Every finding on record at Kern River Transitional Care

Based on interview and record review, the facility failed to notify the family and physician of a change in condition for one of two sampled residents (Resident 1). This failure had the potential for delay in care, untreated, and worsening of skin condition. Findings:During a concurrent interview and record review on 4/29/26 at 4:04 p.m. with Director of Nursing (DON), DON reviewed Resident 1's SBAR (Situation, Background, Appearance, Review and Notify) Communication Form, dated 2/24/26, the SBAR indicated, Resident [1] was noted in the AM [morning] with small raised bumps on scalp close to ear on both sides of head. Pink/red, small lump under skin, pea size, slightly tender when pushed on.During a review of Resident 1's Progress Notes (PN), dated 2/27/26, the PN indicated, Resident [1] on to continue monitoring for red bumps, to head, does not seem in pain, no face grimacing noted, no moaning of pain noted. Red bumps still present.During an interview on 4/29/26 at 4:04 p.m. with DON, DON stated she was unable to find documentation of physician was notified of the continuous red bumps still present. DON stated, It (red bumps) should have been followed up with MD [Medical Doctor/Physician].During a review of the facility's policy and procedure (P&P) titled, Change in a Resident's Condition or Status, dated November 2015, the P&P indicated, 1. The Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician or On-Call physician when there has been: d. A significant change in resident's physical/mental condition. 2. A significant change of condition is a decline or improvement in the resident's status that: a. Will not normally resolve without intervention by staff or by implementing standard disease-related clinical interventions (not self-limiting).

Based on interview and record review, the facility failed to implement a care plan for one of two sampled residents (Resident 1). This failure resulted in Resident 1 not receiving treatment and potential for worsening skin condition.Findings:During a review of Resident 1's SBAR (Situation, Background, Appearance, Review, and Notify) Communication Form, dated 2/24/26, the SBAR indicated, Resident [1] was noted in AM [morning] with small, raised bumps on scalp close to ear on both sides of head. Pink/red, small lump under the skin, pea size, slightly tender when pushed on.During a review of Resident 1's Treatment Administration Record (TAR), dated February and March 2026, the TAR indicated there was no documentation of treatment for Resident 1's red bumps on scalp. During a concurrent interview and record review on 4/29/26 at 4:04 p.m. with Director of Nursing (DON), DON reviewed Resident 1's Care Plan (CP), dated 2/24/26, the CP indicated, [Resident 1] has small, raised bumps to scalp close to ears and is at risk for infection, worsening, and pain or discomfort. Intervention: Moisturize dry and flaky skin to rehydrate skin. DON stated there was no documentation of moisturizing of Resident 1's dry and flaky skin. DON stated the care plan was not followed/implemented.During a review of the facility's policy and procedure (P&P) titled, Care Plans-Comprehensive, dated September 2010, the P&P indicated, Care plan interventions are designed after careful consideration of the relationship between the resident's problem areas and their causes. When possible, interventions address the underlying source(s) of the problem area(s), rather than addressing only symptoms or triggers.

Based on interview and record review, the facility failed to ensure vital documents were provided in primary language for one of three sampled residents (Resident 2). This failure had the potential for Resident 2 to not understand the provided vital information.Findings:During a review of Resident 2's admission Record, (AR) the AR indicated, Resident 2's primary language was Spanish. During a review of Resident 2's Social History Assessment, ([NAME]) dated 4/27/25, the [NAME] indicated Resident 2's preferred language was Spanish.During a concurrent interview and record review, on 7/16/25 at 4:17 p.m. with Admissions Coordinator (AC), AC stated the facility does not have an Admissions Agreement in Spanish. Resident 2's Admissions Agreement, dated 5/6/25 was reviewed. AC confirmed Resident 2's Admissions Agreement was in English. During a concurrent interview and record review, on 728/25 at 10:22 a.m. with Director of Nursing (DON), Resident 2's [NAME] and Hospital Record, (HR) dated 6/5/25, was reviewed. The HR indicated Resident 2's primary language was Spanish and required an interpreter. DON stated the vital documents should have been provided in Resident 2's primary language which is Spanish.During a review of the facility's policy and procedure (P&P) titled, Translation and/or Interpretation of Facility Services, revised November 2020, the P&P indicated, This facility's language access program will ensure that individuals with limited English proficiency (LEP) shall have meaningful access to information and services provided by the facility. 1. In general, the types of language access services provided by this facility shall be determined by the following factors: . c. The nature and/or importance of the information or service that needs to be conveyed; and . 4. All LEP persons shall receive a written notice in their primary language of their rights to obtain competent oral translation services free of charge. If written notice is not possible, such notice shall be given orally. 7. Written translation of vital information is available in the following languages at this time: . 8. Vital information includes the following: a. Eligibility for services or benefits (including language access); b. admission information (including financial responsibility); c. Advance directives; d. Resident rights; e. Authorization for use or disclosure of protected health information; f. Consent for treatment g. Denial, loss, or decreases in Medicaid or Medicare benefits; h. Social services information; and i. Notice of pending discharge and discharge instructions. 10. When written translation of vital information is unavailable, or impractical (i.e., an infrequently encountered language), the facility shall attempt to provide oral translation of vital documents. 13. Family members and friends shall not be relied upon to provide interpretation services for the resident, unless explicitly requested by the resident. 14. It is understood that providing meaningful access to services provided by this facility requires also that the LEP resident's needs and questions are accurately communicated to the staff. Oral interpretation services therefore include interpretation from the LEP resident's primary language back to English.

Based on observation, interview, and record review, the facility failed to ensure physician's orders were followed when:1. Oxygen was not administered as prescribed by the physician for one of three sampled residents (Resident 1).2. Medications were not administered timely for one of three sampled residents (Resident 4). 3. Medications were not administered for one of three sampled residents (Resident 4).These failures had the potential for Resident 1 and Resident 4 to suffer adverse outcomes.Findings:1. During a concurrent observation and interview, on 7/16/25 at 11:43 a.m. in Resident 1's room, Resident 1 was observed wearing a nasal canula and her oxygen was set at 4 liters per minute. During a review of Resident 1 O2 (oxygen) @ (at) 3 LPM (liters per minute) Via Nasal Cannula (thin flexible tube that gives additional oxygen through the nose) Per Concentrator Continuous every Shift . Order Date 07/07/2025 Start Date 07/07/2025During a concurrent observation, interview, and record review, on 7/16/25 at 11:57 a.m. in Resident 1's room, with Licensed Vocational Nurse (LVN) LVN 1, stated he was checking resident on continuous oxygen once a shift to ensure they were at the correct setting. LVN 1 confirmed Resident 1's oxygen was set at 4 liters per minute. Resident 1's physician's orders were reviewed. LVN 1 confirmed Resident 1's oxygen order was for 3 liters per minute.During an interview on 7/16/25 at 4:30 p.m. with Director of Nursing (DON), DON stated the nurse is the person who can initiate oxygen. DON stated the nurses were supposed to do walking rounds and check the flow rate was at the prescribed level. During a review of the facility's policy and procedure (P&P) titled, Oxygen Administration, the P&P indicated, The purpose of this procedure is to provide guidelines for safe oxygen administration. Preparation 1. Verify that there is a physician's order for this procedure. Review the physician's order .1. Adjust the oxygen delivery device so that it is comfortable for the resident and the proper flow of oxygen is being administered.2. During a concurrent interview and record review on 7/28/25 at 2:54 p.m. with DON, Resident 4's Medication Administration Record, (MAR) dated July 2025 was reviewed. DON confirmed the following:Insulin Glargine Solution (long-acting medication used to treat high blood sugar) 100 UNIT/ML (milliliter- unit of measure) inject10 units subcutaneously (the passage of medications beneath the skin) at bedtime for type 2 DM (diabetes mellitus- a long-term condition in which the body has trouble controlling blood sugar and using it for energy) -Start Date-5/31/2025 2100 (9 p.m.) -D/C (discontinue) Date- 07/25/2025 2055 (8:55 p.m.)The MAR indicated, on 7/1/25 for the 9 p.m. administration time, Resident 4's insulin was administered at 12:46 a.m. on 7/2/25 (3 hours and 46 minutes late).The MAR indicated, on 7/5/25 for the 9 p.m. administration time, Resident 4's insulin was administered at 12:18 a.m. on 7/6/25 (3 hours and 46 minutes late).The MAR indicated, on 7/6/25 for the 9 p.m. administration time, Resident 4's insulin was administered at 11:14 p.m. (2 hours and 14 minutes late).The MAR indicated, on 7/7/25 for the 9 p.m. administration time, Resident 4's insulin was administered at 11:25 p.m. (2 hours and 25 minutes late).The MAR indicated, on 7/8/25 for the 9 p.m. administration time, Resident 4's insulin was administered at 12:47 a.m. on 7/9/25 (3 hours and 47 minutes late).The MAR indicated, on 7/11/25 for the 9 p.m. administration time, Resident 4's insulin was administered at 10:45 p.m. (1 hour and 45 minutes late).The MAR indicated, on 7/14/25 for the 9 p.m. administration time, Resident 4's insulin was administered at 2:23 a.m. on 7/15/25 (5 hours and 23 minutes late).The MAR indicated, on 7/15/25 for the 9 p.m. administration time, Resident 4's insulin was administered at 1:31 a.m. on 7/16/25 (4 hours and 31 minutes late).The MAR indicated, on 7/21/25 for the 9 p.m. administration time, Resident 4's insulin was administered at 11:22 p.m. (2 hours and 22 minutes late).The MAR indicated, on 7/22/25 for the 9 p.m. administration time, Resident 4's insulin was administered at 1:56 a.m. on 7/23/25 (4 hours and 56 minutes late). Diclofenac (medication used to treat pain) . Gel 1% . Apply to Left Knee topically (on top of the skin) three times a day for Chronic (long term) left knee pain -Start Date- 06/09/2025 2200 (10 p.m.) -D/C Date- 07/252025 2055The MAR indicated, on 7/5/25 for the 2 p.m. administration time, Resident 4's Diclofenac was administered at 8:50 a.m. (4 hours and 10 minutes early).The MAR indicated, on 7/5/25 for the 10 p.m. administration time, Resident 4's Diclofenac was administered at 12:18 a.m. on 7/6/25 (2 hours and 18 minutes late).The MAR indicated, on 7/7/25 for the 10 p.m. administration time, Resident 4's Diclofenac was administered at 11:26 p.m. (1 hour and 26 minutes late).The MAR indicated, on 7/12/25 for the 10 p.m. administration time, Resident 4's Diclofenac was administered at 12:40 a.m. on 7/13/25 (2 hours and 40 minutes late).The MAR indicated, on 7/18/25 for the 10 p.m. administration time, Resident 4's Diclofenac was administered at 11:28 p.m. (1 hour and 28 minutes late). Diclofenac . Gel 1% . Apply to Right Knee topically three times a day for Chronic left knee pain -Start Date- 06/09/2025 2200 (10 p.m.) -D/C Date- 07/25/2025 2055(10:55 p.m.)The MAR indicated, on 7/5/25 for the 10 p.m. administration time, Resident 4's Diclofenac was administered at 12:19 a.m. on 7/6/25 (2 hours and 19 minutes late).The MAR indicated, on 7/7/25 for the 10 p.m. administration time, Resident 4's Diclofenac was administered at 11:26 p.m. (1 hour and 26 minutes late).The MAR indicated, on 7/12/25 for the 10 p.m. administration time, Resident 4's Diclofenac was administered at 12:39 a.m. on 7/13/25 (2 hours and 39 minutes late).The MAR indicated, on 7/13/25 for the 2 p.m. administration time, Resident 4's Diclofenac was administered at 4:09 p.m. (2 hours and 9 minutes late).The MAR indicated, on 7/13/25 for the 2 p.m. administration time, Resident 4's Diclofenac was administered at 4:09 p.m. (2 hours and 9 minutes late).The MAR indicated, on 7/18/25 for the 10 p.m. administration time, Resident 4's Diclofenac was administered at 11:29 p.m. (1 hour and 29 minutes late). Nystatin Powder (an antifungal medication used to treat fungal skin infections) . Apply to bilateral (both sides) under breast topically three times a day for redness to bilateral under breast -Start Date-07/11/2025 1400 (2 p.m.) -D/C Date- 07/14/2025 1227 (12:27 p.m.)The MAR indicated, on 7/12/25 for the 10 p.m. administration time, Resident 4's Nystatin Powder was administered at 12:39 a.m. on 7/13/25 (2 hours and 39 minutes late).The MAR indicated, on 7/13/25 for the 2 p.m. administration time, Resident 4's Nystatin Powder was administered at 4:09 p.m. (2 hours and 9 minutes late) Nystatin Powder . Apply to bilateral under breast topically three times a day for redness to bilateral under breast for 19 Days -Start Date-07/14/2025 1400 (2 p.m.) -D/C Date- 07/25/2025 2055 (8:55 p.m.)The MAR indicated, on 7/14/25 for the 10 p.m. administration time, Resident 4's Nystatin Powder was administered at 2:25 a.m. on 7/15/25 (4 hours and 25 minutes late).The MAR indicated, on 7/15/25 for the 10 p.m. administration time, Resident 4's Nystatin Powder was administered at 1:33 a.m. on 7/16/25 (3 hours and 33 minutes late).The MAR indicated, on 7/16/25 for the 6 a.m. administration time, Resident 4's Nystatin Powder was administered at 7:15 a.m. (1 hour and 15 minutes late).The MAR indicated, on 7/18/25 for the 10 p.m. administration time, Resident 4's Nystatin Powder was administered at 11:29 p.m. (1 hour and 29 minutes late).The MAR indicated, on 7/20/25 for the 10 p.m. administration time, Resident 4's Nystatin Powder was administered at 11:22 p.m. (1 hour and 22 minutes late).The MAR indicated, on 7/21/25 for the 10 p.m. administration time, Resident 4's Nystatin Powder was administered at 11:23 p.m. (1 hour and 23 minutes late).The MAR indicated, on 7/22/25 for the 10 p.m. administration time, Resident 4's Nystatin Powder was administered at 1:58 a.m. on 7/23/25 (3 hours and 58 minutes late). Humalog . (short acting insulin- medication used to treat high blood sugar) Inject as per sliding scale: . subcutaneously before meals and at bedtime for type 2 DM . -Start Date-5/31/2025 2100 -D/C Date- 07/25/2025 2055The MAR indicated, on 7/1/25 for the 7:30 a.m. administration time, Resident 4's Humalog was administered at 2:47 p.m. (7 hours and 17 minutes late).The MAR indicated, on 7/1/25 for the 9 p.m. administration time, Resident 4's Humalog was administered at 12:47 a.m. on 7/2/25 (3 hours and 47 minutes late).The MAR indicated, on 7/2/25 for the 7:30 a.m. administration time, Resident 4's Humalog was administered at 9 a.m. (1 hour and 30 minutes late).The MAR indicated, on 7/3/25 for the 12 p.m. administration time, Resident 4's Humalog was administered at 1:40 p.m. (1 hour and 40 minutes late).The MAR indicated, on 7/3/25 for the 5 p.m. administration time, Resident 4's Humalog was administered at 6:27 p.m. (1 hour and 27 minutes late).The MAR indicated, on 7/4/25 for the 7:30 a.m. administration time, Resident 4's Humalog was administered at 2:21 p.m. (6 hours and 51 minutes late).The MAR indicated, on 7/5/25 for the 9 p.m. administration time, Resident 4's Humalog was administered at 12:17 a.m. on 7/6/25 (3 hours and 17 minutes late).The MAR indicated, on 7/6/25 for the 9 p.m. administration time, Resident 4's Humalog was administered at 11:14 p.m. (2 hours and 14 minutes late).The MAR indicated, on 7/7/25 for the 9 p.m. administration time, Resident 4's Humalog was administered at 11:25 p.m. (2 hours and 25 minutes late).The MAR indicated, on 7/8/25 for the 9 p.m. administration time, Resident 4's Humalog was administered at 12:47 a.m. on 7/9/25 (3 hours and 47 minutes late).The MAR indicated, on 7/11/25 for the 12 p.m. administration time, Resident 4's Humalog was administered at 1:09 p.m. (1 hour and 9 minutes late).The MAR indicated, on 7/11/25 for the 5 p.m. administration time, Resident 4's Humalog was administered at 6:22 p.m. (1 hour and 22 minutes late).The MAR indicated, on 7/11/25 for the 9 p.m. administration time, Resident 4's Humalog was administered at 10:45 p.m. (1 hour and 45 minutes late).The MAR indicated, on 7/12/25 for the 9 p.m. administration time, Resident 4's Humalog was administered at 10:03 p.m. (1 hour and 3 minutes late).The MAR indicated, on 7/13/25 for the 7:30 a.m. administration time, Resident 4's Humalog was administered at 10:23 a.m. (2 hours and 53 minutes late).The MAR indicated, on 7/14/25 for the 9 p.m. administration time, Resident 4's Humalog was administered at 2:23 a.m. on 7/15/25 (5 hours and 23 minutes late).The MAR indicated, on 7/15/25 for the 9 p.m. administration time, Resident 4's Humalog was administered at 1:31 a.m. on 7/16/25 (4 hours and 31 minutes late).The MAR indicated, on 7/17/25 for the 12 p.m. administration time, Resident 4's Humalog was administered at 1:06 p.m. (1 hour and 6 minutes late).The MAR indicated, on 7/19/25 for the 9 p.m. administration time, Resident 4's Humalog was administered at 10:15 p.m. (1 hour and 15 minutes late).The MAR indicated, on 7/21/25 for the 9 p.m. administration time, Resident 4's Humalog was administered at 11:19 p.m. (2 hours and 19 minutes late).The MAR indicated, on 7/22/25 for the 7:30 a.m. administration time, Resident 4's Humalog was administered at 10:18 a.m. (2 hours and 48 minutes late).The MAR indicated, on 7/22/25 for the 9 p.m. administration time, Resident 4's Humalog was administered at 1:56 a.m. on 7/23/25 (4 hours and 56 minutes late).During a concurrent interview and record review on 7/28/25 at 2:54 p.m. with DON, DON stated the nurses have one hour before and one hour after the ordered administration time to administer medications. DON stated if the medications were administered outside of that time frame the nurse should notify the physician to ensure the medications were safe to administer and document the response in a progress note. Resident 4's progress notes were reviewed. DON stated the physician was not notified of the multiple late medications.3. During a concurrent interview and record review on 7/28/25 at 3:49 p.m. with DON, Resident 4's MAR, dated July 2025 was reviewed. DON confirmed the following: Xarelto (medication used to thin the blood to prevent and treat blood clots) Oral Tablet 20 MG (milligram - unit of measure) . Give 1 tablet by mouth in the evening for A-Fib (Atrial fibrillation- irregularly and often rapidly heartbeat) -Start Date-5/31/2025 2100 -D/C Date- 07/25/2025 2055The MAR indicated, on 7/6/25 for the 6 p.m. administration time, Resident 4's Xarelto was not documented as administered. Humalog . Inject as per sliding scale: . subcutaneously before meals and at bedtime for type 2 DM . -Start Date-5/31/2025 2100 -D/C Date- 07/25/2025 2055The MAR indicated, on 7/13/25 for the 12 p.m. administration time, Resident 4's Humalog was not documented as administered.DON stated the dated were blank and could not confirm if the medications were administered or not. During a review of the facility's P&P titled, Administering Medications, revised April 2019, the P&P indicated, Medications are administered in a safe and timely manner, and as prescribed. 4. Medications are administered in accordance with prescriber orders, including any required time frame. 7. Medications are administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders) . 10. The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. 21. If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall initial and circle the MAR space provided for that drug and dose. 22. The individual administering the medication initials the resident's MAR on the appropriate line after giving each medication and before administering the next ones. 23. As required or indicated for a medication, the individual administering the medication records in the resident's medical record: a. the date and time the medication was administered; . g. the signature and title of the person administering the drug.

Based on interview and record review, the facility failed to follow their policy and procedure (P&P) titled, Bowel Management Protocol, for one of six sampled residents (Resident 3) when Resident 3 was not administered needed medication. This failure had the potential for Resident 3 to experience pain and constipation.Findings:During a review of Resident 3's Task: Bowel Continence, (TBC) dated 6/22/25 to 7/20/25, the TBC indicated Resident 3 did not have a bowel movement (BM) from 6/24/25 to 6/30/25 (six days).During a concurrent interview and record review on 7/16/25 at 4:12 p.m. with the Director of Nursing (DON), Resident 3's TBC was reviewed. DON stated Resident 3 did not have a BM for six days. Resident 3's Medication Administration Record, (MAR) dated June 2025 was reviewed. DON stated bowel protocol was not initiated (a series of medications used to treat and prevent constipation). DON stated no medications were given to Resident 3. DON stated bowel protocol should have been initiated.During a review of the facility P&P titled, Bowel Management Protocol, undated, the P&P indicated, It is the policy of this facility to ensure that residents are free from complications secondary to constipation. This will be accomplished through adequate assessment, tracking and treatment as indicated. Definition Normal bowel pattern is once every day up to once every three (3) days. Constipation results from factors such as immobility, decreased activity, and as a side effect of numerous medications. Procedure . 5. The 3-11 House Supervisor (or charge nurse in the event of no HS) will review the resident flow record daily and compose a list of those residents not having had a BM in three (3) days and record it on the appropriate bowel care list. 6. The 3-11 nurse will provide medications as order by the physician or obtain a physician's order, to the residents on the bowel care list. The medication given should be recorded on the MAR and the bowel care list. The medication could consist of: a. Suppository b. MOM 30-60 cc (cubic centimeters-unit of measure) . 7. The 11-7 nurse is to follow up on those residents on the bowel care list for results. The nurse will document results on the bowel care list and on the MAR.

Based on interview and record review, the facility failed to ensure three of three sampled License Vocational Nurses (LVN) ( LVN 1, LVN 2, and LVN 3) had competencies for continuous positive airway pressure, (CPAP- is a common treatment for sleep apnea, a condition where breathing repeatedly stops and starts during sleep) and bilevel positive airway pressure (BIPAP is a type of non-invasive ventilation that provides breathing support by delivering air at two different pressure levels, one for inhalation and another for exhalation). This failure had the potential for the facility's residents who require the use of CPAP or BIPAP to have improper application.Findings:During an interview on 7/16/25 at 11:43 a.m. with Resident 1, Resident 1 stated when her BIPAP mask is applied by the LVN it depends on who applies the mask if there is a good seal or not.During a concurrent interview and record review on 7/28/25 at 3:36 p.m. with Staffing Coordinator (SC), LVN 1, LVN 2, and LVN 3's training files were reviewed. SC stated there were no skills training for CPAP or BIPAP for the LVN 1, LVN 2, and LVN 3.During an interview on 7/28/25 at 3:49 p.m. with Director of Nursing (DON), DON stated the facility had seven residents with physician orders for CPAP and BIPAP. DON stated based on the facility's population the facility should have training for CPAP and BIPAP because if not performed properly there is no benefit and could make it uncomfortable for the residents.During a review of the facility's policy and procedure (P&P) titled, Staffing, Sufficient and Competent Nursing, revised August 2022, the P&P indicated, Our facility provides sufficient numbers of nursing staff with the appropriate skills and competency necessary to provide nursing and related care and services for all residents in accordance with resident care plans and facility assessment. Competent Staff 1. Competency is a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics that an individual needs to perform work roles or occupational functions successfully. 3. Staff must demonstrate the skills and techniques necessary to care for resident needs .5. Competency requirements and training for nursing staff are established and monitored by nursing leadership with input from the medical director to ensure that: . c. education topics and skills needed are determined based on the resident population .

Based on observation, interview, and record review, the facility failed to: 1. Ensure one of three sampled residents (Resident 1) was wearing non-skid socks (non-slip socks are designed with rubberized grips on the soles, offering the traction needed to walk safely. This feature is particularly vital for elderly residents or those with balance problems, significantly reducing the risk of falls and related injuries) according to the plan of care when Resident 1 was high risk for falls. 2. Follow their in-service on Falls to ensure a Registered Nurse (RN) initially assessed one of three residents (Resident 1) who was found on the floor when a Licensed Vocational Nurse (LVN) 1 did not wait for the RN to assess before transferring Resident 1 from the floor to the wheelchair and to the bed. These failures had the potential to result in Resident 1 falling and sustaining a left hip fracture (broken bone). Findings: 1. During a review of Resident 1's Change in Condition Evaluation (CCE), dated 3/29/25, the CCE indicated, Resident [1] had an unwitnessed fall in her room attempting to the restroom [sic] without assistance. Pain level was assessed. Resident c/o [complained of] pain on her left hip. Resident [1] was then helped into her wheelchair and subsequently into her bed. During a review of Resident 1's Fall Risk Observation/Assessment (FROA), dated 3/12/25, the FROA indicated, Score: 26 [score of 16-42 means high risk for falls]. During a review of Resident 1's Care Plan (CP), dated 3/13/25, the CP indicated, [Resident 1] is at risk for falls. Interventions: Provide proper well-maintained footwear as indicated (Non-Skid Socks, etc). During an interview on 5/16/25 at 9:08 a.m. with CNA 1, CNA 1 stated Resident 1 was not wearing non-skid socks when she fell . CNA 1 stated she removed Resident 1 ' s non-skid socks when she placed Resident 1 in bed prior to the fall incident. During an interview on 5/16/25 at 9:32 a.m. with Director of Staff Development (DSD), DSD stated Resident 1 should be wearing non-skid socks at all times. During an interview on 5/17/25 at 10:22 a.m. with LVN 1, LVN 1 stated when he went to assess Resident 1 after the fall incident, Resident 1 was not wearing non-skid socks. During a review of the facility's policy and procedure (P&P) titled, Falls-Clinical Protocol dated March 2018, the P&P indicated, Based on preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent fals and to address the risks of clinically significant consequences of falling. 2. During an interview on 5/16/25 at 9:08 a.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated LVN 1 called her when LVN 1 found Resident 1 on the floor by the door of the bathroom. CNA 1 stated Resident 1 complained of left hip pain. CNA 1 stated she asked LVN 1 to help her lift Resident 1 back to bed. CNA 1 stated LVN 1 lifted Resident 1 by her upper body and CNA 1 lifted Resident 1's legs to the wheelchair then to Resident 1 ' s bed. CNA 1 stated Resident 1 continued to complain of pain. During a concurrent observation and interview on 5/16/25 at 9:30 a.m. in Resident 1's room, with Resident 1, Resident 1 was in bed with a bed alarm attached to the bed. Resident 1 stated she remembered she had a pain in her left hip when she fell . During an interview on 5/16/25 at 10:35 a.m. with RN Supervisor (RNS), RNS stated he was called to assess Resident 1 after the fall incident. RNS stated he went to see Resident 1 in less than five minutes. RNS stated, When I got there [Resident 1 ' s room], she [Resident 1] was already in bed. Resident [1] was holding her left hip complaining of pain. RNS stated he suspected hip fracture right away, so he sent Resident 1 to the acute care hospital. RNS stated LVN 1 did not wait for him to assess Resident 1 before transferring Resident 1 to the bed. During an interview on 5/17/25 at 10:22 a.m. with LVN 1, LVN 1 stated he was aware RNS should initially assess Resident 1 prior to transferring Resident 1 after the fall incident. LVN 1 stated he did not wait for RNS prior to moving/transferring Resident 1. During a review of the facility's in-service on Falls dated 3/4/25, the in-service on Falls indicated, If a fall occurs: Supervisor [RN] to assess resident prior to moving or touching the resident. Residents must be assessed prior to lifting or transferring resident to ensure it is safe to do so. RN supervisor will delegate if the resident should be referred to 911 services.

Based on interview and record review, the facility failed ensure one of three sampled resident (Resident 1) responsible party (RP) was able to participate in treatment decisions. This failure resulted in a violation of Resident 1's rights. Findings: During an interview on 5/14/25 at 12:46 p.m. with Resident 1's family member (FM 1), FM 1 stated she was informed Resident 1 medical provider ordered hospice (type of care that focuses on the comfort and quality of life of a resident with a serious illness that is approaching the end of life, often includes emotional and spiritual support for both the resident and their loved ones) and she agreed to start hospice care. FM 1 stated she was never given a choice regarding the hospice companies available to provide care for Resident 1. FM 1 stated she never agreed to the hospice company assigned to care for Resident 1. During a review of Resident 1's admission Record, (AR) dated 4/27/22, the AR indicated FM 1 was Resident 1's RP. During a concurrent interview and record review, on 5/15/25 at 12:46 p.m. with the Director of Nursing (DON), Resident 1's medical records was reviewed. DON stated there was no documentation Resident 1's RP was educated on the hospice process or made aware of the hospice companies available to Resident 1. During a review of the facility's policy and procedure (P&P) titled, Resident Rights, revised August 2009, the P&P indicated, 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a. Be informed about what rights and responsibilities he or she has; . c. choose a physician and treatment and participate in decisions and care planning.

Based on interview and record review, the facility failed to ensure one of three sampled resident (Resident 1) plan of care was coordinated with hospice (type of care that focuses on the comfort and quality of life of a resident with a serious illness that is approaching the end of life, often includes emotional and spiritual support for both the resident and their loved ones) care. This failure had the potential for Resident 1's care needs to go unmet. Findings: During a concurrent interview and record review, on 6/3/25 at 11:55 a.m. with Director of Nursing (DON), Resident 1's medical record was reviewed. DON stated Resident 1 started hospice care on 12/11/24, DON stated no IDT (interdisciplinary team- group of professionals consisting of attending physician, a registered nurse responsible for resident care, a nurse aide responsible for residents care member of the food and nutrition services, who assess, coordinate, and manage each resident's comprehensive needs) conference was held at the start of hospice for Resident 1. DON stated IDT conference should have been held once Resident 1 started hospice care. Resident 1's IDT Conference, dated 1/22/25 was reviewed. DON stated the IDT Conference indicated Dietary, Activities, and a Social Services team member, hospice nurse, and Resident 1's RP were present for the IDT conference. DON stated a facility nurse was not present for the IDT conference. Resident 1's care plans were reviewed. DON stated only two of Resident 1's care plans were updated when Resident 1 started hospice care. DON stated the expectation was Resident 1's care plans should have been updated to reflect coordinated care with hospice and a facility nurse should be present for the IDT conferences. During a review of the facility's policy and procedure (P&P) titled, Hospice Program, revised January 2014, the P&P indicated, 2. Hospice providers who contract with this facility are held responsible for meeting the same professional standards and timeliness of service as any contracted individual or agency associated with the facility. 4. When a resident participates in the hospice program, a coordinated plan of care between the facility, hospice agency and resident/family will be developed and shall include directives for managing pain and other uncomfortable symptoms. The care plan shall be revised and updated as necessary to reflect the resident's current status During a review of the facility's P&P titled, Care Plans - Comprehensive, revised September 2010, the P&P indicated, Our facility's Care Planning/Interdisciplinary Team, in coordination with the resident, his/her family or representative (sponsor), develops and maintains a comprehensive care plan for each resident that identifies the highest level of functioning the resident may be expected to attain. 6. Identifying problem areas and their causes, and developing interventions that are targeted and meaningful to the resident are interdisciplinary processes that require careful data gathering, proper sequencing of events and complex clinical decision making. No single discipline can manage the task in isolation. The resident's physician (or primary healthcare provider) is integral to this process. 9. The Care Planning/Interdisciplinary Team is responsible for the review and updating of care plans: a. When there has been a significant change in the resident's condition; .

Based on interview, and record review, the facility failed to: 1. Follow their policy and procedure titled Psychoactive/Psychotropic Medication Use, when Informed Consents (process to ensure the provider has discussed the risks, benefits, and alternatives with the patient and the patient agrees to the provider performing the intervention) were not provided by the physician or consistently witnessed by a licensed nurse for eight of 14 sampled residents (Resident 437, Resident 111, Resident 10, Resident 338, Resident 25, Resident 8, Resident 55, and Resident 36 ) on psychotropic medications, (medications to treat mental health disorders). This failure had the potential for residents or their responsible party to be unaware of alternatives to medications or side effects of medications. 2. Follow their policy and procedure titled Informed Consents when Informed Consents were not provided by the physician or consistently witnessed by a licensed nurse for two of two residents (Resident 119 and Resident 91) with bed alarms (devices which sound an alarm when resident gets out of bed). This failure had the potential for residents or their responsible party to be unaware of the possisbility of residents movements to be restricted, resulting in unintended isolation, loss of strength or the development of bed sores. Findings: 1a. During a concurrent interview and record review on 4/23/25 at 3:35 p.m. with Assistant Director of Nursing (ADON), Resident 437's Initial Informed Consent-Psychoactive Medication - V 4.0 (Consent), escitalopram oxalate (to treat mental illness), dated 4/15/25 and Resident 437's Initial Consent for amitriptyline (to treat mental illness) signed by Resident 437, were reviewed. The Consents for both escitalopram oxalate and amitriptyline indicated Psychoactive Medications: Anti-depressant (medication for low mood, loss of pleasure or interest in activities for long periods of time). Neither Resident 437's Consent for escitalopram oxalate 20 milligram (mg) once a day nor Resident 437's Consent for amitriptyline 50 mg once a day indicated the physician signed the consent form. ADON stated nurses obtained consent for the medications from the family or resident in the facility. During a review of Resident 437's Admission Minimum Data Set (MDS, resident assessment tool) dated 4/19/25, Resident 437's MDS assessment under Section C indicated Resident 437 had a Brief Interview for Mental Status score (BIMS, assesses individual's attention, orientation and ability to register and recall information, a score of 0 to 7 indicates severe impairment, 8 to 12 indicates moderate impairment, 13 to 15 no impairment) of 12. 1b.During a concurrent interview and record review on 4/23/25 at 1:41 p.m. with ADON, Resident 111's Initial Consent for amitriptyline 75 mg at bedtime, dated 1/2/25 was reviewed. The Consent indicated Psychoactive Medications: Anti-depressant, Anti-psychotic (medications used to treat mental illness). The Consent indicated Resident 111's responsible party and a nurse signed on 1/2/25 and physician signed on 1/3/25. ADON stated nurses obtained consent for the medication from family or resident in the facility. During a review of Resident 111's Quarterly MDS, dated [DATE], Resident 111's MDS assessment under Section C indicated Resident 111 had a BIMS of 8. 1c. During a concurrent interview and record review on 4/23/25 at 1:46 p.m. with ADON, Resident 10's Initial Consent for alprazolam (to treat anxiety) 0.5 mg every 12 hours was reviewed. The Consent indicated, Psychoactive Medication s: 1 Antianxiety. The Consent did not indicate a physician signature on the consent. ADON stated the consent was incomplete. During a review of Resident 10's Quarterly MDS, dated [DATE], Resident 10's MDS assessment under Section C indicated Resident 10 had a BIMS of 3. 1d. During a concurrent interview and record review on 4/23/25 at 2:01 p.m. with ADON, Resident 338's Initial Consent for venlafaxine 75 mg 3 capsules once a day, amitriptyline 150 mg daily and Bupropion (to treat mental illness) 150 mg daily, dated 4/18/25 was reviewed. The Consent indicated, Psychoactive Medications: Anti-depressant. The Consent indicated E. Informed Consent Verification 1. A Licensed Nurse has verified the resident or resident representative has given informed consent verbally or via [by] phone Yes 1a. Date and time licensed nurse verified verbal, or phone consent was received [date and time entered], Name of person giving verbal or phone consent [Resident 338] 3. [note there is no 2. on the Consent] Signature of resident or resident representative [Resident 338 name typed in] 4. Printed name of resident or resident representative [blank] 5. Physician Signature and Date [blank] Signed by [blank] Signed Date [blank]. The Consent did not indicate either a nurse's signature or a physician signature. ADON stated the consent was incomplete. During a review of Resident 338's Admission Record AR, dated 4/18/25, the AR indicated Resident 338 was her own responsible party. During a review of Resident 338's Admission MDS, dated [DATE], Resident 338's MDS assessment under Section C indicated Resident 338 had a BIMS of 12. 1e. During a concurrent interview and record review on 4/23/25 at 2:06 p.m. with ADON, Resident 25's Consent for Sertraline (to treat mental illness), dated 4/2/25 was reviewed. The Consent did not indicate either a nurse's signature or a physician signature. ADON stated consents were incomplete. During a concurrent interview and record review on 4/23/25 at 2:06 p.m. with ADON, Resident 25's Consent for alprazolam (medication to reduce anxiety and depression) 0.25 mg at bedtime dated 4/2/25 was reviewed. The Consent indicated, Psychoactive Medication s: 1 Antianxiety 2. Anti-depressant. The Consent indicated E. Informed Consent Verification 1. A Licensed Nurse has verified the resident or resident representative has given informed consent verbally or via phone [not indicated] 1a. Date and time licensed nurse verified verbal, or phone consent was received [blank], Name of person giving verbal or phone consent [blank] 3. [note there is no 2. on the Consent] Signature of resident or resident representative [Resident 25 name typed in] 4. Printed name of resident or resident representative [blank] 5. Physician Signature and Date [blank] Signed by [blank] Signed Date [blank]. The Consent did not indicate either a nurse's signature or a physician signature. ADON stated consents were incomplete. During a review of Resident 25's Admission MDS, dated [DATE], Resident 25's MDS assessment under Section C indicated Resident 25 had not yet had a BIMS assessment for this admission. Resident 25's MDS dated [DATE] and 3/16/25 indicated Resident 25 had a BIMS of 7. 1f. During a concurrent interview and record review on 4/23/25 at 2:14 p.m. with ADON, Resident 8's Initial Consent for Seroquel (medication for mental health condition) 25 mg at bedtime, dated 4/4/25 was reviewed. The Consent indicated Psychoactive Medications: Anti-psychotic. The Consent did not Resident 8, a licensed nurse, nor the physician signed the consent. ADON stated the consent was incomplete. During a review of Resident 8s Admission Record AR, dated 4/18/25, the AR indicated Resident 8 was his own responsible party. During a review of Resident 8's Quarterly MDS, dated [DATE], Resident 8's MDS assessment under Section C indicated Resident 8 had a BIMS of 7. During an interview on 4/23/25 at 3:17 p.m. with Registered Nurse (RN) 2, RN 2 stated nurses obtain the consent from resident or resident representative. 35649 1g. During a concurrent interview and record review on 4/23/25 at 4:30 p.m. with Director of Nursing (DON), DON was unable to find documentation of Resident 55's Informed Consent for Lorazepam (medication to treat panic disorders, anxiety and seizures) 0.5 mg. DON stated the medication was originally ordered on 3/25/25, discontinued, and reordered on 4/11/25. DON was unable to find Informed Consents for either 3/25/25 or 4/11/25. During a review of Resident 55's Order Summary Sheet (OSR, dated 4.24.25, the OSR indicated a Physician Order (PO), dated 3/25/25, indicated Lorazepam oral tablet 0.5 mg give one tablet by mouth every six hours as needed for anxiety M/B [manifested by] episodes of restlessness. Start Date: 3/25/25 DC [discontinue] Date: 4/11/25. The PO dated 4/11/25 indicated, Lorazepam 0.5 mg oral tablet give one tablet by mouth every six hours as needed for anxiety M/B episodes of restlessness for 14 days. Start Date: 4/11/25. DC Date: 4/25/25. During a review of the Medication Administration Record (MAR) dated 4/1/25 to 4/30/25, the MAR indicated, Resident 55 received Lorazepam 0.5 mg oral tablet on 4/1/25 at 8:09 p.m., 4/9/25 at 10:42 a.m., 4/13/25 at 10:57 a.m., 4/20/25 at 8:46 p.m., 4/21/25 at 8:52 p.m., 4/22/25 at 9:12 p.m., and 4/23/25 at 7:42 p.m. During a review of Resident 55's MDS, dated [DATE] and 2/5/25, Resident 55's MDS assessment under Section C indicated Resident 55 had a BIMS of 7. 1h. During a concurrent interview and record review on 4/24/25 at 2:56 p.m. with DON, Resident 36's PO, dated 5/12/25 and 1/12/24, were reviewed. The PO dated 5/12/24 indicated, Clonazepam (medication to treat anxiety disorder and seizures) 1 mg every 12 hours for anxiety. The PO dated 1/12/24 indicated, Bupropion (antidepressant medication) 150 mg once daily for depression. During a concurrent interview and record review on 4/24/25 at 3 p.m. with DON, Resident 36's Initial Informed Consent for Bupropion, dated 1/12/24, was reviewed. The Consent indicated 1. Psychoactive Medications; 1. Anti-anxiety 2. Anti-depressant. DON was unable to find evidence Resident 36's Informed Consent for Buproprion was signed either by the resident or the resident's responsible party. During a review of Resident 36's Quarterly MDS, dated [DATE], Resident 36's MDS assessment under Section C indicated Resident 36 had a BIMS of 14. During a review of Resident 36's MAR, dated 4/1/25 to 4/30/25, the MAR indicated Resident 36 received Bupropion HCL ER (extended release) 24 hour 150 mg one tablet by mouth one time a day m/b verbalization of sadness from 4/1/25 to 4/23/25. During a review of facility's policy and procedure (P&P) titled, Psychoactive/Psychotropic Medication Use, dated 4/2025, the P&P indicated, i. The resident or resident representative has the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or to option he or she prefers. iii. Prior to administration of a psychotropic medication, the prescribing clinician will obtain informed consent from the resident (or as appropriate, the resident representative), and document the consent in the medical record. iv. A licensed nurse must verify informed consent has been obtained from the resident or the resident's representative prior to administering psychotropic medication. V. A licensed nurse must also sign the consent form, declaring that required material information has been provided. 2a. During a concurrent interview and record review on 4/23/25 at 1:54 p.m. with ADON, Resident 119's Informed Consent-Restraint - V 3.0 (IC), dated 2/26/25 was reviewed. The IC indicated, Resident 119's Bed alarm to prevent fall. The Consent indicated 4. Verbal/Phone Consent 4a. Date and time verbal/phone consent received: 5 p.m. 2/26/25 [handwritten in] 4b/ Name of person giving verbal/phone consent: [a small x and a check mark]. 5. Resident Responsible Party Signature .5c a signature and date 2/27/25. The Consent did not indicate either a nurse's signature or a physician signature. ADON stated the consent was incomplete. During a review of Resident 119's Admission MDS, dated [DATE], Resident 119's MDS assessment under Section C indicated Resident 119 had a BIMS of 6. 2b. During a concurrent interview and record review on 4/23/25 at 1:59 p.m. with ADON, Resident 91's IC dated 5/21/24 was reviewed. The IC indicated, Resident 91's Bed alarm to prevent fall. The Consent indicated verbal or phone consent was given by Resident 91's responsible party on 5/21/24 at 2:15 p.m. The Consent did not indicate either a nurse's signature or a physician signature. ADON stated the consents were incomplete. During a review of Resident 91's Annual MDS, dated [DATE], Resident 91's MDS assessment under Section C indicated Resident 91 had a BIMS of 99 (severely impaired). During a review of the facility's policy and procedure (P&P) titled, Informed Consents, revised 4/2017, the P&P indicated, 1. Resident or responsible party will be provided an informed consent when applicable. 2. When applicable, the physician will provide education to the resident or responsible party to include the risks, benefits, alternatives of a given procedure or intervention.

Based on interview and record review, the facility failed to: 1.Ensure three of 32 sampled licensed vocational nurses (LVN 2, LVN 3, and TN 2) were competent (verified ability to perform skill) to perform care for one of one sampled resident (Resident 72) on dialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly). 2. Ensure three of 32 sampled licensed vocational nurses (LVN 2, LVN 3, and treatment nurse [TN] 2) were competent to provide care for one of one sampled resident (Resident 36) with suprapubic catheter (a tube inserted into the bladder to drain urine). 3. Ensure two of 14 sampled registered nurses (RN 1 and RN 3) were competent to provide care for three of three sampled residents (Resident 96, Resident 437, and Resident 187) with on Midline Catheters (thin, soft tubing, placed into a vein to deliver medications directly into the bloodstream). 4. Ensure two of 14 sampled registered nurses (RN 1 and RN 3) were competent to provide care for one of one sampled resident (Resident 34) with a Peripherally Inserted Central Catheter (PICC- a thin, flexible tube that is inserted into a large vein in the upper arm to deliver medications directly into the bloodstream). These failures had the potential for the residents to not receive the appropriate care according to evidence-based practice (quality care based on the most up-to-date research and knowledge) and standards of care (level of care that a healthcare provider is expected to provide according to evidence-based guidelines) when the facility did not ensure nursing staff competencies. Findings: 1. During a concurrent observation and interview, on 4/21/25 at 3:22 p.m. with Resident 72, in Resident 72's room, Resident 72 had an arterio-venous fistula (AV-dialysis access site) on her left upper arm. Resident 72 stated she was on dialysis and went to dialysis treatment three times a week. During a concurrent interview and record review on 4/21/25 at 4:18 p.m. with Director of Nursing (DON), the Nursing Hemodialysis Communication Observation/Assessment (NHCOA), dated 1/15/25, 3/27/25, 3/29/25, 4/3/25, 4/5/25, 4/9/25, 4/12/25, 4/17/25, and 4/22/25 were reviewed. The NHCOA forms indicated the access sites were not assessed for presence of bruit (swooshing sound indicates proper functioning of the fistula) and thrill (a vibration felt under the skin indicates good blood flow) either before or after dialysis treatment. DON stated the nurses should assess the AV site both before and after dialysis treatment. During a concurrent interview and interview on 4/23/25 at 12:05 p.m. with Director of Staff Development (DSD), LVN 2, LVN 3 and TN 2's Competency Based Orientation forms were reviewed. The Competency Based Orientation form, dated 8/2015, indicated on the first page The following symbols will be used: P = Previous experience D = demonstrated and/or instructed by the Dept [department] Head, Supervisor or Mentor/Preceptor, RD = Return Demonstration by the orienteer an or meets performance Objective NE = Needs further experience with performance objective NA = Not Applicable LVN 2 competency form, dated 10/14/24, indicated Date of Employment 8/23/22. The competency form indicated A. Provision of Nursing Care:1. Performs nursing care consistent with resident needs a check mark under P .3. Recognizes changes in resident .5. Demonstrates knowledge of unit routines .l. Outside facility appointment a check mark under P .The competency form did not indicate the facility assessed competency in dialysis. LVN 3 competency form, dated 10/14/24, indicated Date of Employment 11/9/21. The competency form indicated A. Provision of Nursing Care:1. Performs nursing care consistent with resident needs a check mark under P .3. Recognizes changes in resident .5. Demonstrates knowledge of unit routines .l. Outside facility appointment a check mark under P .The competency form did not indicate the facility assessed competency in dialysis. TN 2 competency form, dated 9/27/24, indicated Date of Employment 11/9/21. The competency form indicated A. Provision of Nursing Care:1. Performs nursing care consistent with resident needs a check mark under P .3. Recognizes changes in resident .5. Demonstrates knowledge of unit routines .l. Outside facility appointment a check mark under P .The competency form did not indicate the facility assessed competency in dialysis. DSD stated the licensed vocational nurses LVN 2, LVN 3, and TN 2 did not have completed competencies for dialysis care. 2.During an interview on 4/21/25 at 11:34 a.m. with Resident 36, Resident 36 stated he has a suprapubic catheter and a colostomy bag. During a concurrent interview and record review on 4/24/25 at 11:15 a.m. with DON, Resident 36's medical record (MR) was reviewed. Resident 36's MR indicated Resident 36 was hospitalized on [DATE] and returned to the facility on [DATE] with a suprapubic catheter for neuromuscular dysfunction of the bladder (the nerves and muscles that control urination is not working correctly). During a review of Resident 36's Physician's Order (PO), dated 6/11/24, the PO indicated, Change suprapubic catheter PRN (as needed) for dislodgement, malfunction, and leakage. DON stated the licensed vocational nurses change the suprapubic catheter. During an interview on 4/24/25 at 2:10 p.m. with LVN 2, in the presence of DON, LVN 2 stated she learned how to replace the suprapubic catheter in school. DON was unable to provide documented evidence of licensed vocational nurses' competencies on replacing suprapubic catheter and care of the suprapubic catheter. During a concurrent interview and record review on 4/24/25 at 2:21 p.m. with DSD, LVN 2's skills competency checklist dated 10/14/24, TN 2's skill competency checklist dated 9/27/24, and LVN 3's skill's competency checklist dated 10/14/24, were reviewed. LVN 2 competency form, dated 10/14/24, indicated Date of Employment 8/23/22. The competency form indicated 5. Catheter insertion .c. Suprapubic catheter and a check under P. There was no check under RD to demonstrate competence. LVN 3 competency form, dated 10/14/24, indicated Date of Employment 11/9/21. The competency form indicated 5. Catheter insertion .c. Suprapubic catheter and a check under P. There was no check under RD to demonstrate competence. TN 2 competency form, dated 9/27/24, indicated Date of Employment 11/9/21. The competency form indicated 5. Catheter insertion .c. Suprapubic catheter and a check under P. There was no check under RD to demonstrate competence. DSD was unable to provide documented competencies on all areas of suprapubic catheter care, catheter assessment, and catheter replacement for LVN 2, LVN 3 and TN 2. 3. During an interview on 4/24/25 at 2:38 p. m. with DON, DON stated Resident 96 had a midline catheter on the right upper arm. DON stated a nurse from a contracted company came and inserted the midline catheter on 4/8/25 on Resident 96's right upper arm. DON stated the midline catheter was used for the administration of Ceftriaxone (antibiotic). During a review of Resident 437's Medication Administration Record (MAR), dated 4/1/25 to 4/30/25, the MAR indicated, Resident 437 had a midline catheter on her left upper arm for the administration of Metropenem (antibiotic). During a review of Resident 187's MAR, dated 4/1/25 to 4/30/25, the MAR indicated, Resident 187 had a midline inserted on the left upper arm for the administration of Ertapenem Sodium (antibiotic). During a concurrent interview and record review on 4/24/25 at 2:20 p.m. with DSD, RN 1 Competency Based Orientation dated 7/13/24 and RN 3's Competency Based Orientation dated 6/27/24 were reviewed. During a review of the Competency Based Orientation form, dated 8/2015, the competency form indicated B. Administration 1. Safely administers medications by the following routes .2. IV - Hangs IV in a minimum volume . 3. Hangs on (sic) IV solutions mixed by pharmacy. 4. Checks IV solutions and labels .5. Removes IV solutions requiring refrigeration .6. Consults formulary (authorized list) of IV solutions .C. Discontinuing medication: 1. Draws diagonal line and uses yellow highlighter through medication, dose, frequency/rate, and time 2. Draws a diagonal line through and uses yellow highlighter through remaining dates in charting section .The competency form did not indicate competency in Midlines or removal of IV, Midline or Peripherally (in the arm) Inserted IV DSD was unable to provide documented evidence of RN 1 and RN 3 Midline competencies. 4. During a review of Resident 34's MAR, dated 4/1/25 to 4/30/25, the MAR indicated, Resident 34 had a PICC line for the administration of Cefazolin (antibiotic). During a concurrent interview and record review on 4/24/25 at 2:20 p.m. with DSD, RN 1's Competency Based Orientation Form, and RN 3's Competency Based Orientation Form, were reviewed. DSD was unable to provide documented evidence RN 1 and RN 3 had skills and knowledge validated for PICC line care and management. During a review of the facility's policy and procedure (P&P) titled Licensed Nurse Competency Evaluation Guidelines, [undated], the P&P indicated, Licensed nurses must be competent in nursing skills related to the assigned and probable duties in the course of employment at the facility. For the purpose of competency evaluations: On-boarding is the introductory period of employment, generally the first 90 days. Validated prior to the nurse performing the skills independently. Annually refers to competencies validated every 12 months. Off-cycle or as needed refers to competencies that are validated based on the facility' specific care provided to the residents or used on the individual nurse needs. Documentation of the competency validations is recorded on the Licensed Nurse Master Competency Worksheet.

Based on observation, interview, and record review, the facility failed to follow and implement the Center for Disease Control and Prevention (CDC, nationally recognized health organization) infection control practices when: 1. Licensed Vocational Nurse (LVN) 2 did not follow Enhanced Barrier Precaution (EBP, precautions to reduce transmission of infectious organisms) protocols during closed contact with one of one sampled resident (Resident 72). 2. The X-ray Technician (XRT) stepped out of the room with contaminated gloves and isolation gown to answer a phone call after in close contact with one of one resident (Resident 96) on EBP. 3a. Treatment Nurse (TN) 1 threw the contaminated dressing with serosanguinous (thin, watery, and pinkish red in color fluid from a wound) drainage onto a regular trash bin. 3b. TN 1 did not perform hand hygiene before putting on a new pair of gloves. 3c. TN 1 used a pair of unsterile (free from germs) pair of scissors to cut the sterile not packing strip during wound packing for one of one sampled resident (Resident 96). 4. Central Supply Staff (CS) 1 accessed a disinfectant wipe container without a lid with her hand. These failures had the potential to cause cross-contamination and transmit infectious diseases to other residents, staff and visitors. Findings: 1. During a concurrent observation and interview on 4/21/25 at 3:40 p.m. with LVN 2 in Resident 72's room, Resident 72 had a wound on the right ankle. Signage was posted on the wall indicated Resident 72 was on EBP. LVN 2 put on a pair of gloves but did not wear an isolation gown. LVN 2 measured the left and right toenails without required Personal Protective Equipment (PPE- refers to gowns, gloves, masks, goggles, face shield worn to protect the individual from infection or injury). LVN 2 stated Resident 72 was on EBP and stated she should have worn a gown, but she did not. During a review of Resident 72's Physician Order (PO), dated 4/16/25, the PO indicated, Requires Enhanced Barrier Precautions. During a review of the facility's policy and procedure (P&P) titled, Isolation-Transmission-Based Precautions & Enhanced Barrier Precautions, revised 9/2023, the P&P indicated, The facility has a framework for reducing MDRO [multi-drug resistant organism] transmission through staff use of gowns and gloves while caring for patients at high risk for MDRO transmission at the point of care during specific activities. 1. Wear gowns and gloves while performing the following high-contact tasks associated with the greatest risk for MDRO contamination of staff hands, clothes, and the environment such as: c. Any care activity where close contact with the resident is expected . 2. During an observation on 4/22/25 at 11:34 a.m. in Resident 96's room, with Administrator, the X-Ray Technician (XRT) entered Resident 96's room to take x-rays of Resident 96. Signage posted indicated Resident 96 was on EBP precautions. XRT had gloves on and an isolation gown on during the procedure. XRT stepped out of the room with his contaminated gloves and isolation gown to answer a call on his cell phone. The Administrator saw XRT step out of Resident 96's room, still wearing gloves and isolation gown while using his cell phone in the hallway. XRT returned to Resident 96's room, removed his gown and gloves, but did not perform hand hygiene prior to touching the x-ray machine and re-exiting Resident 96's room. During an interview on 4/22/25 at 11:41 a.m. with XRT, XRT stated he did not remove his gloves and gown when he stepped out of the room to answer the phone call. XRT also stated he did not perform hand hygiene when he exited the room. During a review of the facility's P&P titled, Isolation-Transmission-Based Precaution & Enhanced Barrier Precaution, revised 9/2022, the P&P indicated, e. Gowns and gloves should always be removed inside the room when the care activity is complete. Gowns and gloves should not be worn outside of the room when resident care is not being performed. 3a. During a concurrent observation and interview on 4/22/25 at 12 p.m. with Treatment Nurse (TN) 1 and TN 2, in Resident 96's room, TN 1 and TN 2 entered Resident 96's room to clean and change Resident 96's wound dressing on the left leg. With gloves and gown on, TN 1 removed the old dressing and stated Resident 96 has an open wound on the left shin resulting from a ruptured hematoma. TN 1 stated the wound was draining serosanguinous fluid. After cleaning the wound with normal saline, TN 1 disposed of the contaminated dressing onto the regular trash bin. TN 1 stated there was no biohazard bin inside the room. 3b. During an observation on 4/22/25 at 12:05 p.m. with TN 1 in Resident 96's room, TN 1 removed the contaminated gloves and put on a new pair of gloves without performing hand hygiene. TN 1 irrigated the wound with normal saline and started to prepare for the wound packing (specialized techniques for deep wounds to encourage healing). 3c. During a concurrent observation and interview on 4/22/25 at 12:10 p.m. with TN 1 in Resident 96's room, TN 1 used a pair of non-sterile scissors to cut a sterile strip of gauze for wound packing. With the same gloves on used during wound irrigation, TN 1 soaked the sterile strip of gauze into a cup with Daikin (a strong topical antiseptic widely used to clean infected wounds, ulcers, and burns) solution and then put the wet sterile strip of gauze inside the wound. After the procedure, TN 1 stated he disinfects the scissors after using them. TN 1 stated he cut the sterile strip of gauze with the scissors and the used gauze were discarded. During a review of the facility's P&P titled, Wound Care, revised 10/2010, the P&P indicated, 5. Pull glove over dressing and discard into appropriate receptacle. Wash and dry hands thoroughly. During a review of the facility's P&P titled, Handwashing/Hand Hygiene, revised 10/2023, the P&P indicated, Administrative Practices to Promote Hand Hygiene: 2. All personnel are expected to adhere to hand hygiene policies and practices to prevent spread of infection to other personnel, residents, and visitors.Indications for Hand Hygiene: 1. Hand Hygiene is indicated for: c. after contact with blood, body fluids, or contaminated surfaces. d. after touching a resident. f. before moving from work on a soiled body site to a clean body site on the same resident g. immediately after love removal. 45654 During a concurrent observation and interview on 4/21/25 at 12:35 p.m. with Central Supply (CS), in hallway A, CS wiped a resident's oxygen contractor machine (machine increases the percentage of oxygen in room air) with a Sani Cloth (wipes, sanitizing and disinfecting wipe). There was no lid on top of the Sani Cloth container. CS stated I just wiped down the concentrator and the lid should be placed back on the Sani wipes. During an interview on 4/24/25 at 10:44 a.m. with IP, IP stated no the staff member should not have the top off the Sani wipe container that was not an acceptable practice.

Based on interview and record review, the facility failed to ensure that 108 out of 108 sampled Certified Nursing Assistants (CNAs) were attending at least 5 hours of dementia (a loss of mental function)-specific in-service training on an annual basis. This failure had the potential for CNAs to be uneducated how to meet care need of residents with dementia. Findings: During a concurrent interview and record review on 4/23/25 at 9:09 a.m. with Director of Staff Development (DSD), Dementia Mod [module] 4 (DM 4), dated 6/12/24 was reviewed. The DM 4 attendance sheet indicted 35 out of 108 CNAs attended dementia training. DSD stated only 35 CNAs attended the one-hour Dementia training. During a concurrent interview and record review on 4/23/25 at 9:11 a.m. with DSD, Dementia Review Annual (DRA), dated 8/23/24 were reviewed. The DRA attendance sheet indicated 60 out of 108 CNAs attended dementia training. DSD stated only 60 CNAs attended the one-hour training. During a concurrent interview and record review on 4/23/25 at 9:13 a.m. with DSD, DM 4 dated 9/19/24 was reviewed. The DM 4 attendance sheet indicated 56 out of 108 CNAs attended dementia training. DSD stated only 56 CNAs attended the one-hour training. During a concurrent interview and record review on 4/23/25 at 9:15 a.m. with DSD, DM 3 dated 9/29/24 was reviewed. The DM 3 attendance sheet indicated 68 out of 108 CNAs attended dementia training. DSD stated only 68 CNAs attended the one-hour training. During a concurrent interview and record review on 4/23/25 at 9:17 a.m. with DSD, DM 1 attendance sheet dated 1/21/25 was reviewed. The DM 1 indicated 35 out of 108 CNAs attended dementia training. DSD stated only 35 CNAs attended the one-hour training. During a concurrent interview and record review on 4/23/25 at 9:19 a.m. with DSD, Dementia attendance sheet dated 4/2/25 was reviewed. The Dementia attendance sheet indicated 33 out of 108 CNAs attended dementia training. DSD stated only 33 CNAs attended the one-hour training. During a review of the facility's policy and procedure (P&P) titled, In-Service Training, All Staff, dated 2001, the P&P indicated, All staff must participate in initial orientation and annual in-service training.2.For the purpose of this policy, staff means all new and existing personnel.(3) dementia management and resident abuse prevention.

Based on interview and record the facility failed to provide the completed Baseline Care Plan (BCP-initial instructions for care of the resident) Summary was provided to two of six sampled residents (Resident 72 and Resident 96) or the resident's responsible party within 48 hours of admission. This failure resulted in Resident 72 and Resident 96 or the resident's responsible party to be unaware of the plan of care during the first 48 hours. Findings: During a concurrent interview and record review on 4/23/25 at 9:44 a.m. with Director of Nursing (DON), Resident 72's Admission Record (AR), was reviewed. The AR indicated Resident 72 was admitted on [DATE]. Resident 72's BCP dated 3/26/25 was reviewed. DON was unable to find documentation Resident 72's BCP summary was provided to the resident or the resident representative. DON was unable to provide documentation of Resident 72's signature or her responsible party (RP) signature indicating receipt of the BCP summary. DON stated she did not see a signed document of the BCP summary provided to the resident or her RP within 48 hours of admission. During a concurrent interview and record review on 4/24/25 at 8:56 a.m. with Assistant Director of Nursing (ADON), Resident 96's AR was reviewed. The AR indicated Resident 96 was admitted on [DATE]. Resident 96's BCP, dated 3/25/25, was reviewed, ADON was unable to find documentation the BCP summary was provided to the resident or the resident representative. The BCP summary indicated the resident and his representative participated in the BCP review, but a copy of the BCP summary was not provided to the resident or his RP. ADON stated there was no signature indicating the resident or his RP received a copy of Resident 96's BCP summary within 48 hours of admission. During a review of the facility's policy and procedure (P&P) titled, Care Plans-Baseline, dated 12/2016, the P&P indicated, A baseline plan of care to meet the residents' immediate needs shall be developed for each resident within forty-eight (48) hours of admission . 4. The resident and the resident representative will be provided a summary of the baseline care plan that includes, but not limited to the following: a. initial goals of the residents. b. A summary of the resident's medications and dietary instructions. c. Any services and treatments to be administered by the facility and personnel acting on behalf of the facility. d. Any updated information based on the details of the comprehensive care plan, as necessary.

Based on observation, interview, and record review, the facility failed to ensure : 1. Four of five sampled residents (Resident 132, Resident 35, Resident 437, Resident 34) medications were safely and securely stored from unauthorized personnel and other resident. This failure had the potential for medication to be accessed by unauthorized staff and residents. 2. The facility policy and procedure (P&P) titled, Disposal of Medications and Medication-Related Supplies, for one of one sampled controlled substance destruction record. This failure had the potential for drug diversion. Findings: 1a. During a concurrent observation and interview on 4/21/25 at 10:29 a.m. with Licensed Vocation Nurse (LVN) 1 Resident 132 had micronazole nitrate 2% (to treat itching and burning) was found on bedside table. There was no name on the bottle. Resident 132 stated this bottle is not mine. LVN 1 stated this medication should not be here. LVN 1 stated there is no name on the bottle. During a review of Resident 132's Order Summary Report (OSR), dated 3/2025, the OSR indicated Resident 132 had no order for micronazole nitrate. During a concurrent interview and record review on 4/23/25 at 2:20 p.m. with Assistant Director of Nursing (ADON), Resident 132's clinical record (CR) was reviewed. ADON stated Resident 132 was not assessed for self-administration medication assessment. ADON stated self-administration assessment should be completed before a resident is allowed to self-administer medication. 1b. During a concurrent observation and interview on 4/21/25 at 10:37 a.m. with LVN 1 Resident 35 had eye drops (to treat dry eyes) half a bottle was found on bed side table. Resident 35 stated he received eye drops this morning. LVN 1 stated the eye drops should not be at bed side table. During a concurrent interview and record review on 4/23/25 at 2:23 p.m. with ADON, Resident 35's CR was reviewed. ADON stated Resident 35 was not assessed for self-administration medication assessment. ADON stated Resident 35 cannot keep medication at bedside. 1c. During a concurrent observation and interview on 4/21/25 at 11:10 a.m. with LVN 1 Resident 437 had moisture barrier antifungal cream (relieves and prevents rash) on bed side table. LVN 1 stated It [antifungal cream] shouldn't be in here. During a concurrent interview and record review on 4/23/25 at 2:26 p.m. with ADON, Resident 437's CR was reviewed. ADON stated Resident 437 was not assessed for self-administration medication assessment. ADON stated Resident 437 cannot keep medication at bedside. 1d. During a concurrent observation and interview on 4/21/25 at 11:25 a.m. with LVN 1 Resident 34 had two bottles for nystatin powder (to treat fungal infection of the skin) was found on bedside table. LVN 1 stated nystatin powder shouldn't be there. During a concurrent interview and record review on 4/23/25 at 2:28 p.m. with ADON, Resident 34's CR was reviewed. ADON stated Resident 34 was not assessed for self-administration medication assessment. ADON stated Resident 34 cannot keep medication at bedside. During a review of the facility's policy and procedure (P&P) titled, Medication Labeling and Storage, dated 2/2023, the P&P indicated, The facility stores all medications and biologicals [medications derived from organic bases] in locked compartments under proper temperature, humidity and light control, Only authorized personnel have access to keys.4. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing medications and biologicals are locked when not in use, and trays or carts used to transport such items are not left unattended if open or otherwise potentially available to others. During a review of the facility's P&P titled, Self-Administration of Medications, Dated 2/2021, the P&P indicated, Residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so.If it is deemed safe and appropriate for a resident to self-administer medications, this is documented in the medical record and the care plan. The decision that a resident can safely self-administer medications is re-assessed periodically based on changes in the resident's medical and/or decision-making status. 45654 2. During a concurrent interview and record review on 4/24/25 at 9:25 a.m. with Director of Nursing (DON) the facility's, Controlled Substance Destruction Record (Destruction Record), dated 4/22/25 was reviewed. The Destruction Record indicated, no second registered nurse signature. DON stated she told the ADON to sign but ADON forgot. During a review of the facility P&P titled, Disposal of Medications and Medication-Related Supplies, dated 2019, the P&P indicated, in the presence of two licensed nurses, and the disposal is documented on the accountability record on the line representing that dose. The same process applies to the disposal off unsealed partial tablets and unused portions of single dose ampules and doses of controlled substances wasted for any reason.

Based on interview and record review, the facility failed to ensure Social Services Director (SSD) met the required qualifications to manage and coordinate social services for 126 residents living in the facility and to fulfill the duties of the SSD. This failure had the potential to result in residents not being referred to appropriate social service agencies for their needs, required social services assessments performed and completed timely, accurate documentation and follow-up with residents and resident representatives of the residents' social service's needs, and ensure the residents could attain and maintain highest practicable physical, mental, or psychosocial well-being. Findings: During an interview on 4/23/24 at 10:23 a.m. with Social Services Director (SSD), SSD stated she was new to the facility. She stated her educational qualification included a Bachelor of Science Degree in Psychology, currently working on her master's in social work. SSD stated her work experience included social work in mental health. SSD stated this is her first experience working with residents in a skilled nursing facility. During a concurrent interview and record review on 4/23/25 at 10:30 a.m. with Director of Nursing (DON) and SSD, social services activities for the residents were reviewed. SSD was informed of the issues observed throughout the course of the survey. The following social services had not been facilitated: Advance Directive information had not been provided to six of six sampled residents (Resident 72, Resident 55, Resident 36, Resident 47, Resident 96, and Resident 133) or the resident representatives. (Cross-reference to F658). Dental referral for one of one sampled resident (Resident 133) had not been made for a resident admitted on [DATE]. A physician order dated 4/4/25 indicated dental referral. (Cross-reference to F790). Podiatry referral for one of one sampled resident (Resident 72) had not been made for Resident 72 who showed signs and symptoms of foot problem, possible fungal infection, and toenail deformity. (Cross-refence to F687). SSD stated she had not visited one of one resident (Resident 133) who expressed concerns about his mail and his ability to pay his bill. SSD stated she does not do resident visits in the room but waits for the residents in care conferences. SSD stated she does not do just-in-time documentation. SSD stated she documents after two days in medical records. SSD had not completed Resident 133's Initial Social History Assessment to determine Resident 133's needs. (Cross-reference to F842). The Notice of Transfer and Discharge to the Ombudsman (representatives who assist residents in long-term care facilities with issues related to day-to-day care, health, safety and personal preferences) for one of six sampled resident's (Resident 40) was not completed and sent to the Ombudsman. SSD stated it was not her responsibility to notify the Ombudsman. (Cross-reference to F623). Three of 16 sampled residents (Resident 10, Resident 109, and Resident 115 had not been appropriately assessed and referred for Pre-admission Screening and Resident Review (PASRR-federal requirement to help ensure that individuals are not incorrectly placed in nursing homes or long-term care instead of a psychiatric setting). The facility's policy and procedure (P&P) titled Admission Criteria, dated 2019, indicated The admitting nurse notifies the social services department when a resident is identified as having a possible (or evident) MD, ID, or RD. (2) The social worker is responsible for making referrals to the appropriate state-designated authority. DON stated she was aware of these occurrences as she had been able to verify them throughout the interview and record review with SSD. During a review of SSD's Job Description, dated 2/2024, the Job Description indicated, Essential Duties: Assist the residents in achieving the highest practicable level of self-care, independence, and well-being. Provide medically-related services so that the highest practicable physical, mental, and psychosocial well-being of each resident is attained or maintained. Assist in inventory and tracking of patient belongings. Assist in obtaining resources from community and social services agencies as well as health and welfare agencies to meet the needs of the resident. Assist in discharge planning with appropriate agencies, entities or individuals to include agency services equipment, and agency referrals. Coordinate with interdisciplinary teams. During a review of the facility's policy and procedure (P&P) titled, Social Services, the P&P indicated, The director of social services is a qualified social worker and is responsible for: b. Consultation to allied professional health personnel regarding provisions for the social and emotional needs of the residents in the facility.d. An adequate record system of obtaining, recording, and filing of social services data. f. Assistance in meeting the social services and emotional needs of residents.4. The social services department is responsible for: a. Obtaining pertinent social data about personal and family problems, related to the resident's illness and care. B. Identifying individual social and emotional needs.d. Maintaining regular progress and follow up notes indicating the resident's response to the plan and adjustment to the institutional setting.f. Making referrals to social services agencies as necessary or appropriate.i. Making supportive visits to residents and performing needed services.

Based on observation, interview, and record review, the facility's Quality Assurance and Performance Improvement (QAPI, process to identify problems and initiate improvement processes) committee failed to identify on-going issues, develop, and implement corrective action plans for Infection Prevention and Control practices (F636, F655, F656, and F868) and Social Services (F658, F790, F687, F842 and F623) not provided as identified by the survey team. These failures placed all 126 facility residents at risk for acquiring infectious diseases and not receiving medically necessary services. Findings: During a concurrent interview and record review on 4/24/25 at 3:09 p.m. with the Administrator, the minutes of the facility's QAPI (a committee that identifies quality deficits and implements corrective plans) meeting dated 4/18/25 and 1/19/25 were reviwed. The Administrator stated meetings were held every Tuesday to review new residents assessments. The facility's deficient practices reviewed included failure to assess each resident and care planning of residents. The Administrator stated the above resident assessment deficient practices had not been identified by the facility and were not covered during the most recent (F636, F655, F656, and F880) QAPI meeting. During an interview on 4/24/25 at 3:13 p.m.with the Administrator, Administrator stated previous Social Services Director (SSD) was not competent in job duties and was let go in December of 2024. Administer stated the Director of Nursing had taken on duties and our admission records are reviewed every Tuesday. Administer stated we are at 100% compliance. During a review of the facility policy and procedure (P&P) titled Quality Assurance and Performance Improvement (QAPI) program dated February 2020, the P&P indicated, This facility shall develop, implement, and maintain an ongoing, facility-wide, data-driven QAPI Program that is focused on indicators of the outcome of care and quality of life for our residents.

Based on interview and record review, the facility failed to ensure the facility's Infection Preventionist (IP) attended two of three sampled Quality Assessment and Performance Improvement (QAPI, committee that identifies quality deficits and implements corrective plans) committee's meetings during 2024 and 2025. This failure had the potential for the facility to not be aware of infection control issues and develop a plan to address infection control issues. Findings: During a concurrent interview and record review on 4/24/25 at 3:09 p.m. with the Administrator, the QAPI committee sign in sheets dated 9/24/245, 1/19/25, and 4/18/25 were reviewed. The Administrator stated the IP attends the QAPI meetings. Administrator was unable to verify IPs attendance at the QAPI meetings on 9/24/245 and 4/18/25 with the QAPI attendance sheets. The Administrator stated the QAPI committee met September 2024, January 2025, and April 2025. The sign in sheet dated, 9/24/24 indicated the following signatures: Administrator, Director of Nursing (DON), Business Office Manager (BOM), Director of Staff Development (DSD), Minimum Data Set (resident assessment tool) Coordinator (MDS), Medical Records (MR), (Environmental Services (EVS) Supervisor, and Medical Doctor (MD). The sign in sheet dated, 1/19/25 indicated the following signatures: Administrator, DON, Assistant Director of Nursing (ADON), MD, DSD, MDS, MR, Director of Rehabilitation (DOR), Social Services Director (SSD), BOM, EVS Supervisor, and IP. The sign in sheet dated, 4/18/25 indicated the following signatures: Administrator, DON, BOM, DOR, and four illegible signatures.

Based on interview and record review, the facility failed follow their policy and procedure (P&P) titled, Personal Property when one of one sampled resident (Resident 55) personal belongings were not recorded on the inventory sheet upon admission. This failure resulted in the loss of Resident 55's personal belongings and the potential to result in difficulty replacing the personal belongings reported as lost. Findings: During an interview on 4/21/25 at 10:42 a.m. with Resident 55, Resident 55 stated she lost two sets of pajamas and a pair of pants approximately two months ago. Resident 55 stated she told the nurses and the nursing assistants about them. Resident 55 stated, I was told they are in the pile of resident clothing. They have not been returned or replaced. During an interview on 4/23/25 at 4 p.m. with Social Services Director (SSD), SSD stated she was not aware of Resident 55's lost personal belongings. SSD stated she had not been informed. SSD stated she had not personally visited and spoken with Resident 55 about lost personal belongings. During a concurrent interview and record review on 4/23/25 at 4:10 p.m. with Director of Nursing (DON), Resident 55's Inventory of Personal Effects, dated 1/29/25, was reviewed. DON stated the staff did not complete the personal belongings inventory when Resident 55 was readmitted on [DATE]. DON stated every resident should have an inventory of their personal belongings upon admission. During a review of the facility's policy and procedure (P&P) titled, Personal Property, revised 8/2022, the P&P indicated, 10. The resident's personal belongings and clothing are inventoried and documented upon admission and updated as necessary.

Based on interview and record review, the facility failed to follow its policy and procedure (P&P) titled, Transfer or Discharge, Facility-Initiated, when the facility did not send a notice of transfer to the Ombudsman (representatives who assist residents in long-term care facilities with issues related to day-to-day care, health, safety and personal preferences) for one of six sampled resident's (Resident 40). This failure had the potential to result in Resident 40 not having an advocate who could inform them of their admission, transfer, and discharge rights and options. Findings: During a review of Resident 40's, Hospital Transfer Form (HTF), [undated], the HTF indicated, Resident 40 was transferred to the hospital on 3/6/25 and 3/10/25. There was no evidence of Ombudsman notification done on the hospital transfer. During a concurrent interview and record review on 4/24/25 at 2:59 p.m. with Social Services Director (SSD), Resident 40's HTF, dated 3/6/25 and 3/10/25, were reviewed. SSD stated the nurses were responsible to complete the notification to the Ombudsman. During a review of the facility's P&P titled, Transfer or Discharge, Facility-Initiated, dated 10/2022, the P&P indicated, When residents who are sent emergently to an acute care setting, the scenarios are considered facility-initiated transfers, NOT discharges, because the resident's return is generally expected . Notice of transfer is provided to the resident and representative as soon as practicable before the transfer and to the long- term care (LTC) ombudsman when practicable (e.g., in a monthly list of residents that includes all notice content requirements).

Based on observation, interview and record review the facility failed to prevent abuse for one of 10 sampled residents (Resident 3). This failure resulted in Resident 3 to express feelings of sadness, cry, verbalize a fear of retaliation from staff and had the potential to affect other residents in a negative manner. Findings: During a review of Resident 3's Minimum Data Set (Assessment tool) BIMS (Brief Interview for Mental Status- an assessment tool for cognition), dated 9/8/23, the BIMS indicated, Resident 3 had a score of 12 (moderate impairment). During a concurrent observation and interview on 10/19/23 at 11:46 a.m. with Resident 3 in Resident 3's room, Resident 3 stated, Certified Nursing Assistant (CNA) 9 had been shouting at her. Resident 3 stated she should have reported CNA 9's behavior towards her a long time ago but did not want to get anyone in trouble. Resident 3 stated when she would request assistance with care, CNA 9 would shout at her, I don't have time for this. Resident 3 stated approximately a month and a half ago she had requested assistance to use the restroom and CNA 9 had refused to assist her. Resident 3 stated two CNAs (CNA 10, CNA 11) were passing by and witnessed CNA 9 refusing to assist her. Resident 3 stated CNA 10 and CNA 11 assisted her to the restroom. Resident 3 stated CNA 9 came back to Resident 3's room and stated, You [Resident 3] better figure out a way to call them [CNA 10 and CNA 11] back to get you back up [off the toilet] because I [CNA 9] am not. Resident 3 stated she had reported these issues with the Director of Staff Development (DSD) and with the Activities Assistant (AA). Resident 3 stated she became saddened when she reported it and broke down crying. Resident 3 stated CNA 9 had been threatening to move her to another area of the facility as well. During this interview Resident 3 was observed to be crying when talking about her interactions with CNA 9. Resident 3 stated Family Member (FM) 1 was involved with her care and had information regarding CNA 9 threatening to move her. During a review of Resident 3's Functional Status (FS - an assessment tool), dated 9/8/23, the FS indicated, Resident 3 required extensive one person assistance for toileting, eating, dressing, personal hygiene, and bed mobility. The FS indicated Resident 3 required total assistance with bathing. During an interview on 10/19/23 at 12:15 p.m. with Resident 5, Resident 5 stated he has had issues with the way CNA 9 had been treating him. Resident 5 stated CNA 9 does not know how to talk to residents. Resident 5 stated CNA 9 would tell him things such as, You will stand when I tell you to stand and I have other people to care for not just you. Resident 5 stated he reported the treatment he received from CNA 9 but does not recall who he told. Resident 5 stated, If I am an isolated case [regarding CNA 9 behavior], I have no say, but if there are others [Residents] complaining about her [CNA 9] my concerns should hold water. So, as I said people [person in general] are consistent with their attitude and behaviors and with others complaining [about CNA 9] that should paint a picture on who they are and how comfortable [CNA 9 is on] how she acts around us residents. During a review of Resident 5's BIMS, dated 9/12/23, the BIMS indicated, Resident 5 had a score of 12 (cognitively intact). During an interview on 10/19/23 at 1:07 p.m. with AA, AA stated Resident 3 and CNA 9 in the beginning of Resident 3's facility stay were good friends. FM 1 stated that changed over time. AA stated CNA 9 can get overwhelmed and can come off rough. FM 1 stated Resident 3 had told her she was getting tired of CNA 9's attitude toward her. AA stated Resident 3 had told her that CNA 9 was threatening to move her to another location. AA stated she took Resident 3 to the DSD regarding her complaints. During an interview on 10/19/23 at 1:30 p.m. with FM 1, FM 1 stated she had witnessed CNA 9 tell Resident 3 she could not take her to the restroom. FM 1 stated Resident 3 would hold her urine or lose control and wet her pants. FM 1 stated she would receive text messages from CNA 9 stating how Resident 3 was too needy and if Resident 3 would not calm down she would have her moved to another location. FM 1 stated she had a fear that Resident 3 would be retaliated against if they reported the issues. FM 1 stated she eventually spoke to DSD about her concerns. FM 1 stated Resident 3 felt intimidated by CNA 9. During a review of Resident 3's assessment for Bowel and Bladder (B&B - an assessment tool), dated 9/8/23, the B&B indicated, Resident 3 was occasionally incontinent of bladder and always continent of bowel. During an interview on 10/19/23 at 1:48 p.m. with CNA 10, CNA 10 stated a month ago at approximately 66:30 p.m. she went to visit Resident 3. CNA 10 stated Resident 3 had her call light on to use the restroom. CNA 10 stated she witnessed CNA 9 told Resident 3 in a rude and unprofessional manner she would have to wait to use the restroom since she was busy. CNA 10 stated her and CNA 11 assisted Resident 3 to the restroom since CNA 9 stated she was too busy. CNA 10 stated CNA 9 told Resident 3, Don't even bother calling me, you better call those girls [CNA 10, CNA 11]. CNA 10 stated she provided Resident 3 with her cell number to call her if there was no one to help her. CNA 10 stated Resident 3 had expressed to her she did not like using the call light when CNA 9 was working because of the way she was treated and out of fear of retaliation. During an interview on 10/19/23 at 2:10 p.m. with Activities Director (AD), AD stated approximately two weeks ago she met with Resident 3 with the DSD. AD stated Resident 3 was upset and sad. AD stated Resident 3 requested CNA 9 not to provide care to her because they were not getting along. AD stated Resident 3 told her and DSD, CNA 9 would tell her, I don't have time for this [in regard to providing care]. AD stated her and DSD consoled Resident 3, hugged her, and told her everything would be fine. During an interview on 10/19/23 at 2:17 p.m. with CNA 11, CNA 11 stated approximately a month ago her, and CNA 10 noticed Resident 3's call light was on. CNA 11 stated her, and CNA 10 entered the room and observed CNA 9 attending to Resident 3's roommate. CNA 10 stated Resident 3 had loudly stated that she had to use the restroom. CNA 11 stated CNA 9 stated in a loud annoyed tone, Hey I already told you [Resident 3], you have to wait for an hour. CNA 11 stated her and CNA 11 placed Resident 3 on the toilet. CNA 11 stated CNA 9 told Resident 3, Make sure you get your little friends [CNA 10, CNA 11] number because I'm not getting you off [the toilet]. CNA 11 stated her, and CNA 11 returned to take Resident 3 off the toilet. CNA 11 stated Resident 3cried and stated, she feared CNA 9 and had reported some of the issues to the DSD but nothing had been done. During an interview on 10/19/23 at 2:34 p.m. with DSD, DSD stated a few weeks ago she had met with Resident 3 who reported to her CNA 9 was, treating me different. DSD stated she had spoken with FM 1 who stated there were issues between Resident 3 and CNA 9. DSD stated she heard about CNA 9 texting FM 1 about Resident 3, and it was not appropriate. DSD stated, it is not within the authority of a CNA to move residents to other locations or to indicate that they could in response to resident behaviors. DSD stated, Absolutely that's exploitation or grounds for termination [in regard to CNAs telling family and residents about moving them]. DSD stated, it is not within the authority of a CNA to call resident family members regarding behaviors or any other resident issues. DSD stated, I could see that being a threat. During an interview on 10/19/23 at 3:23 p.m. with CNA 9, CNA 9 stated Resident 3 can be very needy. CNA 9 stated she never had other staff provided care for Resident 3 when she was assigned to her. CNA 9 stated she never texted FM 1 regarding Resident 3. CNA 9 stated all the information she provided was honest and true. During a review of FM 1's Text Messages (TM) dated 6/21/23 at 6:49 p.m., the TM indicated, CNA 9 texted FM 1 about Resident 3. During an interview on 10/19/23 at 3:57 p.m. Director of Nursing (DON), DON stated, an allegation of abuse is any allegation of mistreatment neglect, physical, emotional or sexual misconduct. DON stated, mistreatment is, If care is being withheld, meds, talked down for example. During a review of Resident 3's Care Plans (CP) dated 3/8/23, the CP indicated, Resident 3 was at risk for altered wellbeing and reduced sense of wellbeing related to care needs that required skilled nursing facility placement, depression, or other mental illness. The CP intervention included was to address Resident 3's concerns and complaints timely. During a review of the facility's policy and procedure (P&P) titled, Abuse and Reporting Orientation, dated 12/2020, the P&P indicated, ' Abuse of an elder or dependent adult ' is defined as the following . neglect . Isolation, abduction, or other treatment with resulting physical harm or pain or mental suffering . deprivation by a custodian of goods or services that are necessary to avoid physical harm or mental suffering. Neglect includes, but is not limited to, all of the following . Failure to assist in personal hygiene . Failure to provide medical care for physical and mental health needs. ' Mental Suffering' means fear, agitation, confusion, severe depression or other forms of serious emotional distress that is brought about by threats, harassment or other forms of intimidating behavior. During a review of the facility's job description (JD) titled, Certified Nursing Assistant, dated 2/2019, the JD indicated, The primary purpose of your job position is to provide each of your assigned residents with routine daily nursing care and services in accordance with the resident's assessment and care plan . Create and maintain an atmosphere of warmth, personal interest and positive emphasis, as well as a calm environment throughout the unit and shift. Answer resident calls promptly . Check residents routinely to ensure that their personal care needs are being met.

Based on interview and record review the facility failed to ensure: 1. An accurate pain assessment was done for one of one sampled resident (Resident 1). 2. physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . These failures resulted in Resident 1 suffering from severe pain (scale of 0 = no pain, 1 to 3 = mild pain, 4 to 6 = moderate pain, 7 to 10 = severe pain) and caused a delay in treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings: 1. During a review of Resident 1's Physicians Order (PO), dated 2/10/22, the PO indicated, Resident 1 had an order/start date on 12/30/21 for Monitor and Record Pain Assessment Level q [every] shift 0 = No pain, 1-3 = Mild, 4-8 = Moderate, 7-10 = Severe. During a review of Resident 1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 1's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 1 ' s Physical Therapy (PT - an exercise treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] a. On 2/1/22 Resident 1 had pain on a scale of eight (8) out of 10 (scale of 7 to 10 = severe pain) b. On 2/2/22 Resident 1 complained of left hip pain (no pain scale given). Charge nurse was notified, and x-ray was ordered. c. On 2/3/22 Resident complained of discomfort to the left hip area (there was no pain scale assessment in the therapy note). During a review of Resident 1 ' s Interdisciplinary Team (IDT - a group of various professionals that meet to discuss a resident need) Notes (IDTN), dated 2/4/22, at 11 AM, the IDTN indicated, Resident 1 had complained of pain to hip (no pain scale level in the IDT note) on 2/3/22. During a review of Resident 1 ' s ED [Emergency Department] Physician Notes (EDPN), dated 2/10/22, the EDPN indicated, Resident 1 arrived at the acute hospital with left hip pain on a scale of seven (7) out of 10 (scale of 7 to 10 = severe pain). During a concurrent interview and record review on 2/23/22, at 1:27 PM, with Director of Nursing (DON), Resident 1 ' s Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . DON confirmed there was neither nursing documentation regarding Resident 1 ' s pain nor teratment for pain. DON stated there should have been nursing documentation regarding pain and Resident 1 should have received medication for her pain. DON stated Resident 1 had several medications which could have been given for complaints of pain per physician's (MD) orders. During a concurrent interview and record review, on 7/1/22 at 10:33 AM, with Occupational Therapist (OT - focuses on improving the patient's ability to perform activities of daily living), Resident 1 ' s Occupational Therapy (involves the therapeutic use of everyday activities, or occupations, to treat physical, mental, developmental, and emotional ailments that impact a patient ability to perform day to day tasks, usually involves upper extremities) Notes (OTN), dated 2/1/22 to 2/10/22 were reviewed. OT stated she remembered providing therapy for Resident 1. OT stated Resident 1 complained of pain (not sure what level) and had needed maximum assistance with movement or standing. OT reviewed her notes and confirmed the following: a. On 2/1/22, Resident 1 was in discomfort and had reported it to the charge nurse (cannot recall who the nurse was). b. On 2/2/22, Resident 1 complained of left hip/side pain. OT had reported this to the charge nurse (cannot recall who the nurse was). c. On 2/3/22, Resident 1 had continued discomfort (unable to define how). OT stated she could not recall which nurses she spoke with regards to Resident 1 ' s pain and confirmed she did not indicate the pain level and who she spoke with in her notes. During a concurrent interview and record review, on 7/1/22, at 10:56 AM, with Physical Therapist (PT - focuses on improving the patient's ability to move their body), Resident 1 ' s Physical Therapy Notes (PTN), dated 2/1/22 to 2/10/22 were reviewed. PT stated Resident 1 had verbalized pain to him on a scale of eight (8) out of 10 (scale of 7 to 10 = severe pain) on 2/1/22. PT stated he reported the pain to the charge nurse but could not recall who the charge nurse was. PT stated on 2/7/22 he noted Resident 1 was in pain but there was no pain assessment. PT had to limit Resident 1 ' s movements because Resident 1 was groaning and withdrawing her limbs. During an interview on 7/25/22, at 11:01 AM, with Licensed Vocational Nurse (LVN) 1, LVN 1 stated, he was the charge nurse for Resident 1 from 2/7/22 to 2/9/22. LVN 1 stated he recalled Resident 1 being in pain but also remembers her possibly refusing pain medication. LVN 1 stated Resident 1 could be confused at times. LVN 1 also stated he could not recall if he had documented Resident 1 ' s pain. LVN 1 stated he did not document Resident 1 ' s refusal of pain medication. LVN 1 stated he was aware Resident 1 had a left hip fracture. During a review of the facility P&P titled, Administering Pain Medications, dated 3/2020, the P&P indicated, The pain management program is based on a facility-wide commitment to appropriate assessment and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . ' Pain Management ' is defined as the process of alleviating the resident ' s pain based on his or her clinical condition and established treatment goals. 2a. During a review of Resident 1's Progress Notes (PN), dated 2/3/22, at 11:19 AM, the PN indicated, Resident 1 had a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Tx (treatment) may include Thera Ex (therapeutic exercises), Thera Act (therapeutic activities), Gait training, WC (whelchair) management, Group therapy and safety education as per POC (plan of care) for Rx (treatment) of Difficulty in walking to achieve LTG (long term goal) of returning to Mod (moderate ) 1 level in household ambulation using FWW (front wheel walker) for support. During a review of Resident 1's Physicians Order (PO), dated 2/2/22, the PO indicated, X-ray to left hip rule out fracture. During a review of Resident 1's Radiology (X-ray) Interpretation Report (RIR), dated 2/3/22, the RI indicated, Resident 1 had an X-ray of the left hip on 2/3/22. The results indicated, Acute (new onset) left hip fracture (break in the top of the thigh bone [femur] close to the hip joint). During a concurrent interview and record review on 2/23/22, at 1:27 PM, with Director of Nursing (DON), Resident 1's Radiology (X-ray) Interpretation Report (RIR), dated 2/3/22 was reviewed. The DON confirmed the X-ray was ordered on 2/2/22 at 1:38 PM. The X-ray was not done until 2/3/22 at 7:45 PM (more than 30 hours) and the facility was not informed of the results until 2/4/22 at 1:43 AM. 2b. During a review of Resident 1's Physicians Order (PO), dated 2/4/22, the PO indicated, Ortho (Orthopedic - branch of medicine dealing with bones and muscles) consult. During a concurrent observation, interview and record review on 2/23/22, at 1:27 PM, with Director of Nursing (DON), Resident 1 ' s Radiology (X-ray) Interpretation Report (RIR), dated 2/3/22 was reviewed. The RIR indicated Resident 1 had a left hip fracture. DON reviewed Resident 1 ' s electronic record and confirmed the physician (MD) ordered an orthopedic consult on 2/4/22 when he was informed of the x-ray results. DON stated the orthopedic consult did not occur until 6 days later on 2/10/22 in which the orthopedic MD ordered Resident 1 to be transferred to the acute hospital. DON stated an attempt was made to contact one orthopedic MD regarding the consult on 2/4/22, 2/6/22, 2/8/22, 2/9/22, and then the order for transfer on 2/10/22 was received. DON stated there were no other attempts to contact another orthopedic MD nor was there any documentation to show that any other attempts were made. DON stated there should have been other attempts to contact other orthopedic MDs to provide earlier intervention for Resident 1 ' s left hip fracture. DON confirmed Resident 1 ' s primary MD was never notified of the facility ' s inability to obtain an orthopedic consult for Resident 1 until six days after the order was given. DON stated if Resident 1 needed surgical intervention at the acute hospital, then she would consider the delay in orthopedic consult as a delay in treatment and care for her left hip. During a review of Resident 1 ' s ED [Emergency Department] Physician Notes (EDPN), dated 2/10/22, the EDPN indicated, Resident 1 arrived at the acute hospital with left hip pain on a scale of seven (7) out of 10 (scale of 7 to 10 = severe pain). During a review of Resident 1 ' s Operative Report (OPR), dated 2/12/22, the OPR indicated, Resident 1 had a surgical procedure that included placing an intramedullary rod (a metal rod placed into the cavity of the bone to treat a fracture of a long bone). During a review of the facility's policy and procedure (P&P) titled, Request for Diagnostic Service, dated 4/2007, the P&P indicated, Orders for diagnostic services will be promplty carried out as instructed by the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of the facility's P&P titled Change in a Resident ' s Condition or Status, dated 2/2017, the P&P indicated, Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident ' s medical/mental condition and/or status (e.g. [for example] changes in level of care, billing/payments, resident rights .)