flow rate was set at 3 liters/minute and should have been at 2 liters/minute via nasal cannula. S10 LPN reported that Resident #31's oxygen saturation on oxygen was within normal limits this morning. Observation of S10 LPN adjusted Resident #31's oxygen flow rate down to 2 liters/minute and explained to Resident #31 that her oxygen is ordered to be set at 2 liters per minute instead. Interview on 01/08/2025 at 02:03 p.m. with S8 ADON revealed Resident #31 was care planned for oxygen at 2 liters/minute via nasal cannula and able to take on and off at her discretion but she was not care planned to be able to adjust her oxygen level. Interview on 01/08/2025 at 02:40 p.m. with S11 LPN revealed she was not aware that resident was changing her oxygen flow rate on the oxygen concentrator. S11 LPN revealed she would update Resident #31's care plan interventions today, to include educating Resident #31 to notify the nurse if need to increase oxygen. Interview on 01/08/2025 at 03:00 p.m. with S2 DON revealed that resident changes the oxygen flow rate in her room and is educated to notify the nurse instead. S2 DON confirmed Resident #31's care plan should have been updated and revised to include this and was not. 51096 Findings: Resident #75 Review of the facility's policy and procedure undated and titled Self-Administration of Medication read in part . Policy: It is the policy of this facility that each resident has the right to self-administer medications, but is the responsibility of the interdisciplinary team to determine that it is safe prior to the resident exercising that right. Procedure: 2. If the resident wishes to self-administer medications, the Interdisciplinary Team must assess the resident's overall ability to safely administer his/her own medications. 7. Self- administration of bedside medications must be care planned, including the specific order, granting of approval by IDT, and monitoring for compliance. Review of Resident #75's clinical record revealed an admitted [DATE], with diagnoses which included restlessness and agitation, cataract secondary to ocular disorders, dry eye syndrome of bilateral lacrimal glands and allergic rhinitis. Review of Resident #75's Quarterly MDS with an ARD of 12/23/2024, revealed a BIMS score of 15. Resident #75 was cognitively intact. Physical behavioral symptoms directed toward others; verbal behavioral symptoms directed toward others or other behavioral symptoms not directed towards others not exhibited. Review of Resident #75's Physician Orders with an order date of 04/11/2023 revealed in part Afrin Original Nasal Solution 0.05 % (Oxymetazoline HCl) 2 spray in each nostril every 12 hours as needed for nasal congestion, but did not reflect self-administration. An order with an order date of 05/14/2024 revealed in part Carboxymethylcellulose Sod PF Ophthalmic Solution 0.5 % (Carboxymethylcellulose Sodium (Ophth); Instill 1 drop in both eyes every 12 hours; unsupervised self-administration, May keep drops at bedside and self-administer. Review of Resident #75's Care Plan revealed a problem to include resident to self-administer the following medications per MD order and verification of assessment criteria: Artificial Tears Opthal GTT with interventions in part assessment for self-administration of medications will be completed by interdisciplinary team to verify safe administrations. Resident #75 was not care planned for self-administration of Afrin (nasal spray). Review of Resident #75's medical record revealed no Self-administration Assessment for Afrin (Nasal spray). Interview with Resident #75 on 01/06/2025 at 3:16 p.m. in his room sitting on his rolling walker revealed resident well-groomed and dressed appropriately. Resident had nasal sprays x2; eye drops and inhalers in room. Resident stated that the facility knew he was a big boy and could handle it. Observation in Resident #75's room on 01/07/2025 at 09:01 a.m. revealed eye drops and nasal spray on the stand by Resident #75's bed. Interview with S15LPN on 01/08/2025 at 09:35 a.m. revealed that Resident #75 should have had two medicines to include eye drops and Nasal Spray for use at bedside. Review of Resident #75's orders with S15LPN revealed Resident #75 did not have an order to self-administer the nasal spray at bedside. S15LPN confirmed that Resident #75 should have had an order for self-administration of the nasal spray at bedside and Resident #75's Care Plan should have reflected self-administration of the nasal spray. Observation of Resident #75's room on 01/08/2025 at 09:40 a.m. revealed eye drops and nasal sprays on the stand next to Resident #75's bed. Interview with S12RN and S11LPN on 01/08/2025 at 09:48 a.m. revealed that an assessment for self-administration of medication should be completed for the resident, unsure of how often but an initial one should be in the resident's medical record. Resident should be Care planned for self-administration of that particular medication and the resident's medication order should reflect self-administration before the resident keeps the medication at bedside. Review of Resident #75's Afrin (nasal spray) order and Resident #75's Care plan with S12RN, confirmed there was no bedside administration order for the nasal spray and the resident was not care planned to self-administer the nasal spray at bedside. S12RN confirmed that there was no Self-administration Assessment in Resident #75's medical record for the nasal spray. S12RN and S11LPN confirmed that Resident #75 should not have been self-administering the nasal spray at bedside; was not care planned for self-administration of the Nasal Spray at bedside and the order for Resident #75's nasal spray does not reflect self-administration at bedside. Interview and observation with S2DON and S13RN on 01/08/2025 at 09:50 a.m. confirmed that Resident #75 had Afrin nasal spray in his room on the table next to his bed and it should not be. S2DON and S13RN also confirmed Resident # 75 had no order for self-administration of the Afrin nasal spray at bedside and was not care planned for self-administration of Afrin nasal spray at bedside.