Every finding on record at Landmark Nursing and Rehab Center

Based on observation, interview, record review and facility policy review, the facility failed to follow physician orders for a resident with a Percutaneous Endoscopic Gastrostomy (PEG) tube medication administration for one (1) of four (4) residents observed for medication administration (Resident #5).Findings Include: Record review of facility policy titled Medication Administration, revised on 3/30/2026, revealed, Medications are administered by licensed nurses or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection.Record review of the Order Summary Report revealed an order dated 5/27/25, Enteral Feed Order every shift Flush PEG tube with 30 milliliters (ml) of water before and after medication administration and 5 ml between meds.During a medication administration observation on 8/5/2026 at 9:30 AM, Licensed Practical Nurse (LPN) #1 removed Aspirin, Loratadine, Azithromycin, Linzess, and Hydrocodone from the medication cart. LPN #1 placed all five (5) medications together in one medication crushing pouch and crushed them at the same time. LPN #1 added a small amount of water to the combined crushed medications. LPN #1 also removed Docusate Sodium Liquid and measured the appropriate amount into a medication cup. Prior to administering the medications, LPN #1 verified placement of Resident #5's PEG tube and flushed the PEG tube with 30 ml of water. LPN #1 then administered the five (5) combined crushed medications through the PEG tube, followed by 5 ml of water. LPN #1 then administered the liquid Docusate Sodium, followed by 30 ml of water. LPN #1 did not administer the five (5) crushed medications separately with five (5) ml of water between each medication as ordered by the physician.During an interview on 8/5/2026 at 9:55 AM, LPN #1 confirmed that when administering medications through a PEG tube, each medication should be crushed and administered separately with 5 ml of water between each medication and that she had failed to do that.During an interview on 8/6/2026 at 1:23 PM, the Director of Nursing (DON) acknowledged that physician orders indicated how medications are to be administered. The DON confirmed that the physician order for Resident #5 was not followed and stated that the medications should have been administered according to the physician order.Record review of admission Record revealed Resident #5 was admitted to facility on 3/25/2025 with diagnoses including Dysphagia Following Cerebral Infarction.Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/10/2026 revealed under Section C, a Brief Interview for Mental Status (BIMS) summary score of 15, indicating Resident #5 was cognitively intact.

Based on record review, staff interview and facility policy review, the facility failed to accurately complete the Level I Preadmission Screening and Resident Review (PASARR) screening, resulting in the failure to refer a resident with documented mental illness for a PASARR Level II evaluation, for one (1) of two (2) residents reviewed for PASRR. Resident #7Findings Include:Review of the facility policy titled admission to Facility, revised 5/20/20, revealed under PASARR: This facility coordinates assessments with the preadmission screening and resident review (PASARR) program under Medicaid to ensure that individuals with a mental disorder, intellectual disability, or a related condition receive care and services in the most integrated setting appropriate to their needs. All applicants to this facility will be screened for serious mental disorders or intellectual disabilities and related conditions in accordance with the State's Medicaid rules for screening .Record review of the admission Record revealed the facility admitted Resident #7 on 7/28/25 with a primary diagnosis of Hypertensive Heart and Chronic Kidney Disease with Heart Failure. Other medical diagnoses included Bipolar Disorder, Obsessive-Compulsive Disorder, and Unspecified dementia.Record review of Resident #7's PASARR, dated 7/31/25, revealed the resident had a history of mental illness and took mood stabilizers and antidepressants. Section M, PASARR level II Categorical Determination Criteria, asked: a. Does proper first name of the resident have a primary diagnosis of Alzheimer's /Dementia? The facility marked Yes, although Resident #7 did not have a primary diagnosis of Alzheimer's/Dementia. This inaccurate response resulted in a screening outcome of PASARR Activity Required: No. Therefore, the resident was not referred for a PASARR Level II evaluation despite documented diagnoses of bipolar disorder and obsessive-compulsive disorder.An interview and record review with Social Services (SS) on 8/4/26 at 1:20 PM revealed she was responsible for PASARR submissions. SS confirmed the resident was not referred for a Level II evaluation and stated she thought that was unusual because the resident had bipolar disorder. SS acknowledged Resident #7 did not have a primary diagnosis of dementia. After reviewing the question in Section M, SS confirmed she completed the PASARR inaccurately because she thought the question asked whether the resident had any diagnosis of dementia. SS confirmed the Level I was completed inaccurately and did not represent the resident's true status, which could alter the state mental health authority's findings.An interview with the Director of Nursing (DON) on 8/4/26 at 2:03 PM revealed Resident #7 was admitted to the facility following a hip fracture. The DON confirmed the resident had dementia, but dementia was not the resident's primary diagnosis. She further acknowledged the inaccurate information could alter whether the resident was referred to the mental health authority for a Level II evaluation.Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/15/26 revealed under Section C, a Brief Interview for Mental Status (BIMS) summary score of 15, indicating Resident #7 was cognitively intact.

Based on resident and staff interview, record review, and facility policy review, the facility failed to implement a scheduled toileting program for urinary incontinence after repeated assessments identified the resident as a candidate for scheduled toileting for one (1) of two (2) residents reviewed for urinary incontinence. Resident #10 Findings Include:Review of the facility policy titled Bladder and Bowel Habits, Urinary Incontinence and Catheter Care revised 9/15/22, revealed under, Policy: It is the policy of this facility to re-establish a program of independent bladder and bowel control. Also revealed under, Urinary Incontinence: . A resident who is incontinent of bladder shall receive appropriate treatment and services to prevent urinary tract infections and to restore as much normal bladder function as possible. Each resident who is incontinent of urine is identified, assessed, and provided treatment and services to achieve or maintain as much normal urinary function as possible .An interview with Resident #10 on 8/4/26 at 9:50 AM revealed she was usually continent of urine during the day but occasionally had accidents. She stated, during the night, she was incontinent of urine, and staff came into her room and changed her brief.Record review of Resident #10's Minimum Data Sets (MDS) with Assessment Reference Dates (ARD) of 1/13/26, 4/7/26, and 7/8/26 revealed under Section H-Bladder and Bowel item H0300 that the resident was frequently incontinent. The MDS also revealed under item H0200, Urinary Toileting Program A. Has a trial of a toileting program (scheduled toileting, prompted voiding, or bladder retraining) been attempted on admission/entry or reentry or since urinary incontinence was noted in this facility? No was indicated.Record review of the Bowel and Bladder Evaluation dated 1/8/26, 4/5/26, and 7/4/26 revealed the resident was alert and oriented and had urinary incontinence Not always, but at least daily. The evaluations reflected scores ranging from 12 to 13, which indicated the resident was a candidate for scheduled toileting (timed voiding). Each evaluation reflected, Will not proceed with bladder retraining program, with no additional comments.An interview with the Director of Nursing (DON) on 8/5/26 at 2:42 PM revealed the night shift charge nurse was responsible for completing the bowel and bladder evaluations quarterly. She stated that if staff identified an issue during the evaluation, the night shift charge nurse was to notify the day shift charge nurse, who would contact the physician for orders, such as an order to check the resident's urine for a urinary tract infection. The DON confirmed the facility did not provide bladder retraining programs for urinary incontinence. She also stated Resident #10's bowel and bladder evaluations identified the resident as a candidate for scheduled toileting; however, a program was not implemented to address the resident's urinary incontinence.An interview with the MDS Nurse on 8/5/26 at 2:58 PM revealed the MDS staff reviewed the bowel and bladder evaluations but did not implement interventions when concerns related to urinary incontinence were identified. She confirmed the facility had never implemented a scheduled toileting program for any resident. The MDS Nurse stated Resident #10 preferred to wear a brief at night and chose to be incontinent; however, she acknowledged the facility had not attempted a scheduled program in which staff toileted the resident at night.An interview with Certified Nurse Aide (CNA) #1 on 8/5/26 at 3:12 PM revealed that at night, staff entered Resident #10's room and changed her brief every two hours but did not offer to toilet her. CNA #1 stated, We just change her.Record review of the admission Record revealed the facility admitted Resident #10 on 1/25/25 with medical diagnoses including Spinal Stenosis.Record review of the MDS with an ARD of 7/8/26 revealed under Section C a Brief Interview for Mental Status (BIMS) summary score of 14, indicating Resident #10 was cognitively intact.

Based on observation, interview, record review and facility policy review, the facility failed to ensure pain was adequately assessed, monitored, and managed. The facility failed to complete a comprehensive pain evaluation and reassess and monitor Resident #4 following pain management interventions; and failed to consistently monitor Resident #7's pain and notify the provider for evaluation of the resident's pain management regimen when the resident experienced persistent pain that interfered with daily activities for two (2) of three (3) residents reviewed for pain. Findings Include: Review of the facility policy titled Pain Management, revised 3/10/2025, revealed, The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. The facility will use a pain assessment tool . Assessment of pain shall include location, duration, radiation, precipitating and alleviating factors. Re-assessment shall be performed after each method of pain relief is tried to assess the effectiveness of the method. Attempts to control pain shall be employed until the resident reaches an acceptable comfort level . During an interview on 8/3/26 at 11:25 AM, Resident #4 stated, I have pain at times to my bottom and my knees, but I'm not having any pain at this time. Record review of Resident #4's Visit Note Report: Registered Nurse (RN) Hospice Subsequent Visit, dated 8/3/26 at 4:05 PM, revealed under Pain: Patient Response, Are you uncomfortable because of pain? No. The narrative documentation revealed, Patient states that she is sore from being in the bed; however, denied needing pain medication at time of visit. Record review of Resident #4's Order Summary Report revealed an order for Fentanyl Patch 72 Hour 25 micrograms/hour (MCG/HR), apply one patch transdermally every 72 hours for pain, and an order for Morphine Sulfate (Concentrate) Oral Solution 20 milligrams/milliliter (MG/ML), give 0.2 ML by mouth every four hours as needed for pain. Record review of Resident #4's nursing Progress Note dated 8/3/26 revealed the resident's family reported that Resident #4 complained of leg pain and requested administration of the as-needed Morphine Sulfate. There was no documented comprehensive assessment of Resident #4's reported leg pain, including the location, duration, radiation, precipitating factors, or alleviating factors, prior to administration of the as-needed Morphine Sulfate. Record review of Resident #4's Medication Administration Record (MAR) revealed that on 8/3/26 at 5:00 PM, Resident #4 received Morphine Sulfate Oral Solution 20 MG/ML, 0.2 ML, as needed for pain. The MAR reflected a pain level of 5 associated with the administration. A Fentanyl 72-Hour 25 MCG/HR transdermal patch was applied on 8/3/26 at 5:02 PM. Further record review revealed no completed Pain Evaluation for Resident #4 in accordance with the facility's pain management process and no documented comprehensive pain assessment addressing the location, duration, radiation, precipitating factors, and alleviating factors associated with the resident's reported leg pain. The record also contained no documented reassessment of Resident #4's pain or monitoring for adverse effects following administration of the as-needed Morphine Sulfate. Observations on 8/4/26 at 12:55 PM and again at 2:40 PM revealed Resident #4 lying in bed asleep. During an interview on 8/4/26 at 2:55 PM, RN #1 stated, I've been off work for a week and don't know why she does not have a pain assessment completed. During an observation and interview on 8/4/26 at 3:00 PM, Resident #4 was observed awake and lying in bed. Resident #4 stated, I've been sleeping a lot; they gave me pain medicine. Resident #4 denied pain at the time of the interview and stated that when she experienced pain, it was usually located in her knees and bottom. During an interview on 8/4/26 at 3:55 PM, the Director of Nursing (DON) confirmed that a Pain Evaluation had not been completed for Resident #4 and that the resident's pain had not been comprehensively assessed prior to administration of the as-needed Morphine Sulfate on 8/3/26. The DON confirmed that the hospice nurse's documentation from the 8/3/26 visit at 4:05 PM revealed Resident #4 denied being uncomfortable because of pain and denied needing pain medication at the time of the visit. The DON confirmed that following the hospice nurse's visit, the resident's family reported that Resident #4 complained of leg pain and requested the as-needed Morphine Sulfate. The Morphine Sulfate was subsequently administered, followed by application of the Fentanyl patch. The DON further confirmed that Resident #4 was not reassessed or monitored for adverse reactions following administration of the as-needed Morphine Sulfate. The DON stated, This is concerning to me because the resident could have become overly sedated, and this could have resulted in a bad outcome. During an interview on 8/4/26 at 4:20 PM, the Medical Director confirmed that prior to administration of as-needed pain medication, a resident's pain should be assessed, and the resident should be monitored following administration for effectiveness and adverse effects. The physician confirmed that failure to assess and monitor the resident could result in adverse consequences, including sedation. Record review of the admission Record revealed the facility admitted Resident #4 on 5/25/26 with medical diagnoses that included Chronic Systolic (Congestive) Heart Failure and Major Depressive Disorder. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/25/26 revealed under section C, a Brief Interview for Mental Status (BIMS) summary score of 15, indicating Resident #4 was cognitively intact. Resident #7 A telephone interview with the Resident Representative (RR) on 8/3/26 at 11:35 AM revealed Resident #7 had rheumatoid arthritis and had fractured both hips in the past. The RR stated the resident talked about pain, especially pain in her right hip, and reported the pain was unbearable at times. The RR stated the facility gave the resident Tylenol for pain, which the resident told her, Is just like taking water and did nothing for the pain. An observation and interview with Resident #7 on 8/3/26 at 2:46 PM revealed she was sitting on the edge of her bed with her right hand positioned under her right hip. She stated she had pain in her neck, lower back, and right hip. She explained that she had fallen in the past and fractured both hips, which required surgical repair. The resident stated her right hip had caused pain since the surgery. She stated she felt a nodule in the hip region and the pain increased with movement. She stated she was participating in therapy and had to ride the bicycle, stating, It absolutely kills me. The resident revealed she propped her hand under her right thigh to relieve the pain. She stated she had Voltaren gel and Tylenol for pain, but It does not do much of anything. The resident stated she complained of pain during therapy, but it did not do any good, so she pushed through to complete the therapy. Record review of Resident #7's Physical Therapy (PT) Evaluation and Plan of Treatment, dated 2/16/26, revealed under Patient goals, Decrease pain in order to walk around place and socialize with everyone. The evaluation also revealed under Current Referral: Referred to physical therapy following insidious onset of R (right) hip and leg pain. she has had an onset of pain in her R (right) hip that limits her function. She is unable to provide a date, but pt (patient) has had her R (right) hip replaced prior to admission to this facility. Pt (patient) states that her pain is 0/10 at best and 8/10 at worst w/ (with) worsening symptoms during activity and ambulation . Record review of the Progress Notes for Resident #7, dated 4/21/26, revealed, Complained of continued and increasing pain to right hip. Requested 'Something Done.' Charge nurse made aware. Record review of the August 2026 Medication Administration Record (MAR) revealed an order dated 4/21/26 for Voltaren arthritis pain external gel 1% (percent) apply to lower back/bilateral hip topically every evening shift for hip pain/low back pain and every 8 (eight) hours as needed. The MAR also revealed an order dated 8/4/25 for Tylenol oral tablet 325 MG (milligrams) give 2 (two) tablets by mouth every 6 (six) hours as needed for pain related to generalized osteoarthritis. An interview with the Rehab Director on 8/4/26 at 1:58 PM revealed she had been working with Resident #7 in occupational therapy (OT), but the resident had plateaued. The Rehab Director stated the resident complained of right hip pain, but not consistently, and she had not modified the treatment plan because of the pain. Record review of the Occupational Therapy Progress Notes, dated 6/25/26 through 7/13/26, revealed no documentation that the resident experienced pain during the treatment sessions. Record review of the MDS with an ARD of 4/14/26 revealed under section J, item J0410 How much of the time have you experienced pain or hurting over the last 5 days? Frequently was indicated. Under item J0510 Over the past 5 days, how much of the time has pain made it hard for you to sleep at night? Occasionally was indicated. Further review of the MDS with an ARD of 7/15/26 revealed under section J, item J0410 How much of the time have you experienced pain or hurting over the last 5 days? Almost constantly was indicated. Under item J0530 Over the past 5 day, how often have you limited your day-to-day activities because of pain? Frequently was indicated. Record review of the July 2026 MAR revealed Resident #7 received Tylenol 325 milligrams (two) tablets on the following dates and times. The nurses documented the medication was effective on follow-up: 7/10/26 at 1352 (1:52 PM) for a pain score of 5;7/25/26 at 1330 (1:30 PM) for a pain score of 6;7/27/26 at 1726 (5:26 PM) for a pain score of 5;7/29/26 at 1045 (10:45 AM) for a pain score of 5; and7/31/26 at 0830 (8:30 AM) for a pain score of 4. Record review of the August 2026 MAR revealed Resident #7 received Tylenol 325 milligrams (two) tablets on 8/3/26 at 8:33 AM for a pain score of 5. Documentation indicated the medication was effective for pain. An interview with the MDS Nurse on 8/5/26 at 8:20 AM revealed Resident #7 complained of right hip pain, had arthritis pain, and saw a rheumatologist. When asked about the most recent MDS pain assessment dated [DATE], which indicated the resident experienced almost constant pain that interfered with her day-to-day activities, the MDS Nurse stated, It's nothing new, she has arthritis pain and has Tylenol when needed. She denied that the resident's report of constant pain should have been reported to the physician for review of the pain regimen. An observation and interview with Resident #7 on 8/5/26 at 8:29 AM revealed she was sitting in a chair in her room. She explained that she received Tylenol around 5:00 PM the previous evening and stated, It may have helped some; my hip hurt real bad last night. Record review of Resident #7's July and August 2026 MARs revealed no indication that the resident's pain was monitored every shift. An interview with the Director of Nursing on 8/6/26 at 9:52 AM revealed she expected nurses to monitor residents for pain every shift. She confirmed this was not done for Resident #7. She further revealed the provider should have been notified immediately when the MDS assessment indicated Resident #7 was experiencing constant pain. The DON stated she expected the nurses to follow up after pain medication was given, and if the medication was ineffective, the provider should be notified to alter the pain regimen. Record review of the admission Record revealed the facility admitted Resident #7 on 7/28/25 with medical diagnoses that included Hypertensive Heart and Chronic Kidney Disease with Heart Failure, Rheumatoid Arthritis, and Pain Unspecified. Record review of the MDS with an ARD of 7/15/26 revealed under section C, a BIMS summary score of 15, indicating Resident #7 was cognitively intact.

Based on observation, interview and facility policy review, the facility failed to ensure controlled substances were securely stored in one (1) of two (2) medication room refrigerators observed by failing to permanently affix the locked narcotic storage box inside the refrigerator. Findings Include: Review of the facility policy titled Medication Storage dated 04/26/2023 revealed under Policy explanation and compliance Guidelines: .2. Narcotics and Controlled Substances: a. Schedule II drugs and back-up stock of Schedule III, IV and V medications are stored under double-lock and key. b. Schedule II controlled medications are to be stored within a separately locked permanently affixed compartment .such as in the refrigerator . Observation and interview on 08/06/2026 at 9:06 AM revealed the medication storage room contained a refrigerator identified by Registered Nurse (RN) #1 as being used to store controlled substances. The refrigerator was observed to be unlocked. Inside the refrigerator was a locked black medication box that was not permanently affixed to the refrigerator. The locked box contained Lorazepam Intensol Oral Concentrate 2 milligram (mg)/milliliter (ml) which is a schedule IV-controlled substance. RN #1 stated, It's always been like this. During an interview on 8/06/2026 at 10:30 AM, the Director of Nurses (DON) confirmed the medication lock box located inside the refrigerator is required to be permanently affixed and acknowledged it was not.

Based on observation, interview, record review and facility policy review, the facility failed to ensure a resident's right to personal privacy during a blood glucose check and insulin administration for one (1) of four (4) care opportunities observed. (Resident #24).Findings Include:Record review of facility policy titled Resident Rights and Responsibilities with a revision date of 10/10/2022 revealed .7. Privacy and confidentiality.a. Personal privacy includes accommodations, medical treatment, written and telephone communications, personal care, visits, and meetings of family and resident groups, but this does not require the facility to provide a private room for each resident .Observation on 8/5/2026 at 11:17 AM revealed Licensed Practical Nurse (LPN) #2 assisted Resident #24 from the dining room to the area by the nurses' station. LPN #2 checked the resident's blood glucose, which was 251 mg/dL (milligrams/deciliter). LPN #2 then prepared six (6) units of insulin and administered the insulin into the back of the resident's right upper arm. During the blood glucose check and insulin administration, at least two (2) facility staff members walked past the nurses' station and opened the unit doors. Additionally, three (3) hospice personnel approached and remained at the nurses' station while LPN #2 administered the insulin injection.During an interview on 8/5/2026 at 2:40 PM, LPN #2 stated Resident #24 should have been taken to her room for privacy during the blood glucose check and insulin administration. LPN #2 acknowledged performing the procedures by the nurses' station was a dignity issue.During an interview on 8/6/2026 at 1:31 PM, the Director of Nursing (DON) confirmed Resident #24 should have been provided privacy during the blood glucose check and insulin administration. The DON stated the procedures should not have been performed in an open area where other individuals were present.Record review of admission Record revealed Resident #24 was admitted to facility on 4/25/2024 and had diagnoses of Alzheimer's Disease and Type 2 Diabetes Mellitus with Diabetic Polyneuropathy.Record review of the Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 6/17/2026 revealed under Section C, a Brief Interview for Mental Status (BIMS) summary score of 10, indicating Resident #24 was moderately cognitively impaired.

Based on observation, interview, record review, and facility policy review, the facility failed to implement a pain care plan for one (1) of 19 care plans reviewed. Resident #7 Findings Include:Review of the facility policy titled Comprehensive Plan of Care revised 2/17/25 revealed under, Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and all services that are identified in the resident's comprehensive assessment and meet professional standards of quality.Record review of Resident #7's Care Plan Report revealed under, Focus: 'proper first name of resident' has pain r/t (related to) arthritis, OA (osteoarthritis), RA (rheumatoid arthritis), and history of hip fx (fracture). The care plan also revealed under, Interventions: Observe for s/s (signs and symptoms) of pain every shift.On 8/3/26 at 11:35 AM, during a telephone interview with the Resident Representative (RR), she revealed Resident #7 had rheumatoid arthritis and had fractured both hips in the past. The RR stated the resident talked about pain, especially pain in her right hip, and reported the pain was unbearable at times. The RR stated the facility gave the resident Tylenol for pain, which the resident told her, Is just like taking water and did nothing for the pain.During an observation and interview with Resident #7 on 8/3/26 at 2:46 PM, she was sitting on the edge of her bed with her right hand positioned under her right hip. She stated she had pain in her neck, lower back, and right hip. She explained that she had fallen in the past and fractured both hips, which required surgical repair. The resident stated her right hip had caused pain since the surgery. She stated she felt a nodule in the hip region and the pain increased with movement. She stated she was participating in therapy and had to ride the bicycle, stating, It absolutely kills me. The resident revealed she propped her hand under her right thigh to relieve the pain. She stated she had Voltaren gel and Tylenol for pain, but It does not do much of anything. The resident stated she complained of pain during therapy, but it did not do any good, so she pushed through to complete the therapy.Record review of Resident #7's Physical Therapy (PT) Evaluation and Plan of Treatment, dated 2/16/26, revealed under Patient goals, Decrease pain in order to walk around place and socialize with everyone. The evaluation also revealed under Current Referral: Referred to physical therapy following insidious onset of R (right) hip and leg pain. she has had an onset of pain in her R (right) hip that limits her function. She is unable to provide a date, but pt (patient) has had her R (right) hip replaced prior to admission to this facility. Pt (patient) states that her pain is 0/10 at best and 8/10 at worst w/ (with) worsening symptoms during activity and ambulation.Record review of the Progress Notes for Resident #7, dated 4/21/26, revealed, Complained of continued and increasing pain to right hip. Requested 'Something Done.' Charge nurse made aware.During an interview with the Rehab Director on 8/4/26 at 1:58 PM revealed she had been working with Resident #7 in occupational therapy (OT) and the resident complained of right hip pain, but not consistently.Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/14/26 revealed under section J, How much of the time have you experienced pain or hurting over the last 5 days? Frequently was indicated. Under Over the past 5 days, how much of the time has pain made it hard for you to sleep at night? Occasionally was indicated. Further review of the MDS with an ARD of 7/15/26 revealed under section J, How much of the time have you experienced pain or hurting over the last 5 days? Almost constantly was indicated. Under Over the past 5 day, how often have you limited your day-to-day activities because of pain? Frequently was indicated.During an observation and interview with Resident #7 on 8/5/26 at 8:29 AM, she was sitting in a chair in her room. She explained that she received Tylenol around 5:00 PM the previous evening and stated, It may have helped some; my hip hurt real bad last night.Record review of Resident #7's July and August 2026 MARs revealed no indication that the resident's pain was monitored every shift.An interview with the MDS Nurse on 8/6/26 at 11:42 AM revealed that the purpose of the care plan was to inform staff how to care for residents. She confirmed Resident #7's pain care plan was not followed.Record review of the admission Record revealed the facility admitted Resident #7 on 7/28/25 with medical diagnoses that included Hypertensive Heart and Chronic Kidney Disease with Heart Failure, Rheumatoid Arthritis, and Pain Unspecified.Record review of the MDS with an Assessment Reference Date (ARD) of 7/15/26 revealed under section C, a Brief Interview for Mental Status (BIMS) summary score of 15, indicating Resident #7 was cognitively intact.

Based on observation, staff interview, record review, and facility policy review, the facility failed to ensure staff used appropriate personal protective equipment (PPE) during care for a resident on Enhanced Barrier Precautions (EBP) for one (1) of four (4) residents direct care observations. Resident #50. This represents a pattern of deficiency due to F880 being cited during the last annual recertification survey.Findings include: Record review of the facility policy titled, Enhanced Barrier Precautions dated 3/27/24, revealed, It is the policy of this facility to implement enhanced barrier precautions to prevent transmission of multidrug-resistant organisms. Definitions: Enhanced barrier precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown, and gloves use during high contact resident care activities. An order for enhanced barrier precautions will be obtained for residents with any of the following: .indwelling medical devices (e.g., central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes) even if the resident is not known to be infected or colonized with an MDRO (multidrug-resistant organism). Record review of Enhanced Barrier Precautions Protocol, dated 2024 revealed, Who does it apply to: . Indwelling medical devices (e.g., central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes). When PPE (Personal Protective Equipment) is required: High-contact resident care activities include: . Catheter care, irrigation, and changing of the catheter and bag. Resident #50 During an observation of urinary catheter care on 9/3/25 at 1:30 PM, Certified Nursing Assistant (CNA) #1 and CNA #2 began Resident #50's urinary catheter care without the appropriate PPE required for EBP. Upon their realization, CNA #1 stated, We forgot to put on our gowns! We always use gowns! CNA #2 stated, We use gowns to protect the residents. They both acknowledged they had been in-serviced on EBP but were nervous and failed to put gowns on. An interview with the Director of Nursing (DON) on 9/3/25 at 2:25 PM revealed that each resident with a urinary catheter, feeding tube, wound, or central line is to receive EBP to protect that resident from infection. She acknowledged it was her expectation that all staff follow these guidelines for the residents' protection. She confirmed the facility failed to decrease the likelihood of the spread of infection by not using EBP during care of an indwelling urinary catheter. During an interview on 9/4/25 at 12:30 PM, the Infection Preventionist acknowledged that all of the staff had been in-serviced on EBP, and her expectation was for the staff to use EBP as required for the protection of the residents. Record review of Resident #50's Order Summary Report revealed an order dated 11/15/23 for catheter care with soap and water every shift. Review also revealed an order dated 4/17/24 for EBP for foley catheter. Record review of admission Record revealed the facility originally admitted Resident #50 on 9/28/18 with the most recent admission date of 1/30/2020. Her diagnoses included Neuromuscular Dysfunction of Bladder and Stage 3 Chronic Kidney Disease. Record review of Resident #50's Minimum Data Set (MDS) Section C - Cognitive Patterns revealed the resident had a Brief Interview for Mental Status (BIMS) score of nine (9) which indicated the resident had a moderate cognitive impairment.

Based on observation, staff, resident, and resident representative (RR) interviews, record review, and facility policy review, the facility failed to ensure a resident's right to be free from abuse for one (1) of seven (7) residents sampled. Resident #1 Findings include: Record review of facility policy titled, Abuse, Neglect, and Exploitation, with revision date of 10/10/22, revealed, This facility's policy is to protect each resident's health, welfare, and rights by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property . Abuse means the willful infliction of injury . Record review of the Facility Investigation Final Report to the State Agency and Attorney General dated 2/25/25 revealed that on 2/20/25 at approximately 2:30 AM, the Director of Nursing (DON) was present in the facility and was informed by a hall nurse that Resident #1 had a bruise on her left cheek under her eye, redness to her neck and blood on her lips. DON assessed Resident #1 and noted the injuries above. DON began interviewing staff in the facility who stated that previous shift reported the resident was yelling and combative during 3-11 shift while the nurse was attempting to administer her medications. The Administrator and DON began interviewing 3-11 staff from the previous night. Staff reported hearing Resident #1 yelling she hit me. Staff went in to check on the resident upon hearing her yell and did not see anyone hit resident. Licensed Practical Nurse (LPN) #1 stated Resident #1 became combative, yelling and swinging her arms and knocking the medication cup out of the nurse's hand. LPN #1 stated she did not hit or injure the resident. LPN #1 was suspended on 2/21/25 by the Administrator. There were no witnesses present when the incident was believed to have occurred. Upon investigation, the injuries coincide with someone holding the resident's face showing probability that LPN#1 held the resident's mouth to get her to take her medication while she was being combative causing bruising and redness to resident's face and neck. LPN #1 was terminated on 2/24/25. Abuse is substantiated. Record review of Progress Note of LPN #1 dated 2/20/25 at 11:20 PM, revealed, Resident has obvious redness to left side of neck. Resident was combative during med pass this shift swinging her arms and spitting out PO (by mouth) crushed meds with applesauce down face and clothing. CNA (Certified Nursing Assistant) present just outside resident door during this occurrence. Charge nurse (CN) asked to attempt to administer PO crushed meds for second time. CN stated difficulty attempting to administer PO meds. CNA was also present during this medication administration . Record review of Progress Note dated 2/21/25 at 3:14 AM by the DON revealed, At this time, the RN (Registered Nurse) was present in the facility and was informed of redness on (proper name removed) Resident #1's left face and neck. RN was unaware of any prior skin concerns and accompanied the hall LPN to assess the resident. Upon entering the resident's room, the RN observed redness on the left side of the neck and discoloration along the left cheek near the orbital bone. A small amount of dried blood was noted around the resident's mouth, which was cleaned. Upon further assessment, the RN lifted the resident's upper lip and observed bright red blood at the top of the mouth. No active bleeding or additional concerns were noted at this time. RN attempted to wake up resident to inquire about pain or what might of happened, resident lethargic at this time and in no apparent distress or pain. Administrator notified at 0318. Internal investigation began at this point and statements obtained from staff. Resident is on Aspirin and Plavix. Nurse Practitioner notified, no new orders at this time. Representative aware and will be coming to facility at a later time today. Record review of Progress Note dated 2/21/25 at 3:36 AM by hall LPN #1 on night shift revealed, CNAs brought it this nurse attention redness to neck and face and dried blood on resident's mouth and lips. Upon further assessment of resident this nurse noted there to be redness and possible bruising area on left cheek and redness on right cheek. When CNA was cleaning dried blood from mouth there was noted more blood and bloody tissue inside her mouth around gums and teeth, also a raised area on right side of top of tongue. This nurse reported this to Charge Nurse and DON for further assessment. CNA cleaned resident's mouth as best possible until she stated it hurt her mouth. At present time resident is resting in bed with eyes closed and no complaints of pain or discomfort. Record review of a Progress Note dated 2/21/25 at 7:26 AM, by an LPN revealed, Resident complained of mouth pain. Administered PRN (as needed) pain med at this time. Resident has dried blood in corner of left side. Cleaned up with wash cloth and warm water. Monitoring will continue. An interview and observation on 3/17/25 at 4:55 PM, revealed Resident #1 lying in bed visiting with her Resident Representative (RR) in the room at her bedside. The resident stated she had been treated with kindness and respect except by one nurse and proceeded to say that nurse brought her medications into her room, and she did not want to take them. The nurse got angry and told her she was going to take them, but the resident refused. She stated the nurse hit her in the face and she grabbed her by her neck and stuck her finger in her mouth and forced it open to give the medication. She stated the nurse Jabbed her finger in my mouth and gums and it hurt for a few days. Resident #1 stated she yelled out and tried to get her to stop. She stated, I just wanted to grab her by the hair and get her away, but I didn't. But I should have so she would know not to do that. She said she could not think of the name of the nurse right now, but she would recognize her. She also said if she did not want her medicine, she should not be forced to take it. She acknowledged she was glad the nurse was fired so she could no longer hurt her or anyone else. The RR said this was the same report and account of the event that the resident had given since the event occurred. The RR asked the resident if it was Licensed Practical Nurse (LPN) #1 (proper name removed) and the resident said Yes, that's her name. The RR did not speak when the resident was giving her statement of the occurrence, and she did not prompt the resident during the interview. The resident was speaking clearly and demonstrated the way the nurse held her neck, mouth, and face and this matched the marks that were left on the resident's face. When away from the resident, the RR said the resident had good days and bad days, but today, she had been very clear with her thought process and her communication. She also stated she was glad that it was such a good day for the resident so she could give her statement of what occurred. During an interview on 3/18/25 at 10:20 AM, the DON stated that she came in to work around 3:00 AM on 2/21/25 due to the charge nurse being sick that day and it was reported to her to look at the resident's face and lips and she and another LPN went in to check on the resident. She stated she noted redness to the left side of the neck and on the left cheek near her eye and dried blood was noted around the mouth. She lifted the resident's upper lip and noted bright red blood at the top of the mouth. She was unable to interview the resident since she was drowsy, but she stated that with the interviews and with the injuries, abuse was suspected, and she notified the Administrator right away and reported this incident and began to get statements and began an investigation. She acknowledged each resident has the right to be free from abuse and neglect and she confirmed the facility failed to ensure this for Resident #1. During an interview by phone on 3/18/25 at 11:30 AM, CNA #1 stated she came into work on 2/20/25 for the 11 PM-7 AM shift and during shift change report she was told that Resident #1 was fighting with LPN #1, and the resident had bruising on her face, neck, and a bloody lip. She stated that inside the resident's mouth on her upper gum area, more active bleeding was noted and the resident said it was hurting. She stated that she reported this to the nurse on her shift. During an interview by phone on 3/18/25 at 1:00 PM, Charge Nurse/RN #1 stated she was the nurse on 2/20/25 on the 3 PM-11 PM shift when the incident occurred with Resident #1. She stated around 7:00 PM - 8:00 PM, LPN #1 was in Resident #1's room, and she overheard yelling but could not understand what was being said. LPN #1 came out of the resident's room and told her that Resident #1 was fighting with her and would not take her medication. RN# 1 had LPN #1 gather the medications again and she administered the medications to the resident. She then stated that around 10:30 PM - 11:00 PM, that LPN #1 came to her and asked if she would look at the resident's neck and face and she noted some redness, but she thought it was from the resident resting her face on one of her dolls that was in the bed with her. She did not notice any bleeding from her mouth at that time. She stated the next day, the resident had bruising on her face and neck and bleeding in her mouth and complained of pain from her mouth. An interview with Certified Nursing Assistant (CNA) #2 on 3/18/25 at 3:25 PM revealed she was working the 3 PM-11 PM shift on 2/20/25 and she was at the desk charting around 7:30 PM, and she heard Resident #1 screaming and yelled out, You hit me, you hit me. She then saw LPN #1 come out of Resident #1's room and LPN #1 told the Charge Nurse/RN #1 that the resident was fighting her and would not take her medications, and the charge nurse went in to try to give the medications to the resident. When the charge nurse left the resident's room, I went into Resident #1's room and was talking to the resident and noticed her mouth was bleeding and she kept telling me, She hit me, she hit me, she hit me over and over. CNA #3 also came into the room and saw and heard what the resident was saying. CNA #2 stated she did not report this since she thought RN#1 knew because she had just been in the resident's room, but CNA #3 reported this to RN #1 as well. During an interview on 3/18/25 at 3:40 PM, CNA #4 stated she and CNA #3 were working on Resident #1's hall on the 3 PM-11 PM shift on 2/20/25. She stated on the first round there were no concerns noted, but on the second round, CNA #3 told her that Resident #1's mouth was bleeding, so she went to check on her. She noted her mouth was bleeding and she had red marks on the left side of her neck. She asked the resident what happened, and the resident told her the nurse hit her in the face. CNA #4 stated that she then reported this to LPN #1. An interview with CNA #3 on 3/18/25 at 4:20 PM revealed she was working on Resident #1's hall on 2/20/25 for the 3 PM-11 PM shift. She stated that around 7:00 - 8:00 PM, she was performing resident care next door to Resident #1's room, and she heard yelling. She could not understand what was said, but it was Resident #1 and LPN #1 that were in the conversation. She continued to hear the resident crying so as soon as she completed the resident's care, she went into Resident #1's room to check on her and she was still crying, and she noticed her lips were bleeding. She asked the resident what happened and was told that the nurse had hit her in the face. She stated the resident had a bleeding mouth and bruising to her face and neck. She reported this to RN #1, and was told she would check on the resident. During an interview on 3/18/25 at 4:30 PM, the Administrator stated this abuse of Resident #1 happened on 2/20/25. He confirmed abuse of a resident occurred in the facility and that they had terminated LPN #1 for abuse of a resident. He further confirmed that with the staff interviews, the resident's validation of the event, and assessment of the injuries that matched the resident's statement, there was enough evidence to validate that LPN #1 was abusive to the resident. He stated they did substantiate the abuse, and they terminated the employee. He stated LPN #1 did not return to work in the facility after the shift when this event occurred. He acknowledged that each resident has the right to be free from abuse and to have their rights honored. He confirmed the facility failed to prevent abuse of a resident. The State Agency had attempted to get in touch with LPN #1 while in the facility on 03/17/25 and 03/18/25 and left a voicemail. LPN #1 contacted the State Agency on 03/21/25 and during a phone interview on 3/21/25 at 8:30 AM, LPN #1 stated she had not worked in the facility since the event occurred and that the facility terminated her. She confirmed that she had been in-serviced on abuse and neglect and stated she worked the 3 PM-11 PM shift on 2/20/25. She stated that she went into the resident's room to give her medication that had been crushed and put in applesauce, but the resident got angry and did not want to take it. She was flailing her arms and knocked the medicine cup out of her hand as she was trying to give the medication with a plastic spoon. She stated she left the room and told RN #1. She stated the resident did not take the medications and she did not place the spoon with the medications in the resident's mouth. She confirmed that, She wouldn't open her mouth, so I didn't put the spoon in there. When asked about her documented progress note and statement revealing the resident spit out the medication, she stated she did not know why her statement and her progress note said that since she did not put anything in the resident's mouth. She confirmed she gave a signed statement of the events that occurred and documented the events that occurred in the progress notes but still claimed she did not put anything in the resident's mouth. Stated she did not know how the injuries happened and that maybe she bit her lip and hit herself with her arms. She once again stated she did not care what she had written in her statement or progress note, she did not give the medicine or put anything in the resident's mouth and that the resident bit her own lip and hit herself. Record review of Resident #1's Injury report revealed, discoloration to left cheek along eye bone, discoloration to left side of neck and dried blood to mouth. Record review of Resident #1's Trauma Informed Care assessment dated [DATE] revealed, Have you ever had anyone grab your throat? That girl grabbed me by throat to try and get me to take my medicine. It's still sore; In the past month, have you: 1. Had nightmares about the event(s) or thought about the event(s) when you did not want to? Yes I have; 2. Tried hard not to think about the event(s) or went out of your way to avoid situations that reminded you of the event(s)? Yes, cause that hurt really bad; 3. Been constantly on guard, watchful, or easily startled? Yes; 4. Felt numb or detached from people, activities, or your surroundings? Yes; 5. Felt guilty or unable to stop blaming yourself or others for the event(s) or any problems the event(s) may have caused? Yes - I don't feel it was my fault, I blame her. Record review of Personnel Action revealed that the facility terminated LPN #1 on 2/24/25 for suspected abuse of a resident. Record review of Admission Record revealed the facility admitted Resident #1 on 1/16/24 with diagnoses that included Dementia, Hemiplegia and Hemiparesis following Cerebral Infarction affecting left non-dominant side. Record review of Resident #1's Quarterly Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 12/23/24, revealed a Brief Interview for Mental Status (BIMS) score of 7 which indicated severe cognitive impairment.

Based on observation, resident, resident representative, and staff interviews, record review, and facility policy review, the facility failed to notify the local law enforcement agency and the state Board of Nursing related to abuse of a vulnerable adult for one (1) of seven (7) residents sampled. Resident #1 Findings include: Record review of facility policy titled, Abuse, Neglect, and Exploitation with revision date of 10/10/22, revealed, This facility's policy is to protect each resident's health, welfare, and rights by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. Abuse means the willful infliction of injury . The policy also revealed, The facility will report all alleged violations and all substantiated incidents to the state agency and to all other agencies as required and take all necessary corrective actions depending on the results of the investigation .f. Report to . the nursing board any knowledge of any actions which would indicate an employee is unfit for service . Record review of the Facility Investigation Final Report to the State Agency and Attorney General dated 2/25/25 revealed that on 2/20/25 at approximately 2:30 AM, the Director of Nursing (DON) was present in the facility and was informed by a hall nurse that Resident #1 had a bruise on her left cheek under her eye, redness to her neck and blood on her lips. DON assessed Resident #1 and noted the injuries above. DON began interviewing staff in the facility who stated that previous shift reported the resident was yelling and combative during 3-11 shift while the nurse was attempting to administer her medications. The Administrator and DON began interviewing 3-11 staff from the previous night. Staff reported hearing Resident #1 yelling she hit me. Staff went in to check on the resident upon hearing her yell and did not see anyone hit resident. Licensed Practical Nurse (LPN) #1 stated Resident #1 became combative, yelling and swinging her arms and knocking the medication cup out of the nurse's hand. LPN #1 stated she did not hit or injure the resident. LPN #1 was suspended on 2/21/25 by the Administrator. There were no witnesses present when the incident was believed to have occurred. Upon investigation, the injuries coincide with someone holding the resident's face showing probability that LPN#1 held the resident's mouth to get her to take her medication while she was being combative causing bruising and redness to resident's face and neck. LPN #1 was terminated on 2/24/25. Abuse is substantiated. On 3/17/25 at 4:55 PM, an interview and observation revealed Resident #1 lying in bed visiting with her Resident Representative (RR) in the room at her bedside. The resident stated she had been treated with kindness and respect except by one nurse and proceeded to say that nurse brought her medications into her room and she did not want to take them. The nurse got angry and told her she was going to take them, but the resident refused. She stated the nurse hit her in the face and she grabbed her by her neck and stuck her finger in her mouth and forced it open to give the medication. She stated the nurse Jabbed her finger in my mouth and gums and it hurt for a few days. Resident #1 stated she yelled out and tried to get her to stop. She stated, I just wanted to grab her by the hair and get her away, but I didn't. But I should have so she would know not to do that. On 3/18/25 at 4:30 PM, an interview the Administrator stated this abuse of Resident #1 happened on 2/20/25 and it was reported to the Attorney General's office and the State Agency. He confirmed he did not notify the local police since he thought it was sufficient to notify the Attorney General's Office which was considered the top law enforcement agency in the state. He also stated this incident with the nurse was not reported to the state Board of Nursing since there were no witnesses to the abuse. He confirmed that the facility had gathered statements from witnesses who overheard the incident, and it correlated with the injuries that the resident sustained. He then confirmed that abuse of a resident did occur in the facility and with the staff interviews, the resident's validation of the event, and assessment of the injuries that matched the resident's statement, there was enough evidence to validate. He stated they did substantiate the abuse, and they terminated the employee. He acknowledged that each resident has the right to be free from abuse and to have their rights honored. He confirmed the facility failed to prevent abuse of a resident and confirmed the facility failed to notify and report this to the local law enforcement agency and to the Board of Nursing after a resident was injured by a nurse. Record review of Admission Record revealed the facility admitted Resident #1 on 1/16/24 with diagnoses that included Dementia, Hemiplegia and Hemiparesis following Cerebral Infarction affecting left non-dominant side. Record review of Resident #1's Quarterly Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 12/23/24, revealed a Brief Interview for Mental Status (BIMS) score of 7 which indicated severe cognitive impairment.

Based on observation, staff interview, record review, and facility policy review, the facility failed to use the appropriate Personal Protective Equipment (PPE) while providing care for a resident on contact isolation and failed to dispose of contaminated linens and trash into the designated biohazard containers in the room for one (1) of four (4) residents reviewed for Transmission-Based Precautions (TBP). Resident #72 Findings include: Review of the facility policy titled Transmission-Based Precautions with a revision date of 10/10/2022 revealed Policy: It is our policy to take appropriate precautions to prevent the transmission of pathogens based on the pathogens' modes of transmission .Policy Explanation and Compliance Guidelines: . 8. Contact Precautions- . c. Healthcare personnel caring for residents on Contact Precautions wear a gown and gloves for all interactions, that may involve contact with the resident or potentially contaminated areas in the resident's environment. d. Donning personal protective equipment (PPE) upon entry and discarding before exiting the room is done to contain pathogens, especially those that have been implicated in transmission through environmental contamination . Resident #72 An observation outside Resident #72's door revealed a sign Contact Precautions -apply gown and gloves. Observed a designated plastic container outside the room door with the required PPE that included gown and gloves. An observation inside the resident's bathroom revealed two (2) biohazard containers designated for linen and trash disposal. Record review of the Culture Miscellaneous with Stain dated 3/27/2024 revealed Methicillin Resistant Staphylococcus Aureus (MRSA) of wound drainage for Resident #72. Record review of the Order Summary for Resident #72 revealed an order dated 3/31/2024, Contact Isolation due to MRSA to right hand. An observation of catheter care for Resident #72, on 4/03/2024 at 9:55 AM, with Certified Nurse Aide (CNA) #1 and #2 revealed, they entered the resident's room and did not apply a gown. CNA #2 performed catheter care with the assist of CNA #1. Following the completion of catheter care, they turned the resident over on his side and changed his brief, repositioned the bed pad and pulled the resident up in the bed. CNA #2 gathered the soiled linen and trash in clear trash bags, exited the room, and threw them into the dirty linen and trash container on 200 hall. An interview with Certified Nurse Aide (CNA) #2 on 4/03/2024 at 10:20 AM, revealed she spoke with the charge nurse on Sunday 3/31/2024 and was told that the resident was contagious, but she did not have to wear a gown. She confirmed that she read the sign outside the resident's door that indicated to wear a gown but did not think anything about it. She stated she knew to place the linen and trash in the biohazard containers in the room but got nervous and messed up. CNA #2 revealed the purpose of separating the linen and trash from other residents was to prevent the spread of infection throughout the facility. An interview with the Director of Nursing (DON) on 4/03/2024 at 10:35 AM, revealed for a resident in contact precautions, the staff were expected to dress out in a gown and gloves. He stated the linen and trash were to be discarded in the room to prevent the spread of infection to others in the facility. An interview with the Infection Preventionist (IP) on 4/03/2024 at 10:39 AM, revealed the resident was in contact isolation for MRSA on the right hand. She revealed it was the facility policy to start contact precautions when a culture came back with MRSA. She explained that the staff were expected to wear gowns while providing care. The IP revealed the linen and trash should have been disposed of in the biohazard barrels in the room to prevent the spread of infection. Record review revealed the facility admitted Resident #72 on 2/27/2024 with medical diagnoses that included Alzheimer's disease and Major Depressive disorder.

Based on observation, staff interview, record review, and facility policy review, the facility failed to develop a care plan for a resident with a skin concern and Transmission-Based Precautions (TBP) for one (1) of 19 residents sampled. Resident #72 Findings Include: Review of the facility policy titled Comprehensive Plan of Care with a revision date of 10/10/2022 revealed Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment . Resident #72 Record review of the Order Summary for Resident #72 revealed an order dated 3/31/2024, Contact Isolation due to MRSA (Methicillin Resistant Staphylococcus Aureus) to right hand. Record review of the Order Summary for Resident #72 revealed an order dated 4/03/2024, Clean abrasion to right hand with ns (normal saline), pat dry, cover with small island dressing daily. Record review of Resident #72's Care Plans revealed a care plan was not developed for the skin concern on the right hand that required contact isolation. An interview with Registered Nurse (RN) #1 on 4/03/2024 at 2:10 PM, revealed she was responsible for the development of Resident #72's care plans. She confirmed that she did not develop the care plan related to the skin concern or contact isolation and stated that staff would not know what care to perform. An interview with the Director of Nursing (DON) on 4/03/2024 at 2:50 PM, revealed the purpose of the care plan was for staff to know how to properly care for the resident. Record review revealed the facility admitted Resident #72 on 2/27/2024 with medical diagnoses that included Alzheimer's disease and Major depressive disorder.

Based on observation, staff interview, record review, and facility policy review the facility failed to secure electronic health records as evidenced by an Electronic Medication Administration Record (EMAR) was visible while the medication cart was unattended on the Alzheimer's unit for one (1) of 16 residents residing in the unit. Resident #66 Findings Include: Review of the facility policy with a revision date of 11/28/2017 titled Confidentiality of Information revealed, This facility shall maintain an individual's right to privacy and confidentiality of information . Confidentiality of the resident record shall be maintained at all times by keeping the record closed when not in use. If an electronic health record is used, ensure that no other individual can read the screen and log-off the computer when not in use. An observation on 4/2/24 at 10:15 AM, of a computer that was located on a medication cart on the Alzheimer's unit revealed the computer was opened with Resident #66's EMAR information visible on the screen. Licensed Practical Nurse (LPN) #2 was in Resident #66's room and the screen was visible to anyone passing by the medication cart in the hallway. The visible information included Resident #66's name, medications, and room number. An interview on 4/2/24 at 10:18 AM, LPN #2 confirmed that the EMAR for Resident #66 was visible on the screen to anyone walking by and should be closed when she was away from the medication cart to secure private health information. She stated I have to remind myself every day to close the screen before stepping away from the cart. LPN #2 confirmed that this is a violation of keeping the resident's medical records private and a Health Insurance Portability and Accountability Act (HIPAA) issue. An interview on 4/02/24 at 10:50 AM, the Director of Nursing (DON) confirmed that a resident's information should never be left up on the computer screen while the cart is unattended. The DON stated there is a privacy button that is supposed to be pushed before the nurse steps away from the computer. The DON confirmed this is a privacy issue and could result in a HIPAA violation. Record review of Resident #66's Admission Record revealed the resident was admitted to the facility on [DATE] with diagnoses that included Alzheimer's Disease, Anemia, and Atherosclerotic heart disease.

Based on staff interview, record review, and facility policy review, the facility failed to send written notification to the resident and/or resident representative (RR) upon transfer to the hospital for two (2) of two (2) residents reviewed for hospitalization . Resident #30 and Resident #42 Findings Include: Review of the facility policy titled Transfer and Discharge with a revision date of 10/18/2022 revealed .Policy Explanation and Compliance Guidelines: . 4. The facility's transfer/discharge notice will be provided to the resident and the resident's representative in a language and manner in which they can understand . Record review of Resident #42's Progress note dated 02/22/24 revealed Resident #42 was found to be non-responsive to verbal or tactile stimuli and her oxygen saturation was 82% 911 was notified for transport to the emergency room (ER) . Resident #42 left the facility by ambulance on 02/22/24 at 6:20 PM. Record review revealed there was not a written notification of transfer given to the family for Resident #42 dated 02/22/24 when she was transferred to the hospital. On 04/02/24 at 12:05 PM, in an interview with Director of Nursing (DON), confirmed that they were not mailing written transfer notifications to the residents' RR's when residents were transferred to the hospital. On 04/02/24 at 1:14 PM, an interview with Social Worker (SW), revealed that she did not have a copy of the transfer/discharge notification dated 02/22/24 on Resident #42, the date she was transferred out to the hospital. The SW revealed that she called the Responsible Party (RP) about bed hold only and confirmed that she had not been mailing the notice of transfer/discharge out to the RP. The SW stated, I didn't realize I was supposed to be mailing them to the RPs, but will get them sent out from now on. Record review of Resident #42's Admission Record revealed that she was admitted on [DATE] and had diagnoses including Chronic Obstructive Pulmonary Disease, Muscle Wasting and Atrophy, and Dementia. Resident #30 Record review of the Progress Notes for Resident #30 revealed on 1/12/2024, the resident was transferred to the hospital for .seizure like activity and unresponsive to verbal and physical stimuli . An interview with the SW on 4/02/2024 at 11:20 AM, confirmed she had not mailed out a written notification of transfer/discharge to the RP for Resident #30. She revealed she was unsure who was responsible for doing that. An interview with the DON on 4/02/2024 at 12:02 PM, revealed that the nurses send out the written notification of transfer/discharge with the residents when they were transferred to the hospital. He confirmed they had not been mailing a copy to the RP. An interview with the Administrator (ADM) on 4/02/2024 at 12:07 PM, revealed he was not aware the written notification of transfer/discharge was not being mailed out to the responsible party's (RP) and confirmed it should have been. Record review of the Admission Record revealed the facility admitted Resident #30 on 12/28/2023 with medical diagnoses which included Seizures and Type 2 diabetes mellitus. 47874

Based on observation, policy and procedure reviews, record review and interviews, the facility failed to follow the care plan for fall prevention for Resident (Res) #1. Resident #1 was care planned to use a hoyer lift with a two (2) person assist for all transfers in order to prevent falls. Res #1 was injured when she fell from a hoyer lift that a facility Certified Nursing Assistant (CNA) used independently. Res #1 received injury of a laceration to her right ear with bleeding and was transported to the emergency room (ER) for evaluation. Res #1 was one (1) of eight (8) residents reviewed for Care Plans. Findings include: The facility policy titled Comprehensive Plan of Care, revised 11/28/2017, revealed, Plans of Care are developed by the interdisciplinary team, to coordinate and communicate care approaches and goals for the resident related to clinical diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Record review of the Care Plan for Res #1 revealed a care plan with a start date of 3/5/2021 for falls: Resident Risk for falls will be reduced with interventions through the next review date, intervention: Hoyer lift x2 person assist for all transfers. Interview on 08/29/2022 at 3:00 PM, with the facility Administrator (ADM) revealed that (Res #1) was a total care resident and was dependent upon staff for all of her needs. The ADM stated that Res #1 was to be transferred with a hoyer lift with two persons to assist and that the facility policy and procedure requires two (2) persons to assist with the use of a hoyer lift. She did not ask a second person to assist her with the use of the hoyer lift. CNA #1 used the hoyer lift alone while transferring Res #1 from the shower chair back to her bed. CNA #1 dropped Res #1 from the hoyer lift to the floor. Res. #1 sustained a laceration to her ear which required an evaluation at the local ER. The ADM confirmed that the facility care plan was not followed for fall prevention interventions for Res #1. Interview on 08/29/2022 at 3:20 PM, with the Director of Nursing (DON) revealed the DON went to Res #1's room on 07/18/2022 after a call over the walkie talkie of Code Purple, where she saw the resident on the floor with blood coming from her ear. The resident's head was on the leg of the hoyer lift and CNA #1 stated that she was transferring Res #1 to her bed from her shower chair when she fell from the lift. CNA #1 stated that she was using the hoyer lift alone and had not called for a second person to assist with the lift as required per the facility care plan. Interview on 08/30/2022 at 3:00 PM, with Licensed Practical Nurse (LPN) #1 revealed that she is the Care Plan Nurse and Minimum Data Set (MDS) Nurse for the facility. LPN #1 confirmed that the CNA did not follow the care plan for the use of a two (2) person assist when using a hoyer lift. LPN #1 stated that CNA #1 was terminated for not following the facility policy and the care plan for Resident #1. Record review of Res #1 Face Sheet revealed that she was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) revealed that Res #1 had a Brief Interview of Mental Status (BIMS) score of 3 which indicated that she had severe cognitive impairment. Record review of the facility's investigation revealed, Summary of facts constituting the above offense: Used hoyer lift without second person assist. Did not follow facility Policy on hoyer lift use .On this date (07/18/2022) at 11:15 A.M. I was notified of resident sliding out of the lift sling/pad feet first and landing on the floor with her head on the leg of the hoyer lift. Investigation revealed that (CNA #1) was not following (facility) policy for hoyer lift use, and was using lift without the benefit of a second person .

Based on record review, observation, facility policy review and interviews, the facility failed to prevent an avoidable accident when a Certified Nursing Assistant (CNA) used a hoyer lift without the required two (2) person assistance to operate the lift. Resident #1 fell from the hoyer lift and received a laceration to her right ear and required transfer to the emergency department for evaluation. Resident #1 was one (1) of eight (8) residents reviewed for incidents and accidents. Findings include: The facility policy and procedure titled Safe Lifting Program (Including Hoyer Lift) revised 08/10/2015 revealed .Hoyer Lift: .Residents of (Proper Name of Facility) facilities who are unable to transfer themselves independently or with minimum assistance shall be transferred safely with the Hoyer Lift .At least two (2) nursing staff are needed to transfer a resident when using a Hoyer Lift . Record review of the the Resident Transfer Protocol (Safety Techniques) dated 6/6/2014 revealed Policy:Residents of (Proper Name of Facility) who are unable to transfer themselves independently or with minimum assistance shall be transferred following the principles of this policy to allow for maximum safety during resident transfer. Full lift transfers shall always be conducted following the principles of proper body mechanics and resident safety .Transferring Residents with an Assistive Lift Device: .At least (2) staff members are needed to transfer a resident when using a lift device . Record review of the facility's investigation confirmed that CNA #1 was terminated on 07/18/2022 for failure to obey orders, Regulations, Policies and/or Procedures. Summary of facts constituting the above offense: Used hoyer lift without second person assist. Did not follow facility Policy on hoyer lift use. Personnel Action for termination was signed by CNA #1 and the DON on 07/18/2022. The facility Investigation Report, documented by the DON revealed: Res #1 is a long term care resident at this facility. She has active diagnoses of: Dementia with behavioral disturbances, hypertension, [CONDITION(S)], [CONDITION(S)]. She is dependent on staff for all care and requires the use of hoyer lift for all transfers. On this date (07/18/2022) at 11:15 A.M. I was notified of resident sliding out of the lift sling/pad feet first and landing on the floor with her head on the leg of the hoyer lift. Investigation revealed that (CNA #1) was not following (facility) policy for hoyer lift use, and was using lift without the benefit of a second person. She said that it takes too long for someone to come when she asks for a second person. DON documented: First aid for ear laceration was provided by staff following body assessment. Body assessment revealed scraped area above left ear and some red areas to right side of back, besides the approximately 2.5 cm laceration to right ear. Vital signs were obtained and neuro checks initiated. MD was notified of incident and order for emergency room transfer for evaluation. Resident went to emergency room for evaluation of ear laceration and head injury. CT of the head revealed no acute abnormality though does have severe senescent changes and small vessel ischemic changes. CT of cervical spine revealed no acute fracture Ear laceration was cleaned and glued in ER. On 8/29/2022 during an interview at 3:00 PM with the facility Administrator (ADM) revealed that Res #1 was a total care resident and was dependent upon staff for all of her needs. The ADM stated that Res #1 was to be transferred with a hoyer lift with two persons to assist. The ADM stated that the facility policy and procedure requires (2) persons to assist with the use of a hoyer lift. The ADM stated that the facility staff were trained and in-serviced to use the hoyer lift with (2) persons and that CNA #1 had been trained. The ADM revealed that CNA #1 did not follow the facility policy and procedure and she did not use the hoyer lift in accordance with the facility policy and procedure and she did not ask a second person to assist her with the use of the hoyer lift. CNA #1 used the hoyer lift alone while transferring Res #1 from the shower chair back to her bed and CNA #1 dropped Res #1 from the hoyer lift to the floor causing a laceration to her ear which required an evaluation at the local emergency room (ER). The facility investigated and terminated CNA #1 on 07/18/2022 for not following the facility policy. Interview with the Director of Nursing (DON) on 08/29/2022 at 3:20 PM, revealed that she was in her office on 07/18/2022 when she heard a Code Purple alert come across her walkie talkie from CNA #1. CNA #1 called a Code Purple which signaled that help was needed in Res #1's room. The DON went to Res #1's room where she saw Res #1 on the floor with blood coming from her ear. Res #1's head was on the leg of the hoyer lift and CNA #1 stated that she was transferring Res #1 to her bed from her shower chair when she fell from the lift. CNA #1 stated that she was using the hoyer lift alone and had not called for a second person to assist with the lift as required per the facility policy. The DON revealed that the incident occurred around mid morning at approximately 11:00 AM on 07/18/2022. The DON stated that she and several other staff put Res #1 on a draw sheet and lifted her from the floor to the bed for a full body assessment and to apply pressure to the bleeding ear. The Resident was sent out to the local ER for evaluation and CNA #1 was terminated. The DON confirmed that CNA #1 should have followed the facility policy and procedure for two (2) persons to assist with the use of the hoyer lift and she confirmed that CNA #1 did not utilize two people for the transfer of the resident from the shower chair to the bed and caused the resident to sustain injuries. Interview with Registered Nurse (RN #1) and the Minimum Data Set (MDS) Nurse on 08/29/2022 at 3:45 PM revealed that she was the charge nurse on 07/18/2022 when the fall of Res #1 occurred. She stated that she received a Code Purple alert on her walkie talkie and she went to Res #1's room where she assisted to lift Res #1 from the floor with a draw sheet to her bed after a fall from the hoyer lift. Res #1 had a laceration to her right ear and there was a fair amount of blood from the injury. Res #1 hit her right ear and head on the leg of the hoyer lift. Res #1 was sent to the local ER for evaluation of a head injury and ear laceration. RN #1 assessed Res #1 after the fall from the hoyer lift and stated that Res #1 had been non-verbal for years and was unable to speak, but that the resident did have facial grimaces and expressions of pain after the fall and her gown was wet and she was making blowing motions with her lips during the time the staff were assessing her from the fall. RN #1 stated that Res #1 is totally dependent upon staff for all her needs and is unable to care for herself and that she called Res #1's daughter to report the fall and the ER admission. RN #1 stated that CNA #1 did not follow the facility policy for using a two (2) person assist with hoyer lifts. Interview on 08/30/2022 at 1:35 PM with CNA #2 revealed that she worked first shift on 07/18/2022 and had been working since April 1, 2022 on first shift, which was 7 AM to 3 PM. She confirmed that she was working with CNA #1 that day and that she did not ask her to assist with the hoyer lift transfer of Res #1 on 07/18/2022. CNA #2 stated that they had been trained and in-serviced that two (2) persons must assist with the use of a hoyer lift. Interview on 08/30/2022 at 1:45 PM CNA #3 revealed that she had worked at the facility for eight (8) years. She stated that she was working as a CNA on 07/18/2022 on first shift and CNA #1 had not asked her to assist with the hoyer lift transfer of Res #1. CNA #3 stated that she had been trained and in-serviced to use two (2) persons to assist with the hoyer lift transfers of Res #1. CNA #3 stated that she assisted CNA #2 and RN #1 to transfer Res #1 from the floor to the bed for assessment. CNA #3 stated that Res #1 had a cut to her ear and blood was present. Record review of the ED (Emergency Department) Provider Notes dated 07/18/2022 revealed History .Patient .from local nursing home slid out of the sling struck her head .ED Course .Lac (Laceration) Repair .Location details:Right ear .Laceration length (cm) centimeter:1 .Skin Closure: Glue .Final diagnosis .Laceration of right ear lobe, initial encounter . Interview on 08/30/2022 at 2:10 PM, with the Resident Representative (RR) of Res #1, revealed that she was contacted by the facility that a CNA had not followed the policy and had dropped Res #1 from the lift during a transfer. RR stated that she did not know how that could have happened and she was greatly upset that Res #1 had been injured and sent to the ER for evaluation. RR stated that she came to the facility later on 07/18/2022 to check on Res #1 and found her in her bed with a fair amount of dried blood on her ear. RR stated that she reported to the nurse that Res #1's ear looked crusty and bloody. The nurse told RR that the ER had glued the laceration and because of that she was afraid to try to clean the ear at that time in fear that it may become un-glued and may start to bleed again. RR stated that Res #1 had been non-verbal for a long time and had to depend upon staff for all of her needs. RR stated that Res #1 was bruised and had grim facial expressions when she saw her several hours after the incident. Observation of Res #1 on 08/30/2022 at 2:30 PM revealed that she was lying on her back in bed. Res #1 was starring straight ahead and she did not respond in any way when her name was called. Res #1 was not interviewable on 08/30/2022. Her facial expression was flat and fixed and never varied. Record review of Res #1's Face Sheet revealed that she was admitted to the facility on [DATE] with diagnoses of Dementia with Behavioral disturbances; [CONDITION(S)], among other diagnoses. Record review of the Minimum Data Set (MDS) revealed that Res #1 had a Brief Interview for Mental Status (BIMS) score of 3 which indicated that she had severe cognitive impairment. Record review of Res #1's Physician's Orders dated July 2022 revealed an order written on 03/05/2021 Use Hoyer Lift x 2 Person Assist with Large Lift Pad.

Based on observation, staff interview, and facility policy review, the facility failed to prevent the possible spread of infection as evidenced by failure to utilize a barrier during medication administration, failure to clean/sanitize a pulse oximeter before use, and storing the pulse oximeter in a uniform pocket, prior to use, for one (1) of three (3) medication observations. Findings include: Review of the facility's Infection Prevention Program policy, revised 11/28/2019, revealed the charge of the Infection Prevention Committee shall be to establish an Infection Prevention Program that protects residents, visitors, staff, and volunteers from facility associated, community-acquired and workplace-related infections. During an observation of the medication pass, on 11/25/19 at 8:50 AM, Licensed Practical Nurse (LPN) #1 took a [MEDICATION NAME] Inhaler and an Incruse Inhaler into the resident's room for administration. LPN #1 placed the inhalers on the the resident's overbed table, without the use of a barrier. Following administration of the inhalers, LPN #1 placed the inhalers back in the medication cart. LPN #1 removed a pulse oximeter from her pocket and placed it on the resident's finger. After completing the oxygen saturation monitoring, she removed the pulse oximeter and placed it back into her pocket. The pulse oximeter was not cleaned and/or sanitized prior/after use. During an interview, on 11/25/19 at 2:10 PM, LPN #1 revealed they have plate barriers to use when giving medications, but she just didn't think about it. She confirmed she should not have placed the inhalers on the resident's table, because it was dirty. She stated she carried germs back to the medication cart, when she did not use a barrier, and did not wipe the inhalers before putting them back into the cart. She stated the pulse oximeter was in her pocket, because it was her personal oximeter she brought from home. She confirmed the pulse oximeter should not be in her pocket, because of germs. LPN #1 stated the pulse oximeter should be cleaned before use, and before placement in the medication cart. During an interview, on 11/25/19 at 3:40 PM, the Director of Nursing (DON) revealed LPN #1 knew she should use a barrier or clean the table, prior to putting anything on the table. She confirmed putting the inhalers back in the medication cart, without cleaning them, took germs into the cart. The DON also stated LPN #1 should not use her personal equipment. She stated no equipment should be placed in the nurses' pocket, and the pulse oximeter should be cleaned like the glucometer, before and after use. In an interview, on 11/25/19 at 4:10 PM, the Administrator stated LPN #1 had recently been in-serviced on medication administration the first of the month, and performed a medication administration competency in (MONTH) 2019. The Administrator stated LPN #1 knew better. Record review revealed LPN #1 attended an in-service on 11/6/19, which included infection control instructions to not carry items in your pocket into the room, example: eye drops, test strips, lancets etc

Based on observation and staff interview, the facility failed to ensure that oxygen tubing, and nebulizer mask and tubing was stored in a manner to prevent the possible spread of infection for two (2) of seven (7) residents with respiratory equipment reviewed. Residents #48 and #63. Findings include: Review of the facility's policy titled, Oxygen Administration, dated 03/24/18, revealed a hand written statement signed by the Director of Nurses at the bottom of the page, We do not have a policy specific for storage of O2 (oxygen) supplies. In an interview, with the Director of Nursing (DON), on 10/3/18 at 5:00 PM, she stated the facility does not have a policy specific for storage of respiratory equipment. Resident #48 An observation, 10/02/18 at 3:13 PM, revealed Resident #48's Oxygen (O2) Nasal Cannula (NC) tubing was stored in a zip lock bag in the bedside table drawer with no date on the bag. The humidification bottle on the concentrator was not dated. Review of Resident #48's physician's orders [REDACTED].@ 2L/M) per nasal cannula as needed. Review of Resident #48's current Comprehensive Care Plan revealed an Intervention/Approach for O2 as ordered. In an interview, with Licensed Practical Nurse (LPN) #1, on 10/2/18, at 3:15 PM, she confirmed there was no date on the zip lock bag containing the O2 tubing. She stated it was important to change the water bottle timely to prevent it from becoming stale, and to change and date the tubing to prevent infection. LPN #1 stated O2 tubing is changed every Sunday on the 11 PM to 7 AM shift. Resident #63 On 10/2/18 at 3:30 PM, an observation of Resident #63's Nasal Cannula Oxygen (O2) tubing revealed the zip lock bag the tubing was stored in was not labeled with a date. The Nebulizer mask was connected to the Nebulizer machine by the tubing, and the mask was lying in the drawer of the bedside table. It was not in a bag. Review if Resident #63's physician's orders [REDACTED]. Review of Resident #63's current Comprehensive Care Plan, dated 03/7/17, revealed an Intervention/Approach for O2 as ordered. In an interview, with LPN #1, on 10/3/18, at 3:35 PM, she confirmed the O2 tubing not dated, and the Nebulizer mask was not bagged or dated. She stated it would be important for these items to be kept in a bag to prevent lotions or other things that may be in the drawer from getting on the mask, and getting into the resident's nose and lungs. She stated it could cause respiratory infections. In an interview, with the DON, on 10/3/18, at 4:10 PM, she stated the oxygen and nebulizer tubing, and masks should be stored in a zip lock bag, labeled with the room/bed and date. The night shift changes them once a week. The day shift knows to check them, and they should be put back in the bags after use. The DON stated it was important to keep them stored in bags to keep them clean, and keep the germs down.

Based on record review, staff interview, and facility policy review, the facility failed to develop a comprehensive, individualized care plan to identify the required level of assistance needed to provide Activities of Daily Living (ADLs)for two (2) of 15 resident care plans reviewed, Residents #9, and #14. Findings include: Review of the facility's policy titled, Comprehensive Plan of Care, dated 10/27/14, revealed the plans of care are developed by the interdisciplinary team, to coordinate and communicate care approaches and goals for the resident related to clinical [DIAGNOSES REDACTED]. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being are described. Resident #9 Review of the Comprehensive Care Plan revealed Resident #9 had a problem listed for requires help with activities of daily living (ADL) care. No approaches informing the staff of the individual needs required for locomotion, dressing, eating, bathing, and hygiene were found on Resident #9's care plan. Record review of the Minimum Data Set (MDS), with an Assessment Reference Date (ADR) of 4/29/17, revealed in section G, Resident #9 required extensive physical assistance of one (1) person with locomotion, extensive physical assistance of two (2) people with dressing and personal hygiene, and total physical assistance of two (2) people with bathing, and supervision with set up help with eating. On 7/7/17 at 4:10 PM, an interview with Licensed Practical Nurse (LPN) #1 revealed she was the MDS nurse who is responsible for developing and updating the resident's comprehensive care plans. LPN #1 confirmed the approaches listed with the problem of ADL care for Resident #9 did not provide the staff with an individual, specific guide on the required assistance with ADL's. LPN #1 revealed staff would not know how to take care of Resident #9 by reading the care plan approaches. On 7/7/17 at 4:15 PM, an interview with LPN #2 revealed she was the MDS nurse responsible for developing and updating resident's comprehensive care plans. LPN #2 confirmed Resident #9's care plan did not include a resident specific list of approaches for the problem of ADL needs/requirements, and did not inform the staff on the individual amount of assistance Resident #9 required with ADLs. The staff would not know if Resident #9 only needed supervision with bathing, or total assistance. Review of the Face Sheet revealed Resident #9 was readmitted by the facility, on 4/22/17, with [DIAGNOSES REDACTED]. Review of the MDS, with an ARD of 4/29/17, revealed a Brief Interview of Mental Status (BIMS) score of 4, which indicated severe impaired cognition. Resident #14 Review of Resident #14's Care Plan revealed a Problem for Activities of Daily Living (ADLs): Requires staff for all ADLs related to dementia and aging . The Approaches included, Staff provides all ADL care. The Problems/Approaches did not specify the level of assistance required for the resident's ADL care. Review of the Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 6/27/17, revealed a Staff Assessment of Mental Status Score of 3, indicating the resident's Cognitive Skills for Daily Decision Making was severely impaired. Section G revealed the resident required extensive assist of two (2) persons with transfers, dressing, and personal hygiene. She also required total assistance of two (2) persons for bathing, and total assistance of one (1) person for locomotion on the unit. An interview on 7/7/17 at 3:35 PM, with LPN #! and #2/MDS Nurses, revealed they complete the MDSs, update the care plans, and type up the care plans. LPN #1 and #2 stated you have to start out with any problems that have been identified, and the resident's status. Goals and Approaches are developed. The care plan should be individualized to the resident, for example ADLs should be specific to the resident. LPN #1 and #2 revealed the residents' care plans were not specific regarding the ADL care requirements. An interview on 7/7/17 at 4:16 PM, revealed the Director of Nurses (DON) stated the purpose of the care plan is being specific so you know exactly how to take care of the resident, and it should paint a picture of how much care the resident requires. Review of Resident #14's Face Sheet revealed the facility admitted the resident, on 3/31/14, with a [DIAGNOSES REDACTED]. Findings include:

Based on record review, staff interview, and facility policy review the facility failed to develop a comprehensive care plan related to new [DIAGNOSES REDACTED].#4 upon return from the hospital; One (1) of 13 care plans reviewed. Findings Include: Review of the facility's policy, Intermediate Care Plan Policy, undated, revealed, It is the policy of this facility that the intermediate care plans will be done as follows: As needed in an acute situation, completed by the floor nurse at the time the situation occurs. Review of the facility's policy, Interim Care Plan Policy, undated, revealed, It is the policy of this facility that an Interim Care Plan will be completed as follows: On all new admissions on the day of admission, Covering obvious problem areas until MDS (Minimum Data Set) and RAP's (Resident Assessment Protocols) can be completed to identify other Reminder: The interim care plan is utilized to provide guidance to facility staff concerning the resident and his/her care needs until the Interdisciplinary care plan can be developed by day 21. Review of Resident #4's physician's orders [REDACTED].#4 returned from the hospital on [DATE] with a new [DIAGNOSES REDACTED]. Resident #4 had an order for [REDACTED]. Interview with the Director of Nursing (DON) on 08/09/16 at 8:25 AM revealed the Registered Nurse (RN) on duty at the time of Resident #4's return from the hospital would have been responsible for completion of interim care plans and placing them on the chart. The DON stated the RN on duty worked as needed and failed to place the care plans on the chart. The DON stated the Quality Assurance Nurse should have caught the error and placed the care plans on the chart. Interview with the Quality Assurance Nurse (QA) on 08/09/16 at 8:40 AM revealed she is responsible for checking charts within 24 - 48 hours. The QA Nurse stated she did not check Resident #4's chart on 08/05/16 and did not work the weekend. The QA Nurse stated she did not identify the care plan had not been completed. Interview on 08/09/16 at 9:50 AM with the RN #1 (RN on duty at the time of Resident #4's return from the hospital) stated she completed the care plans but left them on her desk and never placed them on the chart. RN #1 stated she got busy and forgot to do it. Review of the face sheet revealed the facility admitted Resident #4 on 04/03/13 with [DIAGNOSES REDACTED]. Resident #4 was readmitted on [DATE] with a new [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/19/16, revealed Resident #4's cognition was severely impaired.