Every finding on record at Holly Springs Rehabilitation and Healthcare Center

Based on record review, staff interview, and facility policy review, the facility failed to have the required staff present and in attendance for each quarterly Quality Assurance and Performance Improvement (QAPI) meetings for four (4) of 4 quarterly meetings dated 09/30/25, 12/29/25, 03/31/26 and 05/01/26. Findings include:Review of facility document titled QAPI Program undated revealed, .Leadership of the QAPI committee will include the Medical Director and or Nurse Practitioner (NP), Administrator, and Director of Nurses.QAPI meetings will be held monthly. The following individuals serve on the committee: Administrator, or a designee who is in a leadership role; Director of Nursing services; Medical Director; Infection Preventionist; and Representatives of the following departments, as requested by the administrator: Pharmacy; Social Services; Activity Services; Environmental Services; Human Resources; and Medical Records.Review of facility documents titled Stand Up Sign-in Sheet/QA Meeting dated 9/30/2025, 12/29/2025, 3/31/2026, and 5/1/2026, failed to evidence participation of the facility Medical Director in the QAPI meetings reviewed. During an interview on 5/14/2026 at 9:30 AM, the Administrator stated the facility discussed concerns during QAPI meetings but was unable to provide evidence of additional ongoing performance improvement activities, sustained monitoring tools, or systemic corrective actions related to the identified recurring concerns. Additionally, the Administrator confirmed the Medical Director did not attend the QAPI meetings. He stated, I usually just call and fill her in about the meetings, and confirmed that the Medical Director was not in attendance at any of the QAPI meetings.

Based on resident and staff interviews, record review, and facility policy review, the facility failed to resolve resident grievances related to food service concerns identified during Resident Council meetings for five (5) of thirteen residents. (Resident #7, Resident #11, Resident #36, Resident #62, and Resident #74) Findings Include:Review of the facility policy titled Filing Grievances/Complaints with a revision date of 6/2024 revealed .3. All grievances, complaints or recommendations stemming from resident or family groups concerning issues of resident care in the facility will be considered. Actions on such issues will be responded to in writing (if requested), including a rationale for the response .A record review of the Resident Council Minutes dated 12/16/25, under New Business, revealed residents voiced concerns stating, The food is inedible and not worth eating, and The food is awful, it's the same every time and never a different variety. The minutes documented the Dietary Manager (DM) was present during the meeting.A record review of the Resident Council Minutes dated 1/20/26, under Old Business, revealed continued complaints that The food is awful and always the same.A record review of the Resident Council Minutes dated 2/17/26, under New Business, revealed residents voiced concerns including not receiving the foods listed on their meal tickets, tea glasses not being full or containing ice, repeated desserts such as fig newtons and graham crackers, green beans being served three days in a row, and food being served cold. The minutes documented the DM was present during the meeting.A record review of the Resident Council Minutes dated 3/16/26, under New Business, revealed residents complained of inadequate food portions, cold food, repetitive menu items such as rice and green beans being served multiple days in a row, lack of fresh fruit or sliced apples, receiving water instead of tea or lemonade, insufficient meat portions for sandwiches, not receiving the advertised meal of the month, and soup or oatmeal being served in dessert cups.A record review of the Resident Council Minutes dated 4/21/26, under New Business, revealed complaints that the food was too salty. Under Old Business, residents continued to voice concerns that the food was not hot, the food was awful, and fresh fruit was not being provided. The minutes documented the DM was present during the meeting.During an interview on 5/12/26 at 1:51 PM, the Activity Director (AD) confirmed that cold food and food issues had been an ongoing concern discussed during Resident Council meetings for a while. The AD stated the DM routinely attended the meetings and residents consistently voiced their concerns to him. The AD further stated she was unaware of any actions taken by the DM to resolve the issues. During the Resident Council meeting conducted on 5/12/26 at 2:00 PM, residents who were present continued to voice concerns regarding unresolved food service issues that had reportedly been discussed repeatedly during prior Resident Council meetings without a follow up or a resolution to their prior grievances.Resident #7 revealed he had repeatedly requested coffee prior to leaving for dialysis, but coffee service occurred after he had already left the facility. He further revealed the oatmeal was usually cold and it can't even melt butter. Resident #7 stated he had discussed the concerns with both the DM and the Administrator (ADM), but Nothing ever gets done.Resident #11 revealed The food is cold regardless of what you get, and stated, We discuss these food issues all the time, and it falls on deaf ears.Resident #36 revealed that The majority of our Resident Council meetings we are discussing cold food and how bad the food is. She stated the DM attends the meetings, listens to the concerns, but Nothing is ever done. Resident #36 further revealed residents discuss the Meal of the month during each meeting; however, they have never received those meals that they request.Resident #62 revealed, We talk about food issues in each meeting that we have. We just haven't seen any change.Resident #74 revealed, It doesn't matter if we mention how cold or bad the food is; nothing is ever done. He stated the DM attends the meetings and listens to the complaints, and that the Administrator and staff were aware of the residents' concerns.During an interview on 5/12/26 at 3:50 PM, the Administrator (ADM) confirmed awareness of ongoing food-related complaints voiced during Resident Council meetings. The ADM revealed the DM had attended several meetings and had been made aware of the concerns. The ADM stated, I know there have been ongoing concerns about the food, and we are trying to change things up. The ADM confirmed there was no written follow-up documentation regarding the residents' grievances and acknowledged the facility had failed to ensure the residents' concerns were properly addressed and resolved.During an interview on 5/13/26 at 11:40 AM, the DM confirmed awareness of the concerns voiced during Resident Council meetings and stated he had discussed with residents that he was working to resolve the issues. The DM confirmed there was no documented follow-up and acknowledged the concerns had apparently not been resolved at that time.Record review of the admission Record revealed the facility admitted Resident #7 on 8/13/2025 with medical diagnoses that included Muscle weakness and Dependence on Renal Dialysis.Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/9/2026 revealed, under section C, a Brief Interview for Mental Status (BIMS) summary score of 15, indicating Resident #7 was cognitively intact.Record review of the admission Record revealed the facility admitted Resident #11 on 4/04/2025 with medical diagnoses that included Protein-Calorie Malnutrition and Anemia.Record review of the MDS with an ARD of 4/2/26 revealed under section C, a BIMS summary score of 15, indicating Resident #11 was cognitively intact.Record review of the admission Record revealed the facility admitted Resident #36 on 12/19/2025 with medical diagnoses that included Type 2 Diabetes Mellitus and Major Depressive Disorder.Record review of the MDS with an ARD of 3/26/26 revealed under section C, a BIMS summary score of 15, indicating Resident #36 was cognitively intact.Record review of the admission Record revealed the facility admitted Resident #62 on 8/01/2024 with medical diagnoses that included Schizophrenia and Anemia.Record review of the MDS with an ARD of 4/17/26 revealed under section C, a BIMS summary score of 14, indicating Resident #62 was cognitively intact.Record review of the admission Record revealed the facility admitted Resident #74 on 11/25/2021 with medical diagnoses that included Chronic Obstructive Pulmonary Disease and Anemia.Record review of the MDS with an ARD of 4/8/26 revealed under section C, a BIMS summary score of 14, indicating Resident #74 was cognitively intact.

Based on observations, interviews, record review and facility policy review, the facility failed to implement care plan interventions as written for three (3) of 19 sampled residents. (Resident #2, Resident #27, and Resident #39) The scope and severity for this deficiency were cited at an E due to previous citations of F656 on the last two annual recertification surveys completed on 1/4/24 and 6/19/25 representing a pattern of deficiency. Findings include: Review of the facility policy titled Care Plans, Comprehensive Person-Centered, reviewed 6/2/25, revealed, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident . Resident #2 Review of Care Plan Report revealed under Focus: The resident has an ADL (activity of daily living) deficit r/t (related to CVA (cerebrovascular accident).Interventions .Staff to ask resident on shower days if they would like to be shaved and shave as needed (prn) resident or Responsible Party (RP) request. Observations on 5/11/2026 at 11:05 AM, and again on 5/12/2026 at 9:00 AM, of Resident #2 revealed his facial hair was approximately one (1) inch in length. On 5/12/2026 at 1:00 PM during an observation and interview Licensed Practical Nurse (LPN) #1 confirmed that Resident #2 has long facial hair. She stated his shower days are Monday, Wednesday, Friday, and that a Certified Nursing Assistant (CNA) comes on Wednesdays, Thursdays, and Fridays to shave residents. On 5/13/2026 at 9:40 AM, Minimum Data Set (MDS) Coordinator confirmed the care plan had been developed; however, facility staff failed to implement the interventions as written. She stated the purpose of the care plan was to guide staff in providing the care needed for Resident #2. Record review of the admission Record indicated Resident #2 was admitted to the facility on [DATE] with medical diagnoses that included Cerebral Infarction. Record review of the MDS, with an Assessment Reference Date (ARD) of 4/09/2026 revealed under Section C that a Brief Interview for Mental Status (BIMS) was 9, indicating moderate cognitive impairment. Resident #27 Record review of Resident #27's Self-Care Deficit Care Plan revealed, .CNA (Certified Nursing Assistant) to complete fingernail care for resident daily and PRN. CNA to trim/file fingernails PRN.Donn (apply) carrots to bilateral hands daily after lunch and doff (remove) at HS (bedtime) one time a day. Donn bilateral elbow rolls to resident daily after lunch and doff at HS one time a day. On 5/11/2026 at 11:05 AM, during an observation Resident #27's fingernails were observed to be approximately one (1) inch in length with jagged edges. The resident was also observed with contractures to bilateral hands without the ordered interventions in place. Observations of Resident #27 on 5/12/2026 at 9:54 AM and again at 12:44 PM, revealed no carrots, rolled cloths, or gauze in either hand for contracture prevention and the resident's fingernails were jagged and long. During an interview on 5/12/2026 at 2:57 PM, the Director of Nursing (DON) confirmed several of Resident #27's fingernails were very long. She stated long, jagged fingernails could cause injury to the resident and should be kept clean and trimmed. She further confirmed Resident #27 did not have ordered interventions in place for his hands or elbows to prevent contractures. On 5/13/2026 at 9:38 AM, Registered Nurse (RN) MDS Coordinator confirmed the care plan had been developed; however, facility staff failed to implement the interventions as written. She stated the purpose of the care plan was to guide staff in providing care for Resident #27. Record review of the admission Record indicated Resident #27 was admitted to the facility on [DATE] with medical diagnoses that included unspecified severe protein-calorie malnutrition and primary progressive multiple sclerosis. Record review of the MDS, with an ARD of 2/14/2026, revealed under Section C that a BIMS was not conducted because Resident #27 was rarely or never understood. Resident #39 Record review of Resident #39's Activities of Daily Living (ADL) self-care performance deficit care plan revealed, .Donn resting hand splint to left hand after breakfast daily and doff at dinner or as tolerated; check skin prior to donning left hand splint and after doffing left hand splint.oral hygiene: dependent.Personal hygiene: dependent. During an observation on 5/11/2026 at 10:32 AM, Resident #39's fingernails were observed to be approximately one (1) inch in length with jagged edges. Additionally, the resident's upper teeth appeared blackened and deteriorated with visible buildup along the gum line. Significant discoloration and poor oral hygiene were observed. Resident #39 was also observed without the ordered splint in place on his left hand. On 5/12/2026 at 9:51 AM and again at 2:16 PM, observations of Resident #39 revealed no brace or splint in place on the resident's left hand. During the 2:16 PM observation, when asked about the brace, the resident stated he did not know where it was but stated it helps to hold his hand open. On 5/12/2026 at 2:37 PM during an interview the Director of Nursing (DON) confirmed Resident #39 was in need of oral care and that his fingernails should be kept trimmed. She stated nail care and oral care should be provided daily and as needed. She further confirmed braces and splints should be applied as ordered to assist in preventing contractures and stated her expectation was for physician orders to be followed as written. During an interview on 5/13/2026 at 9:38 AM, the Minimum Data Set (MDS) Coordinator confirmed the care plan had been developed; however, facility staff failed to implement the interventions as written. She stated the purpose of the care plan was to guide staff in providing care for Resident #39. Record review of the admission Record indicated Resident #39 was admitted to the facility on [DATE] with medical diagnoses that included post-traumatic seizures, hemiplegia affecting the left nondominant side, and metabolic encephalopathy. Record review of the MDS, with an ARD of 3/23/2026, revealed under Section C a BIMS summary score of 9, indicating Resident #39 was moderately cognitively impaired.

Based on observations, interviews, record review, and facility policy review, the facility failed to provide facial hair grooming, fingernail care, and oral hygiene for three (3) of nineteen (19) samples residents reviewed for activities of daily living (ADL) care. Residents #2, Resident #27, and Resident #39. The scope and severity for this deficiency was cited at an E due to previous citations of F677 on the last two annual recertification surveys completed on 1/4/24 and 6/19/25 representing a pattern of deficiency. Findings include: Review of the facility policy titled Activities of Daily Living (ADL), with a revision date of March 2018, revealed, Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living . Resident #2 On 5/11/2026 at 11:05 AM, and again on 5/12/2026 at 9:00 AM, observations of Resident #2 revealed facial hair that was approximately one (1) inch in length. During an observation and interview on 5/12/2026 at 1:00 PM, Licensed Practical Nurse (LPN) #1 confirmed that Resident #2 had long facial hair. She stated his shower days are on Mondays, Wednesdays, Fridays, and that a Certified Nursing Assistant (CNA) comes on Wednesdays, Thursdays, and Fridays to shave residents. During an interview on 5/14/2026 at 8:45 AM, the Administrator stated residents should be offered a shave on shower days. Record review of the admission Record indicated Resident #2 was admitted to the facility on [DATE] with medical diagnoses that included Cerebral Infarction. Record review of the Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 4/09/2026 revealed under Section C that a Brief Interview for Mental Status (BIMS) was 9, indicating moderate cognitive impairment. Resident #27 During an observation on 5/11/2026 at 11:05 AM, Resident #27's fingernails were observed to be approximately one (1) inch in length with jagged edges. During an interview on 5/12/2026 at 2:43 PM, CNA #2 confirmed several of Resident #27's fingernails were very long. She stated she was unsure whether she could trim the resident's fingernails because the resident might be diabetic and stated, I would have to ask the nurse. During an interview on 5/12/2026 at 2:57 PM, the Director of Nursing (DON) confirmed several of Resident #27's fingernails were very long. She stated long, jagged fingernails could cause injury to Resident #27 and should be kept clean and trimmed. Record review of the admission Record indicated Resident #27 was admitted to the facility on [DATE] with medical diagnoses that included unspecified severe protein-calorie malnutrition and primary progressive multiple sclerosis. Record review of the MDS, with an ARD of 2/14/2026, revealed under Section C that a BIMS was not conducted because Resident #27 was rarely or never understood. Resident #39 During an observation on 5/11/2026 at 10:32 AM, Resident #39's fingernails were observed to be approximately one (1) inch in length with jagged edges. Additionally, the resident's upper teeth appeared blackened and deteriorated, with visible buildup along the gum line. Significant discoloration and poor oral hygiene were observed. During an interview on 5/12/2026 at 2:29 PM, the DON confirmed Resident #39 needed oral care and that his fingernails should be kept trimmed. She stated nail care and oral care should be provided daily and as needed. Record review of the admission Record indicated Resident #39 was admitted to the facility on [DATE] with medical diagnoses that included post-traumatic seizures, hemiplegia affecting the left nondominant side, and metabolic encephalopathy. Record review of the MDS, with an ARD of 3/23/2026, revealed under Section C a BIMS summary score of 9, indicating Resident #39 was moderately cognitively impaired.

Based on observations, interviews, record review, and facility policy review, the facility failed to ensure a dignified existence by failing to apply a privacy bag to a urinary catheter drainage bag (Resident #82) and failing to provide dignified toileting assistance to a resident (Resident #22) for two (2) of 19 sampled residents. Residents #22 and Resident #82. Findings Include: Record review of facility policy titled Nursing Facility Resident Rights dated 3/6/26 revealed, .Facilities are required to protect and promote these rights for every resident. Dignity, Respect, and Freedom from Abuse: To be treated with dignity, courtesy, and respect .Quality of Care and Participation in Care: To receive care necessary to achieve the highest practicable physical, mental, and psychosocial well-being . Resident #22On 5/11/26 at 11:22 AM, observation and interview with Resident #22 revealed she was sitting in her wheelchair near the doorway of her room with frowning facial expressions and scrunched eyebrows. Resident #22 stated she needed to use the bathroom to have a bowel movement, but staff told her they could not put her on the toilet, and she would have to lie in bed, use the bathroom on herself, and then be changed. Resident #22 pointed toward her bed and stated she did not want to lie in bed and use the bathroom on herself. An interview with Certified Nursing Assistant (CNA) #1 on 5/11/26 at 11:25 AM confirmed she told Resident #22 she would have to lie in bed to use the bathroom. During an interview on 5/12/26 at 5:22 PM, the Director of Nursing (DON) revealed Resident #22 required a total lift and the lift would not fit into the bathroom. The DON stated the facility did not have any bedside commodes available; however, the resident should have been offered a bedpan. The DON acknowledged being told to use the bathroom on herself was a dignity concern. Record review of the admission Record revealed the facility admitted Resident #22 on 4/13/26 with medical diagnoses that included Acute Kidney Failure, Chronic Kidney Disease, Anxiety Disorder, and Depression. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/18/26 revealed under Section C, a Brief Interview for Mental Status (BIMS) summary score of 11, indicating Resident #22 was moderately cognitively impaired. Resident #82 During an observation on 5/11/26 at 10:20 AM, Resident #82's catheter drainage bag was observed hanging on the lower bed frame, approximately one-third full of amber-colored urine, without a privacy cover in place. Record review of the Order Summary Report revealed an order dated 7/28/23 for Privacy bag or covering over urine collection bag for dignity. During an interview on 5/12/26 at 12:50 PM, Licensed Practical Nurse (LPN) #3 stated the urinary drainage bag should have a cover in place to provide privacy for the resident. Record review of the admission Record revealed the facility admitted Resident #82 on 7/25/23 with medical diagnoses that included Chronic Kidney Disease, Stage 3, Benign Prostatic Hyperplasia, and Personal History of Malignant Neoplasm of Prostate. Record review of the MDS with an ARD of 4/21/26 revealed under Section C, a BIMS summary score of 12, indicating Resident #82 was moderately cognitively impaired.

Based on resident/resident representative (RR) and staff interviews, record review and facility policy review the facility failed to honor a resident's Advance Directive for end-of life decisions for one (1) of 28 residents advance directives reviewed. Resident #25Findings Include:Review of the facility policy titled Advance Directives, with a revision date of [DATE], revealed, Advance directives will be respected in accordance with state law and facility policy.15. In accordance with current regulatory definitions and guidelines governing advance directives, our facility has defined advanced directives as preferences regarding treatment options and include, but are not limited to: f. Do Not Resuscitate- indicates that in case of respiratory or cardiac failure, the resident, legal guardian, health care proxy, or representative (sponsor) has directed that no cardiopulmonary resuscitation (CPR) or other life-sustaining treatments or methods are to be used .Record review of the Advance Health Care Directive for Resident #25, revealed under End -of-life decisions.Choice Not to Prolong Life signed by the resident and notarized with a date of [DATE].Record review of the Order Summary Report revealed an order for CPR with a date of [DATE].During an interview on [DATE] at 8:27 AM, Licensed Practical Nurse (LPN) #3 confirmed Resident #25's physician order reflected full code status.During a phone interview on [DATE] at 9:13 AM, Resident #25's Resident Representative (RR) stated, My sister has always said she did not want to be resuscitated. The RR stated the facility contacted him some time ago, but I truly didn't understand what they were asking me. He stated, A girl asked if they should do anything for her if she quits breathing, and I responded, 'Well, I guess you should. The RR revealed he was unaware this would change his sister's previously established end-of-life wishes, which were documented when she was in a better mindset, and they should keep them as she wanted.In an interview on [DATE] at 9:22 AM, Resident #25 confirmed her end-of-life wishes were that she had no resuscitation if anything happened to her. She stated, I have always said that because I have heart disease and a pacemaker, and further confirmed that she had completed paperwork documenting those wishes. In an interview on [DATE] at 9:48 AM, the Director of Nurses (DON) confirmed Resident #25 had an Advance Health Care Directive signed on [DATE], indicating under End-of-Life Decisions a Choice Not to Prolong Life. The DON confirmed the residents' previously documented end-of-life decisions should have remained consistent with the advance directive despite the change in the RR.During an interview on [DATE] at 11:11 AM, the Director of Business Development revealed that she is responsible for discussing end-of-life decisions with residents and/or the RRs. She revealed she contacted Resident #25's RR the previous year after he assumed responsibility as the resident's RR because the facility needed to update paperwork, including the code status.Record review of the admission Record revealed Resident #25 was initially admitted to the facility on [DATE] with diagnoses that include Unspecified Dementia, Chronic Kidney Disease, and Presence of Cardiac Pacemaker. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 07, which indicated Resident #25 has severe cognitive impairment.

Based on observation, staff interview, and facility policy review, the facility failed to maintain a clean and sanitary environment by allowing a resident bathroom toilet to remain soiled for one (1) of 32 rooms on the 200 hall. room [ROOM NUMBER]Findings Include:Review of the facility policy titled 7-Step Daily Washroom Cleaning revealed under, Purpose: To teach Environmental Services employees the proper method to sanitize a washroom or bathroom . Additionally, the policy revealed under, 7-Step Daily Washroom Cleaning Procedure:. 5. Clean and Sanitize Commode - .Use [NAME] mop or toilet brush to disinfect the inside of the bowl .An observation of room [ROOM NUMBER]'s bathroom toilet on 5/11/26 at 2:15 PM revealed dark yellow stagnant urine present inside the toilet bowl and black discoloration adhered along the inner rim/water line of the toilet. The black substance appeared as multiple small circular black spots with a mold-like appearance.An observation and interview on 5/11/26 at 2:21 PM with Licensed Practical Nurse (LPN) #4 confirmed there was stagnant urine in the toilet bowl and a black substance along the water line. She stated, It looks like mold. She confirmed the bathroom environment was unclean and unsanitary.An observation and interview with the Training Center Accounts Manager (TCAM) on 5/11/26 at 2:26 PM confirmed the toilet was unclean and that the inside of the toilet looks to have mold. He revealed housekeeping staff were responsible for cleaning the residents' bathrooms, including the toilets, every day, confirming the toilet had not been properly cleaned.

Based on staff interview, record review, and facility policy review, the facility failed to ensure the resident and/or resident representative were provided with written notification of transfer to the hospital for two (2) of 2 residents reviewed for hospitalization. Resident #3 and Resident #95Findings Include:Review of the facility policy titled, Transfer or Discharge Notice with a revised date of 3/3/2026 revealed, .5. The resident and representative are notified in writing of the following information: a. The specific reason for the transfer or discharge; b. The effective date of the transfer or discharge; c. The location to which is resident is being transferred or discharged . Record review of Resident #3's Progress Note dated 5/8/26 revealed the Resident was transported to Proper Name of Hospital for tube/drain replacement. Record review of Resident #95's Progress Note dated 3/27/26 revealed Nurse Practitioner (NP) recommended sending to emergency room (ER) for evaluation due to hitting head. Emergency Medical Transport (EMT) transported resident to Proper Name of Hospital. During an interview on 5/13/2026 at 11:26 AM, the Business Office Manager (BOM) revealed when a resident is transferred to the hospital, the facility only sends the bed-hold notice and notifies the ombudsman. She further revealed the facility was unaware that a written notification explaining the reason, date of transfer, and location of transfer was required to be provided to the resident and/or resident representative. Record review of the admission Record revealed the facility admitted Resident #3 on 4/18/25 with a medical diagnosis that included Disease of Biliary Tract. Record review of the admission Record revealed the facility admitted Resident #95 on 3/12/26 with a medical diagnosis that included Malignant Neoplasm of unspecified part of unspecified Bronchus.

Based on observations, staff interviews, record review, and facility policy review, the facility failed to provide necessary care and services to prevent worsening contractures and maintain range of motion (ROM) for two (2) of four (4) residents reviewed. (Residents #27 and Resident #39)Findings include:Review of facility policy titled Contracture Management Program revised 3/4/2026, revealed, Intent: To have a program within the facility geared towards the prevention of new contractures and maintenance or improvement of Range of Motion.Nursing Responsibilities:.When the resident is discharged from therapy and a Restorative Nursing Program (RNP) has been written, the Director of Nursing (DON) or designee is to ensure the RNP is written correctly and then implemented timely.Resident #27 Review of Resident #27's Order Summary Report, revealed physician orders to Donn (apply) bilateral elbow rolls to patient daily after lunch and doff (remove) at HS (bedtime) and Donn carrots to bilateral hands daily after lunch and doff at HS, both with a start date of 2/21/2024.During an observation on 5/11/2026 at 2:05 PM, Resident #27 was observed with contractures to bilateral hands and elbows without ordered interventions in place.During an observation on 5/12/2026 at 2:44 PM, Resident #27 did not have carrots, rolled cloths, or gauze in either hand for contracture prevention and did not have bilateral elbow rolls or splints in place.During an observation and interview on 5/12/2026 at 2:57 PM, Licensed Practical Nurse (LPN) #2 confirmed Resident #27 did not have carrots, towels, or gauze in either hand or did not have bilateral elbow rolls in place as ordered. LPN #2 searched the resident's room and found two elbow rolls in the chest of drawers and two carrots in the bedside table drawer.During an interview on 5/12/2026 at 3:04 PM, the Director of Nursing (DON) confirmed Resident #27 did not have the ordered interventions in place for his hands or elbows to assist in preventing worsening contractures.Record review of the admission Record indicated Resident #27 was readmitted to the facility on [DATE] with medical diagnoses that included unspecified severe protein-calorie malnutrition and primary progressive multiple sclerosis.Record review of the Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 2/14/2026, revealed under Section C that a Brief Interview for Mental Status (BIMS) was not conducted because Resident #27 was rarely or never understood.Resident #39Review of Resident #39's Order Summary Report, revealed physician orders dated 01/14/26 to Check skin prior to donning left hand splint and after doffing left hand splint two times a day and to Donn resting hand splint to left hand after breakfast daily and doff at dinner or as tolerated; may remove prior to dinner if not tolerated .During observations on 5/11/2026 at 10:32 AM and again on 5/12/2026 at 9:51 AM, Resident #39 was observed without the ordered splint in place on his left hand.During an additional observation and interview on 5/12/2026 at 2:16 PM, Resident #39 was again observed without a splint or brace on his left hand. When asked about the brace, the resident stated he did not know where it was but stated it helps to hold his hand open.During an interview and record review on 5/12/2026 at 2:18 PM, Licensed Practical Nurse (LPN) #5 stated, I really don't know about any brace, I don't usually work this hall. Review of the Medication Administration Record (MAR) revealed the splint order was listed on the MAR. LPN #5 further stated the brace was used to help prevent contractures and confirmed that they have not been on the resident.During an interview on 5/12/2026 at 2:37 PM, the Director of Nursing (DON) confirmed braces and splints should be applied as ordered to assist in preventing contractures. She stated her expectation was for physician orders to be followed as written.Record review of the admission Record indicated Resident #39 was admitted to the facility on [DATE] with medical diagnoses that included post-traumatic seizures, hemiplegia affecting the left nondominant side, and metabolic encephalopathy.Record review of the MDS, with an ARD of 3/23/2026, revealed under Section C a BIMS summary score of 9, indicating Resident #39 was moderately cognitively impaired.

Based on interviews, record review, and policy review, the facility failed to clarify a clinically questionable dialysis fluid restriction order, failed to accurately transcribe and implement the physician order, and failed to monitor fluid intake for one (1) of five (5) residents reviewed for dialysis services. Resident #22 Findings Include:Review of the facility policy titled Dialysis Management Policy revised 3/12/26 revealed under, Policy: The facility will ensure that residents requiring dialysis receive appropriate clinical oversight, coordination with dialysis providers, and monitoring to maintain health and safety. The facility will coordinate care with the dialysis center and physician to ensure appropriate monitoring of the resident's clinical status, dialysis access, laboratory values, dietary needs, and complications related to dialysis therapy .Record review of Resident #22's Medication Administration Record (MAR) revealed an order dated 4/13/26, Resident to receive dialysis 3 (three) days a week on Tues (Tuesday), Thurs (Thursday), Sat (Saturday) at 'Proper name of dialysis center'.Record review of the Proper name of dialysis center Physician Order Sheet for Resident #22 revealed an order dated 4/14/26 for 3200 fluid ounces daily fluid restriction, which reflected a clinically questionable fluid restriction amount for a resident receiving dialysis.Record review of Resident #22's MAR revealed the facility transcribed and implemented the order dated 4/14/26 as, Fluid Restriction: Resident to have 3200 cc/ml (cubic centimeters/milliliters) fluid per 24 hours. Dietary to give 1600 cc/ml per shift. Nursing to give 1600 cc/ml per shift, without obtaining clarification from the dialysis center or physician regarding the questionable order.Further review of the MAR revealed no documented monitoring or tracking of fluid intake since the resident admitted to the facility on [DATE].On 5/12/26 at 4:26 PM, during a telephone interview with the Registered Nurse (RN) at Proper name of dialysis center, she revealed 3200 fluid ounces was not an accurate fluid restriction order and stated dialysis residents were typically instructed to follow approximately a 32-ounce (946 milliliters) daily fluid restriction. The RN confirmed the order should have been clarified by the facility prior to implementation.During an interview with the Director of Nursing (DON) on 5/13/26 at 10:08 AM, she confirmed the fluid restriction order received from the dialysis center was not realistic and they should have communicated with the dialysis center and clarified the order. The DON stated the nurse who received the order then converted the order from ounces to milliliters without obtaining physician or dialysis center clarification. The DON further confirmed the facility monitored dialysis residents' fluid intake through MAR documentation; however, Resident #22's fluid intake had not been monitored or documented since admission, which could result in excess fluid accumulation.Record review of the admission Record revealed the facility admitted Resident #22 on 4/13/26 with diagnoses including Acute Kidney Failure, Chronic Kidney Disease, and Dependence on Renal Dialysis.Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/18/26 revealed under Section C, a Brief Interview for Mental Status (BIMS) summary score of 11, which indicated Resident #22 was moderately cognitively impaired. Further review revealed under Section O, dialysis was indicated.

Based on observations, interviews, record reviews, and facility policy review, the facility failed to implement infection prevention and control practices for one (1) of two (2) sampled residents reviewed for transmission-based precautions (TBP). The facility failed to ensure proper infection control measures related to disposable meal tray use and cleaning/disinfection of a shared shower room following use by a resident on transmission-based precautions. Resident #8 Findings Include:Review of the facility policy titled, Infection Prevention and Control Program, with a review date of 3/03/2026 revealed, An infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmissions of communicable diseases and infections .Record review of physician orders revealed Resident #8 had an order dated 04/24/2026 for contact isolation precautions related to ESBL (Extended-Spectrum Beta-Lactamase) in wound every shift until 06/06/2026. On 5/12/2026 at 9:21 AM, observation revealed Resident #8, who was on transmission-based precautions, was served breakfast on a regular reusable tray rather than a disposable tray, the tray was picked up by an unidentified staff member and carried out with other trays.During an interview on 5/12/2026 at 3:50 PM, the Infection Preventionist (IP) stated she sent a message to dietary staff at approximately 8:00 AM regarding disposable trays for residents in isolation. She also confirmed food trays for residents on transmission-based precautions should be disposable.During an interview on 5/12/2026 at 9:30 AM with Housekeeper #1, she stated the shower room Resident #8 uses, she routinely cleans it at 6:00 AM, and again at approximately 2:00 PM daily.During an interview on 5/12/2026 at 9:42 AM, Infection Preventionist stated residents on transmission-based precautions should be showered last and the shower room should be cleaned after use. She confirmed allowing another resident to use the shower room prior to cleaning was not proper infection control practice.An observation on 5/12/2026 at 10:00 AM revealed Resident #8, who was on transmission-based precautions, was transported to the shower room and showered in the common shower area prior to other residents completing their showers for the day. Observation revealed that the shower room was not disinfected after use.An interview with the Director of Nursing at 10:45 AM on 5/12/2026 confirmed infection control practices should be used to prevent the spread of infection.Record review of the admission Record indicated Resident #8 was admitted to the facility on [DATE] with medical diagnoses that included Atherosclerotic Heart Disease.Record review of the Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 2/10/2026 revealed under Section C that a Brief Interview for Mental Status (BIMS) score was 9, indicating moderate cognitive impairment.

Based on observation, staff interviews, and record review, the facility failed to provide adequate supervision to prevent accidents for one (1) of three (3) residents reviewed for accidents (Resident #1), when the facility did not increase monitoring despite repeated episodes of the resident entering other residents' rooms and consuming food while on NPO (nothing by mouth) status, resulting in multiple transfers to the emergency department for possible aspiration. Findings include:Review of a reported complaint related to Resident #1 revealed the resident has a Percutaneous Endoscopic Gastrostomy (PEG) tube and the facility is not monitoring him closely enough and he is getting food from various places throughout the facility.Review of a statement provided by the facility administration revealed the facility did not have any policies or procedures related to accidents, monitoring or supervision.Record review of the admission Record revealed Resident #1 was admitted on [DATE] with diagnoses of personal history of traumatic brain injury and gastrostomy status.Record review of the Brief Interview for Mental Status (BIMS) dated 10/9/25 revealed a score of 6, indicating Resident #1 was severely cognitively impaired.Record review of a Nutritional Evaluation dated 10/7/25 revealed the assessment: Resident is NPO, swallowing issues noted. Nursing noted this a.m. (morning) that resident is still going into other residents' rooms to take food from their trays.Record review of the October Medication Record for Resident #1 revealed the resident was identified as High Risk for wandering/elopement, with visual monitoring every shift ordered 4/28/25.Record review of a Nurses Note for Resident #1 dated 7/3/25 at 11:36 AM revealed the Nurse Practitioner was aware of the resident eating applesauce. On 7/3/25 at 20:26 (8:20 PM), the resident appeared to be aspirating due to drinking another resident's lemonade, coughing profusely. The resident was sent to the Emergency Department (ED) for further evaluation.Record review of the ED treatment note for Resident #1 dated 7/3/25 revealed the resident was sent from the facility for possible aspiration. The patient was noted to be in no distress during triage.Record review of a Nurses Note for Resident #1 dated 7/20/25 at 23:34 (11:34 PM) revealed the resident was observed drinking a box of liquid supplement and was educated on NPO status.Record review of a Nurses Note for Resident #1 dated 7/23/25 at 13:31 (1:31 PM) revealed staff notified the nurse that Resident #1 was in another resident's room eating their lunch tray. The resident was spitting up chunks of food with increased salivation present. The resident was unable to take full deep breaths. Lung sounds were diminished. Orders were received to send the resident to the ED for possible aspiration.Record review of the ED treatment note for Resident #1 dated 7/23/25 revealed the reason for visit was choking. Diagnosis: Aspiration into airway. The chest x-ray showed no acute abnormality.Record review of a Nurses Note for Resident #1 dated 9/8/25 at 00:05 (12:05 AM) revealed the resident was noted in another resident's room eating chocolate candies. On 9/8/25 at 14:56 (2:56 PM), the responsible party requested the resident be sent out for possible aspiration.Record review of the ED treatment note for Resident #1 dated 9/8/25 revealed the resident was sent from the facility. The reason for visit was documented as eating disorder.Record review of a Nurses Note for Resident #1 dated 9/23/25 at 15:50 (3:50 PM) revealed the resident was observed sitting in his wheelchair with a snack cake in his mouth. The resident is NPO.Record review of a Nurses Note for Resident #1 dated 10/6/25 at 16:13 (4:13 PM) revealed the resident was noted in another resident's room coughing with food all around his mouth and in his chair. On 10/6/25 at 18:42 (6:42 PM), a nurse assessed crackles upon inhalation and exhalation. The nurse asked the resident if he was having trouble breathing or chest pain, and the resident nodded yes. A second nurse entered the room and stated it sounded like crackles. Orders were received to send the resident to the ED.Record review of the ED treatment note for Resident #1 dated 10/6/25 revealed the Reason for Visit was aspiration. Diagnoses included aspiration into airway and rhonchi in both lung bases. Medication changes included beginning Albuterol Hydrofluoroalkane inhaler and amoxicillin-clavulanate.Record review of the Order Summary Report for Resident #1 revealed an order for amoxicillin-clavulanate oral suspension, 7.3 milliliters (mL) via (by) PEG-tube two times daily for upper respiratory infection (URI), and Albuterol-Budesonide inhalation aerosol 90-80 MCG/ACT (micrograms per actuation), two puffs orally every four hours as needed for shortness of breath/wheezing.A continued review of the resident's record with the Minimum Data Set (MDS) Nurse on 11/24/25 at 11:20 AM revealed she could find no increase in monitoring for Resident #1 related to his continuous episodes of going into other residents' rooms and taking food.An interview with the Director of Nursing on 11/24/25 at 11:55 AM revealed Resident #1 was NPO and had a PEG tube for nutrition. She stated he had been to the hospital multiple times related to getting food from wherever. She stated it was difficult to alter this behavior because the resident was mobile in his wheelchair and, if he smelled food, he was going after it. She stated he was on every-shift visual monitoring for wandering behaviors but confirmed the facility had not increased monitoring despite the increase in episodes of taking food and requiring ED transfers for signs of aspiration. She stated, We took the snacks from the desk, but if he wants it, he is going to find it. She stated the facility had been attempting placement in another facility due to his need for increased monitoring and care, but no one would accept him. She confirmed she asked administration about placing the resident on one-on-one supervision, but this never occurred. She confirmed the resident remained at risk for taking others' food and for aspiration.An interview with the Social Worker (SW) on 11/24/25 at 12:45 PM revealed she had sent numerous referrals to other facilities due to Resident #1's need for extra monitoring and care, but no facility would accept him. She confirmed that with the resident's continued attempts to obtain food, the facility should have increased his monitoring until other solutions could be found.An interview with Certified Nurse Assistant (CNA) #1 on 11/24/25 at 12:10 PM revealed she cared for Resident #1 when he lived at the facility. She stated she was not aware of any increased monitoring of the resident. She stated they tried to keep a good eye on him, but he could propel himself and we all have other duties as well.An interview with Licensed Practical Nurse (LPN) #1 on 11/24/25 at 12:15 PM revealed she cared for Resident #1 when he was a resident. She stated the resident continuously tried to go into other residents' rooms. She confirmed she attempted to redirect him but stated this often did not work. She stated, to her knowledge, the facility never increased his monitoring to prevent him from going into other residents' rooms seeking food.An interview with the Assistant Director of Nursing on 11/24/25 at 1:00 PM revealed she was aware of Resident #1's behavior of going into other residents' rooms and obtaining food. She stated placing the resident on one-on-one supervision had been discussed, but it was not in the budget, and with other staffing concerns, no one wanted to come in and do it.Record review revealed that the family discharged the resident from the facility on 11/06/25 prior to the State Agency entrance.

Based on observation, resident and staff interviews, and record review, the facility failed to ensure that residents received necessary services to meet their medical needs when they allowed scheduled medical and dental appointments to be missed for (3) three of twenty-two residents with scheduled appointments. (Resident #2, #3, and #4) Findings include:Review of a statement provided by the facility on company letterhead revealed, The facility has no policy or procedures on appointments.Resident #2An interview with Resident #2, on 11/24/25 at 10:00 AM revealed he confirmed that on 11/10/25, he missed an appointment with his lung doctor. He stated that the staff told him there was no money on the gas card to put gas in the transport van. He stated his appointment was a follow-up and he is doing good but does not like missing his appointments, because when they rescheduled, he cannot be seen now until January.Record review of the calendar of scheduled appointment transfers from 10/27/25-11/10/25 provided by the facility revealed that on 11/10/25, Resident #2's pulmonary appointment was canceled related to van card issue and rescheduled for 1/13/26.Record review of the admission Record revealed Resident #2 was admitted on [DATE] with a diagnosis of chronic obstructive pulmonary disease.Record review of the Brief Interview for Mental Status (BIMS) dated 10/24/25 revealed a score of 15, indicating Resident #2 was cognitively intact.Resident #3An interview with Resident #3 on 11/24/25 at 10:15 AM revealed he missed his dental appointment at the end of October. He confirmed it was because the van was out of gas and he would like to know when he is supposed to go, because he doesn't know if it was rescheduled. He denied having any pain or mouth distress.Record review of the calendar of scheduled appointment transfers from 10/27/25-11/10/25 revealed that on 10/28/25, Resident #3's dental appointment was canceled related to gas card, and no reschedule date was provided.Record review of the admission Record revealed Resident #3 was admitted on [DATE] with a diagnosis of major depressive disorder.Record review of the Brief Interview for Mental Status (BIMS) dated 9/10/25 revealed a score of 15, indicating Resident #3 was cognitively intact.Resident #4An interview with Resident #4 on 11/24/25 at 10:25 AM revealed he missed his cardiology appointment at the beginning of November and was told it was because they had no money to fill the transport van.Record review of the calendar of scheduled appointment transfers from 10/27/25-11/10/25 revealed that on 11/7/25, Resident #4's cardiology appointment (listed under Proper Name) was canceled related to gas card, and no reschedule date was provided.Record review of the admission Record revealed Resident #4 was admitted on [DATE] with a diagnosis of congestive diastolic heart disease.Record review of the Brief Interview for Mental Status (BIMS) dated 10/20/25 revealed a score of 13, indicating Resident #4 was cognitively intact.A phone interview with the van transport driver on 11/24/25 at 10:30 AM revealed she confirmed there were at least (3) three residents who missed their scheduled appointments between 10/27/25-11/10/25 due to not having funds on the company gas card. She stated there would have been a lot more, but the Director of Nursing (DON) and the Business Office Manager (BOM) used their personal credit cards to put gas in the transport van which allowed the residents to be able to make it to their appointments. She stated she did not know the reason for the credit card not having funds and was informed that the Administrator and corporate office were aware.An interview with the DON on 11/24/25 at 10:40 AM revealed she confirmed that between the end of October and the first week of November, Resident #2, #3, and #4 missed their scheduled appointments related to no gas in the van and no funds on the company card to put gas in the van for transport. She confirmed there would have been more, but she personally filled the van once and so did the BOM so the residents could be transported to their appointments. She stated the Administrator and corporate office were aware of the issue and it was discussed daily in stand-up.An interview with the Administrator on 11/24/25 at 10:45 AM revealed he confirmed there had been an issue with the company gas card but stated it was corrected now. He denied that the van was ever out of gas, stating he filled it up himself. He then stated he did not approve any appointments to be rescheduled due to van transport card issues.An interview with the BOM on 11/24/25 at 11:00 AM revealed she confirmed that a few residents missed their scheduled appointments related to there being no funds on the company gas card. She stated that she immediately made the corporate office and the Administrator aware of the issues with the credit card. She stated this went on for about two weeks and that she put gas in the van once because she did not want residents to miss their appointments.

Based on observations, staff interviews, record review, and facility policy review, the facility failed to: 1) label and store food properly and maintain the kitchen and the equipment in a clean and sanitary condition for two (2) of three (3) kitchen tours, and 2) prevent the potential for foodborne illness as evidenced by meal trays left in rooms for a prolonged time (Resident #24, #52, #68, #83) for one (1) of four (4) survey days. Findings Include: Review of facility policy titled, Food Storage: Dry Goods dated 2/2023 revealed, .All packaged and canned food items will be kept clean, dry, and properly sealed . Review of facility policy titled, Food Storage: Cold Foods dated 2/2023 revealed, .All foods will be stored wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination . Review of facility policy titled, Environment revised date 9/2017 revealed, Policy Statement: All food preparation areas, food service areas, and dining areas will be maintained in a clean and sanitary condition . Review of facility policy titled, Environment revised date 9/2017 revealed, Policy Statement: All foodservice equipment will be clean, sanitary, and in proper working order . Review of facility training titled, Glove Usage - Term 2 - 2025 revealed, Our policy requires kitchen staff to be educated on proper glove usage including how to properly put on gloves, activities where gloves are required, when to change gloves, and how to properly remove gloves . Review of facility training titled, Glove Usage In-service revealed, .When to change or remove your gloves: When they are dirty, torn, damaged, discolored or contaminated; Before taking ONE STEP away from your work area . During the initial kitchen tour with the Dietary Manager (DM) on 6/16/25 at 10:14 AM, several observations were made regarding food storage practices. In the reach-in cooler number one (1), several items, including orange juice, tomato juice, ham, shredded cheddar cheese, bell peppers, sliced tomatoes, tomato paste, spaghetti sauce, lettuce, a sliced onion, cold slaw, sliced pears, parmesan cheese, and BBQ sauce were present without dates indicating when they were opened or when they expired. The prep table located next to the reach-in cooler revealed multiple seasonings with open lids, an open cup of salt with no lid, an open bag of bacon bits without an opened date, a five (5) pound container of peanut butter, a container of mixed peanut butter and jelly sitting out, without a date indicating when it was made or when it would expire. An additional prep table in the middle of the workspace area contained a cardboard box on the bottom shelf with gnats flying around inside it. Upon further investigation, several potatoes were found inside the box. The DM remarked, That box is garbage because the garbage can was full and overflowing. Furthermore, flies were observed flying around in the kitchen prep and cook area. The return vent located to the left of the stove was heavily covered with dust. Additionally, five (5) lids for the steam table containers located on the bottom shelf of the steam table that were covered with grease and food crumbs. Three (3) fry baskets on top of the deep fryer contained old grease and crumbs. During an interview on 6/16/25 at 10:30 AM with the DM, she confirmed that no open food items should be stored without an open date. She further emphasized that this practice is unacceptable as it could lead to foodborne illnesses. Additionally, she confirmed the maintenance supervisor was supposed to clean the return vent every other weekend and that it could cause food contamination when it is that dirty. Concerning the lids for the steam table, the DM stated, those were from last night. She further stated that the three (3) fry baskets were used yesterday to cook lunch and that they were supposed to be cleaned daily, if used. The DM verbalized that one of the deep fryers didn't work and hasn't been in working condition for two to three months now. She confirmed that she submitted a work order with TELS (maintenance work request program) two to three months ago. During a second observation of the kitchen on 6/16/25 at 2:41 PM, two (2) half gallon pitchers of tea and lemonade were revealed sitting out on the drink station without a date. Additionally, the stove top was covered with old grease and food buildup. During an interview on 6/16/25 at 2:52 PM, the District Dietary Manager confirmed that the facility policy mandates that all open food items be labeled with an open date for safety and organization. An interview with the District Dietary Manager and the Administrator on 6/16/25 at 3:34 PM revealed that no entries had been made in the TELS system regarding the deep fryer that was out of order. During an observation on 6/18/25 at 11:02 AM with DM focused on dish washing and sanitation practices, the low-temp dishwasher temperature reading was 110 degrees Fahrenheit, which is below the acceptable range of 120 to 140 degrees Fahrenheit necessary for effective sanitation. Review of facility's Dish Machine Log dated June 25 revealed Wash and Rinse temperatures for Lunch were not documented for June 1-16 and they were not documented for Dinner for June 2-17. An observation on 6/18/25 at 11:10 AM noted that the dietary cook walked away from her station and into the office, where she placed her hands in her personal bag. She then returned to the steam table to perform temperature checks without changing her gloves or washing her hands. An interview on 6/18/25 at 11:15 AM with the DM confirmed that gloves should be changed any time staff leave the line, get dirty or become torn, and emphasized the importance of washing hands and re-gloving to maintain hygiene standards. During an interview with the District Dietary Manager on 6/18/25 at 1:00 PM, she confirmed that the dishwasher temperatures should be checked during each meal cleanup, affirming that these records had not been documented. She stressed that maintaining proper temperature readings is essential to ensure that dishes are sanitized effectively. Record review of the facility's infection log revealed no indications of any food-borne illnesses. Resident #24, #52, #68, and #83 Meal Trays The facility provided a statement on letterhead that read, Currently, we do not have a specific policy in place which is implemented on time frames for picking up food trays. An observation of Resident #24 on 6/16/25 at 10:24 AM revealed she was lying in bed, verbal, and confused. Her breakfast tray was in front of her on an overbed table and contained grits, a sausage patty, and French toast. The resident was not eating and stated she was done. On 6/16/25 at 11:18 AM, an observation and interview with Resident # 83, who was found lying in bed with a breakfast tray placed on the bedside table. The tray contained a bowl of oatmeal, which the resident confirmed was from breakfast. An observation of Resident #52 on 6/17/25 at 10:37 AM revealed he was lying in bed with his eyes closed. The breakfast tray had not been removed and was still sitting on the overbed table beside his bed. An observation of Resident #68 on 6/17/25 at 12:11 PM revealed she was lying in bed, verbal, and confused. Her breakfast tray was placed on a chair beside the bed and contained leftovers of French toast and a sausage patty. During an interview with the Infection Preventionist (IP) on 6/17/25 at 3:26 PM, she stated there was no excuse for the breakfast trays not to be picked up in a timely manner and certainly should not be left in the resident rooms until lunchtime. She confirmed leaving the breakfast tray out for long periods of time could make someone sick. An interview with the Administrator on 6/19/25 at 8:56 AM revealed meal trays should be removed from the rooms when the residents were done eating and confirmed that someone could get sick from eating leftover food. Record review of the admission Record revealed the facility admitted Resident #24 on 5/02/25 with a medical diagnosis of Unspecified Dementia. Record review of the admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/12/25 revealed under section C, a Brief Interview for Mental Status (BIMS) score of 9, indicating Resident #24 was moderately cognitively impaired. Record review of the admission Record revealed the facility admitted Resident #52 on 5/08/25 with a medical diagnosis of Unspecified Dementia. Record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/29/25 revealed under section C, a Brief Interview for Mental Status (BIMS) score was not conducted for Resident #52 due to cognitive skills for daily decision making was severely impaired. Record review of the admission Record revealed the facility admitted Resident #68 on 1/04/24 with a medical diagnosis of Major Depressive Disorder. Record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/26/25 revealed under section C, a Brief Interview for Mental Status (BIMS) score of 14, indicating Resident #68 was cognitively intact. Record review of the admission Record revealed Resident #83 was admitted to the facility on [DATE] with medical diagnoses that included Dementia. Record review of the MDS with an ARD of 5/17/25 revealed, under Section C revealed, Resident #83 had a BIMS score of 6, which indicated severe cognitive impairment.

Resident #30 A record review of Resident #30's Care Plan revealed that the resident is resistant to care as evidenced by refusing showers, refusing to get out of bed . Interventions that included: If possible, negotiate a time for ADLs so that the resident participates in the decision-making process. Return at the agreed-upon time. On 6/16/25 at 11:17 AM an observation and interview revealed that Resident #30's fingernails were approximately three-fourths (3/4) of an inch long past the tip of the fingers, with a jagged appearance. Resident #30 stated, I don't like my nails this long and I want them cut. He revealed I don't know when the last time they were trimmed, but I know it's been a while. In an interview on 6/17/25 at 2:58 PM, the Director of Nurses (DON) revealed that the resident has, at times, refused to have his fingernails trimmed. However, we are still responsible for assessing the resident's fingernails each month and documenting his nail care, as well as any refusals. She confirmed that his long and jagged fingernails could cause skin breakdown. During an interview on 6/19/25 at 11:07 AM, the MDS nurse revealed that she and the MDS Coordinator are responsible for developing individualized care plans for each resident. She revealed that even if Resident #30 has at times refused his baths, his nail care should still be addressed and his ADL's should always be offered. She revealed that his intervention needs to be followed, regarding negotiating a time for ADLs, so that the resident participates and is more willing. She revealed that if his hygiene, which includes nail care, had not been addressed, then his plan of care was not being followed. A record review of the admission Record for Resident #30 revealed he was admitted to the facility on [DATE] with diagnoses that included Type 2 Diabetes Mellitus, Hemiplegia, and Hemiparesis following Cerebral Infarction affecting the Left Non-Dominant side. A record review of the MDS with an ARD of 3/31/25, revealed Resident #30 had a BIMS score of 15, indicating the resident was cognitively intact. Resident #70 Record review of Resident #70's Care Plans revealed a care plan was not developed for dementia care. Record review of Resident #70's admission Record revealed a new diagnosis of Dementia Unspecified Severity with other Behavioral Disturbance was added on 12/27/24. During an interview on 6/18/25 at 9:05 AM, with the MDS Coordinator, she confirmed Resident #70 did not have a dementia care plan and stated the resident should have one so that the staff knew he had dementia and how to provide appropriate care for him. An interview with Social Services #1 on 6/18/25 at 9:22 AM, she confirmed that Resident #70 should have a care plan in place for dementia so that the staff knew what care to provide. Record review of the admission Record revealed the facility admitted Resident #70 on 6/26/24 with a diagnosis of Post Traumatic Seizures. Record review of the MDS with an ARD of 3/24/25 revealed under section C, a BIMS score of 9, which indicated Resident #70 was moderately cognitively impaired. Resident #41 Record review of Resident #41's ADL Care Plan revealed the resident has an ADL self-care performance deficit related to (r/t) Activity intolerance, Limited Mobility .Interventions .Bathing/Showering: The resident requires Substantial/Max assistance by staff with bathing/showering (Q) every Tues-Thurs-Sat and as necessary . On 6/16/25 at 11:22 AM during an observation and interview Resident # 41 was noted to have approximately half an inch of facial hair on his chin, cheeks and upper lip. He expressed a desire to be clean shaven and indicated he needed a shower, stating, I don't remember for sure the last time I got a shower, but it has been a long time. On 6/17/25 at 3:00 PM during a follow-up observation and interview with Certified Nursing Assistant (CNA) #2, confirmed that Resident #41 needed both shaving and a shower. She stated that he often refuses personal care but typically gets shaved when he takes a shower. CNA #2 emphasized the staff's responsibility to ensure that residents are maintained in a neat and clean condition, describing it as a dignity issue. Record review of Resident #41's personal hygiene tasks record indicated that he only refused care three (3) times in the past 30 days. During an interview on 6/19/25 at 3:08 PM with the MDS Coordinator, she confirmed that care plans were established to guide staff in providing necessary care. She pointed out that when the staff do not adhere to these care plans, it results in residents not receiving the care they deserve. Record review of the admission Record revealed the facility admitted Resident #41 on 7/24/24 with medical diagnoses that included Chronic Obstructive Pulmonary Disease, Unspecified. Record review of the MDS with an ARD of 4/24/25 revealed, under Section C revealed, a BIMS score of 12, which indicated the resident had moderate cognitive impairment. Resident #78 Record review of Resident #78's care plans revealed the resident had an ADL self-care performance deficit r/t Dementia, Impaired balance, Limited Mobility with Interventions that include .The resident requires substantial/max assistance from staff with personal hygiene . On 6/16/25 at 11:33 AM during an observation with Resident # 78 revealed the resident had curly, coarse chin hair. An observation and interview with Registered Nurse (RN) #1 on 6/17/25 at 1:16 PM, revealed, She (Resident #78) refuses, she will not let us shave her. Record review of Resident #78'S task for personal hygiene revealed the resident only refused care one (1) time in the past 30 day look back. During an interview on 6/19/25 at 3:08 PM the MDS Coordinator confirmed that care plans are put in place so that the staff know how to provide care for their residents. She further stated that when the staff does not follow the care plan, that's failure for them to follow the care plan and residents are not receiving the care they deserve. Record review of the admission Record revealed Resident #78 was admitted to the facility on [DATE] with medical diagnoses that included Dementia. Record review of the MDS with an ARD of 5/22/25 revealed, under Section C revealed, a BIMS score of 00, which indicated the resident had severe cognitive impairment. Based on observation, resident and staff interview, record review, and facility policy review, the facility failed to: 1) develop a care plan for dementia care (Resident #70) and 2) failed to implement an Activities of Daily Living (ADL) care plan for dependent residents (Resident #11, #30, #41, #43 and #78) for six (6) of 30 resident care plans reviewed. The scope of this deficiency was increased to E due to F656 cited on the last annual recertification survey. Findings Include: Review of the facility's policy titled, Care Plan, Comprehensive Person-Centered with a revision date of 6/02/25, revealed under Policy Statement: A comprehensive, person-centered care plan that includes objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Resident #11 Record review of the Care Plan Report for Resident #11 revealed: The resident has an ADL self-care performance deficit r/t Activity Intolerance, Limited Mobility . Interventions . requires total assistance of staff for shower/ bath three times weekly and as necessary .requires substantial- maximum assistance by staff with personal hygiene . An observation and interview with Resident #11 on 6/17/25 at 8:15 AM, revealed that he had not received a bath or shower since his admission. He stated, It's been a month since I've had a bath or shower. A dark brown substance was noted underneath all of the residents fingernails. An observation and interview on 6/17/25 at 1:30 PM, Resident #11 stated he had received his first bath earlier that day and that it was the first since admission. An observation revealed a dark brown substance remained under his fingernails and his toenails were observed to be long, with a brown substance under them. The resident stated he would like his fingernails and toenails trimmed and cleaned. An interview with Registered Nurse (RN) #1 at 6/17/25 at 2:03 PM, she confirmed that Resident #11 had not had a bath, shower, or nail care since being admitted because he refuses every time. Record reviews do not reveal any progress notes or documentation of Resident #11 refusing a bath, shower, or nail care. During an interview with the Minimum Data Set (MDS) Coordinator on 6/19/25 at 3:08 PM, she stated, Care Plans are in place so that staff know how to provide care. She further stated, when staff do not follow the plan of care, it's failure for them to follow the plan of care and residents are not receiving the care they deserve. Record review of Resident #11's admission Record revealed the resident was admitted [DATE] with diagnosis of End Stage Renal Disease. Record review of Resident #11's Minimum Data Set (MDS), Section C, with an Assessment Reference Date (ARD) of 5/23/25, revealed a Brief Interview for Mental Status (BIMS) score of 13, indicating the resident is cognitively intact.

Resident #30 An observation and interview on 6/16/25 at 11:17 AM with Resident #30 revealed his fingernails were long and jagged. Resident #30 recalled that it had been a while since anyone had provided nail care. He then admitted that he does not like his nails this long. An interview and observation on 6/17/25 at 9:25 AM, Resident #30 revealed that no one had come to do his fingernails and stated that he wanted them cut. His fingernails remain long and jagged, measuring approximately three-fourths (3/4) inch past the tips of the fingers. During an observation and interview on 6/17/25 at 2:23 PM, RN #1 confirmed Resident #30's fingernails were long and jagged and needed to be cut. She revealed that with his fingernails being this long and jagged, he could scratch himself and create a skin tear. RN #1 asked Resident #30 if he wanted his fingernails cut, and Resident #30 replied, Yes. On 6/17/25 at 2:58 PM, the DON revealed that the resident (Resident #30) sometimes refuses to have his fingernails trimmed, but we are still responsible for assessing the resident's fingernails each month and documenting his nail care, as well as any refusals. She confirmed that his long and jagged fingernails could cause skin breakdown. A record review of the admission Record for Resident #30 revealed he was admitted to the facility on [DATE] with diagnoses that included Type 2 Diabetes Mellitus, Hemiplegia, and Hemiparesis following Cerebral Infarction affecting the Left Non-Dominant side. A record review of the MDS with an ARD of March 31, 2025, revealed Resident #30 had a BIMS score of 15, indicating the resident was cognitively intact. Resident #41 During an observation on 6/16/25 at 11:22 AM, Resident # 41 was noted to have approximately half an inch of facial hair on his chin, cheeks and upper lip. In an interview, he expressed a desire to be shaved and indicated he needed a shower. He stated that he did not remember for sure the last time he got a shower but knows that it has been a long time. During a follow-up observation and interview on 6/17/25 at 3:00 PM with Certified Nursing Assistant (CNA) #2, she confirmed that Resident #41 needed both shaving and a shower. She stated that he often refuses personal care but typically gets shaved when he takes a shower. CNA #2 emphasized the staff's responsibility to ensure that residents are maintained in a neat and clean condition. She also expressed concern that neglecting personal care could lead to a decline in the residents' health. Record review of Resident #41's personal hygiene tasks record indicated that he only refused care three (3) times in the past 30 days. Record review of the admission Record revealed Resident #41 was admitted to the facility on [DATE] with medical diagnoses that included Chronic Obstructive Pulmonary Disease, Unspecified. Record review of the MDS with an ARD of 4/24/25 revealed, under Section C revealed Resident #41 had a BIMS score of 12, which indicated the resident had moderate cognitive impairment. Resident #78 During an observation on 6/16/25 at 11:33 AM for Resident #78, the resident was noted to have curly, coarse hair on her chin. On 6/17/25 at 1:16 PM, an observation and interview with RN #1, revealed that Resident #78 often refuses to allow staff to shave her. Record review of Resident #78's personal hygiene tasks record indicated that Resident #78 only refused care once in the past 30 days. During an interview on 6/17/25 at 4:22 PM with the DON expressed her expectations for residents to be shaved, if needed, during their showers. She emphasized the importance of maintaining personal grooming, particularly for female residents, noting that having facial hair can significantly affect a resident's dignity and may lead to feeling of embarrassment and lower self-esteem. She acknowledged that the resident may not fully understand the implications of having facial hair but underscored that this does not lessen the importance of addressing the issue. Record review of the admission Record revealed Resident #78 was admitted to the facility on [DATE] with medical diagnoses that included Dementia. Record review of the MDS with an ARD of 5/22/25 revealed, under Section C revealed, a BIMS score of 00, which indicated the resident had severe cognitive impairment. Based on observation, resident and staff interviews, record reviews, and facility policy review, the facility failed to provide activities of daily living (ADL) care for residents who are dependent on staff assistance for five (5) of 83 residents reviewed for ADLs. (Residents #11, #30, #41, #43, and #78) The scope for this deficiency was increased to E due to a previous citation of F677 on the last annual recertification survey completed on 1/4/24. Findings include: Review of the facility policy titled Activities of Daily Living (ADL) with a revision date of March 2018, revealed the following: Policy Statement: Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene .4. If residents with cognitive impairment or dementia resist care, staff will attempt to identify the underlying cause of the problem and not just assume the resident is refusing or declining care. Approaching the resident in a different way or at a different time or having another staff member speak with the resident may be appropriate . Resident #11 On 6/17/25 at 8:15 AM, an observation and interview with Resident #11 revealed that he had dirty fingernails with a brown substance under each nail bed. Resident #11 stated had not received a bath since his admission and thought it had been a month. On 6/17/25 at 1:30 PM, an observation and interview with Resident #11 revealed he had received a bath today for the first time since he got to the facility, but an observation of his fingernails revealed no change in appearance and his toenails were long with a brown substance underneath them. During an interview with Registered Nurse (RN) #1 at 6/17/25 at 2:03 PM, she confirmed that Resident #11 had not had a bath, shower, or nail care since being admitted . She stated he has not had these things because he always refuses. Record reviews do not reveal any progress notes or documentation of Resident #11 refusing a bath, shower, or nail care. During an interview with the Director of Nursing (DON), she stated that the residents should get a bath and have their nails cleaned and trimmed. She confirmed that not being clean would increase the risk of infection in Resident # 11. Record review of Resident #11's admission Record revealed the resident was admitted [DATE] with diagnosis of End Stage Renal Disease. Record review of Resident #11's Minimum Data Set (MDS), Section C, with an Assessment Reference Date (ARD) of 5/23/25, revealed a Brief Interview for Mental Status (BIMS) score of 13, indicating Resident #11 is cognitively intact. Resident #43 On 6/16/25 at 10:45 AM, an observation and interview with Resident #43 revealed long fingernails and a brown substance underneath. When asked if she wanted her nails trimmed, the resident states, Yes, I would like them trimmed. During an interview with Licensed Practical Nurse (LPN) #1 at Resident #43's bedside, on 6/17/25 at 1:48 PM, she confirmed that the resident's fingernails were long and had a brown substance under them and stated, Her fingernails should be cleaned and trimmed. During an interview on 6/17/25 at 2:04 PM with RN #1, she stated that her (Resident #43) fingernails should be kept clean and trimmed. If she had a break in her skin, her dirty nails could lead to an infection. During an interview with the DON on 6/17/25 at 3:00 PM, she stated that, The expectation is that a resident's nails be kept clean and trimmed. Record review of Resident #43's admission Record revealed the resident was admitted [DATE] with diagnoses of Chronic Systolic (Congestive) Heart Failure and Dementia. Record review of Resident #43's MDS, Section C, with an ARD of 4/11/2025, revealed a BIMS score of 9, which indicates the resident is severely cognitively impaired.

Resident #24 An observation of Resident #24 on 6/16/25 at 10:24 AM revealed she was lying in bed, verbal but confused with two visible flies flying over her bed. Her overbed table was pulled across her bed with a remaining breakfast tray uncovered with left over food and the flies were attempting to land on the food tray. Resident #52 An observation of Resident #52 on 6/17/25 at 10:37 AM revealed he was lying in bed with his eyes closed and two flies were flying around his bed and attempting to land on the table beside his bed that had a left over breakfast tray. Resident #70 An observation of Resident #70 on 6/16/25 at 12:22 PM revealed he was lying in bed with multiple flies (3-5) flying around his room, circling over the resident and landing on his covers. An interview with Maintenance on 6/17/25 at 3:51 PM confirmed flies had been a problem for months despite everything they had tried. He admitted that there is a pest control company that visits twice monthly. He revealed that flies could be entering residents opened windows because some screens were damaged. He stated he had been in the process of replacing the damaged screens. An interview with the Administrator (ADM) on 6/17/25 at 9:05 AM confirmed that flies were a concern in the facility despite pest control coming to the facility even recently. He admitted he had not contacted anyone or explored additional pest control services. He additionally revealed leaving the meal trays in the residents' rooms could attract insects. Review of the Proper Name of Pest Control Work Order revealed a visit date of 6/9/25 which targeted flies. Record review of the admission Record revealed Resident #15 was admitted to the facility on [DATE] with medical diagnoses that included Complete Traumatic Amputation at Right Hip Joint, Subsequent and Adult Failure to Thrive. Record review of the admission Record revealed the facility admitted Resident #24 on 5/02/25 with a medical diagnosis of Unspecified Dementia. Record review of the admission Record revealed the facility admitted Resident #52 on 5/08/25 with a medical diagnosis of Unspecified Dementia. Record review of the admission Record revealed the facility admitted Resident #70 on 6/26/24 with a diagnosis of Post Traumatic Seizures. Based on observation, staff interview, and facility policy review, the facility failed to ensure they had an effective pest control as evidenced by multiple sightings of flies in resident's rooms and kitchen and gnats observed in the kitchen for two (2) of four (4) survey days. Findings include: The facility provided a statement on letterhead that read, Currently, we do not have a specific policy in place which is implemented on Pest Control. Review of facility policy titled, Environment revised date 9/2017 revealed, Policy Statement: All food preparation areas, food service areas, and dining areas will be maintained in a clean and sanitary condition . During the initial kitchen tour with the Dietary Manager (DM) on 6/16/25 at 10:14 AM, a prep table in the middle of the workspace area contained a cardboard box on the bottom shelf with gnats flying around inside it. Upon further investigation, several potatoes were found inside the box. The DM remarked, That box is garbage because the garbage can was full and overflowing. Furthermore, flies were observed flying around in the kitchen prep and cook area. Resident #15 An observation on 6/16/25 at 11:44 AM with Resident #15 revealed a fly in his room and a fly swatter on his bedside table.

Resident #20 An observation and interview on 6/16/25 at 11:33 AM, revealed Resident #20 sitting in his wheelchair. The right armrest was noted to have 95% of the vinyl missing from the top, exposing the padding, and the remaining vinyl was tattered. The left arm rest revealed tattered and torn vinyl. The wheelchair frame and spokes of the wheels were covered in a thick, gray substance. The resident revealed he wasn't sure why his wheelchair looked like this and wasn't sure when it would be cleaned. An observation and interview on 6/17/25, at 3:25 PM with the Administrator (ADM) revealed that Resident #20's wheelchair remained in need of repair and cleaning, with the frame and spokes of the wheels covered in a thick, gray substance. The Administrator confirmed the wheelchair was dirty and needed to be cleaned, and the armrests were tattered and needed to be replaced. He revealed he did not know which staff member was responsible for cleaning the wheelchairs, but dirty and disrepaired equipment was not acceptable. In an interview on 6/17/25 at 4:25 PM, the Director of Nurses (DON) revealed that wheelchairs are supposed to be cleaned during the night shift, and the resident's wheelchair should have been cleaned. During an interview on 6/17/25 at 4:31 PM the Maintenance Director revealed he was unaware that the arm rests were so tattered, with missing vinyl exposing the padding. He revealed that the staff should have either notified him or put it in the TELS system. He revealed that replacing the armrest was an easy fix, and it should have already been taken care of. Record review of Resident #20's admission Record revealed the resident was admitted [DATE]. Record review of Resident #20's MDS, Section C, with an ARD of 3/28/2025, revealed a BIMS score of 15, indicating the resident is cognitively intact. Resident #50 An observation of Resident #50's room on 6/16/25 at 10:21 AM revealed a 4-drawer dresser with the fourth drawer broken and missing, leaving the contents inside visible. Several flies were observed flying around inside the room. Resident #55 An observation of Resident #55's room on 6/17/25 at 2:46 PM revealed the lower portion of the privacy curtain had eight circular dark brown stains of various sizes, the largest approximately the size of a nickel. Resident #82 On 6/16/25 at 10:55 AM, an observation of Resident #82's room revealed a straight chair located beside the bed with the right armrest broken and hanging down, exposing a silver screw. An observation and interview with Maintenance Director on 6/17/25 at 3:51 PM confirmed Resident #82's room had a chair with its right arm broken hanging down. Maintenance stated he had not been made aware of the issue and confirmed that a resident or visitor could be injured if they sat in it. He also confirmed Resident #50's dresser drawer was broken and remarked, That's an easy fix, if someone would have let me know. He acknowledged residents should have a homelike environment with furniture in good condition and added, This is their home. He explained that nurses and aides, who are constantly in and out of the rooms, were responsible for reporting such concerns so they could be entered into TELS (the work order platform) for repair. An observation and interview with the Housekeeping Supervisor on 6/18/25 at 3:25 PM revealed that housekeepers were responsible for daily room cleaning and, during that time, were expected to check privacy curtains for cleanliness and condition. She stated she was responsible for replacing them when needed. She confirmed Resident #55's privacy curtain was soiled with a dark brown substance and stated, It needs to be changed. She added that residents should have a clean and healthy living environment and that a clean room makes them feel better. An interview with the ADM on 6/17/25 at 9:05 AM revealed staff were assigned to make daily rounds of the residents' rooms and were supposed to report any repair concerns. Record review of the Proper Name of Pest Control Work Order revealed a visit date of 6/9/25 which targeted flies. Based on observations, resident and staff interviews, record reviews, and facility policy reviews, the facility failed to provide a safe, clean, and homelike environment for five (5) of the 83 residents residing in the facility. (Residents #9, #20, #50, #55, and #82). Findings include: Review of the facility policy titled, Statement of Resident Rights undated revealed, You have a right to: .2. Safe, decent and clean conditions. Review of the facility policy titled Cleaning Cubicle Curtains revised 9/05/17 revealed under, Training &(and) Method: . If the curtain is stained, remove immediately. The facility provided a statement on facility letterhead that read, Currently, we do not have a specific policy in place which is implemented on keeping and maintaining equipment. Resident #9 An observation of the footrests of Resident #9's motorized wheelchair on 6/16/25 at 11:35 AM revealed they were covered with dirt and crumbs. There was also the presence of a fly in the resident's room. During an interview on 6/19/25 at 11:30 AM, Resident #9 stated that his wheelchair had not been cleaned since he received it approximately six months ago. During an observation and interview on 6/19/25 at 11:42 AM with the Housekeeping Manager confirmed that Resident # 9's motorized wheelchair was indeed dirty and required cleaning. She also confirmed that the Certified Nursing Assistants (CNAs) were responsible for cleaning the wheelchairs. Record review of the admission Record revealed Resident #9 was admitted to the facility on [DATE]. Record review of the Minimum (MDS) with an Assessment Reference Date (ARD) of 3/14/25 revealed, under Section C, a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact.

Resident #48 Observations on 6/17/25 at 8:25 AM and 10:45 AM revealed that Resident #48 was in bed with the call light hanging down behind the bed and inaccessible to the resident. An observation and interview on 6/17/25 at 3:05 PM revealed Resident #48 lying in bed, the call light remains hanging down behind the bed and inaccessible to the resident. Resident #48 acknowledged that she was unable to reach her call light. During an observation and interview on 6/17/25 3:20 PM, Certified Nurse Aide (CNA) #4 revealed she is responsible for the resident today. She confirmed the call light was hanging down behind the bed, lying on the floor, and inaccessible to the resident. She revealed I must have forgotten to attach it to her pillow. CNA #4 revealed the call light is supposed to be attached to the resident's pillow so she can call if she needs anything. During an interview on 6/17/25 at 3:30 PM the DON confirmed that staff are expected to ensure call lights are always within residents' reach. She revealed they should always have access to their call lights to request assistance. Record review of the admission Record revealed that Resident #48 was admitted to the facility on [DATE] with diagnoses that included Alcoholic Polyneuropathy, repeated falls, and Schizophrenia. Record review of the MDS with an ARD of 04/18/2025 for Resident #48 revealed a BIMS score of 14, indicating that the resident is cognitively intact. Resident #44 An observation of Resident #44 on 6/16/25 at 10:30 AM revealed he was sitting in his recliner in his room. His call light was out of reach, hanging from the wall outlet box onto the floor. An observation and interview with LPN #4 on 6/16/25 at 10:41 AM confirmed Resident #44's call light was tangled on the floor and out of his reach. She stated the resident knew how to use the call light and confirmed it should be within reach for safety, so he could alert staff if needed. She revealed that all staff were responsible for ensuring call lights were accessible. Record review of the admission Record revealed the facility admitted Resident #44 on 8/24/24 with a diagnosis of Unspecified Dementia. Record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/13/25 indicated in section C, a Brief Interview for Mental Status (BIMS) score of 11, indicating moderate cognitive impairment. Resident #82 An observation and interview with Resident #82 on 6/16/25 at 10:55 AM revealed he was lying in bed, and his call light was not visible. He stated, It's in the floor over there somewhere, while pointing toward the center of the room. He explained this happens often and, if he needed something, he had to wait for staff to come in and check on him. The call light was observed lying on the floor and not accessible to the resident. An observation and interview with LPN #4 on 6/16/25 at 11:05 AM confirmed Resident #82's call light was not accessible and was located on the floor. She stated the resident should have his call light within reach in case he needed help and acknowledged it was a safety concern, as he might try to get up alone with no way to call for assistance. Record review of the admission Record revealed the facility admitted Resident #82 on 4/18/25 with a medical diagnosis of other Specified Diseases of the Biliary Tract. Record review of the MDS with an ARD of 4/25/25 revealed under section C, a BIMS summary score of 15, which indicated Resident #82 was cognitively intact. Based on observation, staff interview, record review and facility policy review, the facility failed to ensure that resident call lights were within reach, which limited a resident's ability to request assistance (Residents #39, #44, #48 and #82) and failed to ensure adequate mattress size needed (Resident #45) for five (5) of 83 residents residing in the facility. Findings include: Review of the facility policy dated October 2022 titled Resident Call System revealed, Residents are provided with a means to call staff for assistance through a communication system that directly calls a staff member or a centralized workstation . Resident #39 An observation on 6/16/25 at 11:00 AM and again on 6/17/25 at 11:08 AM revealed Resident #39's call light was not within reach. On 6/16/25 at 11:00 AM the observation revealed the call light was wrapped around the back of the bed and out of reach. And on 6/17/25 at 11:08 AM, the call light was observed on the floor, behind the bed, out of reach. During an observation and interview with Licensed Practical Nurse (LPN) #5 on 6/18/25 at 11:18 AM she confirmed the Resident #39's call light was out of reach and on the floor. She stated, The call light should always be in reach so that the resident can call us if needed, it should not be on the floor out of reach. During an interview with the Director of Nursing (DON) on 6/18/25 at 11:45 AM, she stated, The call light should be within reach of Resident #39, the call light is the resident's voice. Record review of Resident #39's admission Record revealed the resident was admitted [DATE] with diagnosis of Unspecified Dementia. Record review of Resident #39's Minimum Data Set (MDS), Section C, with an Assessment Reference Date (ARD) of 4/17/2025, revealed a Brief Interview for Mental Status (BIMS) score of 6 indicating the resident was severely cognitively impaired. Resident #45 On 6/16/25 at 11:00 AM, 1:00 PM, and 2:30 PM Resident #45 was observed lying in bed with his feet hanging off the end of the mattress. He was positioned with his head at the head of the bed but both feet were extended past the end of the mattress with no support. During an observation and interview with the DON on 6/17/25 at 8:30 AM, she confirmed that Resident #45's mattress was too short and that he needed a mattress extender. She stated, His feet hanging off of the mattress could result in an injury to his feet. Record review of Resident #45's admission Record revealed the resident was admitted [DATE] with diagnoses of Other Reduction Deformities of Brain. Record review of Resident #45's MDS, Section C, with an ARD of 4/30/2025, revealed a BIMS score of 7, indicating that the resident is severely cognitively impaired.

Based on observation, staff interview, record review and facility policy review, the facility failed to ensure a resident's dignity was maintained as evidenced by a resident wearing a visibly soiled shirt and pants hanging below the hips, exposing undergarments for one (1) of 41 sampled residents. Resident #44 Findings Include: Review of the facility policy titled Dignity, revised 2/2021, revealed under Policy Statement: Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, satisfaction with life, and feelings of self-worth and self-esteem . An observation of Resident #44 on 6/16/25 at 10:29 AM revealed he was sitting in his recliner in his room with the door open. He was wearing a soiled shirt with yellow orange smeared food and five circular stains the size of nickels and quarters, resembling spilled liquids. His pants were pulled down past his hips, exposing his protective underwear. A staff member was observed changing the resident's linen but did not interact with or provide care to the resident. During an observation and interview with Licensed Practical Nurse (LPN) #4 on 6/16/25 at 10:41 AM, she confirmed that Resident #44's shirt was soiled, and his underwear was exposed. She stated, Yes, it looks bad. She acknowledged this was a dignity issue and stated the resident's clothes should be changed when soiled. An interview with Certified Nurse Aide (CNA) #3 on 6/16/25 at 10:50 AM, she revealed she was assigned to Resident #44 and was aware his shirt was soiled. She stated, I saw it after breakfast, but I got busy with another resident and never returned. CNA #3 acknowledged this was a dignity concern. An interview with the Administrator on 6/19/25 at 8:50 AM revealed his expectation was that staff should address Resident #44's needs as soon as they were identified. Record review of the admission Record revealed the facility admitted Resident #44 on 8/24/24 with a diagnosis of Unspecified Dementia. Record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/13/25 indicated in section C, a Brief Interview for Mental Status (BIMS) score of 11, indicating moderate cognitive impairment.

Based on staff interviews, record review and facility policy review, the facility failed to implement a comprehensive care plan to provide for two-person assistance with a lift during a transfer in a manner to prevent an injury for one (1) of three (3) sampled residents. Resident #1. Findings Include: Review of the facility policy Care Plans, Comprehensive Person-Centered with reviewed date of November 2024 revealed, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Record review of Resident #1's Care Plan that was initiated on 07/27/23, revealed that she had an Activities of Daily Living (ADL) self-care performance deficit related to weakness and had interventions in place that included, Transfer: The resident requires Total by two (2) staff to move between surfaces as necessary. Full Body Lift Extra Large Sling 2 Person Transfers . During an interview with the Administrator (ADM) on 01/27/25 at 10:10 AM revealed that on 12/05/24, Certified Nursing Assistant (CNA) #1 went into Resident #1's room to help CNA #2 transfer the resident from the wheelchair to her bed. The ADM revealed that CNA #2 was assigned to Resident #1 that day and had asked CNA #1 to help her with the transfer because she required a total lift for all transfers. ADM revealed that CNA #2 left her room to get a Hoyer lift and that when CNA #2 returned to Resident #1's room with the Hoyer Lift, CNA #1 was transferring the resident from the wheelchair to her bed without a lift. CNA #1 stated that he was told by another CNA that the resident could transfer to the bed without a lift. ADM revealed that a short time later, Resident #1 complained of pain, they sent her out to the hospital, and x-rays confirmed that she had fractures to her right leg. Resident #1 was assessed at that time and sent to the emergency room (ER) for evaluation. Resident #1 returned to the facility on [DATE] with diagnosis of minimally displaced fracture of the distal tibia and fibula. On 01/27/25 at 12:55 PM a phone interview with Assistant Director of Nursing (ADON) revealed that CNA #1 should have looked up Resident #1's plan of care instead of going by what someone else said. The ADON revealed that she hated that it happened, that CNA #1 was great, but he shouldn't have transferred Resident #1 without assistance. She confirmed that CNA #1 did not follow Resident #1's care plan when he allowed her to stand and pivot to transfer from her wheelchair to bed which caused her injury. Record review of Resident #1's X-Ray Final Results completed on 12/05/24 at the hospital revealed, Findings: Comminuted, minimally displaced fractures of the distal tibia and fibula . Record review of Resident #1's Admission Record revealed an admitted [DATE] and that she had diagnoses that included Obesity and Generalized Muscle Weakness. Record review of Resident #1's Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 11/07/24 under Section C revealed a Brief Interview for Mental Status (BIMS) score of 12 which indicated that she had moderate cognitive deficits.

Based on observation, staff and resident interviews, record review and facility policy review, the facility failed to provide two-person assistance during a transfer for a dependent resident in a manner to prevent an injury for one (1) of three (3) sampled residents. Resident #1. Findings Include: Review of the facility policy titled, Safe Patient Handling and Moving Protocol with reviewed date of 06/10/2024, revealed The Quality Assurance (QA) Committee will ensure implementation of this policy to identify, assess, and develop strategies to control risk of injury to residents and nursing staff associated with the lifting, transferring, repositioning or movement of a resident. Under the Transfer and Bed Mobility/Positioning Technique Training topic, , .It is important to remember that each resident is different; transfer techniques and bed mobility/positioning may need to be modified for the particular resident to meet their individual needs. Please verify level of assistance required prior to initiating transfer . An interview on 01/27/25 at 10:10 AM with the Administrator (ADM), revealed that on 12/05/24, Certified Nursing Assistant (CNA) #1 went into Resident #1's room to help CNA #2 transfer Resident #1 from the wheelchair to her bed. ADM revealed that CNA #2 was assigned to Resident #1 that day and had asked CNA #1 to help her with the transfer because the resident required a total lift for all transfers. CNA #2 left the room to get a Hoyer lift and when CNA #2 returned to Resident #1's room with the Hoyer Lift, CNA #1 was already transferring her from the wheelchair to her bed without a lift. ADM revealed that a short time later, Resident #1 complained of pain, they sent her out to the hospital, and x-rays confirmed that she had fractures to her right leg. An observation and interview on 01/27/25 at 10:20 AM with Resident #1 revealed her lying in bed in her room and she had a brace on her right leg. She revealed that a few weeks ago, she hurt her leg while getting into bed from her wheelchair. Resident #1 revealed that she was sitting in her wheelchair to the left side of her bed when the aide came in to help her. She stated that the aide let the bed down low, he placed his hand under her right arm, and she held onto the bed rail with her other hand. Resident #1 confirmed that the aide helped her to stand up and she hit her right leg on the bed, and she stated, I couldn't make another move. Resident #1 revealed that another aide came in with the lift during this time and they got her into the bed. The resident stated that soon after the transfer, her leg started hurting, and she told the nurse. She revealed that the nurse came and checked her out, they sent her to the hospital and after doing x-rays, found that she had a broken leg. A phone interview on 01/27/25 at 12:55 PM with Assistant Director of Nursing (ADON), revealed that she worked on 12/05/24, the date that Resident #1 was hurt during a transfer. ADON revealed that CNA #2 was assigned to Resident #1 that day and had asked CNA #1 to help her transfer Resident #1 using the total lift. ADON revealed that CNA #1 told CNA #2 that another aide had told him that Resident #1 could pivot to transfer. ADON revealed that CNA #2 left her room to get the total lift because she wasn't going to transfer her that way. ADON revealed that when CNA #2 returned with the lift, CNA #1 was transferring Resident #1 into the bed. ADON confirmed that the floor nurse reported a little later that Resident #1 complained of pain to her right leg. ADON stated that she went to the resident's room and assessed her and found that her right leg was a little shorter than the other leg and that her right foot was turned outward. ADON revealed that she notified the Nurse Practitioner (NP) who ordered to send her out to the hospital. The ADON confirmed that both of the CNAs were from a staffing agency and that CNA #1 has not been back to work at the facility again because of the incident. Record review of the facility investigation revealed that on 12/05/2024, CNA #2 was assigned to Resident #1. CNA #2 requested assistance from CNA #1 to put Resident #1 back in bed. CNA #2 had brought the full body lift into the room to use for the transfer as she stated she was told during walking rounds at the beginning of her shift that Resident #1 was a lift transfer. CNA #1 stated to CNA #2 that he was told by another CNA the previous week that Resident #1 could stand and pivot for a transfer. CNA #1 stated at that point Resident #1 had scooted to the edge of the chair and he began to transfer Resident #1. Both CNA #1 and CNA #2 stated Resident #1 wasn't able to pivot and her foot dragged on the ground as CNA #1 continued to transfer Resident #1 to the bed. After being placed on the bed, Resident #1 complained of right leg pain. Resident #1 was assessed at that time and sent to the emergency room for evaluation. Resident #1 returned to the facility on [DATE] with diagnosis of minimally displaced fracture of the distal tibia and fibula. Review of Resident #1's care plan revealed that Resident #1 was care planned for 2 persons assist with full body lift for transfers. Record review of CNA #1's written statement revealed, I (proper name) (CNA #1) went to transfer (proper name) Resident #1 stand by pivot. I was told by a CNA in report the day of [DATE] that's how (proper name) Resident #1 transferred so on [DATE] about 3:15 I went to help her back to bed using the same stand and pivot not knowing she was supposed to be transferred using the hoyer so in the process of transferring (proper name) Resident #1 her ankle turned or something and I think she broke some bone in her leg. This statement was signed by CNA #1. The State Agency (SA) attempted to contact CNA #1 and CNA #2 for an interview but was unsuccessful. Record review of CNA #2's written statement revealed, I ask (proper name) CNA #1 to help me transfer (proper name) Resident #1 to her bed. I took the lift into the room. He stated he can transfer her with the lift. He said a staff stated, she can be pivot. As he lifted her up, she went down on the bed and I noticed that her leg (right) was behind her. We place her on the bed correctly and the nurse walk in. And he told me what he did. And then the DON (Director of Nursing) walk in and he told her what happen. This statement was signed by CNA #2 on 12/05/24 at 4:30 PM. Record review of Resident #1's Progress Note dated 12/05/24 at 15:29 (3:29 PM) revealed, Called to room per other staff members. Resident lying in bed c/o (complain of) leg pain from transfer from w/c (wheelchair) to bed. Right leg noted painful to touch and leaning to the right. NP (Nurse Practitioner) notified . Record review of Resident #1's Progress Note dated 12/05/24 at 15:30 (3:30 PM) revealed, Floor nurse came to my office at this time and stated that the resident was having c/o (complaint/of) that her leg was broke. Floor nurse stated she started having this c/o leg pain after she was transferred assistance x (times) 2 aid to her bed .Upon arrival to the room .the RLE (right lower extremity) was noted to have bruising to the shin, eversion of R (right) foot and the limb presented shorter than the LLE (left lower extremity). Resident did have c/o pain during assessment. (Proper Name) (Nurse Practitioner) was notified at this time . Order was given to transfer the resident out related to possible fracture. Record review of Resident #1's Progress Note dated 12/05/24 at 16:37 (4:37 PM) revealed that Resident transported to (proper name) emergency room r/t (related to) pain in right leg, by ambulance . Record review of Resident #1's X-Ray Final Results completed on 12/05/24 at the hospital revealed, .Findings: Comminuted, minimally displaced fractures of the distal tibia and fibula . Record review of Resident #1's Admission Record revealed an admitted [DATE] and that she had diagnoses that included Obesity and Generalized Muscle Weakness. Record review of Resident #1's Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 11/07/24 under Section C revealed a Brief Interview for Mental Status (BIMS) score of 12 which indicated that she had moderate cognitive deficits.

Based on record review, interview, and facility policy review, the facility failed to prevent neglect in the facility as evidenced by Resident #1 sustained a fall with a fracture that was not immediately reported by a Certified Nursing Assistant (CNA) and also the CNA failed to utilize the appropriate number of staff to turn and re-position the resident during the Activity of Daily Living (ADL) care that allowed the resident to fall from the bed sustaining, an injury, for one (1) of 16 residents reviewed for neglect. Findings include: Review of the facility policy titled, Abuse Prohibition Policy, dated 12/12/19, stated, Any employee who becomes aware of an allegation of abuse, neglect or misappropriation of resident property, shall report the incident to the Abuse Coordinator immediately. Failure to do so will result in disciplinary action, up to and including termination. Record review of the Facility Reported Incident (FRI) stated that the facility investigation revealed on 02/15/20, Resident #1 was being cared for by CNA#1 and that a bed bath was being given when the resident rolled out of bed. The investigation revealed that CNA#1 stated that she attempted to catch the resident but she was unsuccessful and the resident rolled onto the floor and that she picked the resident up and placed her back into the bed. The FRI revealed that the CNA told Licensed Practical Nurse (LPN) #2 that the resident, almost fell out of the bed but that she had caught her before she rolled out of bed. LPN #2 stated that she did not fill out an incident report because it was reported to her that the resident did not fall, but that she had gone in to assess the resident immediately and did not see any bruises or issues at that time. Record review a Nurses Note revealed that on 02/17/20, Resident #1 was complaining of pain to her right upper leg. An x-ray was obtained and revealed no fractures noted. Resident #1 was placed on [MEDICATION NAME] for muscle spasms. Resident #1 complained of pain on several occasions but would take the [MEDICATION NAME] and would be relieved. On 02/27/20, the resident continued to complain of pain and the physician ordered a Computed Tomography (CT) scan. Results of the CT scan revealed an intratrochanteric [MEDICAL CONDITION] right femur. The facility investigation into the incident revealed that the fracture was reported to the Attorney General's Office (AG) and the State Agency (SA) and in-services on Abuse/ Neglect, Resident Rights and Vulnerable Adults Act were completed by all staff. The FRI revealed that statements were gathered and the statement from CNA #1 was a written statement, I was giving (proper name) a bed bath and she rolled off the bed after yelling I'm Falling. I attempted to catch her as quickly as I can but she was already on the floor. After I looked her over, I put her back in the bed then notified her nurse. An interview with LPN #2 on 10/07/20, at 12:15 pm, stated that she was the LPN for Resident #1 on the day of 02/15/20 and that CNA #1 had come to her and said that she had hurt her shoulder giving Resident #1 a bath and I asked her what happened and she told me that she interrupted a fall during her bath and caught Resident #1 before she fell and that she had hurt her shoulder. LPN #2 stated that she had asked her if she wanted her to fill out an incident report on her and CNA #1 said no. LPN #2 stated that she asked her again about Resident #1 and she told her that the resident didn't fall out of the bed, that she had caught her. LPN #2 stated that she went to the room and looked in on the resident and assessed her and did not see any bruises or concerns so she did not fill out an incident report because she was told it was not a fall. LPN #2 stated that she had reported it to the oncoming nurse. The nurse stated that later in the next couple of days the staff saw bruises on her right side and groin area, that's when the resident had the x-ray. LPN #2 said she asked the CNA again, are you sure she didn't fall, but she denied she fell . Then when we got the CT scan back on 02/28/20, and it showed a fracture, I asked the CNA again if she had fell that day and she said yeah, I told you she did. I told her no you didn't tell me that, so you better go now and tell the Director of Nursing (DON) the truth and that you lied. The Administrator got a statement from both of us and we were both suspended pending the investigation on 02/28/20, when we knew she had a fracture. LPN #2 stated that she would have completed the incident report but she was told that she didn't have a fall. LPN #2 stated that she did not see CNA #1 anymore after that because the facility suspended CNA #1 and then fired her. The State Agency (SA) attempted to call CNA #1 on 10/07/20, at 10:50 am, and again at 1:40 pm, and left a voicemail that we needed to speak with her regarding the incident and she did not return the call. An interview with LPN #1, Staff Development and CNA Instructor, stated that she began working at the facility in October 2019, and that she works with the CNAs and nurses at the facility to provide training. She reviewed the Kardex, which is the guide that a CNA would use to document and provide care to a resident and the Kardex for Resident #1 indicated that she was a extensive assist by two staff to turn and reposition in bed and required extensive assist for bathing. The Staff Development LPN #1 stated that anything on the resident's care plan and Minimum Data Set (MDS) pulls over to the Kardex and the CNA uses that to know what care the resident needs. She also confirmed that staff are educated and in-serviced to report any falls and injuries immediately to their supervisor and in this incident it was revealed that CNA #1 did not report the fall to anyone immediately and she failed to utilize two (2) staff to assist Resident #1. Interview with LPN #3 on 10/07/20, at 12:45 pm, stated that she remembered the incident very well and when she came into work on 02/17/20, she stated we were at the nurse's desk and CNA #1 had made the comment that they had a very busy weekend and that Resident #1 had almost fell out of the bed. I had not even asked her, I just remember her saying that and offering up the information but she kept saying she had almost fell . So when I went in to give her meds that morning she was hurting and I had noticed a bruise to her right hip and her right knee was red and I looked back into the nurse's notes to see if an incident report had been made and there wasn't one. The Nurse Practitioner (NP) was here that day so he went in and assessed her and ordered an x-ray and I gave her Tylenol for the pain. Record review revealed Medical Doctor (MD) order dated 02/17/20, stated, Get right femur and knee x-ray. Give [MEDICATION NAME] for right thigh. Record review of a physician progress notes [REDACTED].(patient) wasn't relieved of pain. Pt appears to be dehydrated will give one liter normal saline. Right knee abrasion but staff has no stated fall. Record review of x-ray dated 02/17/20 No acute fracture. Record review of MD order dated 02/27/20 stated, Start [MEDICATION NAME] 15 mg 1 by mouth daily. Record review of MD order dated 02/28/20 stated, Add CT scan to right pelvis and right femur related to right leg pain. Record review of CT of the right hip dated 02/28/20 revealed, There is an intratrochanteric fracture through the right femur with mild proximal migration of the femoral shaft. Record review of MD order dated 03/02/20 stated, [MEDICATION NAME] tablet 50 mg give 2 tablets by mouth every six hours as needed for pain. Record review of MD order dated 03/03/20 stated, Orthopedic appt (appointment) 03/04/20 for follow up of right femur fracture. Review of the Medication Administration Record [REDACTED]. Record review of the Employee file of CNA #1 revealed that she had signed the Abuse/Neglect Policy on 07/25/18, and again on 01/18/20, and attended a facility wide in-service. An interview with the Administrator on 10/07/20, at 3:00 PM, stated that CNA #1 was aware of the reporting policy and also confirmed that she should have informed her Nurse Supervisor immediately of the incident of the fall but that the CNA failed to do this and she was suspended 02/28/20, when the facility was made aware of the fracture and was terminated on 03/02/20. An Interview with the DON on 10/07/20, at 2:00PM, confirmed that CNA #1 had an Ipad that had the Kardex (care guide) for each resident to inform them of the care and the amount of staff needed to care for each resident and she also confirmed that they have Abuse/Neglect in-services quarterly and sometimes more often, so she was aware that she should have reported the incident immediately to her Nurse Supervisor. The MDS nurse was out of the building during the SA investigation into this incident but the DON verified that the MDS assessment needs are carried over to the Kardex for the care that should be provided for the resident. An Interview with the Medical Director on 10/08/20, at 2:00 pm, confirmed that she was aware of the incident, she had heard about it but the physician group that Resident #1's doctor was with is no longer in the facility. The MD confirmed that the CNA neglected care from the resident by not reporting the fall immediately to her supervisor like she had been in-serviced and knew to do. Review of the employee file for CNA #1 revealed that she was hired at the facility on 07/25/18, and had a disciplinary action dated 05/09/19, that stated, resident was left heavily soiled to include the bed linen. Employee received her final termination on 03/02/20, for Employee did not follow care plan guidelines for 2 person assist with a resident. Employee also moved a resident and put resident back in bed without notifying a nurse to assess patient after a fall. Record review the Admission Record revealed that Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/27/20, revealed a Brief Interview for Mental Status (BIMS) score of 07, indicating severe cognitive impairment and a functional status score of 3/3 for bed mobility indicating that the resident required two person physical assist with moving to and from lying position, turning side to side, and positions body while in bed requires two person physical assist and resident is a 4 for bathing, indicating total dependence from staff.

Based on record review, interview, and facility policy review, the facility failed to prevent neglect in the facility as evidenced by Resident #1 sustained a fall with a fracture because the CNA failed to utilize the appropriate number of staff that the care plan indicated to provide care to the resident during the Activity of Daily Living (ADL) care that allowed the resident to fall from the bed sustaining an injury for one (1) of 16 resident care plans reviewed. Findings include: Record review of the facility policy titled, Care Plans, dated 12/16, stated, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The care planning process will include an assessment of the resident's strengths and needs. Record review of the Facility Reported Incident (FRI) stated that the facility investigation revealed on 02/15/20, the resident was being cared for by CNA#1 and that a bed bath was being given when the resident rolled out of bed. The investigation revealed that CNA#1 stated that she attempted to catch the resident but she was unsuccessful and the resident rolled onto the floor and that she picked the resident up and placed her back into the bed. The FRI revealed that the CNA told Licensed Practical Nurse (LPN) #2 that the resident almost fell out of the bed but that she had caught her before she rolled out of bed. LPN #2 stated that she did not fill out an incident report because it was reported to her that the resident did not fall, but that she had gone in to assess the resident immediately and did not see any bruises or issues at that time. Record review revealed that on 02/17/20, the resident was complaining of pain to her right upper leg. An x-ray was obtained and revealed no fractures noted. Resident was placed on [MEDICATION NAME] for muscle spasms. Resident #1 complained of pain on several occasions but would take the [MEDICATION NAME] and would be relieved. On 02/27/20, the resident continued to complain of pain and the physician ordered a Computed Tomography (CT) scan. Results of the CT scan revealed an intratrochanteric [MEDICAL CONDITION] right femur. The facility investigation into the incident revealed that the fracture was reported to the Attorney General's Office (AG) and the State Agency (SA) and in-services on Abuse/ Neglect, Resident Rights and Vulnerable Adults Act were completed by all staff. The FRI revealed that statements were gathered and the statement from CNA #1 was a written statement as follows, I was giving (proper name) a bed bath and she rolled off the bed after yelling I'm Falling. I attempted to catch her as quickly as I can but she was already on the floor. After I looked her over, I put her back in the bed then notified her nurse. An interview with LPN #2 on 10/07/20, at 12:15 pm, stated that she was the LPN for Resident #1 on the day of 02/15/20, and that CNA #1 had come to her and said that she had hurt her shoulder giving Resident #1 a bath and I asked her what happened and she told me that she interrupted a fall during her bath and caught Resident #1 before she fell and that she had hurt her shoulder. LPN #2 stated that she had asked her if she wanted her to fill out an incident report on her and CNA #1 said no. LPN #2 stated that she asked her again about resident #1 and she told her that the resident didn't fall out of the bed that she had caught her. LPN #2 stated that she went to the room and looked in on the resident and assessed her and did not see any bruises or concerns so she did not fill out an incident report because she was told it was not a fall. LPN #2 stated that she had reported it to the oncoming nurse. The nurse stated that later in the next couple of days the staff saw bruises on her right side and groin area, that's when the resident had the x-ray. LPN #2 said she asked the CNA again, are you sure she didn't fall, but she denied she fell . Then when we got the CT scan back on 02/28/20 and it showed a fracture I asked the CNA again if she had fell that day and she said yeah I told you she did. I told her no you didn't tell me that, so you better go now and tell the DON the truth and that you lied. The Administrator got a statement from both of us and we were both suspended pending the investigation on 02/28/20, when we knew she had a fracture. LPN #2 stated that she would have completed the incident report but she was told that she didn't have a fall. LPN #2 stated that she did not see CNA #1 anymore after that because the facility suspended CNA #1 and then fired her. The State Agency (SA) attempted to call CNA #1 on 10/07/20 at 10:50 am and again at 1:40 pm and left a voicemail that we needed to speak with her regarding the incident and she did not return the call. An interview with LPN #1 Staff Development and CNA Instructor stated that she began working at the facility in October 2019 and that she works with the CNAs and nurses at the facility to provide training. She reviewed the Kardex, which is the guide that a CNA would use to document and provide care to a resident and the Kardex for Resident #1 indicated that she required extensive assist by two (2) staff to turn and reposition in bed and required extensive assist for bathing. The Staff Development LPN #1 stated that anything on the resident's care plan and Minimum Data Set (MDS) pulls over to the Kardex and the CNA uses that to know what care the resident needs. She also confirmed that staff are educated and in-serviced to report any falls and injuries immediately to their supervisor and in this incident it was revealed that CNA #1 did not report the fall to anyone immediately and she failed to utilize two staff to assist Resident #1. Record review of resident's care plan revealed that a care plan was dated 11/06/19 through 02/18/20 stated, The resident has an ADL self care performance deficit and requires interventions of extensive assistance by two staff to turn. Record review of the Employee file of CNA #1 revealed that she had signed the Abuse/Neglect Policy on 07/25/18 and again on 01/18/20, and attended a facility wide in-service. An interview with the Administrator on 10/07/20, at 3:00 PM, stated that CNA #1 was aware how to utilize the Kardex and was aware that the resident required 2 person assistance for bathing and turning and that she did not follow the care plan appropriately and because of her negligence she was suspended on 02/28/20, when the facility was made aware of the fracture she was terminated on 03/02/20. An Interview with the DON on 10/07/20, at 2:00 PM, confirmed that CAN #1 had an iPad that had the Kardex (care guide) for each resident to inform them of the care and the amount of staff needed to care for each resident and she also confirmed that they have Abuse/Neglect in-services quarterly. The Minimum Data Set (MDS) nurse was out of the building during the SA investigation into this incident but the DON verified that the MDS assessment needs are carried over to the Kardex for the care that should be provided for the resident. An Interview with the Medical Director on 10/08/20, at 2:00 pm, confirmed that she was aware of the incident, she had heard about it but the physician group that Resident #1's doctor was with is no longer in the facility. The MD confirmed that the CNA neglected care by not utilizing the appropriate number of staff when giving Resident #1 a bath and this would have prevented her from rolling out of the bed. Review of the employee file for CNA #1 revealed that she was hired at the facility on 07/25/18, and had a disciplinary action dated 05/09/19, that stated, resident was left heavily soiled to include the bed linen. Employee received her final termination on 03/02/20 for Employee did not follow care plan guidelines for 2 person assist with a resident. Employee also moved a resident and put resident back in bed without notifying a nurse to assess patient after a fall. Record review of the Admission Record revealed that Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the MDS with an Assessment Reference Date of 1/27/20, revealed a Brief Interview for Mental Status (BIMS) score of 07, indicating severe cognitive impairment and a functional status score of 3/3 for bed mobility indicating that the resident required two person physical assist with moving to and from lying position, turning side to side, and positions body while in bed requires two person physical assist and resident scored 4 for bathing, indicating total dependence from staff.

Based on interview, record review, and policy review the facility failed to provide services in a manner that allowed Resident #1, for one (1) of 11 Residents reviewed, to maintain or achieve the highest practicable physical, and mental well-being. This was evidenced by a lapse in follow-up with obtaining results of an X-ray, which documented a [MEDICAL CONDITION] on 6/30/15, not reporting X-ray results timely to the physician (not reported until 7/6/15), not performing thorough resident assessments for pain, injury and follow-up after falls, and not having the care plan specific for the two (2) person staff required assistance needed for safe transfers with a mechanical lift. Resident #1 was confirmed to have a left [MEDICAL CONDITION] per X-Ray on, 6/30/15, after a fall on, 6/28/15, due to a Certified Nursing Assistant (CNA) used one (1) person assist with a sit to stand mechanical lift to transfer Resident #1, and was not transferred to the hospital until, 7/6/15; thus resulting in a delay in treatment of [REDACTED]. Resident #1 had surgery on, 7/7/15, for the fracture repair. Findings included: Review of the facility's policy entitled, Safe Lifting and Movement of Residents, with a revised date of, 10/3/13, revealed the use of mechanical lift with residents requires the assistance of 2 staff members at all times. Process for Completing Pain Assessments provided by the Administrator on 7/23/15: Pain assessments are completed upon admission, readmission, quarterly, and with a significant change in the resident's status. Residents who are receiving narcotic pain medication are evaluated by the licensed nurse every shift and the results are documented on the resident's Medication Administration Record (MAR). Non-pharmological interventions and/or medication are administered per the physician's orders [REDACTED]. Review of the Medication Administration Policy/Guidelines, dated 5/28/13 revealed: 18. If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall initial and circle the MAR space provided for the drug and dose. 19. The individual administering the medication must initial the resident's MAR on the appropriate line after giving each medication and before administering the next ones. 20. As required or indicated for a medication, the individual administering the medication will record in the resident's medical record: the date and time the medication was administered; the dose; the route of administration, the injection site if applicable, any complaints or symptoms for which the drug was administered; any results achieved and when those results were observed and the signature and title of the person administering the drug. Review of the Process for Documentation Post Incident of a Resident provided by the Administrator on, 7/23/15 revealed: An incident report is completed by the licensed nurse after the incident occurs. The event is documented in the resident's clinical record by the licensed nurse. The event is logged onto the 24 hour communication report. Follow up documentation is completed in the resident's clinical record by the licensed nurse. The facility provided the following policy, procedure or processes by the Administrator on 7/23/15: Lab and Diagnostic Process (prior to the 6/30/15 incident with Resident #1): The charge nurse receives the physician's orders [REDACTED]. The charge nurse notifies the (X-ray Company) via phone for any diagnostic tests that have been ordered. The charge nurse documents on the X-ray tracking log. The charge nurse on duty in which the lab or diagnostic test was obtained, checks to see if the results have been sent prior to the end of their shift. If the results are received while that charge nurse is on duty, that charge nurse will notify the physician of abnormal results as needed. If the result s are not received prior to the end of the charge nurse's shift, the information is communicated to the next oncoming charge nurse. Nursing reviews the results of the ordered lab and/or diagnostic tests daily. Nursing notifies the physician of abnormal results as needed. Upon receipt of the laboratory results, appropriate notification is made. Review of the facility's policy entitled, CARE PLAN, dated, 5/8/13 revealed: An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident. GUIDELINES: 5. Assessments of residents are ongoing and care plans are revised as information about the resident and the resident's condition change. 6. The Care Planning/Interdisciplinary Team is responsible for the review and updating of care plans. Review of a typed letter by the facility's Administrator dated, 7/10/15, revealed Resident #1 had sustained a [MEDICAL CONDITION] of unknown origin. The report noted Resident #1 had a history of [REDACTED]. Resident #1 was sent to the hospital on, 7/6/15, due to the report of a left [MEDICAL CONDITION]. The report noted that staff was interviewed, and denied knowledge Resident #1 had signs of trauma or pain. Review of an X-ray report dated, 6/30/15, revealed Resident #1 had a Garden classification IV acute femoral neck fracture with moderate [MEDICAL CONDITION] and [MEDICAL CONDITION]. Review of a Hospital History and Physical dated, 7/6/15, revealed Resident #1 was admitted to the hospital on, 7/6/15, with a [DIAGNOSES REDACTED]. The history and physical documented Resident #1 reported falls while at the facility (Nursing Home) around, 6/16/15, and again two (2) days prior to hospital admission. The resident reported pain unbearable on the left side when they (facility staff) tried to get him up. X-ray reports of the left femur dated, 7/6/15, revealed Resident #1 had a subcapital left femoral neck fracture, femoral head not dislocated, and suggestion of calcium deposition in the joint capsule. (Calcium deposits could indicate the fracture had already begun to heal and was not acute). Review of the Hospital Discharge Summary dated, 7/10/15, revealed Resident #1 was being discharged to another facility for further rehabilitation after a [MEDICAL CONDITION], and should be noted the resident probably had his [MEDICAL CONDITION] at least two (2) weeks before admission to the hospital. Interview per telephone with Resident #1 on, 7/22/15 at 6:10 PM, revealed he knew who he was, where he was, and that it was July. Resident #1 stated he broke his hip on, 6/17/15 at the nursing home when he was trying to pull his socks off while sitting in the chair, and fell out of the chair. Resident #1 stated that X-rays were taken but they were okay. Resident #1 stated he used to tell staff that his hip hurt, and they said they gave him some pain medication. He stated he reported to Therapy he was hurting after he had fallen several times. Resident #1 could not recall how many falls, but there had been several. Resident #1 stated he had asked the nurse about the X-ray reports and she didn't know. Resident #1 stated he did have some hip pain and wasn't told until three (3) weeks later that it was broken and then he was sent to the hospital. Resident #1 stated he had hip surgery. Resident #1's thought process was slow, and at one point stated everything was normal, then said he had pain and couldn't do normal things. Resident #1 stated he was at another facility, and his hip was still bothering him. Resident #1 stated he did have pain in his hip but nobody was listening to him (at the facility). Resident #1's most recent Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of, 5/14/15, revealed he was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15. The MDS documented that Resident #1 required extensive assistance of one (1) person assist with transfer, dressing and bathing, and had lower extremity range of motion limitations bilaterally; however the quarterly assessment note dated, 5/14/15, revealed Resident #1 needed extensive assist of two (2) persons for transfers. The quarterly note also documented Resident had pain medications, and had complaints of breakthrough pain, and the Resident had two (2) falls since the prior MDS. Review of the Lift Evaluation Form dated, 4/24/15, revealed Resident #1 required the use of a sit to stand lift. A second Lift Evaluation on, 6/29/15, revealed a full body lift was required for Resident #1's transfers. There was no designation of staff required assistance for either evaluation. Review of Resident #1's Fall Risk assessment dated , 4/24/15, revealed a score of 16 (any score above 10 is denoted high risk). Documentation on 6/16/15, 6/21/15, and 6/28/15 revealed a score of 18. Review of Resident #1's SBAR Communication Form (Change in Condition form), and Incident Reports revealed the following: Fall 6/28/15 - 3:45 PM - feet slipped (from lift) and lowered to floor: Review of the SBAR, and an Incident Report dated, 6/28/15, documented Resident #1 was in the process of being transferred with a sit to stand mechanical lift with the assistance of one (1) CNA (CNA #4). The resident's foot slipped off the lift, and he began to slide to his knees. CNA #4 lowered the resident to the floor, and put a pillow under his head. CNA #4 called for the nurse, Licensed Practical Nurse (LPN) #6 documented Resident #1 was lying on his back, actively moved his upper extremities, and was assisted with lower extremities. No complaint of pain at present. The resident's foot slipped off the lift, he began to slide to his knees, was lowered to the floor, and a pillow was put under his head. No noted bruises or abrasions. Resident was changed to a total lift. There was no documentation or care plan revision for the assistance needed with the use of the full body mechanical lift for transfer. Review of a Nurse's note dated, 6/28/15 at 7:00 PM, revealed previously Resident #1 was eased to the floor (d/t the fall at 3:45 PM). At this time the resident indicated discomfort to his privates, pointing toward penis and testicles. The resident had not complained, or hurt them previously when lowered to the floor. The resident was unable to properly verbalize to the nurse when asked if this was all the time, or some of the time. Will observe and follow up if continues hurting. There was no documentation of a physical assessment of Resident #1, or a pain scale. Interview with Certified Nursing Assistant (CNA) #4 on, 7/21/15 at 4:25 PM, revealed she had transferred Resident #1 with the sit-stand lift by herself on, 6/28/15, and the resident's foot fell off the lift. She lowered him to the floor, put a pillow under his head, and went and got the nurse (LPN #6). CNA #4 stated Resident #1 did complain of some groin pain. CNA #4 stated Resident #1 didn't complain of pain anymore until she put him back to bed that night, and he again complained of groin pain, and said no one had given him any pain medication. CNA #4 stated she notified LPN #6, and upon examination there was no redness or bruising that she saw. CNA #4 stated she didn't know if Resident #1 received pain medication. CNA #4 stated she saw Resident #1 over the next few days, and he didn't complain to her. CNA #4 stated she had been trained to use two (2) people with the mechanical lift, but no one was around, and the resident usually had no problems, so she just got him up (attempted) from the bed to the chair by herself. CNA #4 stated she was suspended for using the lift without another staff. CNA #4 stated she looks at the Care Card for care residents needed. (The Care Card had no documentation of the assistance needed to transfer on 6/28/15, only the use of the sit-stand lift). Review of a Certified Nurse Assistant (CNA) Care Card (used by CNA's for resident care instructions), revealed Resident #1 used a sit to stand lift as of, 7/2/13, and was changed to a full body lift on, 6/28/15. Staff required assistance was not designated on either type of lift. Interview with LPN #6 on, 7/23/15 at 12:00 noon, revealed CNA #4 reported Resident #1's feet had slipped off the sit-stand lift platform, and she had lowered him to the floor (6/28/15). LPN #6 stated Resident #1 did complain of some pain in his private parts but doesn't remember giving him pain medication. LPN #6 stated the resident never really complained a lot, especially no excruciating pain for sure, and Resident #1 would have reported if he was in bad pain. LPN #6 stated he did not see any bruising or redness at that time, and Resident #1 didn 't complain to him anymore that night. LPN #6 stated he didn't think about it at the time that it needed to be two (2) people with the mechanical lift, but he changed Resident #1 to a full body lift which for sure would take two (2) person assist. Review of a Nurse's note, and SBAR dated, 6/30/15 at 3:50 PM, revealed a new order to X-ray Resident #1's left hip status/post fall. Resident #1 complained of pain to the left hip area. A small bulging area was noted with verbalization of pain when touched, and when left leg moved. There was no documentation of any follow up assessment for the bulging area on Resident #1's hip, or pain assessment/administration of pain medications on the MAR. Interview with Certified Nursing Assistant (CNA) #1 on, 7/22/15 at 9:23 AM, revealed she had worked the 7A-3P shift on, 6/30/15, and had noticed a bruise that was red on Resident #1's left hip, and the resident did complain of pain, it looked like he had bumped it. CNA #1 stated she told LPN #1. CNA #1 stated it was the first time Resident #1 had complained of hip pain, that he had complained of general aches/pains in his legs off and on. Interview with LPN #1 on, 7/22/15 at 10:10 AM, revealed Resident #1 had complained of pain in his hip on, 6/30/15, and did have a bulge bigger than a ping pong ball, but there was no bruising or redness. LPN #1 stated she was aware the resident had fallen over the weekend, and Resident #1 told her that his hip was probably broken. LPN #1 stated she got the Nurse Practitioner (NP) to look at Resident #1, and X-rays were ordered for his left hip. LPN #1 stated she did not notify the Supervisor (Registered Nurse/RN#2) because the NP was in the building. LPN #1 stated she did offer Resident #1 pain medication but he refused. LPN #1 stated she should have documented the pain medication offer. LPN #1 stated Physical Therapy Staff #1 did report to her that Resident #1 had pain either 6/29/15, or 6/30/15. LPN #1 stated the only time Resident #1 complained of pain to her was on, 6/30/15, and X-rays were obtained. LPN #1 stated the X-ray people was coming in as she left her shift on. 6/30/15 (worked 7A-7P). and then she was off for two (2) days. LPN #1 stated she came back to work. 7/3/15-7/6/15. and Resident #1 never complained of pain to her. and did not ask her about the X-rays. LPN #1 stated she thought the nurses would follow up on Resident #1's X-rays while she was off. LPN #1 stated she should have asked about the X-rays. Review of Resident #1's Controlled Drug Record revealed LPN #1 signed out [MEDICATION NAME] five (5)/325 on, 6/30/15 at 12:00 PM. There was no documentation of a pain assessment scale or follow-up for the [MEDICATION NAME] administration on the MAR. (LPN #1 worked 6/29/15, 6/30/15, 7/3/15-7/6/15). Review of the Nurse Practitioner's note dated, 6/30/15 at 1:45 PM, (e signed) revealed Resident #1 was seen for left hip pain. Resident had a recent fall and stated he must force his leg down. Initially he'd complained of left knee pain with X-ray showing no fracture or dislocation. Left hip was tender to deep palpation. No bruising or swelling. Resident had sharp increase in pain with flexion and rotation. Resident was alert and oriented to person, place, month and year. X-ray of the left hip ordered. Review of Nurse's notes, 6/30/15-7/6/15, revealed no documentation from, 6/30/15 after 3:50 PM until 7/2/15 at 1:44 AM. There was no further documentation of an observation or assessment of Resident #1's left hip or pain he may have had. There was no further complaints of pain documented in the Nurse's notes for Resident #1; however, documentation of the Controlled Drug Record revealed Resident #1 received [MEDICATION NAME] 5/325 on 7/1/15 twice, 7/2/15 once, and 7/3/15 once with no assessment of pain prior to or after administration of the medication. Interview with CNA #3 on, 7/22/15 at 11:25 AM, revealed she had gone to Resident #1's room to assist him to the bathroom, and he was unable to use his urinal because he complained of pain in his legs. CNA #3 stated Resident #1 wouldn't even get up to go smoke, he stayed in the bed all day, and she told the nurse he needed something for pain. CNA #3 could not recall the exact date this took place but it was after a fall. Interview with LPN #2 on, 7/22/15 at 1:35 PM, revealed she was aware of Resident #1 having multiple falls, and had no complaints of pain to her. LPN #2 stated she worked 7P-7A on, 6/30/15, and did not see the X-ray Company in the building, and was not aware Resident #1 had X-rays. LPN #2 stated the X-ray Company usually called if a fracture was documented, and asked if the fax was received. LPN #2 stated she never got a call or fax about an X-ray for Resident #1 on, 6/30/15. LPN #2 stated she doesn't recall if she gave Resident #1 pain medication or not. In a second interview with LPN #2 on, 7/22/15 at 7:00 PM, when asked about giving Resident #1 the pain medication [MEDICATION NAME] on, 6/16/15, 6/19/15, 6/29/15, 7/1/15, and 7/3/15, she replied Resident #1 never complained of hip pain, that he asked for [MEDICATION NAME] to help him sleep. LPN #2 stated she was supposed to document on the MAR for the medication, and effectiveness but guess she got busy and forgot. Interview with LPN #5 on, 7/22/15 at 7:15 PM, revealed Resident #1 complained of a headache one night and some soreness after a fall, and she had given him [MEDICATION NAME] a couple of times, and must have forgotten to document on the MAR. LPN #5 stated Resident #1 never complained of hip pain to her. LPN #5 stated the pain medication should have been documented on the back of the MAR with a pain scale, and whether there was relief or not. LPN #5 stated she had not done any physical assessment on Resident #1, and was unaware of X-rays or results of a fracture until after he'd gone to the hospital. LPN #5 administered [MEDICATION NAME] 5/325mg to Resident #1 on, 7/1/15 at 9:00 PM, and 7/2/15 at 8:00 PM without a pain assessment, documentation on the MAR, or a follow up for pain relief. Review of an X-ray report dated, 6/30/15, revealed Resident #1 had a Garden classification IV acute femoral neck fracture with moderate [MEDICAL CONDITION] and [MEDICAL CONDITION]. There was documentation the Nurse Practitioner was notified, but no date. Resident #1 was sent to the hospital on, 7/6/15, after the X-ray report of, 6/30/15, was discovered. Review of Resident #1's care plan dated, 11/14/12, with a target date through 10/5/15, revealed he was at risk for falls due to poor safety awareness, impulsivity, history of falls related to Hemi paresis, use of [MEDICAL CONDITION] meds, and removing alarms. Interventions included but was not limited to: sit to stand lift for transfers (discontinued 6/28/15), educate for use of call light, non skid surface to wheelchair, fall mats to bedside, alarm pad to wheelchair, educate resident to risk of falls, anti-rollback to wheelchair, and wedge cushion to wheelchair. Interventions that was added after 6/16/16: scoop mattress to bed, refer to therapy for transfer program (6/16); pharmacy review, remains on therapy (6/21); discontinue medication per MD orders (6/26); use full body lift for all transfers (6/28); and transfer to hospital (7/6/15). A care plan dated, 11/14/12, revealed alteration in comfort due to pain in legs related to PAD (Peripheral Artery Disease), [MEDICAL CONDITIONS], and generalized pain. Interventions included evaluation of pain daily using 1-10 scale, goal is 3; administer pain medication as ordered and monitor for worsening of pain. This was updated on, 6/30/15, to include complaint of pain and order of x-ray. There was no documented evidence that Resident #1's pain was assessed using a scale of 1-10, and no documentation that worsening of pain was monitored consistently. Interview with RN #2 on, 7/21/15 at 12:05 PM, while reviewing the X-ray log, RN#2 stated she looked at the log and 24 hour report to make sure orders was followed up, and received. RN #2 stated if an X-ray was done today it should be followed up by the next day. RN #2 stated the X-ray Company usually called with any abnormality, and then followed with a fax, usually the same day of the X-ray. RN #2 stated it was her responsibility to follow up on Resident #1's X-ray of, 6/30/15,, and it slipped her mind until, 7/6/15, when she was checking on X-rays for other residents. RN #2 stated she had interaction with Resident #1 between, 6/30/15-7/6/15, and he'd not complained to her about hip pain, and she had not received reports from anyone that he was complaining. She stated that if anyone would have reported it would have sparked her to recheck, and get the X-ray results. RN #2 stated even on that Monday (7/6/15) when Resident #1 went to the hospital he didn't complain of increased pain. RN #2 stated she found the X-ray report of, 6/30/15, in a rack on the wall inside the medication room on, 7/6/15. The report revealed a [MEDICAL CONDITION] hip. Further interview with RN #2 on, 7/22/15 at 3:55 PM, revealed she was aware of Resident #1 having an X-ray ordered on, 6/30/15. RN #2 stated she did not report to the oncoming Supervisor because when the Supervisor came in prior to 3:00 PM the x-rays hadn't been ordered. RN #2 stated the floor nurse (LPN #1) should have passed on to the next shift (LPN #2) if the X-ray report wasn't done before she left. RN #2 stated the X-ray was documented on the 24 hour report on 6/30/15. RN #2 again stated she herself should have followed up on the X-ray of, 6/30/15, and just didn't do it until 7/6/15. (RN #2 worked 6/29/15-7/3/15, and again on 7/6/15) Interview with RN #3 on, 7/22/15 at 2:26 PM, revealed she had worked, 6/30/15 3P-11P, as the Supervisor. RN #3 stated she wasn't aware Resident #1 had X-rays on his hip. RN #3 stated she worked, 6/29/15-7/2/15, and had no complaint from Resident #1 about pain in the hip. RN #3 stated she looked at the 24 hour report, and talked to the day Supervisor (RN #2) on, 6/30/15, and there was nothing reported about Resident #1 having X-rays or complaint of pain. RN #3 stated the X-ray Company usually called with any fracture, but she received no call that night. RN #3 stated the floor nurses usually goes to the med room to get lab/x-ray results and calls her if there's a problem. RN #3 stated that any nurse knows to look at the x-ray reports, and to let her know of concerns, and no one had reported anything about an X-ray that night (6/30/15). Interview with the X-Ray Representative on, 7/22/15 at 1:05 PM, revealed Resident #1's X-ray of, 6/30/15, was requested at 4:51 PM, completed at 7:45 PM, and reported back to the facility by fax on, 6/30/15 at 9:21 PM. The X-Ray Representative stated no phone call was made to the facility about the X-Ray report. Review of the Physical Therapy (PT) notes dated, 6/29/15-7/6/15, revealed on, 6/29/15, Resident #1 reported a fall over the weekend, and complained of left lower extremity soreness. Nursing reported X-rays were negative for fracture, and he was able to complete exercises. The note for, 6/30/15, revealed activity was discontinued due to resident complaint of pain in the left groin area, and nursing was informed. The 7/1/15 note revealed Resident #1 had increased pain in the left hip with inconsistent ability to maintain seated balance. The note on, 7/2/15, documented resident seemed to have decreased complaint of left hip pain, and his nurse reported she had not seen the X-ray report. The 7/6/15 note revealed resident completed exercises before the X-ray report was known. The nurse had reported she was just getting the report that Resident #1 had a [MEDICAL CONDITION]. Resident was able to get left foot off the foot rest without discomfort, but without support he complained of discomfort, and foot was assisted back to the foot rest. Interview with Physical Therapy (PT) Staff #1 on, 7/22/15 at 12:05, revealed Resident #1 started to complain of pain in his groin on, 6/29/15, and reported he'd fallen over the weekend (per notes). PT #1 stated she spoke with LPN #1 who said X-rays of the knee was negative. PT #1 stated she reported to LPN #1 Resident #1 was still complaining of pain. PT #1 stated she felt of Resident #1's hip, and he reported it being sore, no excruciating pain, maybe a 3-4 scale with movement. PT #1 stated she worked with the resident on, 6/30/15, and he complained of left groin pain, discontinued his activity, informed the nurse, and they got X-rays. PT #1 stated she worked with Resident #1 on, 7/1/15, and he continued to complain of pain on movement but didn't request to stop therapy, or ask for medication. PT #1 stated on, 7/2/15 worked with Resident #1, and he voiced decreased pain. PT #1 stated she asked LPN #4 about Resident #1's X-ray report, and she reported she had not seen them, and the physician had the chart. PT #1 stated she did not ask again about the X-rays, and on, 7/3/15 Resident #1 did not complain of pain that she recalled. Interview with PT #2 on, 7/21/15 at 2:00 PM, and again at 3:10 PM, confirmed PT #1 had documented Resident #1's complaint of pain in the left groin on, 6/30/15 ,and further documentation of pain on, 7/1/15. PT #2 stated the X-ray of, 6/30/15 should have been followed up before continuing therapy. Review of the Occupational (OT) notes dated, 6/29/15-7/6/15, revealed on, 6/29/15 Resident #1 had pain to the right upper extremity, a scale of 2; note on 6/30/15 revealed no complaint of pain documented. The note for, 7/1/15, revealed Resident #1 had increased pain in the right hip with tasks. There was no other documentation on noted pain from OT. Interview with Occupational Therapy (OT) Staff #1 on, 7/21/15 at 2:10 PM, revealed he had treated Resident #1 since, 6/18/15 after a fall. OT #1 stated the resident did have forearm pain which subsided after a few days. OT #1 stated Resident #1 did complain of some left hip pain after a second fall over a weekend. OT #1 stated he pressed on Resident #1's hip and the pain wasn't increased, so he had no reason to suspect a fracture. OT #1 stated Resident #1 never refused therapy, and had no real increased intensity of pain. Review of The Controlled Drug Record revealed Resident #1 received [MEDICATION NAME] 5/325 on 6/19/15 at 9:00 PM, 6/24/15 at 8:00 AM, 6/27/15 at 9:45 PM, 6/29/15 at 9:00 PM, 6/30/15 at 12:00 PM, 7/1/15 at 12:10 PM and 9:00 PM, 7/2/15 at 8:00 PM, and 7/3/15 at 8:00 PM. There was no corresponding documentation on the MAR or Nurse's notes for the administration of [MEDICATION NAME] to Resident #1 on these dates/times. There was no documented pain assessments, or follow up from pain medication administration. The MAR documented, N, (NO) each shift for complaint of pain from, 6/16/15-7/6/15. Interview with the Director of Nursing (DON), and Staff Development Nurse (SD) on, 7/23/15 at 2:35 PM, revealed it was always the policy to use two (2) people with lifts and the lift type is on the care plan. The DON stated everyone was trained on the policy, always 2. The SD Nurse stated during orientation she goes over the lift policy and all mechanical lifts require two (2) people to assist. The DON stated she didn't know why the care plan wasn't revised to include increased supervision for Resident #1. The DON stated Resident #1's falls was reviewed for how he fell , and why he fell , and other interventions were put in place. The DON confirmed that there was a delay in treatment for [REDACTED]., and had gone about his daily activities. The DON stated overall more assessment, and follow-up should have been done, and the physician notified timely of Resident #1's condition/fracture. The DON stated the X-ray (6/30/15) should have been followed up on at least within 24 hours, and if the resident complained of pain then medication should have been given as ordered, and the follow up documented. The DON stated there should be a follow-up with head to toe assessment on any areas of concern after falls. The DON stated Pain should be documented as to intensity on a scale of 1-10, where the pain is, and if a prn (as needed) medication is given then documentation should go on the back of the MAR, and followed up to see if relief is obtained. Interview with the Director of Nursing (DON) on, 7/22/15 at 8:45 AM, with the Administrator present, confirmed there was no documentation of an assessment of Resident #1's skin or follow up from the bulging area to the resident's left hip, or complaint of pain. The DON stated per practice/policy there should be follow up every shift for 72 hours after an incident, and there was a lapse of time in the documentation on, 6/30/15 (11-7), 7/1/15 (all shifts), and 7/2/15 (7-3 and 3-11). The DON stated that all incidents should be documented on the 24 hour report. Interview with the DON on, 7/22/15 at 2:50 PM, revealed she did not know why there was no documentation on the MAR for the 9 doses of [MEDICATION NAME] that was signed out for Resident #1 on the Controlled Drug Record for the dates listed; there should have been. The DON stated there should not be, N, documented for no pain on the MAR every shift if the pain medication was given. The DON stated since there was nothing documented on the MAR, or in the Nurse's notes about pain medication administration, there was no follow-up whether the pain was relieved or not. Review of Resident #1's Weekly Body Audit Form noted the body audits was negative for 6/1/15, 6/8/15, 6/15/15, 6/22/15, 6/29/15, and 7/6/15. Interview with the Treatment Nurse, LPN #3, on 7/22/15 at 4:25 PM, revealed she had done the body audits on Resident #1, and had found no concerns, and the resident had no complaints of pain to her. LPN #3 stated she did his body audit, 7/6/15, prior to finding out about the fracture, and there was no bruising, redness, deformity or pain observed. Interview with the Administrator on, 7/21/15 at 11:00 AM, revealed Resident #1 had surgery for [REDACTED].#1 who could not tell her when he thought his hip was fractured, and did report he hurt some off/on, nothing excruciating. The Administrator stated that through investigation they found that Resident #1 complained of pain, 6/30/15 and X-rays was obtained. They found a gap in the time from the fracture, and reporting to the physician. The Administrator stated the X-ray Company had faxed the x-ray report of the fracture on, 6/30/15 but had not called anyone at the facility, and that was normal procedure for abnormalities or fractures. The Administrator stated LPN #2 was on duty the night of, 6/30/15, and reported she had not seen an X-ray report for Resident #1. LPN #4 worked the following day and did not see an X-ray report. The Supervisor, RN #2 was supposed to follow up on any lab/x-rays, and she just forgot until, 7/6/15 ,when she ended up finding the X-ray report dated, 6/30/15, which documented the fracture. The Administrator stated when they reviewed the MAR, Resident #1 may have gotten three (3) pain pills during that time with the Nurse's notes documenting no complaint of pain. Further interview with the Administrator on, 7/22/15 at 9:00 AM, revealed she was looking at the incident, Resident #1's 6/30/15 fracture, from the perspective

Based on staff interview, record review, and policy review, the facility failed to ensure adequate supervision to provide safe transfers with a mechanical lift requiring two (2) person assistance for one of eleven (1 of 11) residents reviewed, as evidenced by Certified Nursing Assistant (CNA) #4 on, 6/28/15, transferred Resident #1 with a sit to stand mechanical lift with only one (1) person assistance, which resulted in Resident #1's feet slipping off the lift platform, and sliding down to his knees. CNA #4 had to lower the resident to the floor. Resident #1 complained of (c/o) groin pain, and X-Rays was ordered, which confirmed a fractured left hip on 6/30/15. The failure of adequate supervision to ensure residents were lifted and/or transferred with the required staff assistance put Resident #1 at risk for fall/injury. Findings included: Review of the facility's policy entitled, Safe Lifting and Movement of Residents, with a revised date of, 10/3/13, revealed the use of mechanical lift with residents requires the assistance of 2 staff members at all times. Review of a typed letter by the facility's Administrator dated, 7/10/15, revealed Resident #1 had sustained a hip fracture of unknown origin. The report noted Resident #1 had a history of [REDACTED]. Resident #1 was sent to the hospital on, 7/6/15, due to the report of a left hip fracture. The report noted that staff was interviewed, and denied knowledge Resident #1 had signs of trauma or pain. An X-ray report dated 6/30/15 revealed Resident #1 had a Garden classification IV acute femoral neck fracture with moderate osteoporosis and osteoarthritis. Interview per telephone with Resident #1 on, 7/22/15 at 6:10 PM, revealed he knew who he was, where he was, and that it was July. Resident #1 stated he broke his hip on, 6/17/15 at the nursing home when he was trying to pull his socks off while sitting in the chair, and fell out of the chair. Resident #1 stated that X-rays were taken but they were okay. Resident #1 stated he used to tell staff that his hip hurt, and they said they gave him some pain medication. He stated he reported to Therapy he was hurting after he had fallen several times. Resident #1 could not recall how many falls, but there had been several. Resident #1 stated he had asked the nurse about the X-ray reports and she didn't know. Resident #1 stated he did have some hip pain and wasn't told until three (3) weeks later that it was broken and then he was sent to the hospital. Resident #1 stated he had hip surgery. Resident #1's thought process was slow, and at one point stated everything was normal, then said he had pain and couldn't do normal things. Resident #1 stated he was at another facility, and his hip was still bothering him. Resident #1 stated he did have pain in his hip but nobody was listening to him (at the facility). Review of Resident #1's most recent Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of, 5/14/15, revealed he was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15. Resident #1's MDS documented extensive assistance of one (1) person assist with transfer; however the quarterly assessment note dated, 5/14/15, revealed Resident #1 needed extensive assist of two (2) persons for transfers. Review of a Hospital History and Physical dated, 7/6/15, revealed Resident #1 was admitted to the hospital on, 7/6/15, with a [DIAGNOSES REDACTED]. The history and physical documented Resident #1 reported falls while at the facility (Nursing Home) around, 6/16/15, and again two (2) days prior to hospital admission. The resident reported pain unbearable on the left side when they (facility staff) tried to get him up. X-ray reports of the left femur dated, 7/6/15, revealed Resident #1 had a subcapital left femoral neck fracture, femoral head not dislocated, and suggestion of calcium deposition in the joint capsule. (Calcium deposits could indicate the fracture had already begun to heal and was not acute). Review of the Hospital Discharge Summary dated, 7/10/15, revealed Resident #1 was being discharged to another facility for further rehabilitation after a hip fracture, and should be noted the resident probably had his hip fracture at least two (2) weeks before admission to the hospital. Interview with Certified Nursing Assistant (CNA) #4 on, 7/21/15 at 4:25 PM, revealed she had transferred Resident #1 with the sit-stand lift by herself on, 6/28/15, and the resident's foot fell off the lift. She lowered him to the floor, put a pillow under his head and went and got the nurse (LPN #6). CNA #4 stated Resident #1 did complain of some groin pain. CNA #4 stated Resident #1 didn't complain of pain anymore until she put him back to bed that night, and he again complained of groin pain. CNA #4 stated she had been trained to use two (2) people with the mechanical lifts, but no one else was around, and the resident usually had no problems, so she just got him up from the bed by herself. CNA #4 stated she was suspended for using the lift without another staff. Review of Lift Evaluation Form dated, 4/24/15, revealed Resident #1 required the use of a sit to stand lift. The assistance of required staff was not documented. Further review of the Lift Evaluations on, 6/29/15, revealed a full body lift was required for Resident #1's transfers. There was no documentation of the required staff assistance. Resident #1's care plan dated, 11/14/12, with a target date through 10/5/15, revealed he was at risk for falls due to poor safety awareness, impulsivity, and history of falls related to Hemi paresis and use of psychotropic meds and removing alarms. Interventions included but were not limited to: sit to stand lift for transfers (discontinued 6/28/15), Interventions that were added after, 6/16/16, to include the use of a full body lift for all transfers on, 6/28/15. There was no documentation of required staff assistance needed to transfer Resident #1 with the lifts. Review of a Certified Nurse Assistant (CNA) Care Card (used by CNA's for resident care instructions), revealed Resident #1 used a sit to stand lift as of, 7/2/13, and was changed to a full body lift on, 6/28/15. Required staff assistance was not designated on either type of lift. Review of the SBAR, and an Incident Report dated, 6/28/15, revealed the nurse documented Resident #1 was lying on his back on the floor on entrance into the room. Resident #1 could actively move his upper extremities, and was assisted with the lower extremities. No complaint of pain at present. CNA #4 reported Resident #1's foot slipped off the lift during transfer, and he began to slide to his knees, and was lowered to the floor by the CNA, and a pillow put under his head. No noted bruises or abrasions. Resident was changed to total lift. Interview with LPN #6 on, 7/23/15 at 12:00 noon, revealed CNA #4 had reported Resident #1's feet had slipped off the sit-stand lift platform, and she had lowered him to the floor (6/28/15). LPN #6 stated Resident #1 did complain of some pain in his private parts but doesn't remember giving him pain medication. LPN #6 stated he didn't think about it at the time, that it needed to be two (2) people with the mechanical lift, but he changed Resident #1 to a full body lift which would take two (2) person assist. Review of a Nurse's note dated, 6/28/15 at 7:00 PM, revealed previously Resident #1 was eased to the floor (due to the fall). At this time the resident was indicating discomfort to his privates, pointing toward penis and testicles. The resident had not complained, or hurt them previously when he was lowered to the floor. The resident was not able to verbalize if the discomfort was constant, or comes and goes. Interview with CNA #2 on, 7/22/15 at 10:00 AM, and CNA #3 on, 7/22/15 at 11:25 AM, revealed that it always takes two (2) people to assist with transfers when the mechanical lifts are used. Interview with the Director of Nursing (DON) and Staff Development Nurse (SD) on, 7/23/15 at 2:35 PM, revealed it was always the policy to use two (2) people with lifts and the lift type is on the care plan. The DON stated everyone was trained on the policy, always 2. The SD Nurse stated during orientation she goes over the lift policy and all mechanical lifts require two (2) people to assist. The SD nurse agreed that it could put residents at risk (for fall/injury) if only one (1) person transferred with the lift. Review of the Face Sheet revealed Resident #1 was admitted by the facility on,1/6/11 and re-admitted [DATE], with [DIAGNOSES REDACTED].

Based on staff interview, record review, and policy review, the facility failed to promptly inform the physician of an X-ray result for Resident #1, for one (1) of eight (8) Residents reviewed for diagnostic/lab procedures, on 6/30/15, when the X-ray revealed a [MEDICAL CONDITION] hip. The physician was not informed until, 7/6/15. This resulted in delayed treatment for [REDACTED]. Resident #1 was admitted to the hospital on, 7/6/15, and had hip surgery on 7/7/15. Findings included: The facility provided the following policy, procedure or processes by the Administrator on 7/23/15: Lab and Diagnostic Process (prior to the 6/30/15 incident with Resident #1): The charge nurse receives the physician's orders [REDACTED]. The charge nurse notifies the (X-ray Company) via phone for any diagnostic tests that have been ordered. The charge nurse documents on the X-ray tracking log. The charge nurse on duty in which the lab or diagnostic test was obtained, checks to see if the results have been sent prior to the end of their shift. If the results are received while that charge nurse is on duty, that charge nurse will notify the physician of abnormal results as needed. If the results are not received prior to the end of the charge nurse's shift, the information is communicated to the next oncoming charge nurse. Nursing reviews the results of the ordered lab and/or diagnostic tests daily. Nursing notifies the physician of abnormal results as needed. Upon receipt of the laboratory results, appropriate notification is made. A typed letter from the facility's Administrator dated, 7/10/15, revealed Resident #1 had sustained a [MEDICAL CONDITION] of unknown origin. The report noted Resident #1 had a history of [REDACTED]. Resident #1 was sent to the hospital on [DATE]. Review of an X-ray report dated, 6/30/15, revealed Resident #1 had a Garden classification IV acute femoral neck fracture with moderate [MEDICAL CONDITION] and [MEDICAL CONDITION]. A Hospital History and Physical dated, 7/6/15, revealed Resident #1 was admitted on , 7/6/15, had hip replacement surgery on, 7/7/15. A hospital X-ray report of the left femur dated, 7/6/15, revealed Resident #1 had a subcapital left femoral neck fracture, femoral head not dislocated, and suggestion of calcium deposition in the joint capsule. Review of the Hospital Discharge Summary, dated 7/10/15, revealed Resident #1 probably had his [MEDICAL CONDITION] at least two (2) weeks before admission to the hospital. Interview per telephone with Resident #1 on, 7/22/15 at 6:10 PM, revealed he knew who he was, where he was, and that it was July. Resident stated he broke his hip on, 6/17/15, at the nursing home when he was trying to pull his socks off while sitting in the chair, and fell out of the chair. Resident #1 could not recall how many falls he actually had, but there had been several. Resident #1 stated he had asked the nurse about the X-rays, and she didn't know. Resident #1 stated he had hip pain, and they (the facility) didn't tell him until three (3) weeks later that it was broken, and then sent him to the hospital. Resident #1 stated he had hip surgery. Resident #1 stated he did have pain in his hip at the nursing facility but nobody listened to him. Resident #1's most recent Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of, 5/14/15, revealed he was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15. Interview with the Director of Nursing (DON) and Staff Development Nurse (SD) on, 7/23/15 at 2:35 PM, revealed the DON confirmed there was a delay in treatment for [REDACTED]. The DON stated the physician should have been notified timely of Resident #1's condition/fracture. The DON stated the X-ray (6/30/15) should have been followed up on at least within 24 hours. Review of Resident #1's medical record revealed he had falls/report of falls on, 6/16/15, 6/21/15, 6/27/15, and 6/28/15. Resident #1's first complaint of groin pain was documented on, 6/28/15 after being lowered to the floor after a fall. Interview with LPN #4 on, 7/21/15 at 1:15 PM, revealed Resident #1 reported he'd had a fall during the night, and he had abrasions/scratches consistent with a fall to the left knee area. Resident #1 couldn't straighten out his left knee but it didn't look abnormal. LPN #4 stated X-rays was taken of his left knee, and they were negative. LPN #4 stated she thought Resident #1 had another fall when she wasn't here, and when she came back (7/1/15) Resident #1 asked about his X-ray results. LPN #4 stated she asked RN #2 about the results and she didn't have them, but would call and find out. LPN #4 stated she got busy and never followed up with the X-ray results. LPN #4 stated she usually followed up with any X-Ray/Acute labs unless the Supervisor says she's already done it. LPN #4 stated she should have followed up on the X-rays herself (X- ray of 6/30/15), but thought RN #2 had followed up on them. (LPN #4 worked 6/26/15-6/28/15 and 7/1/15- 7/2/15) Review of the SBAR, and an Incident Report dated, 6/28/15, documented Resident #1 was transferred with a sit to stand mechanical lift with only one (1) Certified Nursing Assistant (CNA) assistance/CNA #4. Resident #1's feet slipped off the lift platform, he began to slide to his knees. CNA #4 had to lower him to the floor, and then notified the nurse. Licensed Practical Nurse (LPN) #6 observed Resident #1 lying on his back on the floor with a pillow under his head. LPN #6 documented Resident #1 could actively move his upper extremities, and lower extremities with assistance. No complaint of pain at present. LPN #6 documented CNA #4 reported the resident's foot slipped off the lift, and he began to slide to his knees, and was lowered to the floor, and a pillow put under his head. No noted bruises or abrasions. Review of a Nurse's notes dated, 6/28/15 at 7:00 PM, revealed previously Resident #1 was eased to the floor (r/t to th fall). At this time the resident was indicating discomfort to his privates, pointing toward penis and testicles. Interview with Certified Nursing Assistant (CNA) #4 on, 7/21/15 at 4:25 PM, revealed she had transferred Resident #1 with the sit-stand lift by herself on, 6/28/15, and the resident's foot fell off the lift. She lowered him to the floor and put a pillow under his head. CNA #4 stated Resident #1 did complain of some groin pain at the time, and then again when she put him back to bed that night. Interview with LPN #6 on, 7/23/15 at 12:00 noon, revealed that CNA #4 reported Resident #1's feet had slipped off the sit-stand lift platform, and she had lowered him to the floor (6/28/15). LPN #6 stated Resident #1 did complain of some pain in his private parts. Review of a Nurse's note, and SBAR dated, 6/30/15 at 3:50 PM, revealed a new order to X-ray Resident #1's left hip status/post a fall. Resident complained of pain to the left hip area, and a small bulging area was noted with verbalization of pain when touched, and when his leg was moved. Interview with Physical Therapy (PT) Staff #1 on, 7/22/15 at 12:05, revealed Resident #1 started to complain of pain in his groin on, 6/29/15, and reported he'd fallen over the weekend (per notes). PT #1 stated she spoke with LPN #1 who said X-rays of the knee was negative. PT #1 stated she reported to LPN #1 Resident #1 was still complaining of pain. PT #1 stated she felt of Resident #1's hip, and he reported it being sore, no excruciating pain, maybe a 3-4 scale with movement. PT #1 stated she worked with the resident on, 6/30/15, and he complained of left groin pain, and discontinued his activity, and informed the nurse. PT #1 stated she asked LPN #4 about Resident #1's X-ray report, and she reported she had not seen them, and the physician had the chart. PT #1 stated she did not ask again about the X-rays. Interview with LPN #1 on, 7/22/15 at 10:10 AM, revealed Resident #1 had complained of pain in his hip on, 6/30/15, and did have a bulge bigger than a ping pong ball. LPN #1 stated she was aware that Resident #1 had fallen over the weekend, and Resident #1 told her that his hip was probably broken. LPN #1 stated the Nurse Practitioner (NP) assessed Resident #1, and X-rays were ordered for his left hip. LPN #1 stated she did not notify the Supervisor/Registered Nurse (RN) #2 because the NP was in the building. LPN #1 stated the X-ray people was coming in as she left her shift on 6/30/15 (worked 7A-7P) and then she was off for two (2) days. LPN #1 stated she came back to work, 7/3/15-7/6/15. LPN #1 stated she thought the nurses would follow up on Resident #1's X-rays while she was off. LPN #1 stated she should have asked about the X-rays. (LPN #1 worked 6/29/15, 6/30/15, 7/3/15-7/6/15). Review of the Nurse Practitioner's note dated, 6/30/15 at 1:45 PM, (e signed) revealed Resident #1 was seen for left hip pain. Resident had a recent fall, and stated he must force his leg down. Initially he'd complained of left knee pain with X-ray showing no fracture or dislocation. Left hip was tender to deep palpation. No bruising or swelling. Resident had sharp increase in pain with flexion and rotation. Resident was alert and oriented to person, place, month and year. X-ray of the left hip was ordered. Interview with LPN #2 on, 7/22/15 at 1:35 PM, revealed she was aware of Resident #1 having multiple falls, and had no complaints of pain to her. LPN #2 stated she worked 7P-7A on, 6/30/15, and did not see the X-ray Company in the building, and was not aware that Resident #1 had X-rays. LPN #2 stated the X-ray Company usually called if a fracture was documented, and asked if we got the fax. LPN #2 stated she never got a call or fax about an X-ray for Resident #1 on 6/30/15. During an interview with RN #2 on, 7/21/15 at 12:05 PM, RN #2 stated if an X-ray was done today it should be followed up by the next day. RN #2 stated the X-ray Company usually called with any abnormality, and then followed with a fax, usually the same day of the X-ray. RN #2 stated it was her responsibility to follow up on Resident #1's X-ray of, 6/30/15, and it slipped her mind until, 7/6/15, when she was checking on X-rays for other residents. She stated that if anyone would have reported Resident #1 had pain it would have sparked her to recheck, and get X-ray results. RN #4 stated she found the X-ray report of, 6/30/15, in a rack on the wall inside the medication room on, 7/6/15. The report revealed a [MEDICAL CONDITION] hip. RN #2 stated that the physician should have been notified on Resident #1's X-ray results on, 6/30/15, when the report was sent back to the facility. Further interview with RN #2 on, 7/22/15 at 3:55 PM, revealed she was aware of Resident #1 having an X-ray ordered on, 6/30/15. RN #2 stated the floor nurse (LPN #1) should have passed on to the next shift if the X-ray wasn't done before she left to LPN #2. RN #2 again stated she herself should have followed up on the X-ray of, 6/30/15, and just didn't do it until, 7/6/15. (RN #2 worked 6/29/15-7/3/15 and again on 7/6/15) Interview with RN #3 on, 7/22/15 at 2:26 PM, revealed she had worked, 6/30/15 3P-11P, as the Supervisor. RN #3 stated she wasn't aware Resident #1 had X-rays on his hip. RN #3 stated the X-ray Company usually called with any fracture but she received no call that night. RN #3 stated the floor nurses usually goes to the med room to get lab/x-ray results and calls her if there's a problem. RN #3 stated that any nurse knows to look at the x-ray reports and to let her know of concerns, and no one had reported anything about an X-ray that night (6/30/15). RN #3 stated the physician is called when results are abnormal, and I should have been called about the fracture for Resident #1 on, 6/30/15. Interview with the X-Ray Representative on, 7/22/15 at 1:05 PM, revealed that Resident #1's X-ray of, 6/30/15 was requested at 4:51 PM, completed at 7:45 PM, and reported back to the facility by fax on, 6/30/15 at 9:21 PM. Interview with the Administrator on, 7/21/15 at 11:00 AM, revealed Resident #1 had surgery for [REDACTED].#1 complained of pain on, 6/30/15, and X-rays were obtained. They found a gap in time from the fracture, and reporting to the physician. The Administrator stated the X-ray Company had faxed the x-ray report of the fracture on, 6/30/15, but had not called anyone at the facility. The Administrator stated LPN #2 was on duty the night o,f 6/30/15, and reported she had not seen an X-ray report for Resident #1. LPN #4 worked the following day, and did not see an X-ray report. The Supervisor, RN #2, was supposed to follow up on any lab/x-rays, and she just forgot until, 7/6/15, when she ended up finding the X-ray report dated, 6/30/15, which documented the fracture. The Administrator stated the physician should have been notified. (6/30/15). Interview with the DON, with the Administrator present, on 7/21/15 at 11:30 AM, revealed when an X-ray was ordered, the X-ray Company completed the X-ray and they are supposed to call and fax the results that day. The DON stated if there is no fax they should pick up the phone and call the X-ray Company, and document the attempt. The DON stated there was none of that for Resident #1's X-ray of, 6/30/15. The DON stated RN #2 was working, 7/1/15-7/3/15, and should have followed up on the X-ray report but it got missed. The DON stated the nurse who had gotten the order, LPN #1, even though she was off the next day, should have checked when she came back. The DON stated that when the X-ray report was found RN #2 immediately notified the physician, but the physician should have been notified on, 6/30/15 of the X-ray report with the fracture. Review of Resident #1's medical record revealed an X-ray was taken on, 6/30/15, after Resident #1 complained of groin/hip pain. The X-ray report revealed a [MEDICAL CONDITION] hip. The fracture was not identified by the facility until, 7/6/15. Documentation and resident/staff interview revealed that Resident #1 did complain of pain at times without thorough assessment, and documentation of the intensity, and whereabouts of his pain, or the relief after medication was administered. The failure to locate, and report the results of Resident #1's [MEDICAL CONDITION] to the physician from, 6/30/15-7/6/15, resulted in the resident having delayed treatment of [REDACTED]. Review of the Face Sheet revealed Resident #1 was admitted by the facility on, 1/6/11, and re-admitted [DATE], with [DIAGNOSES REDACTED].

Based on interview, record review, and policy review, the facility failed to revise and update Resident #1's care plan to address actual fall occurrences and interventions to increase supervision after multiple falls, failure to designate the amount of staff assistance needed for transfers with the mechanical lift, and failure to add X-ray/neurological (Neuro) checks, and pain assessment/medication to the care plan after multiple falls, and one of the falls resulted in a serious injury /[MEDICAL CONDITION] per X-Ray on 6/30/15, for one of seven (1 of 7) resident's care plans reviewed. Findings included: Review of the facility's policy entitled, Care Plans, dated, 5/8/13, revealed: An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental psychological needs is developed for each resident. GUIDELINES: 3. Identifying problem areas and their causes, and developing interventions that are targeted to the resident are interdisciplinary processes. 5. Assessments of residents are ongoing and care plans are revised as information about the resident and the resident's condition change. 6. The Care Planning/Interdisciplinary Team is responsible for the review and updating of care plans. Review of Resident #1's care plans revealed he had a care plan dated, 11/14/12, that only addressed the risk of falls due to poor safety awareness, impulsivity, and history of falls with interventions in place which included the full body mechanical lift dated, 6/28/15. Further review of the care plans revealed self care deficit r/t easily fatigues, depression, muscle weakness, [MEDICAL CONDITION], and pain with the included intervention for the sit to stand mechanical lift with transfers (discontinued (d/c 'd) 6/28/15). The care plan did not address the staff assistance required with the mechanical lift transfers. He had a care plan for non-compliance with fall precautions dated, 4/4/15, with education about potential consequences of non-compliance, 6/21/15 for non-compliance with safety interventions. Resident #1 also had a care plan in place for alteration in comfort due to pain in his legs r/t PAD [MEDICAL CONDITION] [MEDICAL CONDITION], and Generalized Pain, with a complaint of pain on, 6/30/15, and an X-ray ordered. Review of Resident #1's care plans revealed no problem/need to address the actual falls dated 6/16/15, 6/21/15, 6/27/15, and 6/28/15. Review of the Lift Evaluation Form dated, 4/24/15, revealed Resident #1 required the use of a sit to stand lift for transfers. There was no documentation for staff assistance required. Further review of the Lift Evaluations on, 6/29/15, revealed Resident #1 was assessed, and changed to a full body lift for transfers, and again, no documentation for staff assistance required. Review of the Certified Nurse Assistant (CNA) Care Card (used by CNA's for resident care instructions), revealed Resident #1 used a sit to stand lift as of, 7/2/13, and was changed to a full body lift on, 6/28/15. Staff assistance required was not designated on either type of lift. Interview per telephone with Resident #1 on, 7/22/15 at 6:10 PM, revealed he knew who he was, where he was, and that it was July. Resident #1 now resides in another nursing home. Resident #1 stated his hip still bothered him some, and he was getting a little therapy now. Resident #1 stated he broke his hip on, 6/17/15, at the (Name of Nursing Home) when he was trying to pull his socks off while sitting in the chair, and fell out of the chair. (The facility's Incident Report 6/27/15 documented similar actions from the resident). Resident #1's thought process was a little slow during the conversation, and he did jump back and forth at times, stated at one time everything was normal, and then next would say he had pain, and couldn't do. Resident #1 stated he told staff that his hip hurt, and they said they gave him some pain medication. He stated he reported to Therapy he was hurting after he had fallen several times. Resident #1 had asked the nurse about the X-rays, and she didn't know. Resident #1 stated he did have some hip pain, and wasn't told until three (3) weeks later that it was broken, and he went to the hospital and had hip surgery. Resident #1 stated he did have pain in his hip but nobody listened to him. Resident #1's most recent Minimum Data Set (MDS) with an Assessment Reference Date (ARD) 5/14/15, revealed he was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15. Per MDS Resident #1 required extensive assistance of one (1) person assist with transfer, and had lower extremity range of motion limitations bilaterally. The quarterly assessment note dated, 5/14/15, revealed Resident #1 needed extensive assist of two (2) persons for transfers. Resident #1 had two (2) falls since the prior MDS. The quarterly note also documented Resident #1 had pain medications, and complaints of breakthrough pain. Review of Resident #1's left hip X-ray report dated, 6/30/15, revealed a Garden classification IV acute femoral neck fracture with moderate [MEDICAL CONDITION] and [MEDICAL CONDITION]. Review of a Hospital History and Physical dated, 7/6/15, revealed Resident #1 underwent hip replacement surgery on, 7/7/15. The history and physical documented Resident #1 reported falls at the facility (Nursing Home) around, 6/16/15, and again two (2) days prior to admission to the hospital. The resident reported unbearable pain on the left side when they attempted to get him up. X-ray reports of the left femur dated, 7/6/15, revealed Resident #1 had a left femoral neck fracture, femoral head not dislocated, and suggestion of calcium deposition in the joint capsule. Review of the Hospital Discharge Summary, dated 7/10/15, revealed Resident #1 underwent surgery to repair his left [MEDICAL CONDITION]. Further review of the Discharge Summary revealed Resident #1 probably had the [MEDICAL CONDITION] at least two (2) weeks before admission to the hospital. The Operative Note dated, 7/7/15, for the left [MEDICAL CONDITION] repair, revealed Resident #1 sustained a left femoral neck fracture a few weeks prior to admission. A typed report by the Administrator from the facility dated, 7/10/15, revealed Resident #1 had a [MEDICAL CONDITION] of unknown origin. Resident #1 had a history of [REDACTED]. Resident #1 was not sent to the hospital for evaluation and treatment of [REDACTED]. Interview with Certified Nursing Assistant (CNA) #4 on, 7/21/15 at 4:25 PM, revealed she had transferred Resident #1 with the sit-stand lift by herself on, 6/28/15, and the resident's foot fell off the mechanical lift. She lowered him to the floor. CNA #4 stated Resident #1 did complain of some groin pain at the time. CNA #4 stated Resident #1 complained of groin pain when she put him back to bed that night, and said no one had given him any pain medication. CNA #4 stated she had been trained to use two (2) people with the mechanical lifts. Review of Resident #1's Incident Reports and SBAR Communication Forms ((Change in condition form) revealed he had the following falls/report of fall: Fall 6/28/15 - 3:45 PM - feet slipped (from lift) and lowered to floor. Review of a SBAR, and an Incident Report dated, 6/28/15, documented Resident #1 was in the process of being transferred with a sit to stand mechanical lift, and the assistance of one (1) Certified Nursing Assistance (CNA) #4. The Resident's foot slipped off the lift, and he began to slide to his knees. CNA #4 lowered Resident #1 to the floor, and put a pillow under his head. CNA #4 called for the nurse. Licensed Practical Nurse (LPN) #6 documented Resident #1 was lying on his back on the floor. Further review of the report revealed Resident #1's vital signs (v/s) was checked, no noted bruises or abrasions and no complain of (c/o) pain was documented. Resident #1 was changed to a total body mechanical lift for transfers. Review of a Nurse's note dated, 6/28/15 at 7:00 PM, revealed Resident #1 was eased to the floor previously (the fall at 3:45 PM). The resident now indicated discomfort to his privates, pointing toward penis and testicles. Resident had not complained, or hurt them previously when lowered to the floor. When asked if hurts all the time or some of the time, resident unable to properly verbalize to nurse, and will continue to observe and follow up if continues hurting. Interview with LPN #6 on, 7/23/15 at 12:00 noon, revealed CNA #4 had reported Resident #1's feet had slipped off the sit-stand lift platform, and she had lowered him to the floor (6/28/15). LPN #6 stated he did not recall giving Resident #1 any pain medication d/t he did not c/o of a lot of pain, excruciating pain for sure. LPN #6 reported he thinks Resident #1 did c/o of some private area pain, but did not c/o of it anymore, and Resident #1 would for sure let them know of any pain. LPN #6 stated he didn't think about it at the time that two (2) people was required with the mechanical lift transfers, and he changed Resident #1 to a full body mechanical lift transfer which for sure would take two (2) person assist. LPN #6 stated the care plan should have been updated to include two (2) persons to assist with Resident #1's mechanical lift transfers. Review of a Nurse's note, and SBAR dated, 6/30/15 at 3:50 PM, revealed a new order to X-ray Resident #1's left hip status/post fall. Resident #1 complained of pain to the left hip area. A small bulging area was noted with verbalization of pain when touched, and when the left leg was moved. Interview with LPN #1 on, 7/22/15 at 10:10 AM, revealed Resident #1 had complained of pain in his hip on, 6/30/15, and did have a bulge bigger than a ping pong ball. LPN #1 stated she was aware the resident had fallen over the weekend, and Resident #1 told her that his hip was probably broken. LPN #1 stated she got the Nurse Practitioner (NP) to look at Resident #1, and X-rays was ordered for his left hip. LPN #1 stated she did offer Resident #1 pain medication, but he refused. LPN #1 stated Physical Therapy Staff #1 reported to her Resident #1 had pain either on, 6/29/15 or 6/30/15. Review of the Nurse Practitioner's note dated, 6/30/15 at 1:45 PM, (e signed) revealed Resident #1 was seen for left hip pain. The Resident had a recent fall, and stated he must force his leg down. Initially he'd complained of left knee pain, with X-ray showing no fracture or dislocation. Left hip was tender to deep palpation. No bruising or swelling. Resident #1 had sharp increase in pain with flexion and rotation. Resident #1 was alert and oriented to person, place, month and year. X-ray of the left hip was ordered. The Controlled Drug Record revealed Resident #1 received [MEDICATION NAME] five (5)/325 one (1) tablet on, 6/27/15 (once), 6/29/15 (once), 6/30/15 (once) 7/1/15 (twice), 7/2/15 (once), and 7/3/15 (once). Review of Resident #1's June and July 2015 Medication Administration Records (MARs), June 27th to June 30th, and July 1st to the 6th, revealed no documentation for the administration of the [MEDICATION NAME] 5/325 for pain. Review of the pain assessment every (q) shift revealed, N , was documented, indicating no pain. Further review of the MAR, and Nurses Notes June 27th to June 30th, and July 1st to July 6th, 2015, revealed no documentation for pain assessments to identify the type of pain, location of pain, duration, precipitating factors, or the effectiveness of the pain medication. Interview with LPN #2 on, 7/22/15 at 7:00 PM, when asked about giving Resident #1 pain medication on, 6/16/15, 6/19/15, 6/29/15, 7/1/15, and 7/3/15, she replied that Resident #1 never complained of hip pain, that he asked for [MEDICATION NAME] to help him sleep. Interview with LPN #5 on, 7/22/15 at 7:15 PM, revealed Resident #1 complained of a headache one night, and some soreness after a fall, and she had given him [MEDICATION NAME] a couple of times. Per the Controlled Drug Record, LPN #5 administered [MEDICATION NAME] to Resident #1 on, 7/1/15 at 9:00 PM, and 7/2/15 at 8:00 PM. Review of Physical Therapy (PT) notes dated, 6/29/15, revealed Resident #1 reported a fall over the weekend, and complained of left lower extremity soreness. The note for, 6/30/15, revealed activity was discontinued due to the resident complaint of pain in the left groin area, and nursing was informed. The, 7/1/15, note revealed Resident #1 had increased pain in the left hip with inconsistent ability to maintain seated balance. Interview with Physical Therapy (PT) Staff #1 on, 7/22/15 at 12:05, revealed Resident #1 started to complain of pain in his groin on, 6/29/15, and reported he'd fallen over the weekend. PT #1 stated she reported to LPN #1 that Resident #1 was still complaining of pain. PT #1 stated she felt of Resident #1's hip, and he reported it being sore, no excruciating pain, maybe a 3-4 scale with movement. PT #1 stated she had worked with Resident #1 on, 6/30/15, and he complained of left groin pain, and discontinued his activity, informed the nurse, and they got X-rays. PT #1 stated she worked with Resident #1 on, 7/1/15, and he continued to complain of pain on movement but didn't request to stop therapy, or ask for medication. Review of the Occupational Therapy (OT) notes dated, 6/29/15-7/6/15, revealed on, 6/29/15, Resident #1 had pain to the right upper extremity, on a scale of two (2). The note for, 7/1/15, revealed Resident #1 had increased pain in the right hip with tasks. Interview with Occupational Therapy (OT) Staff #1 on, 7/21/15 at 2:10 PM, revealed he had treated Resident #1 since, 6/18/15 after a fall. OT #1 stated the resident did have forearm pain which subsided after a few days, OT #1 stated Resident #1 did complain of some left hip pain after a second fall over a weekend. Fall 6/16/15-9:00 AM: Review of the SBAR Communication Form (change in condition form), and an Incident Report dated, 6/16/15 at 9:00 AM, documented Resident #1 was found lying in the floor beside his bed. Resident #1 stated, trying to sit up on side of bed and slid to the floor. Skin assessed with [REDACTED]. Resident voiced no c/o pain. Review of the Nurse's Notes dated, 6/18/15 at 10:00 AM, revealed Resident #1 complained of pain in the right forearm, bilateral ribs, and top of the head post the fall on, 6/16/15. Neurological (Neuro) checks was normal, and new orders was received for X-ray. Review of the June 2015 Medication Administration Record [REDACTED]. Further review of the MAR indicated [REDACTED]. Review of Resident 1's Nurse's notes 6/16/15, 6/17/15, and 6/19/15 revealed no documentation of the pain medication administered, and no pain assessment to address the type of pain, location of pain, pain duration/precipitating factors, or pain relief after receiving the pain medication. Review of the X-Ray reports 6/18/15 revealed no fractures of the right forearm, or the bilateral rib detail. Fall 6/21/15 10:00 PM: Review of the SBAR, and Incident Report dated, 6/21/15 at 10:00 PM, documented Resident #1 was found lying on his back on the floor next to his bed,. Resident #1 stated, he was trying to take his warm ups off and slid to the floor. Neuro checks was initiated, v/s checked, and skin assessment completed. Resident denied pain. Instructed Resident to use call light to call for assistance, continue therapy for strengthening and transfer training, pharmacy review of medications r/t fall risks (Recommendation received to discontinue (d/c) the [MEDICATION NAME], which was d/c'd) Review of the Controlled Drug Record revealed [MEDICATION NAME] 5/325 one (1) tablet was signed out on, 6/24/15 at 8:00 AM for Resident #1. Review of Resident #1's June 2015 MAR, and June 23, 2015 to Jun3 27, 2015 Nurse's notes, revealed no documentation for the administration of the [MEDICATION NAME] on 6/24/15 at 8:00 AM. Further review of the records revealed no documentation for pain assessment, or effectiveness of the pain medication. The pain assessment checks q shift on the [DATE]/23/15 to 6/27/15 was coded, N, indicating no c/o pain. Fall 6/27/15 -unknown time: Review of the SBAR, and an Incident Report dated, 6/27/15 at 9:30 AM, revealed Resident #1 reported to the nurse he had fallen out of his wheel chair during the night while attempting to take off his socks. Resident #1 complained of Left knee pain, and was unable to extend his left leg. There was dried abrasions to the left knee area. Neuro checks was initiated, v/s checked, and an X-ray of the left knee was ordered due to complaint of pain. Resident was medicated as ordered. [MEDICATION NAME] 5/325 was documented signed out on the controlled record for, 6/27/15 at 9:45 AM. Nurse's notes dated, 6/27/15 at 9:15 AM, revealed Resident #1 complained of Left knee pain, and there was dried abrasions noted to the left knee. Resident #1 was unable to extend his left leg. The Nurse Practitioner was notified, and orders obtained for X-ray of the left knee. Interview with LPN #4 on, 7/21/15 at 1:15 PM, revealed during med pass on, 6/27/15, Resident #1 reported he had a fall during the night, and he had abrasions/scratches consistent with a fall. Resident #1 couldn't straighten out his left knee. LPN #4 stated she medicated him for pain. X-rays was obtained of his left knee. Review of the June 2015 MAR, and Nurse's notes 6/27/15, revealed no documentation for the administration of the [MEDICATION NAME] on, 6/27/15 at 9:45 AM. Further review of the records revealed no documentation for pain assessment, or follow up for effectiveness of the pain medication. The MAR's pain assessment q shift for 6/27/15 was coded, N, each shift, indicating no c/o pain. Review of the Face Sheet revealed Resident #1 was admitted by the facility on, 1/6/11, and readmitted on , 11/25/14, with [DIAGNOSES REDACTED]. There was no documented evidence the facility developed a care plan to address Resident #1's actual falls to include, objectives, goals, and timetables to meet the resident's need for falls/injury prevention. Further review revealed the facility failed to include fall/injury interventions r/t to the falls for, X-rays, complaints of pain of the right forearm/rib cage on 6/18/15, the X-ray and complaint of knee pain on 6/27/15, increased supervision of Resident #1 after repeated falls which could help prevent further falls/injury, staff assistance needed to transfer Resident #1 with either the sit-stand or full body lift. This could result in improper transfer causing further falls and/or injury, and improper monitoring of Resident #1's pain level and/or communication of fall/injuries. Interview with the Director of Nursing (DON) and Staff Development Nurse (SD) on, 7/23/15 at 2:35 PM, revealed it was always the policy to use two (2) people with lifts and the lift type is on the care plan. The DON stated she didn't know why the care plan wasn't revised to include increased supervision for Resident #1. The DON stated Resident #1's falls was reviewed for how he fell , and why he fell , and other interventions was put in place. Interview with RN #4 on, 7/23/15 at 1:00 PM, revealed the care plan should be revised after incidents with all interventions timely. RN #4 didn't know why Resident #1's care plan wasn't revised to include interventions of Neuro checks, X-rays, pain/pain medications. RN #4 stated the care plan designated the type of lift, and everyone was trained that two (2) people assist with mechanical lifts. Review of Resident #1's medical record revealed the first complaint of pain of the lower extremity was, 6/27/15, after the resident reported a fall, and was assessed to have abrasions/scratches to the left knee. The next complaint was the next day, 6/28/15, after being eased to the floor when his foot slipped off the sit-stand lift that was operated by one (1) staff member, and he complained of groin pain. X-ray of the left hip on, 6/30/15 revealed there was a fracture. It is a strong possibility/probability that Resident #1's fracture could have occurred during the transfer with the lift on, 6/28/15. The fracture was not identified by the facility until, 7/6/15. Resident #1's care plan revealed he had a history of [REDACTED]. The care plan was not updated to include increased supervision of Resident #1 due to frequent falls to help prevent further falls, nor was it revised to include the complaint of pain from his falls, or X-rays that was obtained on, 6/18/15 and 6/27/15. The care plan was not revised to include the need for two (2) person assistance with transfers. The failure of the facility to review and/or revise Resident #1's falls, and pain care plans to let staff be aware of the continued complaint of pain, and falls resulted in Resident #1 having delayed treatment of [REDACTED].