Every finding on record at Holston Rehabilitation and Care Center

Based on facility policy review, medical record review, facility investigation review, hospital record review, and interview, the facility failed to provide an environment that was as free of accident hazards as possible and provide adequate supervision to prevent accidents for 1 of 5 (Resident #166) residents reviewed for falls. Resident #166 had an unwitnessed fall, nursing staff failed to report the fall to the physician resulting in a 9-day delay in evaluation and Resident #166 was later diagnosed with a left hip fracture. The facility's failure resulted in actual Harm for Resident #166.The findings include: Review of the facility's policy titled, Change in Condition of Residents, dated 1/22/2024, revealed .notification of the physician, legal representative/family member should occur promptly when there is a change in condition .defined .an accident .which results in injury and has potential for physician intervention .accident or incidents resulting in suspected injury . Review of the medical record revealed Resident #166 was admitted to the facility on [DATE] with diagnoses including Chronic Respiratory Failure, Emphysema, and Weakness. Review of a Physician's Order for Resident #166 dated 4/2/2025, revealed .Ropinirole 0.25mg [milligram] PO [by mouth] at bedtime for Restless Leg Syndrome .Trazodone 100mg PO at bedtime for Insomnia .Alprazolam 0.5mg Give 1 tablet every 6 hours as needed for Anxiety .Tramadol 100mg PO every 8 hours as needed for pain .Olanzapine 10mg PO at bedtime for Mood Disorder .Cyclobenzaprine 10mg PO every 8 hours as needed for Muscle Spasms .Gabapentin 100mg PO at bedtime for Neuropathy .Review of the Clinical Health Evaluation for Resident #166 dated 4/2/2025, revealed .fall risk factors .diminished safety awareness .impairment in gait or balance .Impairment to lower extremities .proceed to care plan . Review of the comprehensive care plan for Resident #166 dated 4/2/2025, revealed a terminal prognosis/Hospice related to Chronic Obstructive Pulmonary Disease (COPD). Further review revealed no fall interventions had been documented on the resident's comprehensive care plan. Review of the Hospice Comprehensive Assessment and Plan of Care for Resident #166 dated 4/2/2025, revealed .SN [Skilled Nurse] to instruct patient/caregiver on fall precautions assess for safety hazards .patient/caregiver will understand safety .ensure patient safety .Review of a Skilled Nursing Evaluation for Resident #166 dated 4/4/2025, revealed .vocal complaints of pain .location generalized .score 3 [on a 0 to 10 scale with 0 being no pain and 10 being unbearable pain] .worse with movement .Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #166 scored a 3 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident had severe cognitive impairment. Continued review revealed the resident was dependent on staff for toileting, bathing, personal hygiene, and required moderate assistance with transfers and bed mobility. Review of the Medication Administration Record (MAR) for Resident #166 dated 4/1/2025-4/30/2025, revealed .Tramadol 100mg PO was given .4/5/2025 at 9:01 AM .4/5/2025 at 20:37 .4/6/2025 at 20:35 [8:35 PM].4/7/2025 at 20:34 [8:34 PM] .4/8/2025 at 9:19 AM and 20:57[8:57 PM] .4/9/2025 at 9:09 AM and 21:51 [9:51 PM] .4/10/2025 at 20:42 [8:42 PM] .4/11/2025 at 9:48 AM and 20:24 [8:24 PM] .4/12/2025 at 9:02 AM and 21:26 [9:26 PM] .4/13/2025 17:39 [5:39 PM] . Further review revealed Resident #166 did not receive pain medication until after the fall on 4/4/2025 (fall reported 9 days later on 4/13/2025).Review of the MAR for Resident #166 dated 4/1/2025 - 4/30/2025 revealed .Alprazolam 0.5mg PO was given .4/3/2025 at 23:53 [11:53 PM] .4/4/2025 at 21:49 [9:49 PM] .4/5/2025 at 9:01 AM and 20:28 [8:28 PM] .4/6/2025 at 20:35 [8:35] .4/7/2025 at 8:29 AM, 17:38 [5:38 PM], and 23:45 [11:45 PM] .4/8/2025 at 9:19 AM and 21:58 [9:58 PM] .4/9/2025 9:09 AM .4/10/2025 at 20:42 [8:42 PM] .4/11/2025 at 9:49 AM and 20:24 [8:24 PM] .4/12/2025 at 9:02 AM and 21:45 [9:45 PM] .4/13/2024 at 17:38 [5:38 PM] . Review of the MAR for Resident #166 dated 4/1/2025 -4/30/2025 revealed .Cyclobenzaprine 10 mg PO was given .4/12/2025 at 21:26 [9:26 PM] .4/13/2025 at 17:38 [5:38 PM] . Review of the MAR for Resident #166 dated 4/1/2025 - 4/30/2025, revealed .Hydrocodone 5-325mg PO given 4/13/2025 at 3:02 AM .Review of the Multi-Disciplinary Care Conference for Resident #166 dated 4/10/2025, revealed .alert and orientated X [times ] 1 .confusion .patient [resident] needs maximum assistance with all ADLS [Activities of Daily Living] .resident has difficulty voicing needs and preferences due to confusion .Review of a witness statement authored by CNA X dated 4/13/2025, revealed . I [CNA X] was in [Resident #166's] room picking up her supper tray and she was telling me her left hip was hurting her. I told [Licensed Practical Nurse (LPN) BB] about it . Review of a nursing progress note for Resident #166 dated 4/13/2025, revealed .called [Hospice] .spoke with nurse .advised of increased pain in left hip area .new order issued for x-ray of left hip for Pain/discomfort [9 days after the fall].Review of Review of a Physician's order for Resident #166 dated 4/13/2025, revealed .Hydrocodone 5-325 mg Give 1 tablet by mouth every 4 hours as needed for pain . Review of a Mobile Images Patient Report for Resident #166 dated 4/13/2025, revealed .left intertrochanter femoral/hip fracture [break in the thigh bone that occurs between the two bony prominences on the upper part of the thigh].Review of the nurse's note for Resident #166 dated 4/13/2025, revealed .resident being transported to ER [Emergency Room] due to abnormal hip X-ray .Review of a staff statement for Resident #166 dated 4/14/2025, revealed the CNA reported on 4/4/2025, she was sitting at a desk with another CNA and heard help me help me. The CNA found Resident #166 in her room on floor in front of her bed. Resident #166 complained of left hip pain after fall. Further review revealed the fall was reported to the nursing supervisor on duty several times.Review of a Root Cause Analysis for failure to report a fall for Resident #166 dated 4/15/2025, revealed .staff member failed to document and follow fall procedures .staff member failed to notify provider and family as indicated .Review the facility's fall investigation document completed on 4/16/2025, (12 days after the fall) revealed Resident #166 sustained a fall on 4/4/2025 at 10:30 PM; .patient found on floor in room beside her bed by CNA [Certified Nursing Assistant] .Second CNA in hallway motioned to room. Upon seeing resident on the floor, second CNA notified nurse. Nurse assisted CNA to putting resident back in bed . Review of a Hospital Discharge Summary for Resident #166 dated 4/18/2025, revealed XXX[AGE] year-old .continued complaints of left hip pain .patient and daughter both deny falling or falling at daughters house .admitting diagnosis angulated hip fracture [bone break in the hip area where the broken bone pieces have shifted out of alignment and are tilted at an angle]Review of a staff statement from CNA X dated 9/23/2024, revealed LPN Z was the charge nurse on duty on 4/4/2025, CNA Y found Resident #166 on the floor and CNA X remained with the resident until CNA Y returned with LPN Z. LPN Z and CNA Y assisted Resident #166 back to bed.During an interview on 9/23/2025 at 8:59 AM, RN AA stated the Interdisciplinary Team (IDT) met daily and falls were discussed. RN AA stated Resident #166's fall that occurred on 4/4/2025 was not discussed in the IDT meeting until 4/13/2025. Continued interview revealed after the left hip fracture was identified on 4/13/2025 (9 days later) the facility began an investigation. RN AA further stated, .to my knowledge, I don't think there was an incident report filed when this person fell. It was completed after the ER visit .During an interview on 9/23/2025 at 10:55 AM, the Director of Nursing (DON) stated LPN Z was the supervising nurse on 4/4/2025 and did not report Resident #166 had a fall. On 4/13/2025, the resident complained of increased pain, had a hip x-ray ordered, and determined the resident had sustained a Left Hip Fracture. The DON stated she spoke with the resident regarding her pain and the resident told me she had fallen at home prior to admission to the facility. The DON stated she called the Resident's daughter, and she reported the resident had not fallen at home in over 8 months. During an interview on 9/24/2025 at 7:45 AM, LPN BB stated .I had reported to the doctor she [Resident #166] was having hip pain .the hospice nurse came in and ordered an Xray .I was unaware she had fallen . During an interview on 9/24/2025 at 8:40 AM, the Nurse Practitioner stated he was notified by the facility that Resident #166 had increased pain and ordered an X-rayDuring an interview on 9/24/2025 at 10:10 AM, the DON stated LPN Z did not complete an incident report for Resident #166's fall on 4/4/2025 and 9 days later (4/13/2025) after Resident #166 complained of hip pain, an Xray was completed and with diagnosis of Left Hip Fracture. The DON stated that LPN Z did not follow policies or procedures, did not notify timely, and the care plan was not updated timely with interventions for fall on 4/4/2025. During an interview on 9/24/2025 at 1:00 PM, Hospice RN CC stated she was notified by the facility on 4/13/2025 of Resident #166's increased left hip pain. Hospice RN CC stated she arrived at the facility to evaluate the resident on 4/13/2025 and observed Resident #166 in bed, frail, with pain score 8 out of 10 on her left hip and could not bear weight on her lower left side. Hospice RN CC stated new pain medication of Lortab 500 milligrams and X-ray of left hip was ordered. Hospice RN CC stated that she notified the Resident's daughter of the left hip fracture and requested the Resident be evaluated at the emergency room (ER).During an interview on 9/24/2025 at 4:45 PM, the DON stated .it was possible failure to implement a fall care plan contributed to the resident incurring a fracture from the fall .During an interview on 9/25/2025 at 7:05 PM, CNA Y stated .she and CNA X were sitting at the nurse's desk .heard a scream from Resident #166's room .she went into Resident #166's room and the resident was on the floor at foot of bed .she said she called for LPN Z to come check her [Resident #166] out .LPN Z came and did not assess her [Resident #166] .LPN Z stated she {Resident #166] was all right .LPN Z and CNA X lifted her [Resident #166] up .she [Resident #166] let out a blood curdling scream and was crying that my hip hurts .she called LPN Z several times about the resident's [Resident #166] pain and LPN Z kept saying she [Resident #166] is ok .she said the resident[Resident #166] was in pain the following days that CNA Y worked .notified the nurse of resident's [Resident #166] pain .The facility was cited as past noncompliance, and the facility is not required to submit a Plan of Correction for F-689.The facility immediately implemented corrective actions. The facility's corrective actions were validated onsite by the surveyors on 9/24/2025. The corrective action plan included the following:On 4/13/2025, the facility initiated a Root Cause Analysis Summary. Review of the Root Cause Analysis Summary and interview with the Director of Nursing (DON) on 9/24/2025 at 10:10 AM, confirmed the root cause analysis was initiated on 4/13/2025 and revealed .Resident complained of pain in left hip on 4/13/2025 .LPN notified hospice provider and hospice nurse came and assessed Resident and ordered different pain medication .Xray of left hip .Xray revealed left hip fracture .family was notified on 4/13/2025 .Resident was sent to ER for evaluation and had surgery on left hip .during investigation it was determined that night shift LPN did not complete an incident report for the Resident's fall on 4/4/2025, and 9 days later (4/13/2025) Xray was completed and with diagnosis of Left Hip Fracture .staff member did not follow policies or procedures, did not notify timely, care plan was not updated timely with interventions for fall on 4/4/2025 .DON is responsible for this. The [NAME] will ensure nursing is doing competencies for falls and reporting timely .On 4/13/2025, an Ad Hoc Quality Assurance & Performance Improvement (QAPI) Meeting was held, and the following plan was recommended and implemented: Notification of provider, family, and hospice, results of left hip xray with orders to send to ED for evaluation and treatment r - completed 4/13/2025. Social Services conducted interviews on 100% of patients and families - no concerns identified - completed 4/20/2025. Risk Manager or Designee will conduct in-services with licensed nurses regarding proper fall procedures and reporting procedures - completed 4/20/2025. Risk Manager or Designee will conduct abuse training with all employees - completed 4/20/2025. Risk Manager or Designee will conduct in-services training with licensed nurses on proper procedures for provider and family notification for all patient change in conditions - completed 4/20/2025. Risk Manager or Designee will conduct in-services with licensed nurses who to notify for any patient change in conditions - completed 4/20/2025 Risk Manager or Designee will conduct in -service with all licensed nurses on implementation of fall first responder forms - completed 4/20/2025. Wound Care Nurse or Designee will conduct skin assessment on all patients with BIMS score less than 9 - completed 4/20/2025 Staff Coordinator or Designee will conduct interview/obtain statements with all clinical staff to identify potential concerns with notification of patients who have had fall - completed 4/20/2025Review of the QAPI sign-in sheet dated 4/14/2025, and interview with the Director of Nursing on 9/24/2025 at 10:10 AM, confirmed the QAPI meeting was held, and the corrective action plan had been completed.Review of the 3 X Weekly, 2 X weekly, and 1 X weekly dated 7/31/2025, revealed .There had not been any more issues with notification of falls to facility, provider, fall responder form had been useful in ensuring every incident had been reported, fall procedures had been followed and notification of change in resident's condition .On 4/20/2025, all licensed nursing staff were in serviced regarding proper fall procedures and reporting procedures, who to notify for any patient change in conditions, implementation of fall first responder forms, wound care nurse or designee conducted skin assessments on all resident with BIMS less than 9 and no issues were noted, staffing coordinator or designee conducted interviews and/or obtained statements with all clinical staff to identify potential concerns with notification of patients had a fall. Abuse training was conducted with all staff. During an interview on 19/26/2025 at 2:37 PM, the Director of Nursing (DON) confirmed all licensed nursing staff were in-serviced on proper fall procedures and reporting procedures, who to notify for any patient change in conditions, implementation of fall first responder forms, wound care nurse conducted skin assessments on all residents with BIMS less than 9 and no issues were noted, interviews/statements were obtained from all clinical staff to identify potential concerns with notification of patients had a fall. The DON further stated that abuse training had been conducted with all staff. The DON confirmed that date certain was 4/20/2025 for their Performance Improvement Plan.Review of a Plan of Correction revealed monitoring began on 4/14/2025 with PIP in place with completion date of 7/31/2025.Review of Emergency QAPI Meeting Minutes revealed identified issue, safety plan for residents, plan for other affected residents, system change identified with education plan, and monitoring system.

Based on facility policy review, observations, and interviews, the facility failed to ensure the dumpster area was maintained in a clean and sanitary condition and garbage and refuse were properly contained in 3 of 3 dumpsters.The findings include:Review of the facility's policy titled, Disposal of Garbage and Refuse, dated 9/1/2024, revealed .Garbage and refuse .Surrounding area shall be kept clean so that accumulation of debris and insect/ rodent attractions are minimized .receptacles for refuse shall be maintained in good repair .During an observation with the Certified Dietary Manager (CDM) on 9/22/2025 at 11:50 AM, revealed the following: The 3 of 3 dumpsters were observed with the doors open. Around the dumpster area the following items were observed broken or in disrepair: 2 bed frames, 4 nightstands, 1 end table, 1 office chair, 1 toilet, 1 wheelchair, and 1 file rack. Continued observation revealed various garbage debris scattered on the outer right edge of the dumpster area. The CDM stated the broken items had been around the dumpster area for more than 2 weeks and confirmed the dumpster area was not maintained in an orderly and sanitary condition. Review of a facility invoice dated 8/1/2025 revealed an extra dumpster container was delivered to the facility on 7/9/2025, extra dumpster service was provided on 7/21/2025 and 7/31/2025 for the removal of broken furniture items which could not be collected in the regular dumpster.During an observation of the dumpster area and interview on 9/23/2025 at 9:13 AM, the Administrator stated the broken items around the dumpster area were .piled up. and then a roll dumpster would be ordered to pick up the items when needed. The Administrator stated he was unsure how long the broken items had accumulated around the dumpster area. During an observation and interview on 9/23/2025 at 10:33 AM, revealed a lawn care company crew removing the broken items from the dumpster area. The Lawn Care Crew Director stated this was not part of the normal services provided for the facility although they had removed items once in the past. The Lawn Care Crew Director stated he received a call from his supervisor on 9/23/2025 and was advised to remove the items today from around the dumpster area. The Crew Director stated it was his understanding there were plans in the works as of 9/23/2025 with the lawn care company and the facility to begin routine removal of broken furniture and other items which were unable to be discarded in the regular dumpsters. During an interview on 9/23/2025 at 1:35 PM, the Maintenance Director stated approximately 6 months ago the facility began removing broken items from the facility and placed near the dumpsters until the items could be removed. The Maintenance Director stated an extra roll dumpster was obtained to discard the items and again approximately 1 month ago. The Maintenance Director stated the facility was still in the process of removing old or broken items and those items were being placed around the dumpster area until another roll dumpster could be obtained. The Maintenance Director stated the broken items around the dumpster area observed on 9/22/2025 had been there for more than 2 weeks and there was no current schedule for the items to be removed until 9/23/2025.

Based on facility policy review, medical record review, observation, and interview, the facility failed to ensure appropriate Personal Protective Equipment (PPE) was donned for 2 residents (Resident # 25 and #37) of 25 residents observed for Enhanced Barrier Precautions (EBP) and the facility failed to wear face coverings during a COVID-19 outbreak on 5 of 5 hallways of 1 of 2 shifts.The findings include: Review of the facility's policy titled, Nursing Management Manual, effective 3/21/2024, revealed .implement Enhance Barrier Precautions (EBP) for the prevention of transmission of multidrug resistant organisms .all staff receive training on enhanced barrier precautions upon hire and annually .training in high risk activities .are expected to comply with all precautions .an order for enhanced barrier precautions will be obtained for .wounds .even if the resident is not known to be infected or colonized .PPE for enhanced barrier precautions .necessary when performing high contact care .activities include .dressing .changing . wound care .providing hygiene care . Review of the facility policy titled, Covid-19 Prevention, Response and Reporting, revised 9/1/2024, revealed .source control (refers to the use of masks to cover a person's mouth and nose which helps reduce the spread of large respiratory droplets to others when they are talking, sneezing, or coughing .this measures is crucial to prevent the spread of a respiratory virus) is recommended .By residing or working on a unit or area of the facility experiencing a SARS-CoV-2 or other outbreak of respiratory infection; universal use of source control could be discontinued as a mitigation measure once the outbreak is over .Review of the medical record revealed Resident #25 was admitted to the facility on [DATE] with diagnoses including Diabetes, Muscle Wasting, and Orthopedic Aftercare.Review of the Physician Orders for Resident #25 dated 4/13/2025, revealed .enhanced barrier precautions for wound .Review of the significant change Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #25 scored a 14 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident was cognitively intact. Further review revealed Resident #25 had a stage 3 pressure injury.Review of the comprehensive care plan for Resident #25 revised 8/11/2025, revealed .Pressure Ulcer risk: stage 3 ulcer of the left heel and traumatic injury to the right lower shin .During an observation on 9/22/2025 at 12:05 PM, revealed Enhanced Barrier Precaution (EBP) signage posted on Resident #25's door.During an interview on 9/22/2025 at 12:06 PM, Registered Nurse (RN) W revealed Resident #25 was on EBP for Multi Drug Resistant Organism (MDRO). During an observation on 9/22/2025 at 12:15 PM, Certified Nursing Assistant (CNA) O and CNA P entered Resident #25's room, repositioned the resident in bed, and failed to don PPE for EBP precautions. During an interview on 9/22/2025 at 12:17 PM, CNA O and CNA P stated they had provided care for Resident #25, had not donned appropriate PPE, and confirmed they failed to follow appropriate infection control protocols for EBP. During an interview on 9/22/2025 at 12:18 PM, Licensed Practical Nurse (LPN) Q confirmed Resident #25 was on EBP and signage for EBP was posted on the resident's door. LPN Q confirmed CNA O and CNA P failed to don appropriate PPE before repositioning Resident #25 in bed. During an observation on 9/23/2025 at 4:59 AM, revealed LPN L, CNA B, and CNA G were providing care on the 200 hall with a known COVID-19 outbreak without face coverings for source control in place. During an interview on 9/23/2025 at 5:15 AM, the RN N confirmed it was the facility policy to wear face coverings with known Covid positive residents. RN N further confirmed the staff failed to wear face coverings. During an interview on 9/24/2025 at 9:50 AM, the Director of Nursing stated she expected when staff provided contact activity with a resident on EBP for appropriate PPE protocols to be followed and confirmed if CNA O and CNA P had not donned the appropriate PPE during the contact activity for Resident #25, the CNAs had not followed appropriate infection control practices for the EBP.Review of the medical record revealed Resident #37 was admitted to the facility on [DATE] with diagnoses including Cellulitis of Right Lower Limb, Sepsis with unspecified Organism, Chronic Obstructive Pulmonary Disease, and Obstructive Reflux Uropathy.Review of the admission MDS assessment dated [DATE], revealed Resident #37 scored a 15 on the BIMS assessment which indicated the resident was cognitively intact. Review of the comprehensive care plan for Resident #37 dated 9/23/2025, revealed the resident had a wound to the right shin, the sacrum, had an indwelling urinary catheter, and was on EBP.During an observation on 9/24/2025 at 1:41 PM, the Physical Therapy Assistant (PTA) was observed providing hands on therapy services to Resident #37 in the resident's room while the resident was lying in bed. Continued observation revealed signage posted on the resident's door for EBP and read .PROVIDERS AND STAFF MUST ALSO: Wear gloves and a gown for the following High-Contact Resident Care Activities.Dressing Bathing/Showering Transferring Changing Linens Providing Hygiene Changing briefs or assisting with toileting Device care or use.Wound Care. Further observation revealed the PTA had not donned PPE prior to entering the resident's room or providing therapy services for Resident #37. Continued observation revealed the PTA exited the resident's room at 1:45 PM without donning the required PPE.During an interview on 9/24/2025 at 1:45 PM, the PTA stated she had provided therapy services for Resident #37 in the resident's room and confirmed she had not donned PPE while providing the services. The PTA stated .I didn't see the sign [referring to the EBP signage posted on the door].During an interview on 9/24/2025 at 2:00 PM, the DON stated she expected when staff provided contact activity with a resident on EBP for appropriate PPE protocols to be followed and confirmed if the PTA had not donned the appropriate PPE during the contact activity for Resident #37, the PTA had not followed appropriate infection control practices for the EBP.

Based on facility policy review, medical record review, facility investigation review, personal file review, and interview, the facility failed to protect a resident's rights to be free from misappropriation and/or exploitation when money totaling $23.11 was taken from 1 resident (Resident #43) of 22 residents reviewed for misappropriation. The findings include:Review of the facility policy titled, Abuse, Neglect, Misappropriation of Resident Property, Suspicious Injuries of Unknown Source, Exploitation, undated, revealed .Misappropriation of Resident Property means the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent .Review of the medical record revealed Resident #43 was admitted to the facility on [DATE] with diagnoses including Hereditary and Idiopathic Neuropathy, Respiratory Disorders, and Muscle Wasting and Atrophy. Review of an admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #43 scored a 15 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident was cognitively intact.Review of the facility investigation documentation dated 2/10/2025, revealed Resident #43 informed the Director of Nursing (DON) .2 nights ago, approximately 2/8/2025 she noticed a black card laying on her bedside table. The resident could not retrieve it until yesterday, noticing it to be the card that ordained her to marry people. Resident thought this was odd because the card is usually in her purse. She then noticed that her debit card and 2 credit cards were missing . The DON notified the facility Administrator of the alleged misappropriation. The facility started an investigation. During the facility investigation Certified Nursing Assistant (CNA) V was suspended on 2/10/2025 pending the investigation after the CNA was identified as a possible suspect. Continued review revealed the facility substantiated the abuse and terminated CNA V on 2/27/2025 for misappropriation of resident property.Review of a receipt dated 2/26/2025 revealed Resident #43 was reimbursed for personal funds lost.During an interview on 9/24/2025 at 9:12 AM, Resident #43 confirmed her debit card and 2 credit cards were taken by the facility CNA without her permission with $23.11 stolen. Continued interview revealed the facility did reimburse her for the $23.11 after the theft was identified.During an interview on 9/24/2025 at 2:35 PM, the Administrator confirmed the facility substantiated the allegation of misappropriation on Resident #43. The Administrator stated the $23.11 was reimbursed to Resident #43 by the facility. The Administrator further confirmed the facility employed CNA V was responsible for the misappropriation of Resident #43 property.

Based on review of facility policy, review of medical record, and interview, the facility failed to resubmit a Pre-admission Screening and Resident Review (PASARR) timely after a new mental health diagnosis was added for 1 resident (Resident #10) of 8 residents reviewed for PASARR. The findings include:Review of the facility's policy titled, Resident Assessment-Coordination with Pre-admission Screening and Resident Review (PASARR) Program, undated, revealed .All applicants to this facility will be screened for serious mental disorders .ends the PASARR process unless a possible serious mental disorder or intellectual disability arises later.Review of a PASARR Level 1 screen for Resident #10 dated 8/12/2025, revealed the resident had .no mental health diagnosis known or suspected.Review of the medical record revealed Resident #10 was admitted to the facility on [DATE] with diagnosis including Encephalopathy, Diabetes, and Intraspinal Abscess and Granuloma. Continued review revealed the resident received a new mental health diagnosis of Post-Traumatic Stress Disorder and Major Depressive Disorder on 8/14/2025.Review of the Comprehensive Care Plan revised on 8/15/2025, revealed Resident #10 had a care plan for history of Depression and Post-Traumatic Stress Disorder. Review of the medical record revealed a new PASARR for Resident #10 was not submitted after the new mental health diagnoses was added of Post-Traumatic Stress Disorder and Major Depressive Disorder on 8/14/2025. During a record review and interview on 9/24/2025 at 2:10 PM, the Director of Nursing (DON) confirmed a new PASARR had not been submitted after the new mental health diagnoses were added. Continued interview revealed the DON confirmed the facility policy for referring to the state agency for PASARRS after identifying a new mental health condition was not followed.

Based facility policy review, medical record review, observation, and interview, the facility failed to implement care plan interventions related to blood glucose checks for 1 resident (Resident #109) and falls for 2 residents (Resident #138 and #166) of 25 residents reviewed for care plans.The findings include: Review of the facility policy titled, Comprehensive Care Plans, dated 12/31/2024, .It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing.needs.and.services that are identified in the resident's comprehensive assessment and meet professional standards of quality.The comprehensive care plan will describe, at a minimum.The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Review of the facility policy titled, Fall Prevention Program, dated 12/31/2024, revealed .Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. Review of the facility policy titled, Incident and Accidents, dated 12/31/2024, revealed .It is the policy of this facility for staff.review any accidents or incident that occur or allegedly occur.The purpose of incident reporting can include.Assuring that appropriate and immediate interventions are implemented and corrective actions are taken to prevent recurrences and improve the management of resident care. Review of the medical record revealed Resident #109 was admitted to the facility on [DATE] with diagnosis including Polyneuropathy, Osteomyelitis of Right Ankle and Foot, Diabetes, and Cellulitis of Right Lower Limb. Review of the Physician's Orders dated 7/23/2025, revealed Resident #109 had an order for accuchecks (blood glucose (sugar) monitoring) daily and as needed (PRN). Review of the Comprehensive Care Plan for Resident #109 dated 7/24/2025, revealed .The resident has diabetic ulcer of the right plantar foot r/t [related to] Diabetes .Monitor blood sugar levels . Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #109 scored an 11 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident had moderate cognitive impairment. Further review revealed Resident #109 had a diagnosis of Diabetes. Review of the Medication Administration Records (MAR) dated from 7/23/2025 – 9/24/2025, revealed no documentation the accuchecks had been obtained. During an interview on 9/24/2025 at 1:47 PM, Licensed Practical Nurse (LPN) R stated Resident #109 had an order dated 7/23/2025 for fingerstick blood sugars daily and as needed. LPN R confirmed blood sugars had not been obtained and documented from 7/23/2025 until 9/24/2025. During an interview on 9/24/2025 at 1:57 PM, the Director of Nursing (DON) stated Resident #109 had an order dated 7/23/2025 for blood sugar checks daily and as needed. The DON confirmed the fingerstick blood sugars had not been obtained or documented from 7/23/2025 to 9/24/2025 and the care plan had not been implemented. Review of the medical record revealed Resident #138 was admitted to the facility on [DATE], with diagnoses /including Hemiplegia and Hemiparesis following Cerebral Infarction affecting Left Dominant Side, Lack of Coordination, Muscle Wasting and Atrophy, Right Femur Fracture, Fall, Alzheimer's Disease, and Dysuria. Review of a post fall investigation report dated 7/14/2025, revealed Resident #138 had an unwitnessed fall from the bed with no injuries sustained from the fall. The fall intervention was for Dycem (a versatile non-slip material that enhances stability and safety for wheelchair users by preventing slipping and improving seating posture) to be placed in the resident's wheelchair. Review of a quarterly MDS dated [DATE], revealed Resident #138 scored a 6 on the BIMS assessment which indicated the resident had severe cognitive impairment. Review of the comprehensive care plan for Resident #138 dated 8/6/2025, revealed the resident was at risk for falls related to Deconditioning, with an intervention to have Dycem in the wheelchair for safety. During an observation on 9/22/2025 at 11:37 AM, revealed Resident #138 was seated in a wheelchair. Continued observation revealed no Dycem in the wheelchair. During an observation on 9/23/2025 at 7:57 AM, revealed Resident #138 was sitting up on the side of the bed eating breakfast . A wheelchair was observed at the bedside with no Dycem present in wheelchair. During an observation on 9/23/2025 at 8:38 AM, revealed Resident #138 was in the bathroom. A wheelchair was observed in the doorway of the bathroom with no Dycem observed in the wheelchair. During an observation on 9/24/2025 at 8:21 AM, revealed Resident #138 was in the bathroom. The resident's wheelchair was observed at the resident's bedside with no Dycem observed in the wheelchair. During an observation and interview on 9/24/2025 at 8:47 AM, LPN R stated she was unsure of Resident #138's fall interventions .I will have to look them up. LPN R stated one of the fall interventions included Dycem in the wheelchair. Observation with LPN R in Resident #138's room revealed Resident #138 seated in a wheelchair. LPN R confirmed there was no Dycem in use in Resident #138's wheelchair .I don't see it, I will have to go get some [Dycem]. During an observation on 9/24/2025 at 9:13 AM, revealed Resident #138 in his room seated in a wheelchair with no Dycem observed. During an observation on 9/24/2025 at 1:40 PM, revealed Resident #138 seated in a wheelchair visiting with family. Continued observation revealed no Dycem observed in the wheelchair. During an interview on 9/24/2025 at 1:57 PM, the DON stated Resident #138 had a fall care plan intervention for Dycem to the wheelchair and expected the fall care plan intervention to be implemented for Resident #138. The DON confirmed if the Dycem was not in use, the care plan had not been followed. Review of the medical record revealed Resident #166 was admitted to the facility on [DATE] with diagnoses including Chronic Respiratory Failure, Emphysema, and Weakness. Review of the Clinical Health Evaluation for Resident #166 dated 4/2/2025, revealed .fall risk factors .diminished safety awareness .impairment in gait or balance .Impairment to lower extremities .proceed to care plan . Review of the comprehensive care plan for Resident #166 dated 4/2/2025, revealed a terminal prognosis/Hospice related to Chronic Obstructive Pulmonary Disease (COPD). Further review revealed no fall interventions had been documented on the resident's comprehensive care plan. Review of the Hospice Comprehensive Assessment and Plan of Care for Resident #166 dated 4/2/2025, revealed .SN [Skilled Nurse] to instruct patient/caregiver on fall precautions assess for safety hazards .patient/caregiver will understand safety .ensure patient safety . Review of the admission MDS assessment dated [DATE], revealed Resident #166 scored a 3 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident had severe cognitive impairment. Continued review revealed the resident was dependent on staff for toileting, bathing, personal hygiene, and required moderate assistance with transfers and bed mobility. Review of facility's fall investigation document completed on 4/16/2025 (12 days after the fall) revealed Resident #166 sustained a fall on 4/4/2025 at 22:30PM, .Patient [Resident] found on floor in room beside her bed by CNA [Certified Nursing Assistant] .Second CNA in hallway motioned to room. Upon seeing resident on the floor, second CNA notified nurse. Nurse assisted CNA to putting resident back in bed . During an interview on 9/24/2025 at 10:10 AM, the DON stated LPN Z did not complete an incident report for Resident #166's fall on 4/4/2025 and 9 days later (4/13/2025) after Resident #166 complained of hip pain, Xray was completed with diagnosis of Left Hip Fracture. The DON stated that LPN Z did not follow policies or procedures, did not notify timely, and the care plan had not been updated timely with interventions for the fall on 4/4/2025. During an interview on 9/24/2025 at 4:45 PM, the DON stated .it was possible failure to implement a fall care plan contributed to the resident incurring a fracture from the fall .

Based on facility policy review, medical record review, observation, and interview the facility failed to revise the care plan for 2 residents (Resident #25 and Resident #100) of 25 residents reviewed for care plans.The findings include: Review of the facility's policy titled, Comprehensive Care Plans, revised 12/31/2024, revealed .policy of this facility to develop .implement .person-centered care plan for each resident .Individualized interventions for trauma survivors .care plan will be reviewed and revised . Review of the medical record revealed Resident #25 was admitted to the facility on [DATE] with diagnoses of Diabetes, Muscle Wasting, and Orthopedic Aftercare. Review of the Physician Orders for Resident #25 dated 4/13/2025, revealed .enhanced barrier precautions for wound . Review of the significant change Minimum Data Set (MDS) dated [DATE], revealed Resident #24 scored a 14 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident was cognitively intact. Further review revealed Resident # 25 had a stage 3 pressure injury. Review of the comprehensive care plan for Resident #25 revised 8/11/2025, revealed .Pressure Ulcer risk: stage 3 ulcer of the left heel and traumatic injury to the right lower shin . During an observation on 9/22/2025 at 12:05 PM, revealed Enhanced Barrier Precaution signage on Resident #25's door. During an interview on 9/22/2025 at 12:18 PM, Licensed Practical Nurse (LPN) Q confirmed Resident #25 was on Enhanced Barrier Precautions. Review of the medical record revealed Resident #100 was admitted to the facility on [DATE] with diagnoses including Hemiplegia and Hemiparesis, Diabetes, and Post-Traumatic Stress Disorder (PTSD). Review of the annual MDS assessment dated [DATE], revealed Resident #100 scored an 8 on the BIMS assessment which indicated the resident had moderate cognitive impairment. Further review revealed Resident #100 had diagnosis of PTSD. Review of the comprehensive care plan for Resident #100 revised 9/9/2025, revealed .resident has a potential psychosocial well-being problem r/t [related to] Recent admission . Further review revealed care plan had not been developed or interventions implemented for the diagnosis PTSD. During an interview on 9/22/2025 at 11:30 AM, Resident #100 stated he had PTSD from time served in the Vietnam War. Resident #100 stated loud noises and fireworks were triggers for him. During an interview on 9/23/2025 at 7:55 AM, Resident #100 stated he was tired because he did not sleep much last night. Resident #100 revealed he had not slept much at night since his time in the war. During an interview on 9/23/2025 at 8:22 AM, LPN Q stated she was aware Resident #100 had a diagnosis of PTSD and triggers were loud noises. During an interview on 9/24/2025 at 8:32 AM, the Social Services Director (SSD) stated Resident #100 had a diagnosis of PTSD and was seen by psychiatric services. The SSD confirmed Resident #100's care plan had not been revised to reflect the diagnosis of PTSD. During an interview on 9/24/2025 at 9:25 AM, Registered Nurse (RN) MDS Coordinator confirmed Resident #25's care plan had not been revised to reflect Enhanced Barrier Precautions and Resident #100's care plan had not been revised to reflect the diagnosis of PTSD.

Based on review of facility policy, review of medical records, and interviews, the facility failed to follow the Physician's Orders for blood glucose monitoring for 1 resident (Resident #109) of 5 residents reviewed for blood glucose monitoring.The findings include:Review of the facility's policy titled, Blood Glucose Monitoring, dated 1/1/2025, revealed .It is the policy of this facility to perform blood glucose monitoring to diabetic residents as per physician's orders .The facility will perform blood glucose monitoring as per physician's orders .Verify the physician's order .Document the procedure .Review of the medical record revealed Resident #109 was admitted to the facility on [DATE] with diagnosis including Polyneuropathy, Osteomyelitis of Right Ankle and Foot, Diabetes, and Cellulitis of Right Lower Limb.Review of the Physician's Orders dated 7/23/2025, revealed Resident #109 had an order for accuchecks (blood glucose (sugar) monitoring) daily and as needed (PRN).Review of the Comprehensive Care Plan for Resident #109 dated 7/24/2025, revealed .The resident has diabetic ulcer of the right plantar foot r/t [related to] Diabetes .Monitor blood sugar levels .Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #109 scored an 11 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident had moderate cognitive impairment. Further review revealed Resident #109 had a diagnosis of Diabetes. Review of the Medication Administration Record (MAR) for Resident #109, dated 7/23/2025 - 7/31/2025, revealed no documentation of the daily blood glucose readings.Review of the MAR for Resident #109 dated 8/1/2025 - 8/31/2025, revealed no documentation of the daily blood glucose readings.Review of the MAR for Resident #109 dated 9/1/2025 - 9/24/2025, revealed no documentation of the daily blood glucose readings.During an interview on 9/24/2025 at 1:47 PM, Licensed Practical Nurse (LPN) R stated Resident #109 had an order dated 7/23/2025 for fingerstick blood sugars daily and as needed. LPN R confirmed blood sugars had not been obtained and documented from 7/23/2025 until 9/24/2025. LPN R stated the physician entered the order into the electronic physician's order and had not entered a time for the blood sugars to be obtained. LPN R further stated a night shift nurse had checked the order after it was entered by the physician on 7/23/2025 and had failed to enter a time for the blood sugars to be obtained by the nursing staff which resulted in the fingerstick blood sugars not being done.During an observation of Resident #109 on 9/24/2025 at 1:51 PM, LPN R obtained a fingerstick blood sugar with a result of 160 milligram/deciliter (mg/dl) (normal reference range is 70-99).During an interview on 9/24/2025 at 1:57 PM, the Director of Nursing (DON) stated Resident #109 had an order dated 7/23/2025 for blood sugar checks daily and as needed and was updated on 9/24/2025. The DON confirmed the fingerstick blood sugars had not been recorded from 7/23/2025 to 9/24/2025. The DON stated the physician had entered the order in the electronic medical record and a night shift nurse signed off on the order as a second check and had failed to enter a time for the blood sugar to be obtained.During an interview on 9/24/2025 at 2:16 PM, the Medical Director stated she was not aware Resident #109's blood sugars were not obtained as ordered. The Medical Director stated the resident was non-compliant with the treatments to his diabetic ulcer to his foot and non-compliant with the diet. The Medical Director stated the resident's hemoglobin A1C (a blood test to measure a 3 month time period of blood sugar ranges) was 5.0% in 2/2025 which was normal and not in a diabetic range. The Medical Director stated she had entered the order for the accuchecks in the electronic medical record in 7/2025 for the daily checks and may have had a data entry error which resulted in the facility not obtaining the blood sugars. The Medical Director stated there was no detriment or harm to the resident and failing to obtain the blood sugars had not impeded the healing of the resident's diabetic ulcer to the heel.

Based on review of facility policy, review of the medical record, observation, and interview, the facility failed to follow a physician's order for oxygen therapy for 1 resident (Resident #56) of 5 residents reviewed for oxygen therapy and failed to document CPAP/BIPAP (Continuous Positive Airway Pressure/Bilevel Positive Airway Pressure) (machine that provides continuous positive airway pressure device used to keep the airway open during sleep], BIPAP [machine that provides bi-level positive airway pressure to keep the airway open during sleep) care for 1 resident (Resident #72) of 8 residents reviewed for CPAP/BIPAP. The findings include: Review of the facility policy titled, Oxygen Administration, dated 9/1/2024, revealed .Oxygen is administered to resident who need it, consistent with professional standards of practice.Oxygen therapy.is the administration of oxygen at concentrations greater than that in ambient air.with the intent of treating or preventing the symptoms and manifestations of hypoxia.Hypoxia means decreased perfusion of oxygen to the tissues.Oxygen is administered under orders of a physician. Review of the facility's policy titled Noninvasive Ventilation (CPAP, BIPAP .) undated, revealed .It is the policy of this facility to provide non-invasive ventilation .per physician's orders and current standards of practice .facility will obtain an order for use of CPAP, BiPAP .Document use of the machine, resident's tolerance, any skin, respiratory or other changes and responses . Review of the medical record revealed Resident #56 was admitted to the facility on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease with Acute Exacerbation, Dependence on Supplemental Oxygen, Atrial Fibrillation, and Heart Failure. Review of the Physician's Orders for Resident #56 dated 8/27/2025, revealed Oxygen at 2 liters/minute (l/m) via nasal cannula continuous and as needed. Review of an admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #56 scored a 14 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident was cognitively intact. Continued review revealed the resident used supplemental oxygen. During an observation on 9/22/2025 at 11:45 AM, revealed Resident #56 received supplemental oxygen. Continued observation revealed the oxygen concentrator setting was set at 4 l/m (and not the prescribed 2 l/m). During an observation on 9/23/2025 at 7:55 AM, in the resident's room, revealed Resident #56 was sitting up in bed. The resident's oxygen concentrator was set on 4 l/m (and not the prescribed 2 l/m). During an interview on 9/23/2025 at 8:47 AM, Licensed Practical Nurse (LPN) T stated Resident #56 had a physician's order for oxygen therapy at 2 l/m continuous and as needed. During an observation in Resident #56's room and interview on 9/23/2025 at 8:52 AM, LPN R confirmed Resident #56's oxygen was greater than 2 l/m and the physician's order was not followed. During an interview on 9/23/2025 at 11:45 AM, the Director of Nursing (DON) confirmed the oxygen was ordered for 2 l/m for Resident #56. Continued interview revealed the facility failed to ensure oxygen therapy was administered as ordered. Medical record review revealed Resident #72 was admitted to the facility on [DATE] with diagnoses including Acute and Chronic Respiratory Failure, Chronic Obstructive Pulmonary Disease, and Obstructive Sleep Apnea. Review of a Physician's order for Resident #72 dated 8/13/2025, revealed, .CPAP, BiPAP .at bedtime .remove in AM . Review of a quarterly MDS assessment dated [DATE], revealed Resident #72 scored a 13 on the BIMS assessment which indicated the resident was cognitively intact. Review of a Medication Administration Record (MAR) for Resident #72 dated 9/1/2025-9/30/2025, revealed, .CPAP, BiPAP .at bedtime .remove in AM . Review of the medical record for Resident #72 revealed no documentation of the resident's tolerance, any skin, respiratory or other changes and responses with the use of BiPAP. During an observation and interview on 9/22/2025 at 11:40 AM, in Resident #72's room, revealed, a CPAP/BiPAP on her bedside table. Resident #72 stated she wears a BiPAP, and staff help her put it on at night and take it off in the morning. During an interview on 9/24/2025 at 3:40 PM, the DON confirmed Resident #72 has a BiPAP ordered and confirmed staff are not following facility policy by documenting Resident #72's tolerance, any skin, respiratory or other changes and responses while using the BiPAP machine.

Based on facility policy review, observation, and interview the facility failed to maintain sanitary kitchen equipment which had the potential to effect 120 of the 122 residents in the facility. The findings include: Review of the facility's undated policy titled, Cleaning and Sanitizing Dietary Areas and Equipment, showed .All kitchen areas and equipment shall be maintained in a sanitary manner and be free of build-up of food, grease, or other soil . During the initial kitchen observation on 3/3/2024 at 10:55 AM, with the Certified Dietary Manager (CDM), showed the facility's gas stove griddle had a layer of dried brownish-black food debris observed on the top and the right-side lip of the metal splashguard of the griddle. During an interview on 3/3/2024 at 11:12 AM, the CDM confirmed she was responsible for the oversight of the dietary department. The CDM stated the kitchen equipment was cleaned daily and deep cleaned weekly. The CDM confirmed the stove griddle was in an unsanitary condition and could use further cleaning.

Based on facility policy review, medical record review and interviews, the facility failed to include the resident or resident's representative in the care planning process for 1 resident (Resident #106) of 28 residents reviewed for care planning. The findings include: Review of the facility's policy titled, Person Centered Care Plans, dated 12/18/2023, showed .According to federal regulations, the facility develops a comprehensive person centered plan of care for each resident .Conducting the Interdisciplinary Person Centered Care Plan Meeting .including the resident and their representative when possible .Existing goals and approaches should be reviewed and revised .When the resident is unable to participate in the care plan meeting .due to .cognitive impairment .the residents [resident's] family members should be encouraged to attend .Family participation should be recorded in the EMR [electronic medical record] . Resident #106 was admitted to the facility on [DATE] with diagnoses including Type 2 Diabetes Mellitus, and Obstructive Sleep Apnea. Review of the care plan for Resident #106 dated 1/26/2024, showed the resident had a knowledge deficit with an intervention of .Promote the importance of participation/compliance in treatment regimen . Review of a 5-day Minimum Data Set (MDS) assessment dated [DATE], showed Resident #106 had severe cognitive impairment. During a telephone interview on 3/3/2024 at 3:30 PM, Resident #106's daughter stated she had never been invited to a care plan meeting or had a discussion with anyone at the facility about her mother's plan of care. During an interview on 3/4/2024 at 8:52 AM, the Director of Social Services (DSS) stated Resident #106 had not yet had a care plan meeting held with the family. Typically, care conferences are set up by the admissions team within 48 hours, unless the admission fell on a weekend, then the goal was 72 hours. The DSS confirmed it was her expectation that a care conference was done within that time period and confirmed no care plan conference had been held with Resident #106 or the resident's representative.

Based on review of facility policy, medical record review, and interview, the facility failed to ensure physician orders were followed for 1 resident (Resident #48) of 28 residents reviewed. The findings include: Review of the facility's policy titled, .Medication Administration-General Guidelines ., dated 1/2/2024, showed .Medications are administered as prescribed in accordance with good nursing principles and practices .FIVE RIGHTS-Right resident, right drug, right dose, right route and right time are applied for each medication being administered .The medication administration record [MAR] is always employed during medication administration. Prior to administration of any medication, the medication and dosage schedule on the resident's .[MAR] are compared with the medication label. If the label and MAR are different and the container has not already been flagged indicating a change in directions, or if there is any other reason to question the dosage or directions, the physician's orders are checked for the correct dosage schedule . Medical record review showed Resident #48 was admitted to the facility on [DATE] with diagnoses including, Giant Cell Arteritis (inflammation of certain arteries, especially those near the temples), Chronic Obstructive Pulmonary Disease (COPD), and Asthma. Medical record review of an admission Minimum Data Set (MDS) assessment dated [DATE], showed Resident #48 was cognitively intact. Medical record review of the hospital discharge orders for Resident #48 dated 1/8/2024 showed an order for .Prednisone [steroid] .Take 8 tablets (8 mg [milligrams] total) by mouth daily for 10 days .Dispense 80 tablet . Medical record review of Resident #48's MAR for 1/2024 showed .predniSONE Oral Tablet 10 mg .Give 8 tablet by mouth one time a day for inflammation for 10 days . Continued review showed Prednisone 80 mg was administered to Resident #48 on 1/10/2024 at 8:00 AM by Licensed Practical (LPN) #6. During an interview on 3/4/2024 at 9:50 AM, the Director of Nursing (DON) confirmed the order for Prednisone was transcribed as 80 mg daily instead of 8 mg daily. The DON confirmed Resident #48 received Prednisone 80 mg instead of 8 mg on 1/10/2024. During an interview on 3/4/2024 at10:38 AM, the Medical Director stated she was notified Resident #48 had received 1 dose of Prednisone 80 mg instead of 8 mg. The Medical Director stated the resident had severe COPD .so I don't think that would cause problems for the resident . The Medical Director stated the resident had no negative side effects, she didn't receive reports the resident had not slept that evening. During continued interview the Medical Director stated she did not consider it an excessive dose. During an interview on 3/4/2024 at 11:15 AM, Registered Nurse (RN) #2 confirmed the order was transcribed as 80 mg daily and the orders was transcribed incorrectly. During an interview on 3/5/2024 at 7:50 AM, Licensed Practical Nurse #6 confirmed Prednisone 80 mg instead of 8 mg was administered to Resident #48 on 1/10/2024.

Based on facility policy review, medical record review, observations, and interview the facility failed to provide a safe environment by leaving medications unsecured at the bedside for 1 resident (Resident #419) of 28 residents observed. The findings include: Review of the facility policy titled, Medication Storage in the Facility, dated 1/2/2024, showed .Except for those requiring refrigeration or freezing, medications for internal use are stored in a medication cart or other designated area . Review of the facility policy titled, Preparation and General Guidelines .Self-Administration of Medications, dated 1/2/2024, showed .If the resident demonstrates the ability to safely self-administer medications, a further assessment of safety of bedside medications storage is conducted . Review of Resident #419's Medication Review Report showed the resident admitted to the facility on [DATE] with an order for Spiriva Handihaler Inhalation Capsules 18 microgram (mcg) inhale orally one time a day. There was not an order for antacid tablets on the report. Review of Resident #419's Social Service History & Initial assessment dated [DATE], showed the resident was cognitively intact. During an observation on 3/3/2024 at 12:15 PM, Resident # 419 was lying in his bed. The resident was awake and alert. On the overbed table a box of Tiotropium Bromide bronchodilator (Spiriva Handihaler) with a prescription label on it. Inside the box was an inhalation device and blister pack with 1 capsule remaining. On the nightstand next to the bed was a half full bottle of antacid tables. Resident #419 stated he needed the Tiotropium Bromide refilled so he had the box in the room to give his daughter the information to get it refilled. The resident stated he brought the antacid tablets from home, because when he gets indigestion, he needs them. The resident stated the bottle has been on the nightstand for a few days. There were no residents wandering in the hall during the time of this observation. During an observation on 3/3/2024 at 3:43 PM, the box of Tiotropium Bromide continued to be on the overbed table and the bottle of antiacid tablets continued to be on the nightstand. Continued observation showed there was a second box of Tiotropium Bromide still sealed on the overbed table. The resident stated his daughter brought those in when she came to visit. During an observation and interview on 3/3/2024 at 3:47 PM, with Licensed Practical Nurse (LPN) #4 in Resident #419's room, LPN #4 stated medications are not supposed to be left in a resident room. All medications are to be locked up. LPN #4 stated she did not know there was a full capsule left in the Tiotropium Bromide box when she gave the box to the resident to get a refill. LPN #4 also stated she had not observed the bottle of antacid tablets. LPN #4 stated Resident #419 had not been assessed for self-administration of medication. The medications were removed from the room and locked up in the medication cart. During this observation and interview there were no residents wandering in the halls during the time of the observation. During an interview on 3/5/2024 at 7:36 AM, the Director of Nursing (DON) stated her expectation was the nurses should have educated the resident about not storing medications in the resident room and removed the medication from the room. If the resident refuses to allow the medications to be locked up, the nurse should contact me. The DON confirmed the medication should not have been left in Resident #419's room.

Based on facility policy review, medical record review, observations, and interviews, the facility failed to accurately transcribe an admission order for 1 resident (Resident #48) of 3 residents reviewed for admission orders and the facility failed to ensure admission assessments were accurate for 1 resident (Resident #364) of 28 sampled residents. The findings include: Review of the facility's policy titled, Nursing Assessments, dated 12/18/2023, showed .information in the medication record, as documented by nursing personnel aids in the development of accurate plan . Review of the facility's policy titled, Medication Reconciliation, dated 1/25/2024 .Medication reconciliation refers to the process of verifying that the resident's current medication list matches the physician's orders for the purpose of providing the correct medications to the resident at all points throughout his or her stay .Medication reconciliation involves collaboration with the resident/representative and multiple disciplines, including admission liaisons, licensed nurses, physicians, and pharmacy staff .Pre-Admission Processes .Obtain current medication list from referral source .Obtain current medication/admission orders .Verify resident identifiers .Forward to nursing unit accepting the resident .Admission Processes .Verify resident identifiers on the information received .Compare orders to hospital records; Obtain clarification orders as needed .Transcribe orders in accordance with procedures for admission orders .Have a second nurse review transcribed orders for accuracy and cosign the orders, indicating the review . Resident #48 was admitted to the facility on [DATE] with diagnoses including Giant Cell Arteritis (inflammation of certain arteries, especially those near the temples), Chronic Obstructive Pulmonary Disease (COPD), and Asthma. Review of an admission Minimum Data Set (MDS) assessment dated [DATE], showed Resident #48 was cognitively intact. Review of the hospital discharge orders for Resident #48 dated 1/2024 showed an order for .Prednisone [steroid] .Take 8 tablets (8 mg [milligrams] total) by mouth daily for 10 days .Dispense 80 tablet . Review of Resident #48's Medication Administration Record (MAR) showed .predniSONE Oral Tablet 10 mg (Prednisone) Give 8 tablet by mouth one time a day for inflammation for 10 days . Continued review showed Prednisone 80 mg was administered to Resident #48 on 1/10/2024 at 8:00 AM (and not the ordered 8 mg). During an interview on 3/4/2024 at 9:50 AM, the Director of Nursing (DON) confirmed the order for Prednisone was transcribed as 80 mg daily instead of 8 mg daily and confirmed the order was transcribed incorrectly. During an interview on 3/4/2024 at10:38 AM, the Medical Director stated she was notified Resident #48 had received 1 dose of Prednisone 80 mg instead of 8 mg. The Medical Director stated the resident had severe COPD .so I don't think that would cause problems for the resident . The Medical Director stated the resident had no negative side effects, she didn't receive reports the resident had not slept that evening. During continued interview the Medical Director stated she did not consider that an excessive dose. During an interview on 3/4/2024 at 11:15 AM, Registered Nurse (RN) #2 confirmed the order was transcribed as 80 mg daily and the orders was transcribed incorrectly. Resident #364 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Malignant Neoplasm of Left Breast, Hypertension, and Osteoporosis. Review of an Oral Cavity Observation dated 8/24/2023, showed .No natural teeth .edentulous . Review of a Clinical Admission assessment dated [DATE], showed .has dentures .full lower .full upper .no natural teeth .edentulous . Review of an admission MDS assessment dated [DATE], showed Resident #364 was cognitively intact and was edentulous (no natural teeth). During an observation and interview on 3/3/2024 at 11:30 AM, Resident #364 stated she had a broken tooth on her upper teeth and had not experienced any pain, weight loss, or difficulty eating. Further interview showed the tooth was broken prior to admission. Observation showed Resident #364 had natural teeth and had one broken tooth to her front, right upper teeth. During a telephone interview on 3/4/2024 at 3:15 PM, Resident #364's daughter stated the resident's right upper tooth had broken off prior to admission into the facility. Resident #364's daughter stated the resident had not expressed any pain, weight loss, or difficulty eating from the broken tooth. During an interview on 3/4/2024 at 4:10 PM, Certified Nursing Assistant (CNA) #1 stated Resident #364 had her own teeth and did not have dentures. During an interview on 3/4/2024 at 4:15 PM, Licensed Practical Nurse (LPN) #3 stated Resident #364 had her own teeth and did not have dentures. During an interview on 3/5/2024 at 7:50 AM, the MDS Coordinator stated after reviewing the medical record, Resident #364 had her own teeth and did not wear dentures. The MDS Coordinator confirmed the admission Oral Cavity Observation and Clinical Admission assessments dated 8/24/2023 were inaccurate and did not reflect the resident's natural teeth or dental issues (broken tooth) in the medical record. During an interview on 3/5/2024 at 8:50 AM, LPN #4 stated the Oral Cavity Observation and Clinical Admission assessments completed on 8/24/2023 were inaccurate and edentulous with dentures was marked in error. LPN #4 stated Resident #364 did not wear dentures and had her own teeth at the time of admission. 36003

Based on facility contract review, facility policy review, medical record review, and interview, the facility failed to ensure a coordinated plan of care with the hospice provider was available in the medical record for 1 (Resident #60) of 4 residents reviewed for hospice. The findings include: Review of the facility's hospice contract with Resident #60's hospice provider dated 4/11/2018, showed .Plan of Care .the Skilled Nursing Facility shall provide services in accordance with the Hospice plan of care . Resident #60 was admitted to the facility on [DATE] and readmitted from the hospital on 1/22/2024 with diagnoses including Hemiplegia and Hemiparesis following Cerebral Infarction Affecting Right Dominant Side, Complete Traumatic Amputation at Level Between Left Hip and Knee, Asthma, Diabetes Mellitus, Atrial Fibrillation, Hypertension, and Post Traumatic Stress Disorder. Review of the facility's policy titled, Hospice, dated 5/15/2023, showed .policy of this facility to provide and/or arrange for hospice services .A Communication process, including how the communication will be documented between the facility and the hospice provider .ensure that .resident's written plan of care includes. Recent hospice plan of care .the most recent plan of care .description of services provided . Review of the medical record showed Resident #60 was admitted to hospice services on 2/2/2024. Continued review showed there was no hospice plan of care in Resident #60's medical record. Review of the significant change Minimum Data Set (MDS) assessment dated [DATE], showed Resident #60 was cognitively intact and received hospice care. During an interview on 3/3/2024 at 3:22 PM, Licensed Practical Nurse #3 stated Resident #60 received hospice services. LPN #3 stated she was unaware where hospice's documentation and plan of care was located. During an interview on 3/5/2024 at 7:25 AM, LPN #5 stated Resident #60 was a hospice resident. The LPN was unaware how to locate the resident's hospice plan of care. During an interview on 3/5/2024 at 2:40 PM, Registered Nurse (RN) #1 stated hospice documentation and plan of care was located either in the resident's physical chart at the nurse's station or in the electronic medical record. RN #1 confirmed Resident #60's hospice plan of care was not available to view in the physical chart at the nurse's station. During an interview on 3/5/2024 at 3:00 PM, RN #1 confirmed Resident #60's hospice plan of care was not available to view in the electronic medical record. During an interview on 3/5/2024 at 5:10 PM, the Director of Nursing (DON) stated it was her expectation that the hospice provider's plan of care was available in the resident's medical record either in the computerized chart or in their chart at the nurses' station so that facility staff could provide coordinated care with the hospice company and confirmed the resident's hospice plan of care was not available.

Based on facility policy review, medical record review, observation, and interviews the facility failed to develop and implement a person-centered care plan for 2 residents (Resident #364 and #100) of 28 residents reviewed for care plans. The findings include: Review of the facility's policy titled, Person Centered Care Plans, dated 12/18/2023, showed .Person centered plans of care are developed by the interdisciplinary team, to coordinate and communicate care approaches and goals of the resident, consistent with the residents' rights . Resident #364 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Malignant Neoplasm of Left Breast, Hypertension, and Osteoporosis. Review of Resident #364's comprehensive care plan revised 9/4/2023, showed .dental: the resident is edentulous .provide mouth care . Review of an Oral Cavity Observation assessment dated [DATE], showed .No natural teeth .edentulous . Review of a Clinical Admission assessment dated [DATE], showed .has dentures .full lower .full upper .No natural teeth .edentulous . During an observation and interview on 3/3/2024 at 11:30 AM, Resident #364 stated she had a right, upper broken tooth and the tooth had been broken prior to admission. Resident #364 stated she had no dental pain, no difficulty eating, and had no weight loss. Observation showed Resident #364 had natural teeth and had one broken tooth to her front, right upper teeth. During a telephone interview on 3/4/2024 at 3:15 PM, Resident #364's daughter stated the resident's right, upper tooth had broken off prior to admission into the facility. During an interview on 3/4/2024 at 4:10 PM, Certified Nursing Assistant (CNA) #1 stated Resident #364 had her own teeth and did not have dentures. During an interview on 3/4/2024 at 4:15 PM, Licensed Practical Nurse (LPN) #3 stated Resident #364 had her own teeth and did not have dentures. During an interview on 3/5/2024 at 7:50 AM, the MDS Coordinator stated after reviewing the medical record, Resident #364 had natural teeth and did not wear dentures. The MDS Coordinator confirmed the admission comprehensive care plan was not developed to reflect natural teeth or dental issues. 50216 Resident #100 was admitted to the facility on [DATE] with diagnoses including Hemiplegia following a Cerebral Infarction, Aphasia, and Nontraumatic Intracerebral Hemorrhage. Review of an Activities Initial Review assessment dated [DATE], showed Resident #100 had no preference to participate in spiritual activities, and the resident did not wish to have clergy visits. Review of an admission MDS assessment dated [DATE], showed Resident #100 was severely impaired for decision making. Review of Resident #100's comprehensive care plan dated 1/9/2024, showed .spiritual distress .consult clergy as needed .determine resident's religion affiliation .determine spiritual beliefs regarding death .encourage [the] resident to continue to study spiritual beliefs . Review of Resident #100's Activity Attendance Record dated 2/18/2024 thru 3/4/2024, showed the resident had attended a spiritual activity on 2/22/2024 and 2/29/2024. During an observation and family interview on 3/3/2024 at 11:47 AM, Resident #100 was observed in room with a family member at bedside. The family member stated the resident had been unable to speak since her stroke. During the family interview the family member stated the resident did not have an affiliation to any religion and did not want to attend any religious activities. The family member stated they had visited on two occasions and found the resident was attending a church service. The family member had asked the staff not to take the resident to church because they did not have a religious belief. During an interview on 3/4/2024 at 4:00 PM, the Activities Director (AD) and the Memory Care Activities Director (MCAD) stated they were unaware of Resident #100's desire to not attend religious activities. The AD stated that if they had known the resident's preference, the resident would not have been taken to a church service. During an interview on 3/5/2024 at 8:03 AM, the AD stated she did not remember marking the Activities Initial Review assessment for the resident's preference of no spiritual activities and no clergy visits. The AD confirmed Resident #100's care plan had not been developed to address spiritual preferences outlined in the Activities Initial Review assessment. During an interview on 3/5/2024 at 9:06 AM, the Assistant Director of Nursing (ADON) stated she did not know who initiated the Spiritual Distress problem on the care plan. The ADON added the problem was a generic, as needed plan of care to be used in case the resident's spiritual preferences changed. During an interview on 3/5/2024 at 1:59 PM, the Director of Nursing (DON) confirmed the Spiritual Distress care plan problem was not person centered based on the resident's belief and desires.

Based on facility policy review, medical record review, observation and interview, the facility failed to ensure medical information was not visible for 3 residents (#1, #27, and #31) of 122 residents observed and failed to ensure 1 resident (Resident #47) was assisted to the smoking area of 7 residents reviewed for smoking. The findings include: Based on the facility's undated policy titled, Resident Dignity, showed .It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity .All staff members are involved in providing care to residents to promote and maintain resident dignity and respect resident rights .Maintain resident privacy . Review of the facility's undated policy titled, Resident Rights, showed .The resident has a right to reside and receive services in the facility with reasonable accommodation of resident needs . Resident #1 was admitted to the facility on [DATE] with diagnoses including Hemiplegia, Depression, Dementia, Atrial Fibrillation, Anxiety, and Hypertension. Review of Resident #1's quarterly Minimum Data Set (MDS) assessment dated [DATE], showed the resident had moderate cognitive impairment. Review of Resident #1's comprehensive care plan showed no evidence the resident or resident's representative had requested for signage to be posted in the resident's room. During an observation and interview on 3/3/2024 at 11:35 AM, Resident #1 was lying in the bed resting. There was a sign posted above the resident's bed that read, [Resident #1's first and last name] needs to be at 35 to 45 degree angle sitting up at all times!! .Thank You During an observation and interview on 3/4/2024 at 12:40 PM, with Licensed Practical Nurse (LPN) #3, in Resident #1's room, there was a sign posted above the head of Resident #1's bed that read, [Resident #1's first and last name] needs to be at 35 to 45 degree angle sitting up at all times!! .Thank You LPN #3 confirmed the signage was visible to anyone that entered the room. LPN #3 stated the same sign had been posted in .several residents rooms . either because they get short of breath when lying flat or they were at risk for choking. The LPN stated an unknown staff member had posted the sign and confirmed the resident or resident's representative did not request for the signage to be posted. Resident #27 was admitted to the facility on [DATE] with diagnoses including Adult Failure to Thrive, Encounter for Attention to Gastrostomy, Vascular Dementia, Chronic Kidney Disease, Peripheral Vascular Disease, Depression, Hypertension, and Anxiety. Review of Resident #27's quarterly MDS assessment dated [DATE], showed the resident had severe cognitive impairment. Review of Resident #27's comprehensive care plan showed no evidence the resident or resident's representative had requested for signage to be posted in the resident's room. During an observation and interview on 3/3/2024 at 11:39 AM, Resident #27 was lying in the bed. There was a sign posted above the resident's bed that read, [Resident #27's first and last name] needs to be at 35 to 45 degree angle sitting up at all times!! .Thank You During an observation and interview on 3/4/2024 at 12:35 PM, with LPN #3, in Resident #27's room there was a sign posted above the head of Resident #27's bed that read, [Resident #27's first and last name] needs to be at 35 to 45 degree angle sitting up at all times!! .Thank You LPN #3 confirmed the signage was visible to anyone that entered the room. The LPN stated an unknown staff member had posted the sign and confirmed the resident or resident's representative did not request for the signage to be posted. Resident #31 was admitted to the facility on [DATE] with diagnoses including Hemiplegia and Hemiparesis following Cerebral Disease, Chronic Obstructive Pulmonary Disease, Vascular Dementia, and Dysphagia. Review of Resident #31's quarterly MDS assessment dated [DATE], showed the resident had moderate cognitive impairment. Review of Resident #31's comprehensive care plan showed no evidence the resident or resident's representative had requested for signage to be posted in the resident's room. During an observation and interview on 3/3/2024 at 11:39 AM, Resident #31 was lying in the bed resting. There was a sign posted above the resident's bed that read, [Resident #31's first and last name] needs to be at 35 to 45 degree angle sitting up at all times!! .Thank You Resident #31 stated he had not asked for the sign to be posted and was unaware why the sign was posted. During an observation and interview on 3/4/2024 at 12:24 PM, with LPN #3, in Resident #31's room there was a sign posted above the head of Resident #31's bed that read, [Resident #31's first and last name] needs to be at 35 to 45 degree angle sitting up at all times!! .Thank You The LPN stated an unknown staff member had posted the sign and confirmed the resident or resident's representative did not request for the signage to be posted. During an interview on 3/4/2024 at 3:12 PM, the Director of Nursing (DON) confirmed signage was not to be posted in resident rooms to communicate resident care needs and confirmed signage posted in resident rooms was a dignity concern. The DON stated .we discovered the signs yesterday when surveyors started asking about the signs posted and all signs were removed from the building . The DON stated she was unaware who posted the signage. The DON stated if the resident or resident representative had requested the signage to be posted, it would be documented in the resident's care plan. The DON confirmed the residents' care plans did not reflect that the residents or resident representatives had requested the posted signs. Resident care needs were to be communicated to staff on the care plan and Certified Nursing Assistant (CNA) task sheet. Resident #47 was admitted to the facility on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease, Symptoms and Signs involving Cognitive Functions and Awareness, Protein Calorie Malnutrition, Type 2 Diabetes, Dementia/Moderate without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, Mood Disorder, and Anxiety. Review of Resident #47's comprehensive care plan dated 11/16/2023, showed .ADL [Activity of Daily Living] .MOBILITY .The resident has an ADL self-care performance deficit r/t [related to] impaired mobility .Encourage the resident to participate to the fullest extent possible with each interaction .Resident wishes to smoke and is designated as supervised smoker . Review of Resident #47's Smoking and Safety assessment dated [DATE], showed Resident #47 was safe to smoke with no safety concerns documented. Review of Resident #47's quarterly MDS assessment dated [DATE], showed the resident had moderate cognitive impairment. Further review showed the resident had a diagnosis of Non-Alzheimer's Dementia and had no impairment of the upper and lower extremities. During an interview on 3/3/2024 at 10:45 AM, Resident #47 stated he smoked and Certified Nursing Assistant (CNA) #1 refused to roll him to the smoking area (unable to give dates but stated it had happened multiple times). The resident also stated he was aware of the facility's scheduled smoke breaks and he had not missed a time he wanted to smoke due to CNA #1 not assisting him. During an interview on 3/3/2024 at 10:55 AM, CNA #1 stated she was aware Resident #47 smoked. The CNA also stated the resident was able to propel himself to the smoking area in the wheelchair. The resident had requested the CNA to assist him to the smoking area at times (unsure of the exact dates) and .management said if they [residents] was unable to propel to the smoking area on their [residents] own, they couldn't hold a cigarette .it was a safety concern . Continued interview showed CNA #1 was informed by Licensed Practical Nurse (LPN) #1 on 3/2/2024, if a resident was unable to propel themself to the smoking area, the staff were not to assist them, as this was a safety issue and the facility policy. During an interview on 3/3/2024 at 11:10 AM, LPN #1 stated Resident #47 smoked, staff assisted the resident into the wheelchair and the resident propelled himself to the smoking area. The LPN stated it was the facility's policy if a resident smoked, was unable to propel themselves to the smoking area, staff were not to assist the resident, it was a safety concern. LPN #1 was unable to verbalize what the safety concerns were. Resident #47 had not reported concerns of staff refusing to assist him to the smoking area. LPN #1 stated she had informed CNA #1 of the facility's smoking policy. During an observation on 3/3/2024 at 12:25 PM, Resident #47 was in the hallway and requested CNA #1 to assist him to the smoking area. The CNA informed the resident she was unable to assist him, the resident asked why, and the CNA responded .management said if you can't take yourself, you are not safe to smoke . Resident #47 informed the CNA he wanted to speak to management, CNA #1 informed the resident she would assist him to the smoking area this time and would talk to management about the rules. During an interview on 3/3/2024 at 12:29 PM, the Administrator and Director of Nursing (DON) stated when a resident wanted to smoke, was unable to propel themselves to the smoking area, it was their expectation for the resident to be assisted by staff. During an interview on 3/3/2024 at 5:17 PM, Resident #47 stated he had not informed anyone at the facility which included the Administration staff when CNA #1 would not assist him to the smoking area. During an interview on 3/4/2024 at 10:18 AM, the Social Worker stated Resident #47 had not complained of staff not assisting him to the smoking area. 49568 38810

Based on facility policy review, review of the Resident Assessment Instrument (RAI) Manual 3.0, medical record review, observations, and interviews, the facility failed to accurately complete a Minimum Data Set (MDS) assessment for 2 residents (Residents #364 and #1) of 28 residents reviewed for MDS assessments. The findings include: Review of the Resident Assessment Instrument (RAI) Manual dated 10/2023 showed .The RAI process has multiple regulatory requirements .the assessment accurately reflects the resident's status .a registered nurse conducts or coordinates each assessment with the appropriate participation of health professionals .one of the most important functions .accurate picture of the resident's current health status .active diagnoses in the last 7 days .do not include conditions that have been resolved . Review of the facility's policy titled, Nursing Assessments, dated 12/18/2023, showed .the facility conducts a comprehensive .assessment of each resident functional capacity .based on the resident status .goals .preferences .information in the medication record, as documented by nursing personnel aids in the development of accurate plan . Resident #364 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Malignant Neoplasm of Left Breast, Hypertension, and Osteoporosis. Review of an admission MDS assessment dated [DATE], showed Resident #364 was cognitively intact and was edentulous (no natural teeth). Review of an Oral Cavity Observation assessment dated [DATE], showed .No natural teeth .edentulous . Review of a Clinical Admission assessment dated [DATE], showed .has dentures .full lower .full upper .no natural teeth .edentulous . Review of Resident #364's comprehensive care plan revised 9/4/2023, showed .dental: the resident is edentulous .provide mouth care . Review of a quarterly MDS assessment dated [DATE], showed Resident #364 had moderate cognitive impairment, had no presence of pain, had no weight loss, and had no marked entries for dental status. During an observation and interview on 3/3/2024 at 11:30 AM, Resident #364 stated she had one broken tooth to her front, right upper teeth and the tooth was broken prior to admission. Resident #364 stated she had no pain, no difficulty eating, and had no weight loss. Observation showed Resident #364 had natural teeth and had one broken tooth to her front, right upper teeth. During a telephone interview on 3/4/2024 at 3:15 PM, Resident #364's daughter stated the resident's right upper tooth had broken off prior to admission. Further interview showed the resident had not expressed any pain, weight loss, or difficulty eating from the broken tooth. During an interview on 3/4/2024 at 4:10 PM, Certified Nursing Assistant (CNA) #1 stated Resident #364 had her own teeth and did not have dentures. During an interview on 3/4/2024 at 4:15 PM, Licensed Practical Nurse (LPN) #3 stated Resident #364 had her own teeth and did not have dentures. During an interview on 3/5/2024 at 7:50 AM, the MDS Coordinator stated after reviewing the medical record, Resident #364 had natural teeth and did not wear dentures. The MDS Coordinator confirmed the admission Oral Cavity Observation and Clinical Admission assessments dated 8/24/2023 were inaccurate, the MDS assessment dated [DATE] was not accurate, and the quarterly MDS assessment dated [DATE] did not reflect Resident #364's natural teeth or dental issues. 49568 Resident #1 was admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including Hemiplegia, Asthma, Depression, Dementia, Atrial Fibrillation, Hypertension, and Peripheral Vascular Disease. Review of a quarterly MDS assessment dated [DATE], showed Resident #1 had an active diagnosis of Septicemia (infection of the bloodstream). During an interview on 3/3/2024 at 12:30 PM, LPN #3 stated Resident #1 was not receiving antibiotics for Septicemia. During an interview on 3/4/2024 at 10:30 AM, the MDS Coordinator stated Resident #1 was inaccurately coded on the MDS dated [DATE] for the active Septicemia diagnosis. During an interview on 3/4/2024 at 3:20 PM, the DON stated Resident #1 had not been treated for Septicemia. The DON reviewed the resident's medical record and stated the resident had not been treated for Septicemia in the 7 day look back period for the MDS dated [DATE]. The DON confirmed Resident #1's MDS assessment dated [DATE] had been coded inaccurately for Septicemia. During an interview on 3/5/2024 at 2:00 PM, the MDS Coordinator stated that Resident #1 did not have an active diagnosis for Septicemia in the 7 day look back period for the MDS assessment dated [DATE]. The MDS Coordinator confirmed Resident #1's MDS assessment dated [DATE] was inaccurate and the expectation was the MDS assessment would be coded accurately based upon the RAI manual.

Based on facility policy review, medical record review, observations, and interviews the facility failed to assist 4 residents (Residents #20, #75, #614, and #39) with hand hygiene before meals on 1 of 5 hallways observed for meal service. The findings include: Review of the facility's policy titled, Nursing Procedures Manual, dated 6/1/2023, showed .Basic Care Procedures .Serving a Meal .Prepare .serving area for mealtime and make sure hands .are clean . Resident #20 was admitted to the facility on [DATE] with diagnoses including Parkinsonism, Chronic Obstructive Pulmonary Disease, and Anxiety Disorder. Review of a quarterly Minimum Data (MDS) assessment dated [DATE], showed Resident #20 had moderate cognitive impairment. During an observation on 3/3/2024 at 12:02 PM, Resident #20 was served the lunch meal and staff did not offer or assist the resident with hand hygiene. Resident # 75 was admitted to the facility on [DATE] with diagnoses including Type 2 Diabetes, Chronic Kidney Disease, and Anxiety Disorder. Review of a quarterly MDS assessment dated [DATE], showed Resident #75 was cognitively intact. During an observation on 3/3/2024 at 12:05 PM, Resident #75 was served the lunch meal and staff did not offer or assist the resident with hand hygiene. Resident #614 was admitted to the facility on [DATE] with diagnoses including Type 2 Diabetes, Hypothyroidism, and Hypertension. Review of a 5-day MDS assessment dated [DATE], showed Resident #614 was cognitively intact. During an observation on 3/3/2024 at 12:08 PM, Resident #614 was served the lunch meal and staff did not offer or assist the resident with hand hygiene. Resident #39 was admitted to the facility on [DATE] with diagnoses including Type 2 Diabetes, Vascular Dementia, Delusional Disorders, and Hypertension. Review of a quarterly MDS assessment dated [DATE], showed Resident #39 had moderate cognitive impairment. During an observation on 3/3/2024 at 12:10 PM, Resident #39 was served the lunch meal and staff did not offer or assist the resident with hand hygiene. During an observation of the 200 hallway lunch meal tray distribution on 3/3/2024, showed the Social Services Assistant, Director of Social Services, and Certified Nursing Assistant (CNA) #1 distributing resident meal trays. During an interview on 3/3/2024 at 12:13 PM, the Social Service Assistant stated she had not offered or assisted residents with hand hygiene prior to the meal. During an interview on 3/3/2024 at 12:16 PM, the Director of Social Services stated she had not offered or assisted residents with hand hygiene prior to the meal. During an interview on 3/4/2024 at 8:20 AM, CNA #1 stated she was not aware hand hygiene was to be offered to the residents prior to meal service. The CNA also stated she was aware to offer hygiene now and offered or assisted residents with hand hygiene this morning. During an interview on 3/5/2024 at 4:32 PM, the Director of Nursing stated it was her expectation for residents to be offered or assisted with hand hygiene prior to meals.

Based on facility policy review, medical record review, review of the facility investigation and interview, the facility failed to ensure facility staff did not assume the possession and control of a resident's personal property, for 1 resident (Resident #3) of 5 residents reviewed. The findings include: Review of the facility employee handbook, undated, titled [NAME] MANOR ASSOCIATE HANDBOOK showed .The policies in this handbook are to be considered guidelines .Personal Property of the Residents .Only your immediate Supervisor, Director of Nursing or Administrator may assume, even temporarily, the possession or control of resident's personal property, and then only for the purpose of putting it in a safe place and issuing receipts . Resident #3 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Schizophrenia, Chronic Obstructive Pulmonary Disease and Chronic Kidney Disease. Review of the quarterly Minimum Data Set (MDS) assessment. dated 9/25/2023, showed Resident #3's Brief Interview of Mental Status (BIMS) score was 9, indicating the resident had moderate cognitive impairment. The resident required assistance of 1 or more persons with activities of daily living (ADL's). Review of a facility investigation showed on 5/8/2023 at 6:30 AM, Resident #3 alleged he asked a Nurse Assistant (NA) #1 to take his Automated Teller Machine (ATM) card to the ATM machine and get money out for him. NA #1 took the ATM card and withdrew money. Review of the written statement NA #1 provided for the investigation, undated, showed .End of shift Sat [Saturday 5/6/2023] took card [ATM card] & he [Resident #3] asked to go get cash pull out as much as I could he told me to go to shelle [Shell gas station] 500 x 2 [$500 dollars times 2 transactions] He gave me his pin-came back to work it was 20 dollar Bills He counted it . Review of measures taken in response to NA #1's actions showed she was terminated for not following facility policy, by taking the resident's debit card and withdrawing money. During an interview on 11/9/2023 at 9:40 AM, the Director of Nursing (DON) stated .I talked to him [Resident #3] and he said 'yes I gave her [NA #1] my card' .she [ NA #1] did say 'I took the card and went to the shell station' and she said 'he told me to get as much as I could' and she took out 500 twice because that was all she could take out at a time and she said she gave it all to him with the receipts wrapped around it .she was let go because she took the card and .if a resident tries to give them anything of value they are to take it and turn it in to inform their supervisor or the DON or the administrator .it's our policy .

Based on medical record review, observation, and interview the facility failed to ensure one resident (#228) received the required nutrition to maintain an acceptable body weight of thirty-five residents reviewed. The facility's failure resulted in harm to resident # 228. The findings included: Resident #228 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the admission History and Physical (H&P) on August 13, 2013, revealed the resident had fallen at home in August 2013 and sustained a SDH. Review of the H&P revealed "...is high risk for aspiration and pneumonia with cloudy sensorium." Medical record review of the Minimum Data Sets (MDS) dated [DATE] and 23, 2013, revealed a Brief Mental Status score of 11, indicating moderate cognitive impairment, and was total dependence on staff for assistance with eating and drinking. Medical record review of the speech therapist Discharge Report dated September 7, 2013, revealed, "Patient is tolerating current diet of puree/thin liquids well with no overt signs or symptoms of distress...Patient is to remain on puree at this time due to optimal safety...Patient scored a 172/200 at this time indicating a mild dysphagia and aspiration risk on puree/thin consistency." Observation on September 23, 2013, at 12:45 p.m., in resident #228's room revealed the resident remained upright in bed, had a three compartment plate of pureed food on the lunch tray, with soupy pureed beans in one section of the plate. Continued observation revealed the resident ate several bites of creamed potatoes, but none of the pureed beans. Continued observation revealed a carton of whole milk, a green-colored pudding, and a "Magic Cup" (frozen protein supplement) were included on the tray. Observation revealed a family member seated at the resident's bedside. During observation, the family member volunteered... visited "several times each week" and stated "understand (the resident) supposed to be helped when eating...I've never seen anyone help...won't eat those (referring to the Magic Cup)...". Continued observation revealed no facility staff in the room offering assistance to the resident. Review of the Food Intake Record for September 23, 2013, revealed the resident took 25% of the observed lunch. Review of the resident's August and September 2013 Vital Signs and Weight Record revealed the following: August 9 - 156 pounds (on admission); August 10 - 154 pounds; August 17 - 145 pounds (a 7% weight loss); September 15 - 140 pounds (a10.2% weight loss); and September 22 - 140 pounds. Review of the Nurse Practitioner's Resident Encounter Sheet dated August 23, 2013, revealed "...Abnormal Physical Exam Findings: eats 25% maybe of meals. Has lost 11 pounds in 8 days...will add House supplements and [MEDICATION NAME]" (a liquid supplement used to promote appetite). Review of the Care Plan dated August 15, 2013, revealed the problems of "Alteration in Nutrition...Unable to feed self." Review of the care plan revealed a goal was set for "Adequate Nutritional Intake and No Significant Weight Changes." Continued review revealed the approaches to address the problems included "...Dietician to evaluate and offer intervention; encourage resident to consume 75-100% of each meal...offer substitutes if resident refuses food items...feed resident at all times..." Continued review of the care plan revealed a new problem was added by the Dietary Manager on August 26, 2013, "sig wt (significant weight) changes/unable to feed self." Medical record review of the Dietary Progress Notes dated August 26, 2013, revealed "...DON (Director of Nurses) informed on August 23, 2013, of resident's weight loss...Staff documents some self feeding and at other times resident requiring feeding assistance...Magic Cup added to meal tray at lunch and supper..." Record review of the Nutritional Assessment Recommendations dated September 11, 2013, revealed "...continued weight loss...d/c (discontinue) [MEDICATION NAME] (a drug used to stimulate appetite) 25 mg BID (twice a day)...request [MEDICATION NAME] (a lab test to help evaluate nutritional status)..." Review of the Food Intake Record revealed from September 1, 2013, through September 21, 2013, the resident had refused twenty meals, breakfast five times, lunch five times, and supper 10 times with an average meal intake of 30% intake. Record review of the Daily Skilled Nurses Notes for the same period, from September 1-21, 2013, did not reflect the resident was offered an alternative when a meal was refused. Interview and review of the resident's kardex with the Nurse Supervisor at the 400-500 hall nursing station at 8:40 a.m., on September 24, 2013, revealed the kardex indicated the resident was a "feed." Interview continued and the Nurse Supervisor confirmed the resident's bedside nursing staff could refer to the kardex to know how to assist the resident at meals. Interview with the Registered Dietician (RD) on September 24, 2013, at 9:00 a.m., at the 400-500 hall nursing station, verified the RD meets with the Dietary Manager during weekly meetings each Wednesday and reviewed residents with weight loss. Interview revealed "sometimes someone from nursing is there...we don't have an official group that meets to address weight loss." Interview with the Dietary Manager on September 24, 2013, at 1:40 p.m., at the 400-500 hall nursing station, comfirmed the resident had been reviewed for continued weight loss during the August 26?, 2013, and September 11, 2013, meetings with the RD. Continued interview revealed the resident's physician orders [REDACTED]. Interview confirmed the resident was now below the ideal body weight by eight pounds. Interview confirmed the Dietary Manager had continued to request the resident be fed as restated on the August 26, 2013, Care Plan update, "sig (significant) wt (weight) changes, unable to feed self" Continued interview revealed the Dietary Manager was not aware the resident did not like the "Magic Cups" that were being sent with each lunch and supper tray. Interview with the Nurse Supervisor at 2:30 p.m., on September 24, 2013, in the conference room, confirmed the Nurse Supervisor was "unsure" of what happened to the dietary recommendations received from the Dietary Manager and RD. Continued interview revealed the Nurse Supervisor was responsible to convey the recommendations to the physician or the nurse practitioners. Further interview confirmed the nursing staff had not been following the Care Plan to feed the resident and had been setting up the tray in the room to feed self. Interview and review with the Nurse Supervisor at 3:30 p.m., on September 24, 2013, in the conference room, of the Food Intake Record for August 2013, and September 2013, confirmed the following: from August 22 to the present time, the nursing staff had not been following the care plan to feed the resident as documented on the Daily Skilled Nurse's Notes, the resident had meal trays set-up in the resident's room; the resident had refused more meals in September than August; and the resident had consumed less of all meals, especially the breakfast meal in September. Interview continued and the Nurse Supervisor confirmed the licensed nursing staff had not reviewed the way the resident was currently receiving meals with the Certified Nurse Aides (CNA's), the Dietary Manager, or the Speech Therapist. Interview on September 25, 2013, at 10:40 a.m., in the foyer area adjacent to the main dining room, with the Nurse Practitioner (NP) confirmed the dietary recommendations submitted to the nursing staff by the RD and the Dietary Manager on September 11, 2013, were not received by the NP and no orders were written to change the appetite stimulant [MEDICATION NAME] to [MEDICATION NAME] or for a laboratory test to measure the resident's pre-[MEDICATION NAME]. Interview with the Medical Director and the DON at 12:45 p.m., on September 25, 2013, in the Medical Director's office, revealed the physician had not seen the resident since the initial admission evaluation on August 10, 2013. Interview verified the physician had not been notified of the resident's weight loss or the RD's recommendations. Continued interview confirmed the professional nursing staff had not met as a group to discuss the resident's weight loss, and nursing had not met with the family, the Dietary Manager, the RD, or the Speech Therapist to address the resident's continued weight loss. .

Based on medical record review, observation and interview, the facility failed to ensure one resident (#3) with a fractured ankle was seen by the orthopedic physician of five residents reviewed. The facility's failure to ensure the resident was evaluated by an orthopedic physician resulted in more difficult surgical procedures and complications of infection and wound healing as a direct result of a delay in treatment for [REDACTED]. The findings included: Resident #3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated dated [DATE], revealed the resident had moderately impaired decision-making skills; required extensive assistance with bed mobility and assistance with transfers; was totally dependent on staff for dressing, toileting, hygiene and bathing; had no impairments of range of motion and had no pain. Medical record review of a nurse's note dated November 8, 2010, at 10:00 a.m., revealed, "Resident found in floor in front of w/c (wheelchair) in floor. [MEDICAL CONDITION] activity noted. Resident shaking & jerking uncontrollably. Unable to obtain accurate vital signs...NP (Nurse Practitioner) notified...transport to ER (emergency room ) for eval (evaluation)..." Medical record review of a nurse's note dated November 8, 2010, revealed, "...will be transported back (to facility with no) new orders..." Continued medical record review revealed no documentation of the time the resident returned to the facility on [DATE]. Medical record review a of a nurse's note dated November 9, 2010, at 3:15 p.m., revealed, "X-ray done on (L) (left) foot...NP notified of results. Order to wrap...ace bandage and schedule appt (appointment) with (orthopedic physician) ASAP (as soon as possible)...Foot wrapped (with) ace bandage." Medical record review of an X-ray report dated November 9, 2010, revealed, "...Acute nondisplaced oblique (diagonal) fracture of distal fibula (outer bone of the leg)...moderate lateral soft tissue swelling...Mild [MEDICAL CONDITIONS]" Medical record review of a nurses' notes dated November 10, 2010, revealed the resident complained of pain in the left ankle. The Nurse Practitioner was notified and ordered the resident sent back to the hospital. The resident was transported back to the hospital emergency roiagnom on [DATE], at 10:05 a.m. Review of a hospital x-ray report dated November 10, 2010, revealed, "...Mildly displaced..." [MEDICAL CONDITION] ankle. Medical record review of a hospital physician's orders [REDACTED]." Medical record review of a nurse's note dated November 10, 2010, (no time recorded) revealed the resident was returned to the facility with a "...walker boot on left lower extremity...NWB LLE (non-weight bearing left lower extremity)..." Medical record review of nurses' notes dated November 10, 2010-January 20, 2011, revealed no documentation the resident was seen by the orthopedic physician as ordered on November 10, 2010. Medical record review of a NP note dated January 20, 2011, revealed, "...F/U (follow up)...resident (with) nondisplaced fx of left distal fibula...was fitted (with) a boot in ER and has worn it since 11/9/10...missed appt (appointment) (with) orthopod (orthopedic physician). Will reassess...(L) foot is fully rotational (without) [MEDICAL CONDITION] redness or pain..." Medical record review of a physician's orders [REDACTED]. Medical record review of an x-ray report dated January 20, 2011, revealed, "...Acute moderately displaced fracture of distal fibula and medial malleolus (lower end of the inner leg bone) with disruption of ankle mortise (joint)...Moderate lateral soft tissue swelling..." Medical record review of a nurse's note dated January 21, 2011, revealed the orthopedic physician was not able to see the resident in the physician's office, and the resident was transferred to the hospital on January 21, 2011. Review of a hospital physician's progress note dated January 21, 2011, revealed, "...fell [DATE] injuring (L) ankle. Had nondisplced fx then-was splinted & (and) sent back to (nursing home)...did not f/u (with) orthopedic surgeon (after) injury. Sent here today (with) ankle dislocated..." Review of a hospital postoperative progress note by the orthopedic surgeon dated January 22, 2011, revealed, "Preoperative Diagnosis: [REDACTED]. Review of a hospital Discharge Summary dated January 24, 2011, revealed, "...The patient was admitted to the emergency room with chronically dislocated left ankle and non-united trimalleolar fracture...taken to operating room on 01/22/2011. At that time after mobilization...was felt that trying to proceed with an open reduction internal fixation bit more or less futile effort...for that reason, we elected to proceed with arthrodesis. Postoperatively...course was relatively uneventful...did ooze a good bit from...ankle in the postoperative period...By postop (postoperative) day #2...medically stable and was felt...was ready for discharge back to (nursing home)...cast was changed prior to discharge...will follow up in the office in about a week and half..." Review of the orthopedic surgeon's office note dated February 3, 2011, revealed, "Almost 2 weeks s/p (after) arthrodesis of...left ankle for nonunited chronically dislocated trimalleolar ankle fracture...says...hasn't walked since...left hospital...still had drainage from both sides of the ankle from both wounds...nothing to suggest an infection...Replaced the short leg cast...will return in a week for suture removal..." Review of the orthopedic surgeon's office note dated February 10, 2011, revealed, "...removed the cast today...lateral wound has dehisced (burst open)...medial wound has stopped draining...removed sutures from the medial side...reasonable to go ahead and wash out the lateral wound and maybe wound vac (vacuum) it to try and avoid a chronic infection...was admitted to (hospital)..." Review of a hospital history and physical dated February 10, 2011, revealed, "...3 weeks status [REDACTED]. Review of a hospital operative report dated February 11, 2011, revealed, "...Wound dehiscence, left ankle...irrigation of the left ankle and application of a [DEVICE] of all devitalized soft tissues. All the sutures were removed...Wound VAC was then cut to fit the wound and applied in the usual fashion. Once it was certain that it was working...was placed in anterior-posterior plaster splints..." Review of a hospital consultation by an infectious disease physician dated February 16, 2011, revealed, "...presenting with left ankle pain...nondisplaced left ankle fracture to which...was seen and a restraining boot was applied...patient then subsequently fell between the cracks as...had not had any followup to monitor...fracture recovery...led to the patient being reassessed and therefore undergoing on the 22nd January 2011, for neglected trimalleolar fracture with dislocation on the left ankle to an actual arthrodesis...at this point (February 16, 2011) I would recommend...PICC (Peripherally Inserted Central Catheter) line that is dual port should be inserted such that the patient will be continued on defepime (antibiotic) using the operative day as day #1, which was the 11th of February...stop date will be estimated as March 9th at 2 g (grams) every 12 hours with a 1-hour infusion for each dose coupled with the reinitiation of [MEDICATION NAME](antibiotic)...until the 9th of March 2011..." Review of the orthopedic surgeon's office note dated March 17, 2011, revealed, "...medial wound has an eschar (dead tissue) over it but there is no drainage...healing well. The lateral wound is almost closed...still a couple of areas of granulation, nothing to suggest infection...Neglected [MEDICAL CONDITION] ankle...wound dehiscence post-operatively with acute osteo[DIAGNOSES REDACTED] of the fibula...placed...in a cast...back in 2 weeks out of plaster to check...wound..." Review of the orthopedic surgeon's office note dated April 19, 2011, revealed, "Three months s/p arthrodesis of the left ankle...Neglected fracture, left ankle, s/p arthrodesis...Wound dehiscence postoperative for acute osteo[DIAGNOSES REDACTED] (inflammation of the bone) of the fibula...hardware has backed out a little bit which was present last month and there is still a gap at the arthrodesis site so...not convinced this had healed...placed...back in a short leg cast...will remain partial weightbearing...will follow-up here in one month with x-rays of the ankle out of plaster...still a lucency at the arthrodesis site which suggests this probably has not healed..." Observation on May 3, 2011, at 8:40 a.m., with Licensed Practical Nurse (LPN #1) revealed the resident lying in bed with a cast on the left ankle extending to just below the knee. Observation revealed the toes were normal in color, and the skin was dry. Observation revealed the resident was awake and alert but with nonsensical communication. Medical record review and interview in the conference room on May 2, 2011, at 2:35 p.m., with LPN #1 confirmed an x-ray dated November 9, 2010, revealed an acute [MEDICAL CONDITION] ankle. Continued interview with LPN #1 confirmed the physician's orders [REDACTED]. Continued medical record review and interview with LPN #1 confirmed the resident was not evaluated by an orthopedic physician until January 21, 2011, (two and one-half months after the fracture occurred). Medical record review and interview in the conference room on May 2, 2011, at 3:15 p.m., with the Director of Nursing confirmed the facility failed to follow the physician's orders [REDACTED]. Telephone interview on May 3, 2011, at 9:00 a.m., with the orthopedic surgeon confirmed surgery to repair the displaced [MEDICAL CONDITION] ankle was delayed because the facility failed to ensure the resident was evaluated by the orthopedic physician after the fracture occurred. Continued interview with the orthopedic surgeon confirmed the surgical procedure was more difficult resulting in more complications due to the delay in treatment of [REDACTED]. Interview in the conference room on May 3, 2011, at 9:05 a.m., with the Medical Director confirmed the facility failed to ensure the resident had the follow-up appointment as ordered on November 10, 2010, resulting in a delay of treatment by the orthopedic surgeon. C/O #