Every finding on record at Lakeshore Rehabilitation Center LLC

Based on interview and document review, the facility failed to provide sufficient nursing staff to ensure 13 of 13 residents (R7, R4, R13, R31, R45, R35, R37, R42, R29, R35, R8, R24, R33), reviewed for sufficient staffing, received care and assistance in a timely manner. The lack of sufficient staff had the potential to affect all 42 residents who resided in the facility. Findings include: Refer to F676: Based on interview, observation, and document review, the facility failed to provide the necessary assistance with activities of daily living (ADL) to maintain ral hygiene for 1 of 2 residents (R42) reviewed for ADL assistance. Refer to F677: Based on interview and document review, the facility failed to provide oral care to 1 of 1 resident (R13) who was reviewed for assistance with activities of daily living (ADLs) and who was dependent upon staff for ADL cares. Refer to F688: Based on interview and document review, the facility failed to maintain, restore or improve the functional ability for 2 of 2 residents (R29, R37) reviewed for ADLs, when the facility failed to ensure residents were walked according to physical therapy (PT) instructions and physician orders. RESIDENT/FAMILY INTERVIEWS/ CALL LIGHT RESPONSE TIMES R7's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated orthopedic aftercare for hip fracture. R7 had intact cognition, clear speech, could understand and be understood. R7 required substantial assistance or was dependent upon staff for activities of daily living (ADLs). R7 was always incontinent of bowel and did not walk. During an interview on 7/13/26 at 11:21 a.m., R7 stated the facility was chronically short-handed; he didn't have bowel control and used his call lights to have his brief changed or to get in or out of bed. R7 stated he was frustrated with the length of time it took staff to answer his call light. R7 had 216 call light activations dated 5/12/26- 7/12/26, indicating call lights were answered in the following time frames: 21-30 minutes = 17 31-40 minutes = 6 41-50 minutes = 5 51-60 minutes = 1 61-70 minutes = 1 >70 minutes = 2 >130 minutes = 2 >150 minutes = 1 R4's quarterly MDS assessment dated [DATE], indicated cardio/respiratory condition, including congestive heart failure (when the heart cannot pump efficiently to meet the body's needs). R4 had intact cognition, clear speech, could understand and be understood. R4 required substantial assistance with oral hygiene, dressing, standing, sitting, toileting and walking short distances. During an interview on 7/13/26 at 10:25 a.m., R4 stated it took a long time for staff to answer her call light, I'm at the end of the hallway and I feel pissed off; happens daily. R4 had 342 call light activations dated 5/12/26- 7/12/26, indicating call lights were answered in the following time frames: 21-30 minutes = 19 31-40 minutes = 2 41-50 minutes = 1 51-60 minutes = 2 61-70 minutes = 1 R13's admission MDS assessment dated [DATE], indicated orthopedic after care for fractures and other multiple trauma. R13 had intact cognition, clear speech, could understand and be understood. R13 was dependent on staff for most all ADLs, was frequently incontinent of stool and did not walk. During an interview on 7/13/26 at 1:33 p.m., family member (FM)-A stated a few times when she had come into R13's room, her call light was not in reach and R13 had to yell for help. FM-A stated R13 was able to activate her call light and had waited up to 45 minutes for someone to respond. FM-A stated R13 had called her crying when no one came. FM-A stated R13 had pounded a cup on the overbed table to get the staff's attention. Observed call light on the floor behind the bedside dresser. FM-A handed it to R13. R13 had 111 call light activations dated 5/12/26- 7/12/26, indicating call lights were answered in the following time frames: 21-30 minutes = 3 31-40 minutes = 3 41-50 minutes = 2 51-60 minutes = 2 >80 minutes = 1 R31's quarterly MDS assessment dated [DATE], indicated fractures, heart failure and Alzheimer's disease. R31 had severe cognitive impairment, clear speech, could understand and be understood. R31 required substantial assistance with most ADLs, was always incontinent of bladder and bowel, and did not walk. During an interview on 7/13/26 at 2:08 p.m., R31 stated the facility was short staffed in the evening, and it took a long time for his call light to be answered. R31 stated he waited up to 45 - 60 minutes. R31 stated call lights were discussed at resident council meetings, but residents were pretty much blown off. R31 stated he used his call light to use bathroom or lay down. R31 stated staff ran and hurried and apologized, but there were not enough of them. R31 had 172 call light activations dated 5/12/26- 7/12/26, indicating call lights were answered in the following time frames: 21-30 minutes = 13 31-40 minutes = 5 41-50 minutes = 6 51-60 minutes = 1 71-80 minutes = 1 >140 minutes = 1 R45's quarterly MDS assessment dated [DATE], indicated stroke and heart failure. R45 had moderately impaired cognition, clear speech, could understand and be understood. R45 was always incontinent of bladder and bowel and did not walk. During an interview on 7/13/26 at 11:08 a.m., R45 stated he waited a long time for his call light to be answered. R45 stated service was better when he moved in (2024), but not now. R45 stated he had called the fire department and his sister for help in the past when no one answered his call light. R45 stated he used his call light for brief changes, get in or get out of bed. R45 had 34 call light activations dated 5/12/26- 7/12/26, indicating call lights were answered in the following time frames: >30 minutes = 1 >40 minutes = 2 R35's quarterly MDS assessment dated [DATE], indicated heart failure and diabetes. R35 had intact cognition, clear speech, could understand and be understood. R35 required substantial assistance for most all ADLs, was always incontinent of bladder and bowel and did not walk. During an interview on 7/13/26 at 3:13 p.m., R35 stated she had waited up to 1 1/2 hours for staff to answer her call light. R35 stated she used her call light for the bathroom and to go to activities. R35 stated she stayed in her wheelchair rather than recliner because it took too long for staff to come, and if in her wheelchair, was ready to go. R35 had 257 activations call light activations dated 5/12/26- 7/12/26, indicating call lights were answered in the following time frames: 21-30 minutes = 19 31-40 minutes = 11 41-50 minutes = 6 51-60 minutes = 1 61-70 minutes = 4 71-80 minutes = 1 91-100 minutes = 1 R37's annual MDS assessment dated [DATE], indicated R42 was cognitively intact, required supervision with personal hygiene, and partial/moderate assistance with dressing and transfers, utilized a manual wheelchair and diagnoses included muscle weakness. R37's care plan dated 6/2/26, indicated fall risk related to weakness, history of falling, assistance with ADL (activity of daily living) and transferring and interventions including monitor and document on safety, reminder sign on bathroom door to call for staff assist with toileting, assist of one with toileting. On 7/13/26 at 11:30 a.m., R37 was seated in a wheelchair in their room and stated they sometimes had to wait a long time for assistance while in the bathroom. R37 stated when they were unable to clean themselves after toileting, they remained in the bathroom waiting for staff assistance for approximately 30 minutes to one hour. R37 stated they would do what they could independently and return to their room without receiving assistance. R37 stated they did not like having to wait but understood staff were busy. R37 stated the delay was worse on the day shift and stated they were no longer able to clean themselves independently. Call light times dated 5/12/26-7/12/26, indicated the following : 143 activations 21-30 minutes = 8 31-40 minutes = 9 41-50 minutes = 8 51-60 minutes = 3 61-70 minutes = 1 >70 minutes = 2 R42's admission MDS dated [DATE], indicated cognitively intact, no rejection of care, required supervision or touching assistance with oral hygiene, diagnosis included displaced trimalleolar fracture of the right lower leg, subsequent encounter for closed fracture (break of the lower leg), and history of falling. R42's CAA (care area assessment) dated 5/21/26, indicated R42 had a decline in mobility following hospitalization for a fall that resulted in a right ankle fracture, in PT (physical therapy) and OT (occupational therapy) at this time, needing assistance with mobility and ADLs (activities of daily living), alert and oriented and able to make her needs known, plan to continue to provide assistance with ADLs and follow therapy recommendations. R42's care plan dated 5/15/26, indicated alternation in mobility, does not walk, assist with movement in bed and in/out bed, set up with personal hygiene. On 7/13/26 at 10:46 a.m., R42 stated they had to wait approximately 30 to 45 minutes for staff assistance with toileting needs, including urination and bowel movements. R42 stated they had not experienced accidents due to the delays but began wearing a brief because of the concern. R42 stated weekends were the worst due to short staffing and stated delays also occurred during shift change and during the week. R42 stated they learned to request assistance before shift change because staff would tell them, Sorry, we are short staffed. R42 stated there were times when they were left waiting on the commode and reported they had previously complained and cried about the delays, resulting in a room change to a different hallway. R42 stated delays continued after the move and were especially concerning when only one staff member was available when two staff members were needed for assistance. Call light times dated 5/12/26-7/12/26, indicated the following : 280 activations 21-30 minutes = 20 31-40 minutes = 11 41-50 minutes = 3 RESIDENT COUNCIL R29's quarterly MDS assessment dated [DATE], indicated intact cognition, use of walker and wheelchair, partial assistance with toileting, bathing, and transfers, and diagnoses of heart failure and high blood pressure. R35's quarterly MDS assessment dated [DATE], indicated intact cognition, use of wheelchair, dependent with toilet use, substantial assistance with bathing, substantial assistance for transfers, and diagnoses of heart failure and kidney insufficiency. R8's admission MDS assessment dated [DATE], indicated intact cognition, use of walker and wheelchair, substantial assistance for toileting and dressing, independent with transfers, and diagnoses of high blood pressure and diabetes mellitus. R24's quarterly MDS assessment dated [DATE], indicated intact cognition, use of walker, independent with hygiene, dressing, and transfers, and diagnoses of cancer and heart failure. R33's quarterly MDS assessment dated [DATE], indicated intact cognition, use of walker and wheelchair, independent with dressing, eating, and transfers, and diagnoses of high blood pressure and Parkinson's disease. During resident council meeting on 7/14/26 at 1:50 p.m., the following statements were documented: R29 stated staffing was a big concern at the facility. R29 stated she waited over 30 minutes for her light to be answered and sometimes had to have her bath rescheduled. R29 further stated concerns had been brought up at resident council meetings but the council had not heard back on what had been done about staffing concerns and long call light wait times. R35 stated her call light was answered after 30 minutes and sometimes up to 90 minutes. R35 stated that was too long to wait. R35 also stated she missed her bath due to lack of staff at the facility. R8 stated she was fairly independent and did not need much help, but has heard other residents say it took a long time for their lights to be answered. R8 stated she participated in resident council meetings and staff response time and lack of staff was always a topic, but had not heard a response from the facility. R24 stated she waited over 30 minutes multiple times for her light to be answered and she thought weekends were particularly worse. R24 further stated she had missed her bath and it sometimes took three days for staff to get caught up and give her a bath. R24 stated she did not like waiting an additional three days. R33 stated 20 minutes was too long for him, and he often had to wait over 20 minutes. R33 further stated if he had to go to the bathroom and waited over 20 minutes, he would have an accident in his brief. R33 stated he had accidents due to waiting more than he would like to admit. During interview on 7/15/26 at 7:58 a.m., activities assistant (AA)-A stated she facilitated resident council meetings and took meeting minutes. AA-A stated the facility did not do a formal follow-up to resident concerns, did not have anything in writing, and did not recall how or if resident council concerns regarding staffing had been addressed. STAFF INTERVIEWS During a confidential interview, employee-C stated the unit known as the south unit, used to have three nursing assistants (NAs) and now had two. Employee-C was aware some residents complained of long call light wait times. Employee-C stated the unit had a lot of residents who required significant assistance from NA staff for dressing, toileting, and two staff for transfers and/or use of mechanical lifts. In addition, employee-C stated staff were not provided walkie-talkies so spent a lot of time looking for each other. Employee C stated it was important for NA staff to be able to communicate information to the nurse quickly, and if had to go room to room looking for the nurse, valuable time could be wasted. Employee C stated many times she has had to go room to room looking for an NA. During a confidential interview, employee-F stated it was pretty common to get complaints from residents about long call light wait times and they were surprised when she got there right away. Employee-F stated the facility did not use walkie-talkies and often had to go room to room to look for a coworker. Employee F stated she had been in a situation where a resident fell, had to put a pillow under their head, and leave the room to find the nurse. Employee-F stated they had a meeting last year after State surveyors left and they brought up walkie-talkies, but nothing changed. Employee F stated a lot of things were talked about, but nothing got done. Employee-F stated currently six residents required the use of a mechanical lift which tied up two NAs for long periods. Employee F stated NAs gave baths on the evening shift which she didn't think was good because that left the other NA on the floor alone causing delays in helping with two-person assists. During a confidential interview, employee B stated she was aware some agency nurses would not return to work at the facility because staffing levels never improved. Employee B stated the south unit had 24 high-acuity residents with only two NAs, adding that was a safety concern. Employee-B stated leadership knew they were short staffed and should be doing something about it. Employee-B stated staff were afraid to speak up for fear of losing their job. Employee-B stated there were no walkie-talkies for communication, so staff had to run around to track people down. Employee-B stated the facility was not able to meet the needs of residents and was aware some families had removed their family member from the facility because of that. During a confidential interview, employee-D stated they were short staffed and used a lot of agency staff. Employee D stated they did their best but acknowledged residents sometimes waited a long time to get care. Employee D stated they did not use walkie-talkies, so often had to go up and down the hall looking for help and that caused delays. On 7/13/26 at 5:00 p.m., nursing assistant (NA)-B stated there were two nursing assistants working today. NA-B stated that on the previous evening, after 6:00 p.m., they were the only nursing assistant because the agency staff member who had been scheduled to work did not report. NA-B stated the agency staff member had been scheduled to work doubles throughout the weekend but was unsure whether they had reported for any of the shifts. NA-B stated they provided evening cares and answered call lights by herself the day prior. NA-B stated it was not common to have only one nursing assistant scheduled on the east and west, due to agency staff not showing for the scheduled shift. NA-B stated there were usually two nursing assistants assigned to the south hall and estimated approximately six residents required two-person assistance. NA-B stated call light response times could be delayed depending on the how many staff were working and the needs of the residents. NA-B stated the facility does not have any tools in place to assist staff with requesting help such as walkie talkies and staff would need to yell if assistance was needed. On 7/13/26 at 5:10 p.m., licensed practical nurse (LPN)-A, stated two nursing assistants were sufficient for the east and west hallway, but if only one nursing assistant was available the nurse would need to assist. LPN-A stated it occurred more often that only one nursing assistant was available because agency staff failed to report for work. LPN-A stated when this occurred, staff attempted to call employees who were off duty and notified the director of nursing for direction. On 7/13/26 at 5:43 p.m., a call light illuminated for room [ROOM NUMBER]. NA-C was observed responding to the call light. At 5:46 p.m., another call light illuminated for Room W-2 while NA-C remained in room [ROOM NUMBER]. NA-C stated, I can't leave this resident alone. My partner is on break. The call light remained active until 5:57 p.m. On 7/13/26 at 6:21 p.m., NA-C stated they had been asked to report early to their shift because baths scheduled over the weekend had not been completed and staff were attempting to complete the missed baths. On 7/14/26 at 8:32 a.m., the trained medication aide (TMA)-B stated it was difficult for one TMA to complete medication administration and additional help would be beneficial. The TMA stated they were the only TMA for the building. The TMA stated there were usually two NA's scheduled for east and west hall but occasionally only one was available when someone called in or agency staff did not report. On 7/14/26 at 8:46 a.m., NA-A stated they were scheduled to work from 6:00 a.m. to 2:30 p.m., on 7/11/26, but remained at the facility until 6:00 p.m. because another staff member did not report. NA-A stated they were the only nursing assistant on Sunday 7/12/26, from 6:00 a.m. to 2:30 p.m. NA-A stated baths, resident weights, and ambulation were not completed because only one nursing assistant was available. NA-A stated residents experienced delays in call light response times and questioned why staff took longer to respond. NA-A stated it was not uncommon to have only one nursing assistant working on weekends. On 7/14/26 at 9:07 a.m., the social services director (SS)-A stated residents had complained about call light response times and was not a surprise. SS-A stated when residents have concerns regarding call light response times, residents were encouraged to speak with the charge nurse and staff are educated regarding the concerns. SS-A stated concerns regarding call light response times were a known concern at the facility and stated it was not a surprise that concerns regarding resident call lights were identified during the survey. On 7/14/26 at 9:09 a.m., the administrator stated call light response times had previously been reviewed and acknowledged there were some lengthy response times. The administrator stated they could not specifically recall any exceeding 30 minutes but believed any response time over 30 minutes would be considered significant. The administrator stated R42 voiced concerns with long call light times and R42 call lights were reviewed and the administrator stated they did not remember whether there were more than two occurrences over 30 minutes. The administrator stated staff discussed the concerns with R42 and believed transferring R42 to another wing would improve response times. The administrator stated additional call light logs were not reviewed because no grievances had been filed. The administrator stated the facility does not routinely conduct call light audits. The administrator stated the last review of call light logs occurred approximately two months earlier during an investigation in which each wing was reviewed. The administrator stated concern would generally be identified if more than two or three rooms demonstrated call light response times exceeding 30 minutes. The administrator stated they did not review the call light logs provided during this survey, did not believe the facility had long call light response time issues, and stated concerns would be addressed in real time rather than through the QAPI process. On 7/14/26 at 9:36 a.m., LPN-B stated call light response times on the south hall could exceed 30 minutes. LPN-B stated staff were burned out, were frequently called on their days off to pick up shifts due to staffing shortage, residents missed baths and resident ambulation was not completed occurred due to staffing shortages. LPN-B stated some residents did not receive breakfast until approximately 9:30 a.m. because morning cares were delayed. LPN-B further stated the facility did not provide walkie-talkies, requiring staff to search for coworkers when assistance was needed, which further delayed resident care and call light response. On 7/14/26 at 9:45 a.m., NA-D stated when staff members leave for breaks, only one staff member remains on the unit, resulting in residents frequently experiencing long wait times for assistance. NA-D stated when a resident requires a two-person transfer to the toilet, other residents may have to wait for assistance until additional staff are available. NA-D stated management was aware of long call light response times and that the facility's computer system tracked call light response times. NA-D stated staff had voiced concerns regarding delayed response times to management and were instructed to respond to residents more timely; however, staffing levels were not increased. NA-D stated staff responded to call lights as quickly as possible and did not have downtime but could not respond more quickly when there were not enough staff available. NA-D further stated staffing decisions were based solely on resident census. NA-D confirmed R42 had been moved to a different unit due to concerns regarding delays in receiving care. NA-D further stated overnight staff would at times assist R42 to the toilet and then leave to assist another resident, resulting in R42 waiting approximately 30 minutes for assistance before staff returned. On 7/14/26 at 2:42 p.m., nursing assistant (NA)-C stated the facility had a lot of staff who didn't come for their shifts, especially on the weekends, particularly agency staff. NA-C further stated the facility used a star system to ensure coverage and she had to stay later than her scheduled shift often to cover for other staff who didn't show up. NA-C stated staffing was not adjusted based on resident needs, there was always a set number of three or four nursing assistants no matter how many residents there were in the facility. NA-C stated it was hard to get help when needed and residents had to wait a long time. On 7/14/26 at 2:46 p.m., NA-B stated when they were short-staffed residents had to wait a long time for help. NA-B further stated they were short-staffed a lot, especially on weekends. On 7/14/26 at 4:51 p.m., the director of nursing (DON) stated weekend staffing schedules posted in the facility were not updated in real time to reflect actual staffing. The DON stated they spent a significant portion of her day providing resident care because of staffing shortages and stated agency staff had contributed to the staffing problems and doing a disservice to the facility. On 7/15/26 at 6:38 a.m., LPN-C stated she worked the night shift and if there were 42 residents, one nurse and two NAs were adequate, but when the census rose to 47 or 48 it was not. LPN-C stated there were one NA on each floor and her, and at 1:30 a.m., and 4:30 a.m., the NA from first floor went to second floor to help, and they covered each other for breaks. LPN-C stated they used to have walkie-talkies but didn't anymore and didn't know why, so they used their personal cell phones or the house phone to contact each other. In order to know if a call light was going off, LPN-C stated staff had to be in the hallway to observe the scrolling marquee and might hear the beep (indicating a call light was activated) or you might not. On 7/15/26 at 8:49 a.m., LPN-A stated that when staffing is limited, nurses may need to assist; however, one staff member caring for approximately 21 residents is insufficient. LPN-A stated they have heard residents report staffing shortages on multiple occasions. LPN-A further stated the south wing requires three staff members and delays occur when staff must search room-to-room for assistance. LPN-A stated staff previously used walkie-talkies, but without them staff may not know another resident requires assistance. LPN-A stated they had spent significant time looking for available staff and has been told by residents they have waited up to 30 minutes for assistance. LPN-A stated the director of nursing (DON) was aware of these concerns and frequently works on the floor, where the issues should be readily apparent. LPN-A stated the facility did not provide staff with walkie-talkies. LPN-A stated this created a safety concern because if a resident fell, was bleeding, or required immediate assistance while staff were in another resident's room, they would not be able to quickly obtain help from another staff member. On 7/15/26 at 9:05 a.m., maintenance director (MD)-A provided resident care unit distance measurements: first floor from beginning of the east hallway to end of the west hallway was 130 feet (equivalent to a 12-13 story building). Distance on the south unit, from first room to last room was 206 feet (more than half the distance of a football field) On 7/15/26 at 11:00 a.m., the vice president of operations (VPO) stated that Interim Regional Operations Director was on vacation at the time of the interview and that he was covering her responsibilities. VPO stated the facility administrator was responsible for completing the facility assessment, and stated that he would expect the facility assessment to include staffing numbers and information regarding the facility's staffing levels. VPO did not identify any specific staffing concerns and stated that the facility occasionally utilizes agency staff to address staffing needs when necessary. VPO stated that the administrator would be expected to review staffing trends and patterns, ask specific questions regarding identified issues, and ensure that appropriate actions were implemented. VPO stated if concerns such as extended call light response times were identified, the administrator would be expected to investigate the issue by asking questions such as when the delays are occurring, whether they are isolated to a particular shift and what interventions were needed. VPO stated that the organization uses a standardized QAPI meeting format across all facilities. VPO stated that the facility should monitor call light response times, evaluate whether staffing adjustments are necessary, and address any identified concerns through the QAPI program. On 7/15/26 at 2:30 p.m., the DON stated staffing levels were determined based on resident acuity, resident census, holidays, anticipated resident needs, and hours per resident day (PPD), with a target of approximately 3.0 PPD. The DON stated resident needs were reviewed during the morning meeting, including new admissions and residents requiring additional assistance. However, when asked how resident acuity was incorporated into staffing decisions, the DON was unable to clearly explain the process or identify how staffing assignments were adjusted to meet resident care needs. The DON stated staffing assignments varied by unit, with lighter staffing on the east and west halls and staff floating to the south hall as needed. The DON stated staff were supposed to carry pagers to receive call light notifications but acknowledged the pagers were missing and stated, Maybe they're lost. The DON further stated staff would have to leave a resident's room to view the scrolling call light display at the end of the hallway. The DON stated the facility had purchased walkie-talkies approximately one month earlier but had not implemented their use. After discussion regarding delayed staff response, the DON stated walkie-talkies could be implemented that evening to improve communication. When asked how the facility determined staffing was adequate, the DON stated residents were cared for, there were no odors, pressure ulcers were not worsening, residents were happy, and meals were provided. However, the DON was unable to identify specific monitoring processes to ensure resident oral care, bathing, and other activities of daily living (ADLs) were consistently completed. The DON acknowledged managers, including the DON, frequently provided direct resident care because of staffing shortages and stated the facility did not have enough staff to add additional personnel. The DON further stated nursing assistant documentation was poor because some staff lacked electronic medical record (EMR) access, documentation was lost, agency staff lost documentation, and staff did not have time to complete documentation. When informed that multiple residents and staff independently reported delays in care and prolonged call light response times, the DON stated there was no explanation for why this was occurring. On 7/15/26 at 3:03 p.m., the administrator stated daily staffing decisions were based on resident census, resident acuity, and PPD following discussion of admissions, discharges, and resident needs during the daily stand-up meeting. The administrator stated staffing adequacy was evaluated by the absence of wounds, falls, odors, resident complaints, and whether residents were coming to the nurses' station. The administrator acknowledged the facility did not routinely monitor call light response times and stated the last review of call light data occurred approximately two weeks earlier for a single resident concern rather than reviewing facility-wide trends. The administrator stated staffing was adjusted for resident acuity, including hospice residents, residents requiring mechanical lifts, extensive wounds, and psychosocial needs. However, the administrator acknowledged staff communication regarding resident call lights was not functioning as expected. The administrator believed staff carried pagers but acknowledged only one working pager was available at each end of the building and stated staff would have to leave a resident's room to obtain assistance or holler for help because no established communication process was in place. The administrator further stated staff were expected to complete documentation throughout the shift when they have a minute, however no time is dedicated to documentation. On 7/15/26 at 3:41 p.m., RN-C, known as the regional nurse consultant, stated staffing levels were based on PPD and resident acuity, with staffing increased when residents required additional care. RN-C stated the facility was budgeted for a specific PPD and staffing adjustments required clinical justification. However, RN-C acknowledged resident care was not consistently being completed and specif

Based on interview and document review, the facility failed to ensure the Facility Assessment included information on staffing levels needed for specific shifts. This deficient practice had the potential to affect all 42 residents who resided in the facility.Findings include:Review of Facility assessment dated 6/2026, indicated the following:Section 3. Facility resources needed to provide competent support and care for our resident population every day and during emergencies:3.2 & 3.3. Direct Care Staffing Plan: To ensure an adequate amount of staff at Lakeshore Rehabilitation Center at all times, the resident population, case mix index (CMI), and census if taken into account daily to determine sufficient staffing needs. Lakeshore's interdisciplinary team (IDT) reviews census on the daily census template sent out daily by Health Information to determine the needs on each unit. Any admissions and discharges planned also factor in and assist in determining the staffing needs for each day on each unit. Individual staff assignments for continuity of care for residents and across staff assignments is determined by the director of nursing (DON), nurse management, charge nurse, unit nurse in that order of hierarchy.The facility assessment did not include information on staffing levels needed for specific shifts, such as day, evening, and night and adjusted as necessary based on changes to resident population.During interview on 7/14/26 at 3:37 p.m., when confirming the provided facility assessment was correct, administrator stated she gave the state agency (SA) the correct and most current version and she would not put specific information in the facility assessment about staff requirements for each shift because staffing fluctuates so much.During interview on 7/15/26 at 8:02 a.m., administrator stated she was aware specific staffing date should be in the facility assessment, and she must have accidentally deleted the staffing information. Administrator stated she reached out to corporate for an updated version. Administrator further confirmed the facility did not use the daily census template to review staffing needs as directed in the facility assessment, but the IDT did talk about census daily. Administrator also stated the facility did not have a specific algorithm they used to determine needed staffing levels and would refer to their facility assessment to determine staff needed to meet resident's needs.A facility document titled Staffing Levels Per Patient Day (PPD) Compliant undated, indicated staffing levels were based on resident census numbers.A facility policy on facility assessment requirements was requested but not received.

Based on interview and record review, the quality assurance and performance improvement (QAPI) committee failed to identify resident call light wait time concerns prior to survey, nor make a good faith attempt to correct the deficiency. This deficient practice had the potential to affect all 42 residents residing in the facility. Findings include: QAPI meeting minutes dated 3/31/25, indicated, Call lights tend to be #1 issue. Call light response times had not been included/mentioned again in the subsequent six QAPI meeting minutes. During an interview on 7/14/26, 11:07 a.m., with regard to the 3/31/25, meeting minutes about call lights being the number one issue, the administrator stated she assumed they (QAPI committee) had conducted follow-up related to concerns about call light wait times, did an audit and determined it wasn't an issue, however there was no documentation to support this. During an interview on 7/15/26 at 11:00 a.m., the vice president of operations (VPO) stated that Interim Regional Operations Director was on vacation at the time of the interview and that he was covering her responsibilities. VPO stated that the organization uses a standardized QAPI meeting format across all facilities. During QAPI meetings, the facility is expected to analyze data, discuss findings, review audit results, perform root cause analyses, develop action plans, and monitor the effectiveness of interventions. VPO stated regarding call light response times, that if ongoing concerns existed, the facility should utilize call light logs to identify trends, review the information through the QAPI process, and implement corrective actions. VPO stated that the facility should monitor call light response times, evaluate whether staffing adjustments are necessary, and address any identified concerns through the QAPI program. During an interview on 7/16/26 at 9:46 a.m., the administrator stated current survey findings of long call light response times had not been on her radar. The administrator admitted there had been no staff meetings where QAPI meeting activities had been communicated to employees nor were employees asked for feedback about potential concerns related to resident care. Facility QAPI Plan with review date of 1/2/26, indicated the organization used QAPI to make decisions and guide their day-to-day operations, and included all employees, all departments and all processes. Decisions were based on data which included input from caregivers, residents, families and other stakeholders. Data sources for bench making progress would include information from residents and family interviews and staff surveys. All staff would be encouraged to communicate concerns and ideas to any department manager.

Based on interview and document review, the facility failed to develop and implement action plans, measure the success of actions and track performance, conduct a performance improvement project (PIP), and regularly review, analyze, and act on data collected. This deficient practice had the potential to affect all 42 residents residing in the facility. Findings include:Due to numerous sufficient staffing and long call light wait time concerns expressed by residents, family members and staff, QAPI (quality assurance and performance improvement) meeting minutes were reviewed.QAPI meeting minutes from March 2025 through June 2026, indicated the following:3/31/25 - Minutes lacked substance. No actions or resolutions. Identified under grievances: call lights tend to be #1 issue. Not mentioned again. 6/18/25 - No documentation of minutes.9/30/25 - Minutes lacked substance. Not able to determine actions or resolutions.12/17/25 - No documentation of minutes.1/14/26 - No documentation of minutes.3/18/26 - No documentation of minutes.6/10/26 - No documentation of minutes.During an interview on 7/14/26, 11:07 a.m., with regard to the lack of documentation of actions or resolutions at QAPI meetings, the administrator stated their meeting discussions were mostly verbal and admitted the minutes did not reflect their discussions. The administrator stated they needed to take better notes. With regard to the 3/31/25, meeting minutes about call lights being the number one issue, the administrator stated she assumed they (QAPI committee) had conducted follow-up related to concerns about call light wait times, did an audit and determined it wasn't an issue, however there was no documentation to support this. During an interview on 7/16/26 at 9:46 a.m., the administrator stated she set the QAPI meeting agenda, facilitated the meetings and documented the meeting minutes, and that quality measures were monitored at both a corporate level and locally. The administrator admitted the minutes lacked identification of issues, analysis, monitoring, auditing, outcomes, and acknowledged the documentation needed to be improved as the minutes did not reflect activities of the committee. During the same interview, the administrator stated a PIP for 2026, had been unplanned weight loss. The administrator stated the only data obtained had been weight loss information from the dietician, and admitted they had not conducted a root cause analysis nor considered other important data such as diet orders, food preferences, observations of residents eating, involvement of family, use of supplements, etc. The administrator admitted their work lacked all available data and did not include a comprehensive analysis, action plan or audits.During a telephone interview on 7/15/26 at 11:00 a.m., vice president of operations (VPO) stated he had not been aware of anything specific related to quality indicator concerns at the facility. If there were resident concerns about call lights, he would ask specific questions, look at trends and patterns. For example, if long call lights were around the supper meal, he would expect an analysis of the situation and potentially add staff or reassign responsibilities. VPO stated he would expect QAPI minutes to identify data had been analyzed, a root cause analysis completed, action/interventions identified. For long call light wait times, circle back with residents, look at specific grievances, ask specific questions - time of day, day of week, etc. Adjust operations and business practices, monitor, audit. Call light logs should be utilized if a facility can run them, and then data presented to the QAPI committee for review.

Based on interview and document review, the facility failed to ensure resident concerns identified at resident council meetings were addressed and residents notified of a resolution or ongoing measures to ensure compliance. This affected all 9 residents (R8, R24, R25, R28, R29, R30, R33, R35, and R36) who attended resident council. Findings include:R29's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated intact cognition, use of walker and wheelchair, partial assistance with toileting, bathing, and transfers, and diagnoses of heart failure and high blood pressure.R35's quarterly MDS assessment dated [DATE], indicated intact cognition, use of wheelchair, dependent with toilet use, substantial assistance with bathing, substantial assistance for transfers, and diagnoses of heart failure and kidney insufficiency.Review of the resident council minutes dated 7/6/26, 6/10/26, 3/26/26, and 3/11/26, indicated concerns with wheelchair maintenance, toilet leaking, missing socks, mealtime service delays, food quality and temperature, and long call light times. The meeting minutes did not include follow-up or explanations of how or when the concerns would be addressed, or if they were ever addressed.During resident council interview on 7/14/26 at 1:50 p.m., R29 stated staffing was a big concern at the facility and she sometimes waited over 30 minutes for her call light to be answered. R29 further stated she had brought those concerns up at resident council but had never gotten any answer from facility staff whether her concern was addressed. R29 stated the council brought things up at meetings but didn't hear back and nothing was ever done about it. R20 stated she didn't know the council was supposed to get a response to their concerns.During resident council interview on 7/14/26 at 1:50 p.m., R35 stated she was unaware of any follow-up on resident council concerns and had never heard any solutions to concerns brought up at resident council.During interview on 7/15/26 at 7:58 a.m., activities assistant (AA)-A stated she helped facilitate the resident council meetings and typed the minutes. AA-A stated she was unable to find any evidence of replies to resident council concerns but was sure they were addressed verbally. AA-A stated she was not aware a formal response in written form should be given to the resident council and would have to start documenting follow-up for resident concerns.During interview on 7/15/26 at 1:40 p.m., administrator stated she would expect the resident council to receive responses from leadership addressing their concerns. Administrator further stated she was unaware concerns were not being addressed or documented. Administrator stated she would expect staff to follow federal regulations.A facility policy on responses to grievances and resident council concerns was requested but not received.

Based on observation and interview, the facility failed to maintain a clean, comfortable, and homelike environment for residents residing in East and [NAME] hallways resulting in large dark stains, fraying and worn carpet throughout the hallway and damaged, cracked, sagging, and discolored ceiling tiles in the east hallway bath tub room. Findings Include: On 7/13/26 at 5:09 p.m., observation of the east hallway outside resident rooms identified a discolored dark stain on the flooring measuring approximately 11/2 feet by 6 inches, irregularly shaped with darkened edges and concentrated areas of discoloration. The stains were distributed throughout the hallway and were readily visible from a distance due to the contrast between the stained areas and the surrounding carpet. The carpeting appeared worn and soiled. On 7/13/26 at 5:21 p.m., the licensed practical nurse (LPN)-A stated the hallway carpeting was stained and frayed, and further stated the carpet was not securely attached at the seams. LPN-A stated the carpet had been shampooed the previous week; however, the stains remained because the carpeting was old. On 7/13/26 at 5:53 p.m., the environmental services manager (EVSM)-C stated the flooring had been scrubbed multiple times without improvement and that requests for replacement flooring had been ongoing for an extended period. EVSM-C stated the ripped carpet and stained flooring were maintenance issues, described the condition as embarrassing and unfair to the residents, and confirmed the concerns were included in weekly reports submitted to environmental management. EVSM-C stated the carpeting was a concern and reported attempts had been made to clean the carpet; however, the staining worsened during humid conditions. On 7/14/26 at 10:04 a.m., the maintenance director (MD)-A and administrator confirmed the carpeting was not secure and frayed and stated anything could be tripped on. They stated the carpet had been glued previously at the seams and replacement had been discussed; however, no replacement date had been established. The administrator acknowledged residents would not be expected to live with frayed carpeting or holes in the carpet as it is not a homelike environment. The administrator stated the carpet condition was a known concern and acknowledged the stains remained despite shampooing. The administrator stated the carpeting does not look good or homelike, confirmed awareness of the condition. The administrator confirmed the carpets on the East and [NAME] halls did not provide a homelike environment. On 7/14/26 at 12:23 p.m., observation of the east hallway identified multiple areas where the carpeting was worn through with the carpet backing visible. Several carpet seams were frayed and separated, creating raised edges. Numerous irregularly shaped dark brown and black discolored areas of varying sizes were present throughout the hallway carpeting. On 7/15/26 at 7:13 a.m., observation of the bath tub room on the east hallway revealed a ceiling tile surrounding the sprinkler head with a large circular brown discolored area measuring approximately 18 to 24 inches in diameter, with a darker brown ring around the outer edge and a lighter-colored center. An adjacent ceiling tile had an additional irregularly shaped brown discolored area extending across the edge of the tile. Additional ceiling tiles were observed to be cracked, broken, and sagging, with visible deterioration to the tile surfacesOn 7/15/26 at 12:55 p.m., MD-A while observing the ceiling confirmed the ceiling tile in the bathroom was stained and stated the facility has a flat roof. MD-A further stated the ceiling tile was busted.On 7/15/26 at 12:59 p.m., the administrator observed the condition of the ceiling and confirmed they would expect the stained and cracked ceiling tiles to be replaced. The Facility document The Revisor of Statues dated 2007, indicatedA nursing home must provide a safe, clean, functional, comfortable, and homelike physical environment, allowing the resident to use personal belongs to the extent possible.

Based on interview and document review the facility failed to ensure the Minimum Data Set (MDS) assessment was coded accurately for 1 of 1 resident (R50) reviewed for discharge a by inaccurately coding a planned discharge as an unplanned discharge, and failed to follow the Resident Assessment Instrument (RAI) Manual.Findings include:R50's discharge assessment - return not anticipated MDS dated [DATE], indicated unplanned discharge to home/community on 6/28/26, cognitive skills for daily decision making: modified independence - some difficulty in new situations only; was independent with oral hygiene, toileting hygiene, dressing, personal hygiene, transfers, walking, did not use a wheelchair, diagnoses indicated hemiplegia following cerebral infarction affecting left non-dominant side (stroke-related condition where a blood clot or blockage; has caused paralysis or severe weakness on the left side of the body). R50's discharge instructions dated 6/25/26 at 1:37 p.m., licensed practical nurse (LPN)-A indicated discharge home, reason for discharge: resident request, admission date 4/28/26, came to our facility following hospitalization for CVA (stroke) with left sided weakness and left sided vision deficit. Has worked with therapy and is now independent with all cares, further the document was signed by R50 and indicated understood the medication instructions and other instructions given to me by the healthcare professional.R50's document titled notice of resident/patient transfer or discharge 6/29/26, social services (SS) director-A indicated date of anticipated discharge 6/28/26, date notice provided 6/26/26, the transfer or discharge is/was appropriate because the resident's health has/had improved sufficiently so the resident no longer needs/needed the services provided by the facilityR50's provider note progress note dated 6/25/26, nurse practitioner (NP)-D indicated okay to discharge to home with current meds and treatment plan. R50's progress note dated 6/28/26 at 8:45 a.m. the director of nursing (DON) indicated R50 packed personal belongings and brought to the front door awaiting on dtr (daughter) pick up, ambulating independently w/o (without) aid, reviewed d/c medications with resident again. Understanding noted AEB (as evidenced by)resident repeating instructions, reading out loud and familiarity/awareness with names and dosing of medications, provided printed out MAR (medication administration record) for June/July so resident has 'a graph' so she can check off after taking. informed resident and dtr that writer spoke with pharmacist at pharmacy yesterday to ensure medications were ready for pick up, R50 excited to be returning home. D/C (discharge) instructions, meds and personal belongings with resident. discharged to home via private vehicle/dtr.On 7/15/26 at 10:00 a.m., the director of nursing (DON) stated R50's MDS had been completed as an unplanned discharge because the timing of the discharge changed at the last minute and the facility was not prepared for the resident to leave that day. The DON stated the family situation was dysfunctional and there was uncertainty regarding transportation and whether R50 would return home with family or independently. The DON confirmed R50 was ready for discharge; however, the facility had not planned for the resident to leave on the day of discharge. The DON confirmed the discharge process was followed, a provider discharge order was obtained, all necessary discharge paperwork and education were provided to R50, and R50 did not leave AMA (against medical advice).On 7/15/26 at 11:49 a.m., registered nurse (RN)-A, the MDS coordinator, stated R50's discharge arrangements were finalized only a couple of days before discharge and the assessment was coded as an unexpected discharge because they believed that coding was consistent with the Resident Assessment Instrument (RAI) Manual. The MDS coordinator stated R50 did not leave AMA and that although the facility did not know the exact day R50 would leave until shortly before discharge, a provider discharge order had been obtained and facility discharge instructions had been completed.On 7/15/26 at 11:59 a.m., licensed practical nurse (LPN)-A stated R50 had been working toward discharge home, discharge planning discussions had occurred several days before discharge, and a provider discharge order had been obtained. The nurse stated the uncertainty involved whether R50 would return home with family or independently, not whether R50 would be discharged from the facility.On 7/15/26 at 12:22 p.m., the nurse practitioner (NP)-D stated R50's discharge was planned and was not an unexpected discharge.On 7/15/26 at 12:47 p.m., the social services (SS)-A director stated R50's discharge had been planned, a care conference had been held regarding the discharge, and the MDS would not be expected to be coded as an unplanned discharge.Review of the RAI Manual dated 10/25, indicated an unplanned discharge occurs when the discharge was unexpected, such as an acute hospitalization or the resident leaving against medical advice. Because R50's discharge planning had occurred over several days, a provider discharge order had been obtained, discharge instructions were completed, and the resident did not leave AMA, the discharge did not meet the definition of an unplanned discharge. Facility Discharge Planning Policy dated 1/25, indicated at discharge the rounding provider must write an order for discharge, if the rounding provider refuses to write a discharge order and the resident insists on being discharged anyway refer to Against Medical advice policy.

Based on interview, observation, and document review, the facility failed to provide the necessary assistance with activities of daily living (ADL) to maintain oral hygiene for 1 of 2 residents (R42) reviewed for ADL assistance. Findings include: R42's admission Minimum Data Set (MDS) dated [DATE], indicated cognitively intact, no rejection of care, required supervision or touching assistance with oral hygiene, diagnosis included displaced trimalleolar fracture of the right lower leg, subsequent encounter for closed fracture (break of the lower leg), and history of falling. R42's CAA (care area assessment) dated 5/21/26, indicated R42 had a decline in mobility following hospitalization for a fall that resulted in a right ankle fracture, in PT (physical therapy) and OT (occupational therapy) at this time, needing assistance with mobility and ADLs (activities of daily living), alert and oriented and able to make her needs known, plan to continue to provide assistance with ADLs and follow therapy recommendations.R42's care plan dated 5/15/26, indicated alternation in mobility, does not walk, assist with movement in bed and in/out bed, set up with personal hygiene. R42's task: personal hygiene the ability to use suitable items to clean teeth, dated 6/16/26-7/14/26, indicated the following data that R42 was provided setup assistance, partial assistance, or independent6/19/266/20/266/22/266/24/266/26/266/27/266/28/266/29/266/30/2667/1/267/2/267/3/267/5/267/7/267/9/267/13/26The data provided failed to indicate R42 was provided daily set up assistance with oral care. R42's treatment administration record (TAR) dated 7/1/26-7/30/26, indicated start date 5/14/26, NWB (non-weight bearing) rt (right) leg every shift, CAM boot; wea with all activitiesincluding sleeping. May remove for skin hygiene, icing and ankle ROM every shift for right ankle fractureOn 7/13/26 at 10:51 a.m., R42 was observed seated in a recliner wearing a black orthopedic boot on the right lower leg. R42 stated she was non-weight bearing due to a fractured leg and required staff assistance to obtain her toothbrush, toothpaste, a cup of water, and assistance to empty the water after brushing her teeth. R42 stated she did not receive assistance with morning oral care every day. R42 stated she frequently requested assistance; however, staff told her they did not have time because they were assisting other residents. R42 stated she stopped asking because she did not want another resident to have to wait for care. R42 stated she had been moved from another area of the facility because she was told the current hallway was less busy and she would receive timelier assistance. On 7/14/26 at 8:18 a.m., R42 stated she had not yet received morning care. She stated she preferred to eat breakfast before receiving assistance to wash up. R42 also stated she previously experienced long call light response times and had been instructed to call the facility's main telephone number when her call light was not answered.On 7/14/26 at 8:51 a.m., nursing assistant (NA)-A stated there were times staff did not have enough time to assist R42 with obtaining the supplies needed to brush her teeth and acknowledged assistance could be delayed until approximately 1:00 p.m. NA-A confirmed there were occasions when R42 requested assistance and they told R42 they were too busy. NA-A further stated R42 required assistance to obtain a glass of water and to empty the cup after brushing her teeth.On 7/14/26 at 9:00 a.m., the social services director (SS)-A stated R42 had previously been moved to another hallway due to concerns regarding long call light response times. SS-A confirmed review of call light logs identified response times exceeding 25 minutes for R42. Staff were educated regarding timely responses, and R42 was provided the front desk telephone number if assistance was not received. SS-A acknowledged R42 should not have to call the front desk to obtain assistance.On 7/14/26 at 9:09 a.m., the administrator confirmed R42 had expressed concerns regarding long call light response times and that the call light logs had been reviewed. The administrator stated she did not recall response times greater than 30 minutes and considered call light response times exceeding 30 minutes to be significant. The adminstrator stated R42 to was moved to a less busy hallway. On 7/14/26 at 12:37 p.m., R42 stated her teeth had been brushed that day; however, she reported she was not routinely offered assistance with brushing her teeth on weekend mornings.On 7/15/26 at 8:19 a.m., NA-A confirmed they did not have sufficient time to provide all required care to R42 on Saturday, 7/11/26, including oral care.On 7/15/26 at 8:49 a.m., licensed practical nurse (LPN)-A stated staff were expected to provide R42 with assistance to set up for teeth brushing. LPN-A stated nursing assistants were expected to notify the nurse if they were unable to provide the required assistance. LPN-A acknowledged R42 was particular about her oral hygiene. LPN-A further acknowledged staffing shortages could delay care, stating there were not enough staff to care for all residents, staff frequently had difficulty locating assistance, residents had reported waiting up to 30 minutes for assistance, and the director of nursing (DON) was aware of these concerns. On 7/15/26 at 10:20 a.m., the DON stated staff were expected to provide R42 with daily assistance to set up for tooth brushing and document the care provided. The DON stated staff were expected to complete ADL (activity of daily living) documentation before leaving their shift. The DON confirmed R42's documentation did not identify oral care was completed daily. Facility Activities of Daily Living (ADLs)/Maintain Abilities Policy dated 3/31/23, indicated:1. Based on the comprehensive assessment of a resident and consistent with the resident's needs and choices, the facility will provide the necessary are and services to ensure that a resident's abilities in activities of daily living do not diminish 3. The facility will provide care and services for the following activities of daily living a. hygiene-bathing, dressing, grooming, and oral care.

Based on interview and document review, the facility failed to provide oral care to 1 of 1 resident (R13) who was reviewed for assistance with activities of daily living (ADLs) and who was dependent upon staff for ADL cares. Findings include:R13's diagnosis report dated 7/16/26, included diagnoses of fractured vertebrae, fracture of right radius (bone in forearm) and fracture right humerus (bone in upper arm).R13's admission Minimum Data Set (MDS) assessment dated [DATE], indicated intact cognition, clear speech, could understand and be understood. R13 was dependent on staff for most all ADLs, including oral hygiene. R13 did not walk. R13's care plan dated 7/7/26, indicated self-care deficient related to impaired mobility and right arm fractures. Staff would assist with dental hygiene for upper denture and lower partial.During an interview on 7/13/26 at 1:43 p.m., family member (FM)-A stated staff had not been cleaning R13's dentures, a full upper and partial on the bottom. R13 stated the same, that staff did not clean her dentures. FM-A stated R13 slept with her dentures in and when FM-A removed them to clean them, they would have food and white material on them.During an interview on 7/15/26 at 10:55 a.m., nursing assistant (NA)-G stated R13 had her own teeth (R13 had upper dentures and lower partial) and admitted she had not provided oral care that morning. NA-G stated she probably should have and could have done it when R13 was sitting up in the wheelchair earlier. During an interview on 7/15/26 at 1:20 p.m., both R13 and family member (FM)-A stated R13's dentures and teeth had not been cleaned yet. During an interview on 7/15/26 at 1:35 p.m., NA-G stated she still had not cleaned R13's dentures/teeth, adding that it had been busy. NA-G stated it was important to clean a resident's teeth for their overall health. During an interview on 7/16/26 at 8:48 a.m., the director of nursing (DON) was informed of findings and stated oral care was the responsibility of NAs and would expect it to be done at least twice a day. The DON stated R13 was not able to do her own oral care due to her arm injuries. Together looked POC (point of care) in the electronic medical record where NAs documented cares. For oral hygiene, in the 15 days and 30 opportunities to complete oral care there were only 12 checkmarks indicating the level of care R13 needed for oral care, not specifically if oral care had been completed or not.Facility Activity of Daily Living/Maintain Abilities policy dated 3/31/23, indicated the facility would provide care and services for oral care. A resident who was not able to carry out ADLs would receive the services to maintain oral hygiene.

Based on interview and document review, the facility failed to implement a bowel movement (BM) protocol for 1 of 1 resident (R13) reviewed for constipation. Findings include:R13's diagnosis report dated 7/16/26, included diagnoses of fractured vertebrae, fracture of right radius (bone in forearm) and fracture right humerus (bone in upper arm).R13's admission Minimum Data Set (MDS) assessment dated [DATE], indicated intact cognition, clear speech, could understand and be understood. R13 was dependent on staff for most all activities of daily living (ADLs) and did not walk. R13's physician orders dated 6/30/26, included senna (laxative) oral tablet 8.6 mg (milligrams), give three tablets by mouth as needed for constipation; three tablets two times a day as needed for constipation. In addition, orders dated 6/30/26, included: may use standing orders as signed by provider. Standing orders signed by provider 3/11/26, indicated for bowel protocol:--Milk of Magnesia (laxative) 30 cc (cubic centimeter) orally daily PRN (as needed) if no bowel movement for two days.--Dulcolax suppository (laxative), one per rectum daily PRN if no bowel movement for three days.--Fleets (brand name) or tap water enema rectally daily PRN constipation.R13's care plan dated 7/7/26, indicated an alteration in elimination related to mobility limitations and R13 would move bowels every three days or greater.R13's bowel movement task list completed by NAs, indicated R13 did not have a documented BM from 7/9/26 through the morning of 7/14/26 (six days).During an observation on 7/14/26 at 11:17 a.m., licensed practical nurse (LPN)-B spoke to R13 to ask how she was feeling. R13 reported pressure down there (hand over lower abdomen) and stated she had not had a BM for a while. After leaving the room, LPN-B accessed the electronic medical record (EMR) and saw the last documented BM for R13 had been on 7/8/26, six days ago. LPN-B had not been aware if the facility had a BM protocol or standing orders and stated she would give R13 the PRN laxative ordered for her.During an interview on 7/14/26 at 2:04 p.m., nursing assistant (NA)-D stated NAs documented resident BMs in POC (point of care) in the EMR. If a resident was independent with toileting, might not know if they had a BM unless asked. For other residents, we know if they had BM because we change their brief or take them to the bathroom. NA-D admitted a NA might forget or not have time to document cares including BMs, in POC.During an interview on 7/15/26 at 11:45 a.m., registered nurse (RN)-C stated R13 had no results from the PRN medication given the day before, and therefore gave R13 a suppository that morning and R13 had a BM.During an interview on 7/15/26 at 12:50 p.m., RN-C stated nursing staff were expected to monitor resident BMs via the EMR and the BM sheet the night shift staff filled out indicating residents to receive a suppository after not having a BM for three days. If a resident went more than three days without a BM, staff should start the protocol per the standing orders which indicated to start with a stool softener or Milk of Magnesia, then a suppository, then an enema. RN-C pointed to the standing orders posted on the bulletin board in the nurses' station office. RN-C confirmed by what she could see, nursing staff had not been monitoring R13's BMs since she had gone six days without a BM and no intervention.During an interview on 7/16/26 at 8:48 a.m., the director of nursing (DON) had been informed of findings. The DON stated it was not okay for a resident to go six days without a BM. The DON stated by day three, should receive a suppository per the standing orders and that all nursing staff should know that. The DON acknowledged staff had not been monitoring and addressing R13's BMs per the standing orders.A bowel monitoring policy was requested and not received.

Based on interview and document review, the facility failed to maintain, restore or improve the functional ability for 2 of 2 residents (R29, R37) reviewed for ADLs, when the facility failed to ensure residents were walked according to physical therapy (PT) instructions and physician orders. Findings include:R29's diagnosis report dated 7/16/26, included generalized osteoarthritis, diabetes, generalized muscle weakness and obesity.R29's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated intact cognition, clear speech, could understand and be understood. R29 required partial to moderate assistance with most ADLs including walking 150 feet. R29 used a walker and wheelchair for mobility.R29's physician orders dated 7/15/25, indicated per therapy, ensure resident is walked two times a day with staff, every day and evening shift.R29's Therapy Alert from PT dated 7/15/25, indicated R29 should ambulate one to two times a day with FWW (front wheeled walker) and assistance of one staff.R29's care plan dated 1/26/25, indicated R29 had an alteration in mobility related to impaired mobility and to follow PT instructions. On 7/15/25, care plan indicated to ambulate R29 two times a day with FWW and assist of one.R29's Kardex (a quick reference used by nursing assistants to inform them of a resident's care) printed on 7/16/26, indicated ambulate resident two times/day with FWW and assist of one. May progress distance as tolerated by resident.R29's documentation of ambulation in POC (point of care, where NAs document in the electronic medical record) indicated out of 28 days and 56 opportunities, documentation indicated R29 had been walked only nine times.R29's TAR (treatment administration record) completed by nursing staff, indicated: ensure R29 walked two times a day with staff every day and evening shift. Since 7/1/26, documentation indicated out of 15 days and 30 opportunities, R29 was walked 21 times. Documentation between the NA who was responsible to perform the task and documentation of the nurse who was to be informed of task completion, did not match. During an interview on 7/15/26, at 9:36 a.m., R29 had been sitting in her wheelchair in her room with walker off to the side. R29 stated she used to be on a walking program but had not walked for a while because the facility was short staffed. R13 stated she would like to walk in the hallway, so her legs stayed strong. R37's diagnosis report dated 7/16/26, included diagnoses of congestive heart failure (when the heart doesn't pump as well as it should) diabetes, generalized muscle weakness, history of falling, and obesity.R37's annual MDS assessment dated [DATE], indicated intact cognition, clear speech, could understand and be understood. R37 required partial to moderate assistance with ADLs, including walking 150 feet. R37 used a walker and wheelchair for mobility.R37's physician orders dated 4/13/26, indicated ensure resident ambulates one to two times per day with assist of one to manage O2 (oxygen), every day and evening shift.R37's Therapy Alert from PT staff dated 4/7/26, indicated ambulate resident one to two times a day with FWW and assist of one to manage O2 tubing. R37's care plan dated 4/10/24, indicated alteration in mobility related to weakness and history of falling, and to follow PT instructions. PT's walking recommendations/instructions from 4/7/26, were not included in the care plan.R37's Kardex printed on 7/16/26, did not include ambulation recommendations by PT. R37's POC had not been set up to include recommendations from PT and therefore no location in POC for NAs to document if/when they ambulated R37.R37's TAR completed by nursing staff, indicated: ensure R37 ambulates 1-2x/day with assist of 1 to manage O2 tubing, every day and evening shift. Since 7/1/26, documentation indicated out of 15 days and 30 opportunities, R37 was walked 27 times. However there had been no documentation by the NAs who were responsible for performing the task. During an interview on 7/15/26 at 9:30 a.m. R37 had been sitting in a wheelchair in her room with a walker off to the side. R37 stated she used to walk in the hallway but didn't anymore. R37 stated it was something she wanted to do in order to keep mobile, adding it was good for her to walk. R37 stated she used to walk to the shower room, but no longer. R37 felt she could walk if staff helped her.During an interview on 7/15/26, at 10:16 a.m., physical therapy assistant (PTA)-E, who was also the department director provided Therapy Alert forms for R29 and R37. PTA-E stated copies of the forms were given to the director of nursing (DON) and NAs. During an interview on 07/15/2026 1:40 p.m., nursing assistant (NA)-D stated R29 and R37 were on walking programs but admitted NAs were not always able to walk residents, including R29 and R37, due to being so busy. NA-D stated residents would usually be walked on the day and the evening shifts and sometimes that depended upon what was going on, such as an activity. NA-D stated walking was important, so residents didn't lose the ability to walk. During an interview on 7/15/26 at 4:48 p.m., with nursing assistant NA-E and NA-F, NA-E stated R29 and R37 were on a list at the desk to be walked in the morning and the afternoon. NA-E stated residents only got walked once a day due to their workload - it gets so heavy, we don't have time. NA-F agreed. NA-E stated if a resident was walked, it was charted in POC. NA-E stated sometimes the nurse would ask if they got it done and would document it too. NA-F stated most residents were in the facility for rehabilitation, and it was important they walked, adding, if you don't use it, you lose it.During an interview on 7/15/26 at 4:53 p.m., licensed practical nurse (LPN)-D stated she documented on the TAR when NAs ambulated a resident. LPN-D stated she did not always see residents being ambulated so asked the NA; if they said yes, she documented it and didn't question it. During an interview on 7/16/26 at 8:22 a.m., licensed practical nurse (LPN)-A, stated she did not know why nurses were asked to document a task they did not do themselves. LPN-A stated she kept track if she saw a resident being walked, or if an NA told her they walked a resident, adding she had to trust what they told her.During an interview on 7/16/26 at 8:56 a.m., the director of nursing (DON) stated resident recommendations for walking came from PT. When received, the residents name would be added to a list at the nurses' station to inform NAs which residents should be walked. The DON was asked to look in POC for documentation of R29 and R37 being walked. For R29, the DON admitted R29 had not been walked according to PT recommendation, physician order, care plan and Kardex. For R37, POC had not been set up for NAs to document her walking and couldn't say why, or how NAs documented this task without POC. The DON stated she did not monitor whether or not residents were walked according to PT recommendations, nor did she monitor documentation. The DON stated she asked the nurses if residents were walked even though they did not perform the task. The DON stated she knew the afternoon shift struggled with walking residents due to meals, bedtime and staff breaks. The DON stated it was important to walk residents, so they didn't lose the ability to walk, it improved breathing and prevented formation of contractures. The DON stated she had been informed by NA staff they didn't have time to walk residents but told them they could ask nurses to help them. Facility Activities of Daily Living/Maintain Abilities policy dated 3/31/23, indicated the facility would ensure a resident was given the appropriate treatment and services to maintain or improve his/her ability to carry out the activities of daily living. The facility would provide care and services including walking.

Based on observation, interview, and document review the facility failed to maintain reusable resident care equipment in a manner that could be effectively cleaned and disinfected by continuing to use a bathtub chair with torn and cracked cushion surfaces in the east hallway bath room. This had the potential to affect any of the 19 residents residing on the east and west hallways who used the tub room. Findings include: On 7/15/26 at 7:13 a.m., observation of the bath tub room on the east hallway revealed the shower chair seat with a black vinyl cushion contained multiple tears, cracks, and openings throughout the seating surface. Portions of the vinyl covering were missing, exposing the underlying light-colored cushion material. The damaged areas created multiple irregular surfaces and openings across the seat cushion. On 7/15/26 at 12:50 p.m., nursing assistant (NA)-A stated the bathtub room was used for residents and confirmed the cracked shower chair was used. NA-A stated they placed a towel on the chair before residents use it.On 7/15/26 at 12:51 p.m., licensed practical nurse (LPN)-A stated the bathtub chair cushion was cracked and had openings and stated it could be an infection control issue. On 7/15/26 at 12:55 p.m., maintenance director (MD)-A confirmed the bathtub chair cushion was cracked and damaged and stated they it would be expected to be replaced and stated they were not aware of the cushion's condition. On 7/15/26 at 12:59 p.m., the administrator observed the bathtub chair cushion and confirmed the cushion should not be in that condition due to infection control concerns. The administrator stated staff would not be expected to use the shower chair if the cushion was cracked. On 7/15/26 at 4:48 p.m., the director nursing (DON), also known as the infection preventionist, stated the shower chair was not expected to have cracked cushions and stated the damaged cushion could present an infection control problem. The facility Infection Prevention and Control Program policy dated 11/24, indicatedPrevention of Infectioninstituting measures to avoid complicationseducating staff and ensuring that they adhere to proper techniques and procedures

Based on observation, interview, and document review the facility failed to ensure the posted nursing hours were updated when there was a change to staffing levels. This had the potential to affect all residents and visitors of the facility.Findings include:During an observation and interview on 3/14/26 at 10:45 a.m., the daily staffing hours were posted in the main entrance area visible to all residents and visitors but were dated 3/13/26. Licensed practical nurse (LPN)-A was observed taking out the page for 3/13/26, and inserting the new daily staffing hours for 3/14/26.Review of the daily staffing hours posted for 3/13/25, indicated the following hours:Days: one registered nurse (RN), one LPN, one trained medication aide (TMA), four nursing assistants (NAs).Evenings: two RNs, four NAs.Nights: one LPN, two NAs.Review of the daily staffing hours posted for 3/14/26, indicated the following hours:Days: two LPNs, one TMA, four NAs.Evenings: one RN, one LPN, four NAs.Nights: one LPN, two NAs.Review of facility schedules dated 7/13/26 and 7/14/26, indicated additional NAs on each day to assist with baths that were missed on the weekend. On 7/13/26, an additional nursing assistant was scheduled from 10:30 a.m. to 2:30 p.m., and on 7/14/26, an additional nursing assistant was scheduled from 11:00 a.m. to 2:30 p.m. There were no changes made to the daily staffing posting to reflect these changes in staffing totals.During interview on 7/14/26 at 10:45 a.m., director of nursing (DON) stated she had added extra staff to assist with making up baths from the weekend that did not get done. DON further stated she would expect the daily staff posting to be updated when there were changes to the schedule. DON confirmed the postings had not been updated to reflect accurate information on either 7/13/26 or 7/14/26.During interview on 7/16/26 at 2:45 p.m., administrator stated it was the responsibility of the TMA to update the daily staff posting in real time, but she also kept on eye on it. Administrator confirmed the updates had not been made on 7/13/26 or 7/14/26, and she would have expected them updated to reflect accurate staffing levels.A policy on daily staff postings was requested but not received.

Based on observation, interview, and document review, the facility failed to ensure frozen food items were stored in a manner to reduce the risk of cross contamination and potential foodborne illness in 1 of 1 walk-in freezers, failed to ensure food stored in the refrigerators and dry storage were labeled, dated and discarded properly. This deficient practice had the potential to affect all 48 residents, staff and visitors who received food from facility kitchen. Findings include: Freezer During the initial kitchen tour on [DATE] at 12:50 p.m., a walk-in commercial freezer had a cooling fan mounted to the top of the unit which had visible ice built up on numerous places along the unit. The ceiling of freezer had ice built up, thick in some areas and in frozen droplet forms in other areas, that went from the back wall of the freezer towards the front of the freezer cover two-thirds of the ceiling on the left side. The back wall of the freezer had ice build-up with the thickest of the ice towards the bottom with a mound of ice on the floor. [NAME] substance, approximately 5-inch diameter, was melted into the mound of ice. The floor of the freezer and the metallic shelving used also had ice build-up present . Approximately, one-third of the floor was covered with thick ice build-up. The metallic shelving units were used to hold food and sat parallel with the walls of the freezer from the front wall to the back wall of the freezer. Immediately to the right of the cooling unit, there were several food items stored in boxes. Boxes were cardboard which were soft and somewhat mushy feeling to touch. Several boxes had visible ice buildup covering them. A gauge present measured the unit at -4 degrees Fahrenheit (F). During a subsequent visit to the kitchen on [DATE] at 10:15 a.m., ice continued to be present in the freezer. During interview on [DATE] at 10:23 a.m., culinary services director (CSD) confirmed ice buildup in the freezer's wall, ceiling, shelves and boxes. CSD stated the fan in the freezer was blocked and was not working. CSD stated maintenance looked at the fan yesterday and fixed it. CSD stated it has been an on-going process to get the ice out of the freezer since she started several months ago. CSD stated the ice buildup could be a concern as it could contaminate food, cause freezer burn on food or could cause food to rot from the mushy boxes that food is being store in. During interview on [DATE] at 12:30 p.m., administrator stated she was not aware of the ice buildup in the freezer. Administrator stated she would expect staff to notify her if there was ice buildup in the freezer. Administrator confirmed ice buildup was a concern on the last annual survey but to her knowledge it was addressed and taken care of. Administrator stated the ice buildup could impact food quality and overall functionality of the freezer. Label, cover and date of foods: During an observation and interview on [DATE] at 12:20 p.m., CSD confirmed the following food items were observed in the prep cooler in the kitchen that were not labeled or dated: -Jar of opened salsa that did not have an opened date on container. - Opened plastic storage bag with Hot dogs were dated [DATE]. CSD stated they were expired. -Container of opened cottage cheese that did not have an opened date on container. - Container of opened egg salad that did not have an opened date on container and had an expiration date of [DATE]. CSD stated it was expired. During observation and interview on [DATE] at 12:58 p.m., CSD confirmed the following food items were observed in the walk-in cooler were not labeled or dated: - Opened bag of lettuce had brown slime that did not have an opened date. - Opened plastic storage bag with sliced American cheese that had several slices that were dried out. Bag did not have an opened date. - Opened plastic storage bag with sliced white cheese that did not have an opened date. - Container of opened sour cream that did not have an opened date on container. During an interview on [DATE] at 1:12 p.m., CSD verified all items should be labeled, covered and dated as soon as food is removed from its original container. The CSD stated it was important to label and date food items to know when food items are fresh. During an interview on [DATE] at 10:15 a.m., cook stated when food is opened, they are to label and date before putting it away. [NAME] stated it was important to complete to know if a food was expired or should be thrown away. During an interview on [DATE] at 10:20 a.m., culinary aide (CA)-A stated when food is opened it needed to be labeled and dated so you know when it was opened or expired. The facilities Freezer policy, dated ,d+[DATE], indicated cleaning procedure of freezer which consisted of: 1. All items should be removed from freezer and transferred to another freezer. 2. Let all ice melt and unit warm up. 3. Wash out inside of freezer with warm soapy water. Rinse well. 4. Wipe out with weak solution of baking soda and water. Rinse well. 5. Dry inside with soft cloth. Let air dry. 6. Plug in unit and let freezer return to proper temperature. 7. Wash shelves with soapy water. Rinse, dry and replace in freezer. 8. Replace frozen food. 9. Clean per cleaning schedule of facility. The facility Food Storage policy, dated ,d+[DATE], indicated facility would maintain sanitary techniques in non-perishable food storage in order to protect the health of those dependent on the service. The remaining contents of opened food packages will be stored in plastic containers with tight-fitting lids or plastic zip lock bags. All containers will be properly labeled and dated as to contents.

Based on observation, interview, and document review, the facility failed to monitor orthostatic blood pressures for 3 of 3 residents (R7, R8, and R32) and failed to ensure residents were routinely assessed for side effects who received physician ordered antipsychotic medications for 1 of 5 residents (R8), reviewed for unnecessary medications. Findings include: R7's quarterly Minimum Data Set (MDS) assessment dated [DATE], identified R7 had intact cognition and required assistance with all activities of daily living (ADL)'s. R7's diagnoses included orthostatic hypotension, depression, bipolar disorder, secondary Parkinsonism, mild cognitive impairment of uncertain or unknown etiology, and insomnia. R7's physician orders included Aripiprazole (antipsychotic) 10 milligram (mg) by mouth in the morning for bipolar disorder and Olanzapine (antipsychotic) 5 mg by mouth at bedtime for bipolar disorder. R7's medical record lacked evidence orthostatic blood pressures had not been obtained three out of six months for R7 with use of an antipsychotic medication. R7's care plan indicated R7 had a potential for psychotropic drug adverse drug reactions related to daily use of psychotropic medication for diagnosis of bipolar disorder. Goal was for resident to not experience adverse drug reactions to current psychotropic drug medication regimen and have interventions of monthly orthostatic blood pressures. R8 R8's annual Minimum Data Set (MDS) assessment dated [DATE], identified R8 had intact cognition and required assistance with all activities of daily living (ADL)'s. R8's diagnoses included hypertension, anxiety disorder, depression, and schizophrenia. R8's physician orders included orders for Aripiprazole (antipsychotic) 10 milligram (mg) by mouth in the morning for bipolar disorder and Olanzapine (antipsychotic) 5 mg by mouth at bedtime for bipolar disorder. R8's medical record lacked any evidence orthostatic blood pressures had been obtained for R8 in the past six months. R8's had Abnormal Involuntary Movement Scale (AIMS) assessment (measures involuntary movements of tardive dyskinesia (TD)) completed on 8/1/24 . R8's care plan indicated R8 had a potential for psychotropic drug adverse drug reactions related to daily use of psychotropic medication for diagnosis of bipolar disorder. Goal was for resident to not experience and adverse drug reactions to current psychotropic drug medication regimen and have interventions of monthly orthostatic blood pressures and TD screening or AIMS per protocol. During interview on 3/26/25 at 10:22 p.m., consultant pharmacist (CP) stated any resident on an antipsychotic medication should have orthostatic blood pressures checked monthly and AIMS assessment should be initiated within 30 days of admission or upon start of an antipsychotic medication and be reassessed at least every six months. CP stated orthostatic blood pressures and AIMS assessment were important to monitor for side effects and for orthostatic blood pressures. During interview on 3/27/25 at 11:08 a.m., director of nursing (DON) stated monitoring for antipsychotic medications consisted of orthostatic blood pressures and a baseline AIMS assessment. DON stated orthostatic blood pressures should be obtained monthly and orthostatic blood pressures are important to see if the resident is displaying side effects of the antipsychotic medication and could increase risks for falls. DON confirmed the finding for R7 and R8 . DON stated AIMS assessments should be completed every six months and R8 should have had an AIMS assessment completed in February and confirmed last assessment was on 8/1/24. DON stated it was important to assess for TD to see if resident is having any symptoms of TD as the resident may need dosage of their antipsychotic medication changed. R 32 R32's Quarterly MDS dated [DATE], indicated cognitively intact with no behaviors. No limitations to upper and lower extremities, substantial assist for toileting and activities of daily living (ADL's) and was continent of bowels and occasionally incontinent of urine. R32's diagnoses list included psychotic disorder with delusions, mood disorder, anxiety disorder, and major depressive disorder. R32's provider orders included Aripiprazole (medication to treat psychiatric/mood disorders) 5 mg twice a day with a start date 9/3/2024, monitor orthostatic blood pressure while resident is receiving antipsychotic medications every day shift starting on the 7th of every month starting 10/7/24. R32's care plan included potential for psychotropic drug ADR's (adverse drug reactions) related to daily use of psychotropic medication. Interventions included monthly orthostasis blood pressure. A mobility care plan indicated R32 was an extensive assist of 1-2 with movement in bed and in/out of bed and extensive assist of 1-2 with transfers; use sit to stand lift [a machine used to assist residents to a standing position] when resident is tired. R32's medication administration indicated R32 received Aripiprazole October 2024- March 2025. Orthostatic blood pressure documentation was as follows: 10/7/24: Lying-118/66, Sitting-114/60, standing- NA 11/7/24: Lying-106/56, sitting-110/71, standing-143/67 12/7/24: lying-137/73, sitting-156/84, standing-indicated 9 1/7/25: Lying-108/50, Sitting- 117/51, standing- [left blank] 2/7/25: lying, sitting, and standing were left blank 3/7/25 lying, sitting, and standing were left blank. Progress notes dated 9/3/24-3/25/25 lacked documentation resident refused orthostatic blood pressures or orthostatic blood pressures were rescheduled. During interview on 3/26/25 at 9:58 a.m., nursing assistant (NA)-A stated R32 can stand and ambulate short distances with staff assistance. A sit to stand lift is used for transfers when R32 is feeling weak. During interview on 3/27/25 at 8:24 a.m., licensed practical nurse (LPN)-A stated residents on antipsychotic medications are monitored for side effects, orthostatic hypotension once a month, and extrapyramidal symptoms (uncontrolled muscle movements related to antipsychotic medication use). LPN-A stated R32 can stand and probably could stand long enough to get standing blood pressures because they walk [R32] During interview on 3/27/2025 at 9:59 a.m., the director of nursing (DON) stated orthostatic blood pressures are monitored monthly for residents who receive antipsychotic medications. If a resident is unable to stand safely, staff check a lying and sitting blood pressure only. The DON stated staff are expected to document a behavior note indicating a resident refused and attempt the blood pressures later. The DON stated orthostatic blood pressures are scheduled the entire day so staff can attempt on a different shift if there is a refusal. If a resident continues to refuse, the DON stated she would hope she is updated. The DON stated R32 does tire easily however, can stand and do a pivot transfer. The DON confirmed the MAR lacked documentation of orthostatic blood pressure or refusals for February and March 2025. The facility Psychotropic Medication use policy, dated 1/25, indicated with initiation of an antipsychotic medication, residents will have an orthostatic blood pressure performed on a monthly basis, unless otherwise indicated by provider. AIMS will be performed on residents receiving antipsychotic medications to screen for tardive dyskinesia at baseline, semi-annually, and after discontinuation every month x 3.

Based on observation, interview and document review, the facility failed to ensure residents were comprehensively assessed for self-administration of medications for 1 of 1 resident (R35) reviewed for self-administration of medications. Findings include: R35's admission Minimum Data Set (MDS) assessment dated [DATE], identified R35 had intact cognition and required assistance with all activities of daily living (ADL)'s. R35's diagnoses included atrial fibrillation, heart failure, hypertension, renal failure, diabetes mellitus, thyroid disorder and arthritis. MDS indicated R35 required substantial/maximal assistance with personal hygiene. R3's physician orders included order for Ipratropium-Albuterol inhalation solution 0.5-2.5% (3) mg (milligram)/3 ml (milliliter) - inhale one vial orally three times a day related to respiratory syncytial virus as the cause of diseases classified elsewhere. During interview and observation on 3/24/25 at 1:56 p.m., R35 was sitting in a wheelchair in her room. Nebulizer mask and canister was laying on the over the bed table with solution remaining in the canister. R35 stated she completes the nebulizer herself after the nurse sets it up. During observation on 3/25/25 at 1:15 p.m., R35 was sitting in her wheelchair holding the nebulizer mask to her face. Nebulizer cup contained a clear solution and nebulizer machine was running with no staff present in room. R35's record identified neither a self-administration of medication assessment was completed or an order for self-administration. During interview on 3/27/25 at 8:42 a.m., trained medication aide (TMA)-A stated if a resident was able to self-administer medications, it would be displayed in the resident's electronic health record (EHR). TMA-A confirmed R35 did not have an order to self-administer medications which included nebulizer treatments. TMA-A stated she sets the nebulizer machine up placed the solution in the canister and will leave the room and come back in 10-15 minutes to ensure treatment is completed and shut the nebulizer machine off. During interview on 3/27/25 at 8:42 a.m., licensed practical nurse (LPN)-B stated the TMA's administers the nebulizer treatments. LPN-B stated if a resident was able to self-administer medications, it would be displayed in the resident's EHR. LPN-B confirmed R35 did not have a self-administration of medications order. During interview on 3/27/25 at 9:53 a.m., nursing assistant (NA)-A stated if we notice R35 does not have the nebulizer mask on, we go into her room and assist her with reapplying the mask. NA-A stated this morning, R35 had the mask on her face however, it was not correct and NA-A had to help R35 readjust the mask. During interview on 3/27/25 at 11:08 a.m., director of nursing (DON) stated she completes the self-administration of medications assessments. DON stated TMA's administer the nebulizer by placing the medication in the canister and places the mask on the resident's face and will go back later to ensure treatment is complete and shut off the machine. DON confirmed a self-administration of medications assessment was not completed and confirmed there was no order in place for R35 to self-administer her medications. DON stated it was important for the resident to be assessed for self-administration of medications as the medication would not be effective if R35 removed the mask. The facility Self-Administration of Medications policy, dated 2/24, identified residents have the right to self-administer medication if the interdisciplinary team (IDT) has determined that it is clinically appropriate and safe for the resident to do so. As part of the evaluation comprehensive assessment, the IDT assesses each resident's cognitive and physical abilities to determine whether self-administering medications is safe and clinically appropriate for the resident.

Based on observation, interview, and record review the facility failed to provide assistance with facial hair removal for 1 of 1 resident (R35) reviewed for activities of daily living (ADL')s . Findings include: R35's admission Minimum Data Set (MDS) assessment dated [DATE], identified R35 had intact cognition and required assistance with activities of daily living (ADL)'s. R35's diagnoses included diabetes mellitus, and arthritis. MDS indicated R35 required substantial/maximal assistance with personal hygiene. R35's care plan lacked evidence of resident's shaving preferences. During observation and interview on 3/24/25 at 1:46 p.m., R35 had white facial hair on chin approximately 1 inch long. R35 stated staff has assisted before and would like to be shaved. During observation on 3/25/25 at 10:47 a.m., R35 continued to have facial hair on chin. During observation on 3/26/25 at 7:12 a.m., R35 continued to have facial hair on chin. During observation on 3/27/25 at 9:22 a.m., R35 continued to have facial hair on chin. During interview on 3/27/25 at 9:53 a.m., nursing assistant (NA)-A stated if a resident had facial hair, she would ask the resident if they would like to be shaved. If resident stated they would like to be shaved, NA-A would go and find a shaver and assist resident with shaving. NA-A stated she has not asked or shaved R35. During interview on 3/27/25 at 10:36 a.m., NA-B stated they are supposed to shave residents if facial hair is noticed. NA-B stated she assisted R35 with morning cares and stated she noticed chin hairs but stated she did not shave R35. During interview on 3/27/25 at 10:39 a.m., licensed practical nurse (LPN)-B stated nursing assistants perform shaving when doing morning cares with residents, but it should be addressed on the resident's bath days. LPN-B stated R35's scheduled bath occurs Monday evenings. LPN-B confirmed R35 had facial hair and should have been shaved. During interview on 3/27/25 at 11:08 a.m., director of nursing (DON) indicated staff are to shave resident's facial hairs if seen, women especially. DON stated facility has razors to use if family members do not provide one. DON stated staff should have asked R35 if she would like to be shaved. DON stated it was important for the resident to be shaved for dignity of the resident. The facility Activities of Daily Living Policy, dated 3/31/23, indicated the facility is to specify the responsibility to create and sustain an environment that humanizes and individualizes each resident's quality of life by ensuring all staff, across all shifts and departments, understand the principles of quality of life, and honor and support these principles for each resident; and that the care and services provided are person-centered, and honor and support each resident's preferences, choices, values and beliefs.

Based on interview and document review, the facility failed to ensure the Quality Assurance and Performance Improvement (QAPI) committee identify, investigate, analyze and respond to freezer maintenance (i.e., prevent ice buildup) by developing and implementing action plans for the process improvement identified to be a current concern with past identified non compliancy. This had potential to affect all 45 residents, staff and visitors who consumed food at the care center. Findings include: Facilities QAPI (Quality Assessment and Performance Improvement) Plan, identified the purpose of QA (Quality Assessment) would be to take a proactive approach to continually improve the way we provide care, with each employee to participate in the ongoing QAPI efforts. The facility QA plan outlined the facility would review data from areas defined by the facility as high risk or problem prone areas; and it outlined a process for how Performance Improvement Projects (PIP) would be completed. The QA team will determine what information is needed for the project and how to obtain it. A root cause analysis will be completed to assure the problem is identified. The team will develop an action plan for the improvement and the QA committee will require reporting of the project effectiveness. Facilities last three recertification surveys dated [DATE], [DATE], and [DATE] identified F-tag 812-Food Procurement, Store/Prepare/Serve Sanitary was cited each time with similar concerns including: the facility failed to label opened containers of food, not sanitize a deep fat fryer in storage, or kitchen commercial can opener; the facility failed to mark/date opened containers of food stored in one kitchen refrigerators and freezer; and failed to ensure expired/damaged food were identified and removed; the facility failed to ensure frozen food items were stored in a manner to reduce the risk of cross contamination and potential foodborne illness in walk-in freezers. See F812 for further details of the kitchen tour. During an interview on [DATE] at 10:23 a.m., dietary manager (DM) stated the fan in the freezer was blocked and was not working, however maintenance looked at it the day before and fixed the fan. DM stated the ice buildup has been there for several weeks. The DM stated ice buildup could be a concern as it could contaminate food, causing freezer burn on food or cause food to rot from mushy boxes the food is being stored in and said it was not appropriate. During an interview on [DATE] at 12:30 p.m., the administrator stated she was not aware of ice buildup in the freezer and would expect the DM to have notified her. The administrator confirmed the concern was identified during the last recertification and the plan of corrections was to replace the draping in the freezer. The administrator confirmed the freezer did not currently have any draping and stated ice buildup was a problem because it could impact food quality and overall functionality of the freezer. The administrator stated the QA team met monthly and explained the current facility's PIP's included various projects, with all current goals for them being met. The administrator stated the QA team included members from clinical care services, culinary, activities, maintenance, housekeeping, and administration. The QA focus may extend to any one of these service areas. The administrator reviewed the QAPI meeting minutes and confirmed the committee did not identify any current or previous issues with the freezer. The administrator confirmed monitoring of the last years recertification was not performed.

Based on observation, interview, and document review, the facility failed to ensure frozen food items were stored in a manner to reduce the risk of cross contamination and potential foodborne illness in 1 of 1 walk-in freezers using the main production kitchen. This had potential to affect all residents who could potentially consume the items. Findings include: On 5/28/24 at 9:57 a.m., an initial kitchen tour was completed. A single [NAME] walk-in commercial freezer was in use, opened and inspected. Inside, the unit had a cooling fan mounted to the top of the unit which had visible ice built up on numerous places along the unit. The ceiling of freezer had ice built up, thick in some areas and in frozen droplet forms in other areas, that went from the back wall of the freezer towards the front of the freezer cover two-thirds of the ceiling on the left side. The back wall of the freezer had ice build-up with the thickest of the ice towards the bottom. The floor of the freezer and the metallic shelving used also had ice build-up present on them. Approximately, one-third of the floor was covered with thick ice build-up. The metallic shelving units were used to hold food and sat parallel with the walls of the freezer from the front wall to the back wall of the freezer. Immediately to the right of the cooling unit, there were several food items stored including opened box of salmon and an unopened box of cod. Both boxes were cardboard which were soft and somewhat mushy feeling to touch. The salmon box had visible ice buildup covering the open box, the plastic bag that contained the salmon fillets was open and salmon fillets were partially out of the box. The salmon that could be seen was covered in ice in the box. The box of cod was sealed, appeared to have wet spots on the cardboard box but were dry to touch and pieces of the tape were starting to come unattached on the top. A gauge present measured the unit at -8 degrees Fahrenheit (F). When interviewed on 5/28/24 at 10:20 a.m., director of culinary services (CMD)-A verified that he is the director of culinary services and is responsible for overseeing the kitchen. CMD verified it has been an on-going process to get the ice out of the freezer. CMD stated that maintenance with chisel the ice out when it gets bad and it has been done approximately 4-5 times in the past 7 months. CMD stated that he notifies maintenance when it gets bad, and they assist with chiseling the ice out. CMD verified the ice buildup as listed above. CMD stated it is difficult to tell how thick it is but probably about 6 inches. CMD verified the salmon box was open, salmon fillets were exposed directly, and the box is covered in ice. CMD verified the box of cod was covered in ice and was unopened. CMD stated contamination would be of concern. CMD discarded the box of salmon. During a subsequent visit to the kitchen on 5/29/2024 at 2:45 p.m. it was observed the much of the ice had been removed from the freezer. It was observed the box of cod covered in ice continued to be present in the freezer. CDM verified that he chiseled the ice out of the freezer yesterday. During interview on 5/30/24 at 9:45 a.m., administrator stated she would refer to the director of culinary services for their expertise for concerns regarding ice buildup in the freezer in relation to food. A provided Refrigerators and Freezers Policy, dated 12/14, identified refrigerators and freezer will be kept clean, free of debris and mopped with sanitizing solution on a scheduled basis and more often as necessary. The policy outlined several steps to ensure refrigeration was maintained, however, lacked any guidance or direction on what, if any, steps were taken to ensure proper freezer storage given the repeated ice-build up from the dated equipment.

Based on observation, interview, and document review, the facility failed to ensure residents were assessed for appropriateness to be assisted by paid feeding assistants (PFA)'s at meals including residents with or without difficulty swallowing and/or with complicated feeding problems requiring a mechanically altered diet and/or special precautions for 6 of 6 residents (R4, R5, R6, R10, R16, and R30) reviewed. The facility also failed to ensure the PFA's were supervised at all times by a nurse while performing feeding assistance. Findings include: R4's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R4 had moderate cognitive impairment, was dependent on staff for Activities of Daily Living (ADL) and supervision or touching assistance for meals. R4's face sheet, printed 5/30/24, indicated R4 moved in on 1/12/10. Diagnoses included dementia with other behavioral disturbance, expressive language disorder, dsyarthria (speech disorder caused by weak muscles) following cerebral infarction (disruption of blood flow to the brain due to problems with the blood vessels that supply it), hemiplegia (paralysis of one side of the body) and hemiparesis (another term for hemiplegia) following cerebral infarction affecting right non-dominant side, ataxia (lack of voluntary coordination of muscle movements), and delusional disorder (mental health condition which a person can't tell what's real from what's imagined). On R4's therapy tab in the electronic medical record (EMR) indicated a diagnosis of dysphagia (difficulty swallowing). R4's orders, printed 5/30/24, indicated a regular diet, regular texture, regular consistency with a start date of 6/21/22. R4's care plan, printed 5/30/24, indicated R4 needed assist of 1 with eating with a start date of 10/5/22. R4 needs feeding assist; able to hold 'kennedy' cup and feed self finger foods. There was no mention of being able to be assisted by a PFA or mention of dysphagia diagnosis. R4's Clinical Nutrition Evaluation, dated 5/2/24, identified the following: under section f adaptive equipment: n/a (not applicable) and section f1 amount of feeding assistance required full assist. The assessment lacked identification of diagnosis of dysphagia or if R4 was able to be assisted by a PFA. R4's EMR lacked an assessment to identify if R4 would be appropriate to be assisted by a PFA. R5's quarterly MDS assessment dated [DATE], indicated R5 had moderate cognitive impairment, was dependent on staff for ADL's and supervision or touching assistance for meals. R5's diagnoses included osteoarthritis and osteoporosis. R5's orders, printed on 5/30/24, indicated a regular diet, pureed texture, regular consistency, small portions with a start date of 1/12/24. R5's care plan, printed 5/30/24, indicated R5 had potential for alteration in nutrition r/t [related to] need for mechanically altered diet secondary to hx [history] of chew/swallow difficult. R5's care plan lacked identification of assistance needed with eating, mention of being able to be assisted by a PFA. R5's Clinical Nutrition Evaluation, dated 3/6/24, identified R5 had a lost of 5% or more in the last month or loss of 10% or more in the last 6 month in her weights and a radio-button answered was marked yes, not on a prescribed weight-loss regimen. The assessment lacked identification if R5 was able to be assisted by a PFA. R5's progress note reviewed from 11/29/23 to 5/15/24 indicated the following: -4/14/24: resident had 1 episode of vomiting immediately upon leaving supper table. NAs reported resident ate a grilled cheese sandwich. Resident stated she felt fine after episode of emesis. -3/27/24: .1/12/24-diet downgraded to Pureed, may chop or mash foods. Initially trialed downgraded diet starting 12/31 d/t [due to] reports of prolonged chewing . -12/31/23: [R4] continues to have great difficulty eating-she chews for long periods of time before finally swallowing .we are going to try a pureed diet x 1 week . -12/29/23: .Per RN notes, [R4] has been pocketing foods and having some swallow difficulty .staff to continue to encourage adequate meal/supplement intakes, assist with intake PRN [as needed] . -12/26/23: [R4] was observed pocketing food at breakfast and lunch today. [R4] continued to keep putting food in her mouth without swallowing. When she drank it would run out of her mouth. CAN (certified nursing assistant) sat with R4, but she was unable to follow cues to swallow. -12/11/23: [R4] was having a difficult time swallowing and was coughing when she took a drink. R5's EMR lacked an assessment to identify if R5 would be appropriate to be assisted by a PFA. R6's quarterly MDS assessment dated [DATE], indicated R6 had moderate cognitive impairment, was dependent or maximal assistance of staff for ADL's in areas of toileting, dressing, showering, mobility, and transfers. R6's diagnoses included heart failure (heart not working properly), diabetes (disease that results in too much sugar in the blood), stroke (condition in which poor blood flow to the brain causes cell death), and unspecified toxic encephalopathy (a brain dysfunction caused by a toxin). R6's orders, printed on 5/30/24, indicated a regular diet, regular texture, regular consistency, and small portions with a start date of 6/17/22. R6's care plan, printed on 5/30/24, identified resident needs feeding assist; often refuses assist with a date initiated of 9/26/22. R6's care plan lacked identification of being assessed for appropriateness to be assisted by a PFA at meals. R6's Clinical Nutrition Evaluation, dated 3/12/24, identified R6 was independent regarding amount of feeding assistance required. R6's progress notes were reviewed from 12/4/23 to 5/15/24 indicated the following: -12/27/23: speech therapist came in at supper time. [R6] tolerated thin liquids, his egg sandwich, and his bowl of cereal with no difficulty. No coughing or choking noted. -12/27/24: [R4] tolerated mechanical pork with gravy and mashed potatoes. [R4] coughed on thin liquids but tolerated nectar thick liquids. R6's EMR lacked an assessment to identify if R6 would be appropriate to be assisted by a PFA. R10's quarterly MDS assessment dated [DATE], indicated R10 had intact cognition, was moderate to maximal assistance of staff for ADL's in areas of toileting, dressing, showering, mobility, and transfers. R10's diagnoses included dysphagia (difficulty swallowing), aphagia (inability or refusal to swallow), coronary artery disease (buildup of plaque in the coronary arteries), hypertension (high blood pressure), rheumatoid arthritis, gastro-esophageal reflux disease (disease in which stomach acid irritate the food pipe lining), and chronic obstructive pulmonary disease (progressive lung disease). R10's orders, printed 5/30/24, indicated a regular diet, regular texture, and regular consistency with a start date of 1/4/24. R10's care plan, printed 5/30/24, identified R4 has a history of mechanically altered diet due to dysphagia and aspiration. R4 refused altered textures despite repeated education on risks associated with non-compliance of recommendations. Provider liberalized diet on 1/4/24. R4's care plan lacked identification of need of assistance with eating, being assessed for appropriateness to be assisted by a PFA at meals. R10 was observed by speech therapy on 5/29/24. Initial assessment, dated 5/29/24, indicated R4's prior medical history was respiratory failure due to inhalation of food at a meal. Current recommendation was mechanical soft/chopped textures: chopped meat only. R10's progress notes were reviewed from 12/1/23 to 5/29/24 indicating the following: -5/27/24: R4 observed while eating supper meal in room to have choking episode while eating meat of beef commercial served. [R4] did not have dentures in while eating at time episode occurred. R4 was able to clear throat on own without nursing intervention -3/16/24: [R4] also reported during assessment she should not have eaten pork that was served for supper yesterday, as had a hard time swallowing it., Concern for possible aspiration pneumonia based on resident report -2/24/24: [R4] had a coughing episode during breakfast after medication was given. Episode lasted for approximately 10 minutes. -12/31/23: activities stated resident had a choking spell during the afternoon party when she was eating. R10's EMR lacked an assessment to identify if R10 would be appropriate to be assisted by a PFA. R16's quarterly MDS assessment dated [DATE], indicated R16 had intact cognition and independent with ADL's. R16's face sheet, printed 5/30/24, included diagnoses of dementia, fracture of left femur (broken bone in upper left leg), and heart failure. R16's orders, printed 5/30/24, indicated a regular diet, regular texture, and regular consistency with a start date of 9/27/23. R16's care plan, printed on 5/30/24, lacked evidence that R16 prefers to sit at the table with residents that need assistance with meals. It further lacked evidence that R4 was assessed to be appropriate to be assisted by a PFA at meals, if needed. R16's EMR lacked an assessment to identify if resident would be appropriate to be assisted by a PFA if needed. R30's admission MDS assessment dated [DATE], indicated severe cognitive impairment and was dependent or maximal assistance of staff for ADL's in areas of toileting, dressing, showering, mobility, and transfers. R30's diagnoses included, hypertension, diabetes, malnutrition, malaise (chronic tiredness). On R30's therapy tab in the electronic medical record (EMR) indicated a diagnosis of dysphagia (difficulty swallowing). R30's order, printed 5/30/24, indicated a consistent carbohydrate diet, mechanical soft texture, and regular consistency. R30's care plan, printed on 5/30/24, identified R4 has a history of chewing and swallowing difficulty. R30's care plan lacked identification of being assessed for appropriateness to be assisted by a PFA at meals. R30's progress notes were reviewed from 5/10/24 to 5/30/24 identifying the following: -5/28/24: staff report that he eats a lot at one time, which causes occasional emesis-last episode was 4+ days ago. -5/24/24: staff note that patient had 3 episodes of emesis on Wednesday and one earlier in the day today. Eating pattern, I minimal food intake for a day or two and then eat large amount of food .known sensitivity to dairy that does not deter intake . -5/10/24: resident on a CCHO [carbohydrate-controlled diet] diet with regular texture but expressed difficulty chewing/swallowing. Culinary Director spoke with administrator and [director of nursing] to help set up a speech eval . During observation on 5/28/24 at 12:00 p.m., activities director (AD)-A was observed sitting in the dining room with residents during lunch. AD-A was observed putting R4 peanut butter and jelly sandwich in her hand while prompting her to eat. AD-A was observed putting R4's cup in her hand and prompting her to take a drink. AD-A was observed feeding R4 her desert. AD-A was sitting next her while she ate and making conversation with her during the meal. R30's electronic medical record lacked an assessment to identify if resident would be appropriate to be assisted by a PFA if needed. On 5/28/24 at 12:19 p.m., AD-A was observed wiping R5 mouth as she had spilled pureed food on her chin. It was not observed how the food got on the R5's chin. During an interview on 5/29/24 at 3:38 p.m., AD-A stated that she can assist any resident that needs assistance with eating. AD-A stated that all the staff in the activity department, which includes herself and two activity aides, have taken the paid feeding assistant course. AD-A verified they are able to feed any resident. AD-A stated she took a course many years ago to assist residents with eating but took another course last year which was a lot more in depth. AD-A stated, we can assist anyone [in regards in to eating] no matter what the level of assistance is needed. AD-A verified she was assisting R4 yesterday at lunch and added, she usually needs more assistance than she did yesterday. AD-A stated that by having the training, it helps because if we do snacks or take residents out in the community, we are trained to assist with feeding them. AD-A verified the activities department are the only staff that are present on resident outings. During an interview on 5/30/24 at 8:39 a.m., activities aide (A)-A verified that she is familiar with the residents and worked at the facility for over 2 years. A-A verified that she has completed the paid feeding assistant training course. A-A stated that the activity department has been trained in assisting residents to eat and we are able to help anyone who needs helps eating. A-A verified that there is not a list of residents that they are able to assist, and they are able to assist any resident that needs assistance. A-A verified the activity department takes residents out to eat and may offer snacks during outings. A-A verified that a nurse is not present during these outings as when we go on resident outings, it is the three-activity staff that are present. A-A stated that if she were helping a resident eat on an outing without a nurse present and something happened, then she would notify her supervisor, the director of activities. A-A stated she doesn't typically get instructions from the nurses on residents and how they eat but she would ask if she had any questions. On 5/30/24 at 9:07 a.m., A-A was observed assisting R4 with breakfast by putting her cup to her mouth to take a drink. On 5/30/24 at 9:08 a.m., director of culinary services (CMD)-A stated there are 5-7 residents needing assistance with eating including some that sit at the table that is known to need assistance. CMD-A verified diets change frequently and at this time, they are serving 7 mechanical diets and 1 pureed diet which are some of the diets which are of residents that need assistance. CMD-A stated that residents are on modified diets as there is a choking risk and choking and aspiration are huge things. CMD-A stated don't want anyone to become injured by having the wrong diet. CMD-A stated, I believe everyone in the rec [recreation] department is trained .help residents who need assistance with eating. CMD-A is not sure if there is a list of residents the PFA's are able to assist. A document titled, Diet Type, was provided by the facility dated 5/30/24. The following information was included: -seven resident on a mechanical soft diet -one resident on a pureed diet On 5/30/24 at 9:16 a.m., director of nursing (DON) verified she oversees the paid feeding assistants. DON verified the facility has three paid feeding assistants (PFA) which are the staff in the activity department. DON stated they have no residents with feeding tubes or any complicated residents. DON verified they can assist any residents that need assistance. DON verified there is no formal assessment for residents to be appropriate to be fed by paid feeding assistance as we just know. DON stated that the director of activities is part of the interdisciplinary (IDT) team. DON stated that residents who need assistant sit at a specific table and sometimes we have a nurse in there [dining room] supervising. DON verified they do not have a list of residents that PFA's can or cannot assist. DON was unable to provide a list of residents who utilized assistance from the PFA's. DON stated if a resident uses a PFA, it should be on their care plan. On 5/30/24 at 9:46 a.m., administrator verified the facility utilizes PFA's. Administrator stated she believes the residents at the sitting at a specified table are the residents that are primarily assisted by the PFA's. Administrator verified that nursing assistants or nurses do not go on resident outings with residents. Administrator verified that resident outings may include meals and snacks and that some of those residents may needs assistance but cannot verify that without looking into it further. On 5/30/24 at 10:14 a.m., dietary aide (DA)-A indicated they are familiar with the residents. DA-A stated the following information regarding residents who sit at the table who need assistance: -R4: need to be fed, can eat things that are placed in her hands like a boiled egg or sandwich but needs assistance with silverware and drinks. -R5: eats pureed food because her dentures don't fit well, and was unsure if she has any swallowing issues adding, I don't think so, all we were told was it was related to her dentures. -R6: needs supervision and encouragement because he falls asleep. -R30: gets his food cut up into small pieces. -R10: needs supervision due to choking is what we were told. -R16: was grandfathered in as she was sitting at that table before they combined the residents who needed assistance. She likes the table, so they just keep her there. A facility policy, paid feeding assistant policy, undated was provided. The policy indicated resident selection of eligibility for feeding assistance will include an interdisciplinary team assessment of the resident's current condition, the latest comprehensive assessment, and plan of care.

Based on observation, interview and document review, the facility failed to comprehensively assess 2 of 2 residents (R5 and R16) reviewed for falls. The facility's failure to assess for risk factors and implement resident appropriate safety interventions, resulted in harm for R5 who fell and required hospitalization for a fractured nose. Findings include: R's [DIAGNOSES REDACTED]. R5's annual Minimum Data set (MDS) assessment dated [DATE], indicated R5 had severe cognitive impairment, exhibited no behaviors, suffered from mild depression, required supervision for walking, required one assist to supervision with activities of daily living including dressing, grooming and hygiene, and experienced occasional incontinence. Additionally the quarterly assessment dated [DATE], identified R5 had experienced falls since the last assessment. R5's care area assessment (CAA) for cognition dated 11/20/18, indicated R5 was not able to complete a brief interview for mental status (BIMS) due to short and long term memory impairments. A CAA for falls dated 11/20/18, indicated R5 used a rolling walker for ambulation to maintain balance. In addition, R5 received antipsychotic medications (used to treat symptoms of [MEDICAL CONDITION] such as delusions (for example, hearing voices), hallucinations, paranoia, or confused thoughts), and exhibited impulsivity or poor safety awareness. The CAA also indicated R5 would at times forget that she needed a walker and would walk without it. R5's care plan for falls updated 11/20/18, indicated R5 had the potential to fall down, lose balance and stumble. The care plan indicated R5 had fallen in the past forgetting her assistive device. Care plan approaches directed staff to remind R5 to wear glasses, use the rolling walker, and to report signs of pain to the charge nurse. R5 required assistance to get ready in the morning, and again at night related to dementia, experienced confusion, and had poor balance without her walker. The care plan also indicated staff were to remind the resident to call for help for transfer assistance. R5's Fall risk assessment last completed 11/14/17, indicated a score of 27 (10 or more may represent a risk for falling). R5's incident reports indicated the following falls: On 12/5/18 at 6:54 a.m., R5 was found lying on the floor in the middle of her room, R5 denied hitting her head. The report indicated the resident complained of right elbow discomfort, no redness or bruising noted. Resident unable to state how fall occurred. Further, the incident report indicated R5 was disoriented, confused, and unable to follow directions. Current interventions at the time of the fall included: low bed, nonskid carpet next to bed, room close to nurses' station, and a wanderguard bracelet (a device used to alert staff of the resident trying to leave the building). Additional actions indicated: continue to observe. Teaching provided post fall included: Instructed resident on safe use of assistive device, safe transfer techniques, use of call light and to wait for staff assist. An incident from 5/20/19 at 1:25 a.m., indicated R5 had been found lying on her right side next to her bed. The report indicated R5 had stated, I fell but was unable to state what happened to cause the fall. The report indicated R5 was disoriented, resident unable to tell writer what caused her to fall. Actions indicated: continue to observe. Teaching provided post fall included: Instructed resident on safe use of assistive device, safe transfer techniques, use of call light and to wait for staff assist. An incident from 5/21/19 at 1:15 a.m., indicated R5 was found lying on the floor with the top half of her body under the bed, lying face down, and a large amount of blood next to her. There was a large amount of bright red blood with several large blood clots next to resident's head and clots in the resident's hair. The report indicated 911 was summoned, and the nurse could not determine where the blood was coming from. Documentation included, Dried blood in resident's nose. Transferred to hospital by emergency medical team. R5 was hospitalized from [DATE] to 5/24/19 following the fall incident of 5/21/19. R5's history and physical identified R5 had been diagnosed with [REDACTED]. Documentation indicated the consult had been conducted 5/24/19, and R5 was diagnosed with [REDACTED]. Follow up as needed. An interdisciplinary progress note for R5 dated 5/24/19, at 9:12 a.m. included: Nervous system findings: alert and awake, alert to person only. Speech is garbled as previously. Gait: slow; needing nursing assistant to guide wheeled walker initially because she was steering toward right when walking in the hall. Taking fluids with staff assist. Did not appear to understand what to do when handed a glass of juice or when instructed to drink. Staff had to guide hand with glass to mouth for resident to take a drink and then resident began drinking on her own. Facial bruising starting to turn yellow on outside of bruising, under eyes, and across nose. During an observation/interview on 5/28/19 at 1:52 p.m., R5 was laying in bed with her eyes open with her bed in the lowest position. R5 was able to make eye contact however, her speech was garbled and nonsensical. R5's face was observed to be severely bruised, with varying shades of dark purple around her face and eyes, extending below her nose, into her cheeks, around her eyes and lower forehead. During an interview with R5's daughter (FM)-C on 5/28/19 at 2:56 p.m., FM-C confirmed R5 had experienced a fall that required hospitalization on [DATE], and had fractured her nose. FM-C also stated R5 had fallen the day prior to breaking her nose, 5/20/19. During an interview on 5/29/19 at 12:47 p.m., registered nurse (RN)-A stated the facility did not have a falls' committee, and was not involved in implementing immediate interventions when falls occurred. RN-A stated the DON determined the fall interventions, and RN-A confirmed R5 had severe cognitive impairment. During an interview with the director of nursing (DON)-A on 5/29/19 at 3:01 p.m., DON-A stated a falls' care plan had not been updated for R5 since 11/20/18. DON-A reviewed R5's Incident Reports including the actions taken, and confirmed with R5's severe cognitive impairment, teaching was not appropriate. Further, the interventions in place were reviewed and included: bed in low position, non skid carpet next to bed. DON-A stated she was unaware R5's bed was in the low position. At that time, the DON and surveyor observed R5's room and found R5 sitting up on the edge of her bed with only stockings on her feet. Her shoes were off and her walker was within 3 feet of the bed. DON-A stated gripper socks on while in bed could help to prevent falls for R5, and setting the bed at a normal level may be an intervention to better promote safe transfers. R16's cumulative [DIAGNOSES REDACTED]. R16's care area assessment (CAA) dated 9/25/18, indicated moderate cognitive impairment, oriented to her name and family, and where room was located, R16 made poor decisions. The CAA for falls indicated resident took medications for anxiety, and cardiovascular system that put her at risk for falls. R16 required staff assistance with bed mobility, transfers, and ambulation. The CAA further indicated R16 could not always make good decisions or remember to use her call light or to wait for staff assist with transfers and would often transfer herself in her room. R16's care plan for falls dated 9/30/16, indicated potential for injury, trauma, and falls due to impaired mobility, dementia, depression, anxiety, hypertension, and [MEDICAL CONDITION]. The interventions included: wanderguard, transfer with assistance, instruct to call for help, keep personal items in reach, assist with ambulating, transferring, toileting, and report pain. R16's physician orders [REDACTED]. R16's incident reports indicated the resident had sustained the following falls: On 4/7/19, at 7 p.m., R16 was found on the floor with her wheelchair beside her and a blanket wrapped around her feet. The report indicated current interventions included: low bed, non skid carpet next to bed, room close to the nurses' station. Actions identified included: continue to observe. Immediate teaching done indicated: Use of call light. On 4/14/19, at 8:38 p.m., R16 was found on the floor with her folded wheelchair leaning against her. R16 was leaning on the dresser. Current interventions included: low bed, non skid carpet next to bed, room close to nurses' station. Actions identified included: continue to observe. Immediate teaching done indicated: Safe transfer technique, bumped head neuro's started; A subsequent note indicated, bruising on left side of back observed on 4/15/19, treatment set up to monitor bruising until resolved. On 4/27/19, at 1:45 p.m., R16 was found sitting on the floor in front of her wheelchair in her room, with her legs out in front of her. The report indicated, Apparently was trying to transfer to her recliner by herself and slipped out of wheelchair. Bruising was noted on her right breast. Current interventions were identified as including: low bed, non skid carpet next to bed, room close to nurses' station, wanderguard. Actions: continue to observe. Teaching was identified as conducted for use of call light. The progress notes indicated a fax was sent to the physician on 5/6/19, due to R16's complaints of pain, a chest x -ray was done and was negative for fractures. On 5/17/19, at 8:00 p.m., R16 was found on the floor in front of her recliner with the foot rest still up. Current interventions included: low bed, fall mat, hit head- neuro checks started. Actions were identified to continue to observe. Post fall teaching included: Use of call light. On 5/19/19, at 9:13 a.m. R16 was observed on floor laying on her left side spread out in front of her recliner mostly on her stomach. According to the report, R16 stated she'd been trying to get to my recliner. Other factors identified included: Resident was up for most of the night per night nurse and appears tired, confused and restless. Call light was in reach, resident doesn't use. The current interventions were identified as: Reclining chair. Actions: continue to observe. Teaching done: Instructed R16 on safe transfer techniques, use of call light, and to wait for staff assistance. On 5/21/19, at 3:55 a.m., R16 was observed sitting on the floor next to her bed. The report indicated her wheelchair was tipped over and was laying across R16's right lower leg. Additionally, the report indicated R16 had been in bed prior to the incident. Writer had checked on resident approximately 5 minutes before incident occurred. No injuries noted. Did complain of pain to right lower leg where wheelchair was laying, but no redness or bruising noted denied hitting head. The notes indicated R16 had stated, I fell , I was going to go to the bathroom. The current interventions identified included: Low bed, non skid carpet next to bed, room close to nurses' station, and wanderguard. Actions included: Continue to observe. Immediate teaching done included: Instructed resident on safe use of assistive device, safe transfer technique, use of call light, and to wait for staff to assist. A physician's progress note dated 4/16/19, identified an additional [DIAGNOSES REDACTED]. Further the note indicated R16 was exhibiting increased behaviors, which required an [MEDICATION NAME] dose (antianxiety) after not being able to redirect her behaviors with non pharmacological interventions. The physician orders [REDACTED]. A fax to the physician dated 4/19/19 at 7:45 a.m., included a request for an as needed order for [MEDICATION NAME] to be used during the evening or night. The fax included: Many evenings goes out main door, swings and grabs at staff, twists staff arm, can be belligerent and difficult to redirect. The physician's response was returned by fax on 4/23/19 with orders to give [MEDICATION NAME] (antianxiety) 0.5 mg, 1 tab 2 times per day as needed, in addition to scheduled for agitation and restlessness that does not respond to non-pharmacological interventions, and to review in 3 months. A fax to the physician dated 5/23/19 at 4:15 a.m., indicated R16 had experienced multiple falls, more behaviors and nausea. The physician's response included: New catheter, check urinalysis and urine culture. Review of the subsequent laboratory report revealed the urinalysis was negative for infection. During an interview and observation on 5/30/19 at 7:05 a.m., nursing assistant (NA)-A described R16 as being impulsive. NA-A stated R16 would get up and try to transfer, not realizing her disabilities. During an observation of a.m. cares at that time, R16 appeared comfortable, and did not resist with cares, but was cooperative. NA-A explained whenever she goes by R16's room she does a visual check to monitor safety. During an interview with DON-A on 5/30/19 at 7:22 a.m., the incident reports were reviewed. DON-A confirmed the incident reports did not reveal an analysis of the fall, or new interventions to prevent future falls. During an interview on 5/30/19 at 10:55 a.m., DON-A presented a format to better analyze a fall incident and confirmed understanding of the need to immediately implement interventions to prevent another fall. The facility's Accident and Supervision Policy and Procedure revised 11/7/13, included: The policy of Lake Shore Inn is to provide an environment that is free from hazards over which the facility has control, and to provide appropriate supervision to each resident to prevent avoidable accidents. The policy included the following procedure: 9.) After a fall the facility will determine the cause or contributing factor to the fall, address the cause or contributing factor, revise the care plan, and/or facility practices to reduce the likelihood of another fall. The facility's Falls- Clinical Protocol revised (MONTH) (YEAR), included: 1. The physician will help identify individuals with a history of falls and risk factors for falling. a. staff will ask the resident and the caregiver about history of falling. Cause identifications: 1. For an individual who has fallen, the staff and practitioner will begin to try to identify possible causes. Treatment and management: 1. Based on the preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls and address the risks of clinically significant consequences of falling.

Based on observation, interview and document review the facility failed to assess pain and provide adequate pain control for 1 of 1 residents (R2) reviewed for pain. This resulted in harm for R2 as he experienced moderate to severe pain on a daily basis that remained unassessed and untreated. Therapy notes identify R2 had untreated pain going back to date of admission. Findings include: Physician orders [REDACTED]. The quarterly Minimum Data Set ((MDS) dated [DATE], identified moderate cognitive impairment, extensive assistance needed with all activities of daily living (ADL's) and a functional limitation of upper and lower extremities. The admission Care Area Assessment (CAA) dated 10/27/15, identified R2 as having a history of [MEDICAL CONDITION] right [MEDICAL CONDITION]. Staff provide extensive to total assistance with all ADL's. R2 did not walk, transferred with a mechanical lift and received PT (physical therapy) and OT (occupational therapy) to increase strength and mobility. During observation on 7/19/16, at 6:00 p.m. P2 was observed to grimace any time the right arm/hand was touched or he attempted to move it. P2 was observed to lift his right hand/arm up with his left hand and stated Ouch! When asked if it hurt he nodded his head yes. On 7/20/16, at 7:15 a.m. R2 was observed sitting up in the wheelchair. R2 was unable to open his right hand. R2 stated it hurt if he tried to open it. On 7/20/16, at 11:00 a.m. R2 was observed sitting up in the wheelchair. R2 had his right hand clenched. When asked if he could open his hand he shook his head no and indicated it hurt if he tried. When his arm was lightly touched, R2 grimaced. On 7/20/16, at 12:47 p.m. OTRL (occupational therapist registered licensed)-A observed R2 in the dining room. When OTRL-A touched R2's right arm/hand, he grimaced with pain and loudly stated ouch! OTRL stated she had worked with R2 in occupational therapy (OT) in the fall and she recalled that R2's right side was very sensitive. On 7/20/16, at 2:29 p.m. R2 was observed sitting in the dining room with his wife. His wife attempted to lift his right arm/hand to look at his hand. R2 was observed to grimace. When asked if it hurt, he nodded his head yes. R2's wife stated, it does really seem to hurt him. On 7/21/16, at 8:32 a.m. R2 was again observed in the dining room. When asked about his right arm/hand, he shrugged his shoulders. R2 was unable to open his hand and when he attempted to lift arm/hand he grimaced and expressed pain. On 7/21/16, at 10:09 a.m. nursing assistant (NA)-E and NA-F were observed using the EZ lift (mechanical lift device) to lay R2 in bed. When NA-F attempted to lift his right arm to hold onto the EZ lift R2 cried out, No! No! Ouch! Ouch! NA-F asked R2 what his pain level was and R2 stated 7 (on a scale of 0-10 with 10 being the most pain). Review of the medical record identified R2 had received OT from 10/15/15 to 12/8/15. OT notes included: · 10/29/16 - (R2) was not wearing right resting splint on therapist arrival. Pt presents with significant pain and contracture/limited PROM (passive range of motion) in RUE (right upper extremity). · 11/3/15 - (R2) care conference was held with wife and daughters. Many concerns were discussed including RUE pain management. · 11/9/15 - PROM very limited due to (R2) reporting pain and refusing. · 11/16/15 - (R2) had significant pain in right hand and forearm today. · 11/20/15 - (R2) complained of discomfort at times. · 11/23/15 - PROM RUE with limited ROM and complaints of pain. · 11/25/15 - did not verbalize pain but grimaced with movement with PROM. · 11/26/15 - PROM with maximum complaints of pain, OT only able to do minimal ROM. · 11/27/15 - (R2) has stiff digits and extension caused pain in RUE. · 12/2/15 - Limited PROM as (R2) would not allow due to pain. · 12/8/15 - noted right hand joint contracture, (R2) tolerated gentle PROM. · 12/8/15 - Therapist Progress & Discharge Summary dated identified (R2) reports pain in right hand to severe on 10/29/15, pain in right hand to mild on 11/25/15 and pain in right hand to mild but demonstrated facial grimaces and verbalizations during ROM to indicate pain is moderate on 12/8/15. Review of the medication administration records (MAR) from April 2016, to July 2016, identified R2 had an order for [REDACTED]. Review of the nurses' notes clarified of the 12 times the PRN Tylenol was given, it had been given 3 times for an elevated temperature and 9 times for pain. Nursing notes identified on 5/24/16, R2 complained of pain all over and had identified a pain level of 5 of 10 (0 not pain, 10 being worst pain). On 5/26/16, R2 had vocal complaints of pain (that hurts, ouch, stop). On 5/29/16, R2 had expressed pain all over and a pain level of 5. On 6/1/16, R2 complained of pain all over and a pain level of 4. On 6/2/16, R2 again complained of pain all over and rated the pain at a level 5. On 6/3/16, R2 complained of pain all over and rated the pain level as 5. On 6/6/16, R2 complained of pain all over and rated his pain level as 6. On 6/11/16, R2 had pain all over and rated his pain level as 4. On 6/12/16, R2 had pain all over and rated the pain level as 5. The Pain Management Policy revised 8/03, identified the facility pain protocol included identifying the intensity of pain using a 0-5 scale (5 as the highest amount of pain). Although this was the facility policy, staff did not consistently utilize this scale as evidenced by R2 rating his pain greater than 5. There was no documentation with the PRN Tylenol to identify what pain scale was used or the level of relief obtained with the administration of Tylenol. Further, without a pain assessment, there was no evidence of what an acceptable level of pain was for R2. In addition, it was unclear what R2's level of pain was with movement, at rest, and at rest following movement. The care plan dated 10/26/15, identified impaired mobility due to history of [MEDICAL CONDITION] with right [MEDICAL CONDITION] and identified an approach of assure adequate pain management. There were no interventions identified. Without a comprehensive assessment for pain, there were no individualized pain management approaches identified for R2. On 7/20/16, at 11:10 a.m. NA-B stated, he can't open his hand it hurts too much. On 7/21/16, at 9:15 a.m. NA-C stated she did morning cares for R2. She stated, we don't do ROM for him as it is too painful. She stated R2 really complained of pain when staff try to lift his right side. NA-C stated she let the nurse know if pain is more than usual. She stated the nurse was aware that it bothered him to move too fast. On 7/21/16, at 10:08 a.m. NA-D stated, sometimes I try to do a little ROM on him but he is usually resistive because it hurts him so I don't do it. On 7/21/16, at 9:40 a.m. licensed practical nurse (LPN)-A stated the aides had not reported R2 stated he had pain. She stated I think he just doesn't like anyone touching that arm. On 7/21/16, at 11:00 a.m. registered nurse (RN)-B verified a pain assessment should have been completed on R2 and staff should have been reporting increased pain to nurse. The Pain Management Policy revised 8/03, identified it was facility policy to assess the amount of pain a resident was experiencing and to evaluate the [MEDICATION NAME] prescribed. The facility pain protocol included identifying the intensity of pain using a 0-5 scale (5 as the highest amount of pain), [MEDICATION NAME] used, plan and comments and efficacy of pharmacological and non-pharmacological interventions. The policy also indicated an ongoing pain management plan would be addressed on the resident's care plan.