Every finding on record at Largo Nursing and Rehabiliation Center

Based on review of a facility reported incident, record review, and staff interviews, it was determined that the facility failed to ensure an allegation of abuse was reported to the Office of Health Care Quality (OHCQ) timely as required. This was evident for 1 (Resident #1) of 4 residents reviewed during the complaint survey.The findings include:On 06/23/2026, review of the facility reported incident #3015153 revealed Resident #1 alleged Resident #4 entered the room and kicked the Resident's right leg on 04/19/2026. Further review of the facility investigation revealed the initial report to OHCQ was not submitted until 05/14/2026.Review of Resident #1's clinical record revealed a health status note written by LPN #4, dated 04/20/2026, documenting Resident #1's allegation, notification of the responsible party (RP), and stating, DON (Director of Nursing) was made aware.Review of the facility policy titled Responding to Abuse/Neglect/Misappropriation/Crime, effective 01/29/2024, revealed that staff observing or suspecting abuse are required to immediately report allegations to their immediate supervisor. The policy further revealed that the Administrator and/or Director of Nursing will promptly initiate the investigation and follow reporting guidelines.On 06/23/2026 at 4:20 p.m., during an interview, LPN #4 stated she responded to Resident #1's allegation on 4/19/2026 and reported the allegation to the DON.On 06/23/2026 at 5:17 p.m., during an interview, the DON revealed she was not aware of the allegation until 05/14/2026.On 06/23/2026 at 6:27 p.m., during an interview, the Administrator revealed that the allegation was not reported to OHCQ until 05/14/2026 because facility leadership was not aware of the incident before that date.At the time of the exit conference, the facility did not provide any additional information indicating that the allegation was reported timely to OHCQ as required.

Based on investigation into a complaint, clinical record review and staff interviews, it was determined that the facility failed to implement provider-recommended interventions to prevent pressure ulcers for residents. This was evident for 1 (Resident #8) of 3 residents reviewed for pressure ulcers during the complaint survey. The findings include:On 04/13/2026 at 9:15 AM, a review of complaint #2749307 revealed allegations that Resident #8 developed a pressure ulcer to the sacrum and wounds to both feet while residing in the facility.On 04/13/2026 at 10:02 AM, clinical record review revealed a Skin and Wound Progress Note dated 01/22/2026 that documented the resident had no wounds and was at risk for skin breakdown. The Wound Nurse Practitioner (NP) provider recommended preventative interventions, including floating heels while in bed.Review of Resident # 8's physician orders did not reveal orders to implement heel floating.Review of Resident # 8's care plan revealed the resident was identified as at risk for pressure ulcers; however, the care plan did not include interventions to float heels while in bed.Review of Resident # 8's Progress notes revealed a Skin and Wound Progress Note dated 02/20/2026 that documented the resident had developed multiple wounds, including pressure injuries to the heels/feet and a Stage 2 pressure ulcer to the sacrum.Continued review of Resident # 8's January and February 2026 Treatment Administration Records (TAR) revealed weekly skin assessments were documented as completed on 01/19/2026, 01/26/2026, 02/02/2026, 02/09/2026, and 02/16/2026. However, review of Resident #8's skin observation tool documentation did not reveal evidence to show that skin assessments were completed on those dates. Further review revealed one skin observation tool dated 02/20/2026 was completed since admission on [DATE].On 04/14/2026 at 11:24 AM, in an interview, the Assistant Director of Nursing (ADON) stated that the wound care provider assesses residents and communicates recommendations to the assigned nurse and unit manager, who are responsible for entering orders into the the electronic medical record, Point Click Care (PCC) and updating the resident's care plan. The ADON also stated that weekly skin assessments are completed for all residents and documented in PCC using the skin observation tool.On 04/14/2026 at 12:07 PM, subsequent clinical record review revealed documentation of a skin observation tool completed on 02/20/2026; however, there was no documentation to show weekly skin assessments were consistently completed from admission.In an interview on 04/14/2026 at 3:15 PM, Licensed Practical Nurse (LPN) #6 stated that residents receive weekly skin assessments which are documented in PCC using the skin observation tool. LPN #6 reviewed Resident #8's record together with the surveyor and confirmed that no additional weekly skin assessments were documented aside from the 02/20/2026 entry. LPN #6 further stated that when the wound care provider completes wound rounds, recommendations are documented in Progress Notes in PCC and communicated to the unit manager; however, she was not sure who is responsible for entering new orders based on those recommendations.In an interview on 04/14/2026 at 1:17 PM, the surveyor requested documentation related to Resident #8's weekly skin assessments.In a follow-up interview on 04/14/2026 at 3:58 PM, the Director of Nursing (DON) and Assistant Director of Nursing (ADON) confirmed that TAR documentation indicated Resident #8 was checked weekly for skin assessments on 01/19/2026, 01/26/2026, 02/02/2026, 02/09/2026, and 02/16/2026; however, there was no documentation in Resident #8's clinical record to support that the skin observation tool was completed on those dates. The DON and ADON also confirmed that the 01/22/2026 provider recommendation for Resident #8 to float heels while in bed was not implemented through physician orders or the care plan.At the time of exit conference, no additional documentation was provided to show that provider-recommended interventions for pressure ulcer prevention were implemented for Resident #8.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure staff provided the appropriate level of assistance for bed mobility to ensure a resident did not fall from their bed for 1 (Resident #6) of 3 sampled residents reviewed for falls. The facility further failed to ensure fall interventions were implemented for 2 (Resident #4 and Resident #6) of 3 sampled residents reviewed for falls.The findings include:A facility policy titled, Falls Management Program, effective 01/29/2024, indicated, The center considers all patients to be at risk for falls and provides an environment as safe as practicable for all patients. The center utilizes a systematic approach to a falls management program that facilitates an interdisciplinary approach with evidence-based interventions to develop individual care strategies. 1. An admission Record revealed the facility admitted Resident #6 on 11/17/2025. According to the admission Record, the resident had a medical history that included diagnoses of other cerebral infarction and hemiplegia and hemiparesis following cerebral infarction. A Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/05/2025, revealed Resident #6 had a Brief Interview for Mental Status (BIMS) score of 0, which indicated the resident had severe cognitive impairment. The MDS indicated the resident was dependent on staff for toileting hygiene and to roll left and right in bed. Resident #6's Care Plan Report included a focus area initiated 11/18/2025, that indicated the resident required assistance with activities of daily living. Interventions directed staff to provide two-person assistance with bed mobility (initiated 11/18/2025). The Care Plan Report also included a focus area initiated 12/28/2025, that indicated the resident was at risk for falls due to a recent hospitalization. Interventions directed the staff to place falls mats to both sides of the resident's bed (initiated 01/07/2026) and to place the resident's bed in the lowest position while the resident was in bed (initiated 11/18/2025). Resident #6's progress note created by Registered Nurse (RN) #12 and dated 12/28/2025, indicated RN #12 was notified by the resident's assigned nurse that Resident #6 fell during activity of daily living care with no injuries noted. During an interview on 02/11/2025 at 4:04 PM, Licensed Practical Nurse (LPN) #5 stated she worked the day that Resident #6 fell. LPN #5 stated Geriatric Nursing Assistant (GNA) #9 told her that she was providing care to resident, when she pulled the resident toward her to turn the resident in bed, and the resident rolled off the bed. Per LPN #5, Resident #6 was too heavy for GNA #9 to hold on to, so GNA #9 lowered the resident to the floor. During an interview on 02/12/2026 at 2:36 PM, GNA #9 stated she was providing incontinence care to Resident #6 when the resident fell. GNA #9 stated when she released contact with the resident to retrieve an incontinence brief, the resident began to roll forward. GNA #9 stated she ran to the resident's right side of the bed and caught the resident mid fall and eased the resident to the floor. GNA #9 stated she thought the resident was a one-person assist. During an interview on 02/13/2026 at 11:30 AM, the Assistant Director of Nursing (ADON) stated Resident #6 required two-person assistance for bed mobility. During an interview on 02/13/2026 at 1:02 PM, LPN #10 stated Resident #6 required two-person assistance for bed mobility and there should have been two people present to provide care when the resident fell during care. During an interview on 02/13/2026 at 2:54 PM, the Director of Nursing stated she expected that when a resident required two-person assistance for bed mobility, two people should be present to provide the care. During an interview on 02/13/2026 at 3:26 PM, the Administrator stated she expected the staff to provide the right level of assistance to residents when care was being provided. During an observation of Resident #6's room on 02/11/2026 at 4:23 PM, the resident was in bed and there were no fall mats on either side of the resident's bed. During a concurrent observation and interview on 02/12/2026 at 3:50 PM, Resident #6 was observed in bed. Geriatric Nursing Assistant #7 observed Resident #6's room and stated fall mats were not in place next to the resident's bed. During an interview on 02/13/2026 at 11:30 AM, the ADON stated fall mats were added to Resident #6's care plan as an intervention after the resident experienced a fall. During a concurrent observation and interview on 02/13/2026 at 11:52 AM, Resident #6 was observed in bed. The ADON observed Resident #6's room and stated the resident's bed was not in the lowest position and the fall mats were not in place next to the resident's bed and they should have been according to the resident's care plan. 2. An admission Record revealed the facility admitted Resident #4 on 12/26/2025. According to the admission Record, the resident had a medical history that included diagnoses of hemiplegia and hemiparesis following cerebral infarction, muscle weakness, cerebral infarction, and lack of coordination. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/30/2025, revealed Resident #4 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident had moderate cognitive impairment. Resident #4's Care Plan Report included a focus area initiated 12/27/2025, that indicated the resident was at risk for falls related to weakness and hemiplegia recent hospitalization. Interventions directed staff to place fall mats to the sides of the resident's bed (initiated 01/05/2026). During an observation of Resident #4's room on 02/10/2026 at 10:58 AM and 02/11/2026 at 10:49 AM, the resident was in bed and there were no fall mats present. During a concurrent observation and interview on 02/11/2026 at 11:14 AM, Geriatric Nursing Assistant #2 observed Resident #4's room and stated there should be fall mats placed by the resident's bed. During an interview on 02/13/2026 at 11:45 AM, the Assistant Director of Nursing (ADON) stated fall mats on the side of Resident #4's bed was the intervention placed on the resident's care plan after the resident had a fall. During a concurrent observation and interview on 02/13/2026 at 3:07 PM, the ADON observed Resident #4's room and stated fall mats were not present and there should be according to the resident's care plan. During an interview on 02/13/2026 at 2:54 PM, the Director of Nursing stated she expected fall interventions to be implemented. During an interview on 02/13/2026 at 3:26 PM, the Administrator stated she expected fall interventions to be implemented.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure staff wore personal protective equipment (PPE) when they entered the room of a resident on contact precautions and when they provided care to a resident on enhanced barrier precautions (EBP) for 2 (Resident #10 and Resident #12) of 2 sampled residents reviewed for infection control.Findings included: A facility policy titled, Transmission Based Precautions-General Practice, effective 12/01/2021, indicated The Center initiates transmission-based precautions (TBPs) to protect other patients, employees and visitors from the spread of a confirmed or suspected infection or contagious disease. The TBPs will be based on the type of pathogens, knowledge of the natural history of certain diseases and studies of epidemiology. 1. An admission Record indicated the facility admitted Resident #10 on 09/18/2017. The admission Record revealed the resident had a medical history that included diagnoses of a local infection of the skin and subcutaneous tissue and extended spectrum beta lactamase (ESBL) resistance. Resident #10's Order Summary Report with active orders as of 02/09/2026, revealed an order dated 01/28/2026, for contact precautions for an ESBL wound infection every shift. Resident #10's Care Plan Report included a focus area initiated 01/28/2026, that indicated the resident required contact precautions related to an ESBL wound infection. Interventions directed staff to use appropriate PPE per policy (initiated 01/28/2026) and to maintain isolation precautions per order (initiated 01/28/2026). During a concurrent observation and interview on 02/11/2026 at 8:48 AM, there was a sign posted on the resident's door that specified contact isolation. Licensed Practical Nurse (LPN) #1 entered Resident #10's room, without wearing a gown or gloves, and stood next to the resident's bed. LPN #1 stated she was required to wear a gown and gloves when she entered Resident #10's room if she was providing care to the resident. LPN #1 stated she did not put on a gown or gloves because she was only in Resident #10's room to ask a question and did not provide care. LPN #1 then reviewed the contact isolation information posted on the resident's door and stated she should have put on gown and gloves before she entered the resident's room. The Assistant Director of Nursing (ADON), who functioned as the Infection Preventionist, was interviewed on 02/12/2026 at 12:22 PM and stated if staff entered a room of a resident on contact isolation, for any reason, even to ask a question, the staff must put on both a gown and gloves. The Director of Nursing (DON) was interviewed on 02/13/2026 at 1:02 PM and stated if a resident was on contact isolation a gown and gloves were to be worn whenever the staff entered the resident's room. The DON stated the PPE was needed to keep the staff from transferring the organisms. The Administrator was interviewed on 02/13/2026 at 2:28 PM and stated if a resident required EBP or contact isolation the staff were expected to wear PPE as listed on the signage. 2. An admission Record revealed the facility had admitted Resident #12 on 01/26/2026. According to the admission Record, the resident had a medical history that included a diagnosis of urinary retention. Resident #12's Order Summary Report with active orders as of 02/09/2026, revealed an order dated 01/26/2026, for EBP for urinary catheter and surgical wound every shift. Resident #12's Care Plan Report indicated a focus area initiated 01/27/2026, that indicated the resident had an indwelling urinary catheter secondary to urinary retention. Interventions informed staff the resident required EBP (initiated 01/27/2026). During an observation on 02/10/2026 at 11:33 AM, Geriatric Nursing Assistant (GNA) #2 and Licensed Practical Nurse (LPN) #3 used a mechanical lift to transfer Resident #12 from their bed to their wheelchair. GNA #2 and LPN #3 wore gloves, but neither staff member had on a gown when they used the mechanical lift to transfer the resident. LPN #3 was interviewed on 02/10/2026 at 1:20 PM and stated EBP should be utilized to include the wearing of PPE when caring for residents that had urinary catheters. LPN #3 stated when the transfer started and she saw the resident's urinary catheter she should have stopped the transfer and put on a gown. GNA #2 was interviewed on 02/10/2026 at 1:45 PM and stated EBP was used for residents that had wounds, infections, feeding tubes, or catheters. GNA #2 stated if a resident was on EBP, a gown and gloves were to be worn when care was provided. The Assistant Director of Nursing (ADON), who functioned as the Infection Preventionist, was interviewed on 02/12/2026 at 12:22 PM and stated EBP was required when a resident had wounds, intravenous access, indwelling urinary catheters, or feeding tubes. The ADON stated if staff provided care to the resident, then the staff must use both a gown and gloves and would be needed when transferring a resident with a mechanical lift. The Director of Nursing (DON) was interviewed on 02/13/2026 at 1:02 PM and stated that if a resident was on EBP the staff were expected to wear PPE when care was provided including transferring a resident. The DON stated this was needed to keep organisms from being transferred. The Administrator was interviewed on 02/13/2026 at 2:28 PM and stated if a resident required EBP or contact isolation the staff were expected to wear PPE as listed on the signage.

Based on interview, record review, and facility policy review, the facility failed to ensure 1 (Resident #7) of 20 sampled residents was free from a significant medication error when staff administered an anticonvulsant medication, Dilantin, to a resident when there was an order to hold the medication.The findings include: A facility policy titled General Guidelines for Medication Administration, effective 09/2018, indicated Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to administer. The policy specified, 2. Medications are administered in accordance with written orders of the prescriber. An admission Record indicated the facility admitted Resident #7 on 09/10/2021. According to the admission Record, the resident had a medical history that included a diagnosis of seizures. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/11/2025, indicated Resident #7 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident had intact cognition. The MDS indicated the resident received an anticonvulsant medication during the assessment period. Resident #7's Care Plan Report included a focus area initiated 02/02/2023, that indicated the resident was at risk for complications secondary to seizures. Interventions directed the staff to administer medications as ordered (initiated 02/02/2023). Resident #7's Order Summary Report for active orders as of 12/15/2025, revealed an order dated 12/03/2025, for Dilantin Infatabs oral tablet chewable 50 milligrams, give three tablets by mouth two times a day for seizures. Resident #7's Health Status Note electronically signed by Licensed Practical Nurse (LPN) #5 and dated 12/16/2025 at 6:17 PM, indicated the resident remained alert and verbally responsive. Per the Health Status Note, the resident's Dilantin was on hold. Resident #7's Laboratory Note electronically signed by LPN #5 and dated 12/16/2025 at 8:00 PM, indicated the resident's laboratory tests results were received and the resident's Dilantin level was greater than 40 micrograms per milliliter (mcg/mL). Per the Health Status Note, the physician was notified and provided an order for the staff to hold the resident's Dilantin and repeat the Dilantin level on 12/18/2025. Resident #7's Medication Admin [Administration] Audit Report for medications scheduled during the timeframe 12/01/2025 - 12/31/2025 indicated LPN #5 administered Dilantin to the resident on 12/16/2025 at 11:44 PM. During a telephone interview on 02/12/2026 at 3:04 PM, Physician #8 stated he was concerned that Resident #7 received more Dilantin after he ordered the medication to be held, but Resident #7 had no lasting effect from the extra dose of Dilantin. During an interview on 02/12/2026 at 3:41 PM, LPN #5 stated she was assigned to care for Resident #7 on 12/16/2025 when the laboratory notified the facility of the resident's elevated Dilantin level. LPN #5 reviewed the resident's electronic medical record and confirmed she administered Dilantin to the resident on 12/16/2025. During an interview on 02/13/2026 at 10:34 AM, the Assistant Director of Nursing (ADON) stated Resident #7 should not have received the scheduled dose of Dilantin after the elevated laboratory test result was received. The ADON reviewed the resident's electronic medical record and confirmed LPN #5 administered a dose of Dilantin to the resident on 12/16/2025 when the medication should have been held. During an interview on 02/13/2026 at 1:02 PM, the Director of Nursing (DON) stated she was aware of Resident #7's elevated Dilantin level. The DON reviewed the resident's electronic medical record and stated the nurse signed the document that specified she administered the medication to the resident. During an interview on 02/13/2026 at 2:28 PM, the Administrator stated she expected the nurse to follow the physician's orders.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure fall interventions were implemented as care planned for 2 (Resident #4 and Resident #6) of 3 sampled residents reviewed for falls.The findings include:A facility policy titled, Care Planning, effective 11/01/2019, indicated, A licensed nurse, in coordination with the interdisciplinary team, develops and implements an individualized care plan for each patient in order to provide effective, person-centered care, and the necessary health-related care and services to attain or maintain the highest practical physical, mental, and psychosocial well-being of the patient.1. An admission Record revealed the facility admitted Resident #6 on 11/17/2025. According to the admission Record, the resident had a medical history that included diagnoses of other cerebral infarction and hemiplegia and hemiparesis following cerebral infarction. A Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/05/2025, revealed Resident #6 had a Brief Interview for Mental Status (BIMS) score of 0, which indicated the resident had severe cognitive impairment. Resident #6's Care Plan Report included a focus area initiated 12/28/2025, that indicated the resident was at risk for falls due to a recent hospitalization. Interventions directed the staff to place falls mats to both sides of the resident's bed (initiated 01/07/2026) and to place the resident's bed in the lowest position while the resident was in bed (initiated 11/18/2025). During an observation of Resident #6's room on 02/11/2026 at 4:23 PM, the resident was in bed and there were no fall mats on either side of the resident's bed. During a concurrent observation and interview on 02/12/2026 at 3:50 PM, Resident #6 was observed in bed. Geriatric Nursing Assistant #7 observed Resident #6's room and stated fall mats were not in place next to the resident's bed. During an interview on 02/13/2026 at 11:30 AM, the Assistant Director of Nursing (ADON) stated fall mats were added to Resident #6's care plan as an intervention after the resident experienced a fall. During a concurrent observation and interview on 02/13/2026 at 11:52 AM, Resident #6 was observed in bed. The ADON observed Resident #6's room and stated the resident's bed was not in the lowest position and the fall mats were not in place next to the resident's bed and they should have been according to the resident's care plan. 2. An admission Record revealed the facility admitted Resident #4 on 12/26/2025. According to the admission Record, the resident had a medical history that included diagnoses of hemiplegia and hemiparesis following cerebral infarction, muscle weakness, cerebral infarction, and lack of coordination. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/30/2025, revealed Resident #4 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident had moderate cognitive impairment. Resident #4's Care Plan Report included a focus area initiated 12/27/2025, that indicated the resident was at risk for falls related to weakness and hemiplegia recent hospitalization. Interventions directed staff to place fall mats to the sides of the resident's bed (initiated 01/05/2026). During an observation of Resident #4's room on 02/10/2026 at 10:58 AM and 02/11/2026 at 10:49 AM, the resident was in bed and there were no fall mats present. During a concurrent observation and interview on 02/11/2026 at 11:14 AM, Geriatric Nursing Assistant #2 observed Resident #4's room and stated there should be fall mats placed by the resident's bed. During an interview on 02/13/2026 at 11:45 AM, the Assistant Director of Nursing (ADON) stated fall mats on the side of Resident #4's bed was the intervention placed on the resident's care plan after the resident had a fall. During a concurrent observation and interview on 02/13/2026 at 3:07 PM, the ADON observed Resident #4's room and stated fall mats were not present and there should be according to the resident's care plan. During an interview on 02/13/2026 at 2:54 PM, the Director of Nursing stated she expected fall interventions to be implemented. During an interview on 02/13/2026 at 3:26 PM, the Administrator stated she expected fall interventions to be implemented.

Based on observation and interviews, it was determined the facility failed to ensure medications were properly stored and wasted. This was evident for 3 of 4 medication carts and 1 of 1 medication storage rooms observed during the recertification survey.The findings include:Some medications should be stored in the refrigerator until opened because cold temperatures help maintain the stability and effectiveness of their active ingredients. Improper storage can cause these medications to degrade and become less potent, which may make them ineffective. 1)On [DATE] 8:37 AM, an observation of Licensed Practical Nurse (LPN) #2 medication cart revealed 1 bottle of stored unopened eye drops for Resident #99 in a pharmacy bag labeled refrigerate until opened. 2 new unused insulin pens for Resident #71 and Resident #35 were observed being stored on the medication cart in pharmacy bags labeled refrigerate until opened. On [DATE] at 8:50 AM, interview with LPN #2 confirmed that the medications observed on the cart were unopened and were labeled with refrigerate until open on the packaging from the pharmacy. LPN#2 contacted the Director of Nursing (DON) to remove the medication from the cart. 2) On [DATE] 8: 55 AM, an observation of LPN #3 medication cart revealed 3 new unused insulin pens for Resident #76, Resident #17, and Resident #4 were observed being stored on the medication cart in pharmacy bags labeled refrigerate until opened. On [DATE] at 9:30 AM, interview with LPN #3 confirmed that the 3 insulin pens observed on the cart were unused and were labeled with refrigerate until open on the packaging. LPN #3 contacted the DON to remove the medication from the cart. 3) On [DATE] 9:45 AM, an observation of LPN #1 medication cart revealed 3 new unused insulin pens for Resident #123, Resident #74, and Resident #124 were observed being stored on the medication cart in pharmacy bags labeled refrigerate until opened. An unopened vial of Respiratory Synclinal Virus Vaccine was observed on the cart labeled for Resident #124 with instructions to refrigerate until administered. 3 vials of unopened Retacrit for Resident #123 were observed being stored on the medication cart in a pharmacy bottle labeled refrigerate until administered. 2 medication bottles brought in from home, lisinopril 40mg and metoprolol 25mg, were observed being stored on the medication cart. On [DATE] at 9:52 AM, interview with LPN #1 confirmed that the medications observed on the medication cart were unused and were labeled with refrigerate until open on the packaging. LPN #1 also confirmed that resident medications from home should not be stored on the cart and stated they should be locked up in the medication storage room until the family can pick up the medications from the facility and take them home. 4) On [DATE] 9:57 AM, an observation of the medication storage room and medication room refrigerator revealed 2 expired insulin pens observed being stored in the medication refrigerator for Resident #74 expired on [DATE] and Resident #128 expired on [DATE]. 2 vials of Prevnar pneumonia vaccine were observed being stored in the medication refrigerator for Resident #22 expired on [DATE] and Resident # 127 expired on [DATE]. On[DATE] at 10:05 AM, an interview with the Director of Nursing (DON) confirmed the medication stored in the refrigerator had expired and the DON immediately removed the insulin pens and vaccine vials from the medication storage refrigerator. At this time the DON was also made aware of the improperly stored medications observed on the 3 medication carts. On [DATE] at 1:00 PM, a record review was completed and it revealed Resident #126 was discharged on [DATE]; Resident #127 was discharged on [DATE]; and Resident #128 was discharged on [DATE]. On [DATE] at 12:30 PM, The Director of Nursing (DON) was informed of the findings and no evidence was provided to refute the finding prior to exit.

Based on observations and interview, it was determined that the facility failed to ensure that the environment was in good repair. This was found to be evident in 6 (Resident rooms #239, #240, #237, #245, #235, & 242) out of 6 Resident rooms observed for the environment during the recertification survey.The findings include: During the initial tour of the [NAME] Wing conducted on 11/17/25 at 8:30 AM several resident rooms had patched up walls, stained ceiling tiles, wall damage, peeling paint, missing bed remote, broken bed remote, broken furniture, broken clock, dirt buildup on floor in front of wardrobe cabinets. During a tour of the [NAME] Wing of the facility conducted on 11/21/25 at 8:45 AM , the Surveyors and Maintenance Director (MD) observed wall damage, peeling paint, and walls patched and not painted in Resident rooms #239, #240, #237, #245, resident room [ROOM NUMBER] had a missing bed remote, resident room [ROOM NUMBER]-1 had the front of the top drawer of the night stand broken off and laying on the floor, resident room [ROOM NUMBER] - 2 bed remote did not work, the clock was not holding time, and there were stained ceiling tiles above the bed, and resident rooms #235 & #242 had a large amount of black substance that appeared to look like dirt in front of the wardrobe cabinets. The MD reported that he was not aware of the broken items. He stated that staff are to put in maintenance repair requests in a system called records where he would be notified of the broke equipment however he had not received repair requests for the broken items.

cited:Based on interview and record review, it was determined that the facility failed to provide sufficient pain management. This was found to be evident for 1 (Resident #75) out of 1 resident reviewed for pain management during the annual survey. The findings include:The 0-10 pain scale is a standardized numeric rating tool used to assess a resident's level of pain. Residents are asked to rate their pain on a scale from 0 to 10, where 0 indicates no pain and 10 represents the worst pain imaginable. This scale helps staff measure the resident's subjective pain experience, monitor changes over time, and evaluate the effectiveness of pain interventions. PRN pain medication refers to analgesic medication that is ordered to be administered as needed based on the resident's reported pain level or clinical presentation. PRN pain medications must be given in accordance with the prescriber's parameters-such as pain score, frequency limits, and specific indications-and require staff to assess, document, and monitor the resident's response to ensure effective and safe pain management.On 11/18/2025 at 11:21 AM, this surveyor interviewed Resident #75, who reported having recently fallen out of bed. The resident stated he/she had pain in the left shoulder, where he/she landed on the floor during the fall. At that time, the resident was observed wincing when attempting to move the shoulder.On 11/25/2025 at 10:06 AM, record review of Resident #75's progress notes showed the fall occurred on 11/16/2025 at 5:00 PM. A progress note dated 11/17/2025 by Licensed Practical Nurse (LPN) #20 documented that the resident verbalized shoulder pain, rated 3/10, was able to move and elevate BL arms with assistance.On 11/25/2025 at 10:55 AM, record review of Resident #75's Medication Administration Record (MAR) for November 2025 showed the MAR included a 0-10 pain scale section. For 11/17/2025, LPN #20 documented a pain level of 0 out of 10. The MAR also showed the Resident did not have any PRN pain medication ordered.On 11/25/2025 at 11:35 AM, an interview was conducted with LPN #12. When asked what the expectation is when a resident reports pain but has no PRN pain medication ordered, LPN #12 stated that staff are expected to obtain an order from the physician. LPN #12 reported that pain assessments may be documented in the MAR and in progress notes.On 11/25/2025 at 11:49 AM, this surveyor interviewed the Director of Nursing (DON). When asked her expectation for a resident who experiences a fall and reports pain, the DON stated that staff are expected to assess pain using a 0-10 scale, notify the physician if no pain medication is ordered, and ensure pain medication is prescribed. The DON was informed of the concern that LPN #20 documented the resident's pain as 3/10 in the progress note on 11/17/2025, yet no pain medication was obtained for the resident at that time. The DON reported understanding the concern.

Based on observations, medical record reviews, and staff interviews, it was determined that the facility failed to implement measures to prevent pressure ulcers. This was evident for 1 (Resident #6) of 1 resident reviewed for pressure ulcers during the annual survey. The findings include: An in-house acquired pressure ulcer is a pressure injury (also called a bedsore or decubitus ulcer) that develops or worsens while a resident is receiving care in a healthcare facility, such as a hospital, nursing home, or long-term care facility. These ulcers were not present on admission but occur due to factors such as immobility, pressure, friction, shear, or inadequate preventive care during the resident's stay.On 11/17/25 at 2:57 PM Resident #6's Responsible Party reported that the resident had no pressure ulcers upon admission to the facility but has since developed a pressure ulcer in the sacral area.During unit rounds on the first floor on 11/18/25 at 9:50 AM Resident #6 was observed lying on his/her back at 10:00 AM and remained on his/her back at 12:00 PM. On 11/19/25, the resident was lying on his/her left side at 8:00 AM and 10:00 AM, calling for help. The surveyor made the first-floor unit manager aware of these observations.On 11/21/25 at 12:00 PM review of Resident #6's medical record revealed that the resident was admitted from the hospital to the facility on 8/4/25. The admission assessment, including a skin assessment completed on 8/4/25, indicated that the resident's skin was intact with no issues. The Braden Scale, completed on 8/4/25, scored 11, indicating the resident was at high risk for developing pressure ulcers. On 11/21/25 at 12:10 PM review of Resident #6's medical record revealed that the resident was totally dependent on staff for transfers, bed mobility, and personal care, and was incontinent of both bladder and bowel, requiring full assistance with all activities of daily living (ADLs). Further review of Resident #6's medical record on 11/21/25 at 12:30 PM revealed that an At Risk assessment was completed on 8/18/25 for excoriation to the left buttock. The resident subsequently developed an in-house acquired Stage II pressure ulcer, measuring 2.5 cm x 1.5 cm x 0.1 cm, on 8/21/25.On 11/21/25 at 2:40 PM review of Resident #6's medical record revealed that on 10/2/2025, the resident's sacrum wound worsened to a Stage III pressure ulcer, measuring 4 cm x 11 cm x 0.2 cm.On 11/22/25 at 7:00 AM review of Resident #6's weekly skin observation sheets revealed ongoing documentation of a Stage III sacral pressure ulcer with the following measurements:On 10/9/25, the ulcer measured 3 cm x 4.5 cm x 0.3 cm.On 10/16/25, the ulcer measured 4.0 cm x 4.0 cm x 0.3 cm.On 10/23/25, the ulcer measured 2.0 cm x 4.0 cm x 0.3 cm.On 10/30/25, the ulcer measured 2.0 cm x 3.5 cm x 0.3 cm.On 11/6/25, the ulcer measured 0.5 cm x 0.5 cm x 0.0 cm.On 11/13/25 the ulcer measured 5.5 cm x 6.5 cm x 0.4 cm, indicating a significant increase in size compared to the prior week. On 11/24/25 at 7:30 AM review of the physician's wound notes for Resident #6 revealed the following: 8/8/25: Resident evaluated as a new admission for a comprehensive wound assessment. Skin was dry and intact with no wounds present. 8/21/2025: Resident evaluated for a new Stage II sacral pressure injury measuring 2.5 cm x 1.5 cm x 0.1 cm with 100% granulation tissue. Subsequent note indicated the wound was improving, measuring 0.5 cm x 0.3 cm x 0.1 cm with 100% granulation.10/2/25: Wound worsened to Stage III, measuring 4 cm x 11 cm x 0.2 cm, with a wound base of 70% granulation and 30% slough.10/9/25: Wound documented as improving without complications; however, wound base showed 0% granulation and 100% slough, measuring 3 cm x 4.5 cm x 0.3 cm.On 11/24/25 at 7:53 AM the surveyor reviewed Resident #6's skin assessment observation sheet with the DON and ADON, and both acknowledged that the resident's wound had worsened.On 11/24/25 at 8:36 AM the surveyor informed both the DON and ADON of the above concerns, and they acknowledged receipt.

Based on interview and observation, it was determined that the facility failed to provide quality of care to residents. This was evident for 1 (Resident #56) out of 1 resident reviewed during the annual survey.The findings include:On 11/17/2025 at 2:19 PM, this surveyor conducted an interview with Resident #56. The Resident reported he/she had pressed the call bell at approximately 11:30 AM because he/she needed assistance with being changed and cleaned. The Resident reported he/she had not yet received assistance. Resident #56 pressed the call bell again while this surveyor was present in the room.On 11/17/2025 at 2:33 PM, this surveyor was in the hallway and observed that Resident #56's call bell light remained illuminated outside the room and was visible on the nurse's station display.On 11/17/2025 at 2:34 PM, this surveyor observed Certified Nursing Assistant (CNA) #6 walking down the hallway and noted that Resident #56's call bell light was now turned off. CNA #6 then proceeded onto the elevator. Before the elevator doors closed, this surveyor asked CNA #6 if she had checked on Resident #56 prior to entering the elevator. CNA #6 confirmed that she had, but stated that she was now going on break. This surveyor asked whether she had informed another staff member that the Resident still required assistance before going on break. CNA #6 responded, hold on, exited the elevator, and notified two staff members seated at the nurse's station that she was going on break and requested that they assist Resident #56.On 11/17/2025 at 2:36 PM, two healthcare staff were observed entering Resident #56's room and closing the door.On 11/25/2025 at approximately 12:30 PM, this surveyor informed the Director of Nursing (DON) and Assistant Director of Nursing (ADON) of the concern. It was explained that CNA #6 had acknowledged answering Resident #56's call bell but was preparing to go on break without notifying another staff member that the Resident still required assistance. This surveyor also explained that the Resident had reported waiting since approximately 11:30 AM that morning to be changed and cleaned up. The DON and ADON confirmed understanding of the concern.

Based on interviews, observations, and record reviews, it was determined that the facility failed to offer comprehensive activities in accordance with resident interests, physical, mental, and psychosocial well-being. This was evident for 3 (Resident #61, Resident #9, Resident # 10) of 24 residents reviewed for activities. The findings include: 1) On 11/17/2025 at 11:08 AM, resident #61 stated there are no activities for blind people, only bingo. Resident # 61 reports facility staff have never offered or brought activities in their room. Resident #61 was observed lying in bed with the TV on with no activity supplies in their room. On 11/20/2025 1:20 PM, review of resident #61 activity care plan, attends some activities daily and also pursue independent activities and watching television in his/her room. with the interventions Assist in planning/Encourage to plan own leisure-time activities; Encourage participation in group activities of interest; Provide assistant to accommodate participation in activities of choice; Provide daily Activity Flyer; Provide supplies/materials for leisure activities as needed/requested; Respect choice in regard to limited/no activity participation. On 11/20/2025 at 1:25PM a review of Resident #61 activity records for a 30-day look back period for activities was documented every day as watching TV in their room as the daily activity. On 11/20/2025 2:40 PM, an interview with the Director of Recreation was conducted. She reported that if a resident is unable to get out of their bed, they have an activities cart they go around with from room to room with different activities and supplies. On 11/21/2025 10:00 AM, an interview with Recreation Assistant #5 revealed that they have been understaffed for about a year and would like to do more 1:1 with residents, however they do not have the time. She reported the department just hired another person to assist and going forward more activities would be offered to residents including 1:1 activities. When asked about resident #61 and what activities are offered for blind residents, she stated she did not know what to offer the residents other than music or talking with them. When asked if she documents her interactions, she stated she has a form where she documents if she does a 1:1 where more than just talking with the resident occurs. She reports she does not document the encounter as an activity if she just sits and talks with the resident. 11/21/2025 10:35 AM, interview with the Director of Recreation confirmed that resident #61 were not found to have any documented 1:1 interactions for the last 90 days. When asked what the recreation department offered for resident #61 or residents who are visually impaired, she stated the resident will participate in group activities if nursing staff would get him up. She stated the recreation department has been short staffed for the last year and have recently hired more help. The Recreation Director stated that going forward more activities would be offered to residents including 1:1 activities. Director of Recreation confirmed they do not offer 1:1 activities to Resident #61 or provide activity supplies. 2) On 11/17/2025 at 12:11 PM, an interview with Resident #9 reveals their daughter brings in coloring books and activity books for the resident to do. When asked if the recreational department provides activity supplies for the resident, they stated no. Resident #9 was observed to be lying in bed coloring in a sketch pad with colored pencils. On 11/ 20/2025 at 1:20 PM, a review Resident #9 activity care plan, while in the facility, resident stated that it is important that he/she has the opportunity to engage in daily routines that are meaningful relative to their preferences and the resident prefers or requires 1:1 activities due to being unable or unwilling to participate in other activities with the interventions provide 1:1 activities in the room or location that is the residents preference as needed. On 11/20/2025 at 1:25 PM, a review of Resident #9 activity records for a 30-day look back period for activities was documented every day as watching TV in their room as the daily activity. On 11/21/2025 10:00 AM, an interview with Recreational Assistant #5 reports that the department has been understaffed for about a year. She stated she would like to do more 1:1 with residents, however they do not have the time. She reported the department just hired another person to assist. When asked about resident #9 and if the recreation department offered coloring or drawing supplies to the resident, the recreation assistant #5 confirmed they have not offered the resident supplies for drawing. When asked if she documents her 1:1 interactions, she stated she has a form where she documents if she does a 1:1 when more than just talking with the resident occurs. On 11/21/2025 10:35 AM, interview with Recreational Director confirmed that Resident # 9 were not found to have any documented 1:1 interactions for the last 90 days. She also confirmed they have not offered activity supplies for resident #9 to use to draw. On 11/25/2025 at 12:30 PM, the findings were presented to the Director of Nursing and the Administrator. The Administrator stated the Recreation department is fully staffed and provided a print out of the facility staffing. No further evidence was provided before the exit conference. 3) During an observation conducted on 11/18/25 at 10:07 AM, Licensed Practical Nurse (LPN) #4 and the Surveyor observed Resident #10 in bed and receiving an enteral feeding. The LPN #4 reported that the Resident was bed bound and non-verbal. During an interview conducted on 11/21/2025 at 10:00 AM, Activities Assistant #5 revealed that they have been understaffed for about a year. She stated she would like to do more 1 on 1 activities however she did not have the time. When asked what activities were offered to bedbound residents, she stated she tried to find out what the Resident liked either from the resident or family. When asked what activities had been offered for resident #10, the Activities Assistant stated she did not recognize the Resident's name. When asked if 1 on 1 activities were documented she stated she has a form where she documented the 1 on 1 activity and that the Recreational Director holds the completed forms. During an interview conducted on 11/21/2025 at 10:35 AM, the Recreational Director stated the recreation department had been short staffed for the last year and have recently hired more help. When asked about resident #10 and what was offered for bed bound residents who were cognitively impaired, the Recreational Director stated she did not recognize the name and had to search for the resident's picture in the medical record. She stated they will play music or put lotion on their hands. The Recreational Director confirmed that resident #10 was not documented to have any 1 on 1 activities with the Recreation Assistant.

Based on interviews and record reviews, it was determined that the facility failed to ensure that residents requiring assistance with Activities of Daily Living (ADLs) received scheduled showers. This was evident for 1 (Resident #6) out of 1 resident reviewed for ADLs during the annual survey. The findings include: On 11/17/25 at 2:33 PM an interview with the resident's Responsible Party (RP) revealed that the resident has been in the facility since 8/4/25 and has not received a shower, only bed baths. The RP also stated that he is aware the facility has a chair that could be used to transport the resident to the shower room.Record review on 11/18/25 at 1:17 PM showed that Resident #6 had been in the facility since August 4, 2025. The Plan of Care indicated that the resident was to receive showers on Mondays and Thursdays, totaling eight showers per month, with staff assistance required. On 11/18/25 at 1:30 PM a review of GNA shower documentation for Resident #6 from 11/1/25 to 11/19/25 revealed that no showers were provided on 11/3, 11/6, and 11/13. On 11/17, the resident was marked as not available, but the medical records did not indicate the reason or whether the resident was out of the facility. On 11/19/25 at 10:00 AM an interview with the 1st Floor Unit Manager (UM) revealed that residents are scheduled for showers twice weekly and as needed, with GNAs documenting each shower in the shower book. When a resident refuses a shower, the GNA notifies the nurse, who determines the reason for the refusal, notifies the family, and ensures all actions are properly documented.On 11/19/25 at 11:11 AM an interview with GNA #18 revealed that when a resident refuses a shower, the charge nurse is notified. If the resident continues to refuse, a bed bath is offered. Refusals and interventions are documented in the Plan of Care (POC) and on the skin sheet.On 11/21/25 at 9:41 AM the ADON stated that residents are scheduled for showers twice weekly and as needed. If a resident refuses, the GNA notifies the nurse, who encourages the resident or notifies the family if the resident cannot respond. Refusals are documented, and bedbound residents receive showers using a shower bed.On 11/21/2025 at 11:34 AM, the DON and ADON confirmed that there was no documentation explaining why Resident #6 did not receive showers on the identified dates. They stated that the facility's expectation is for GNAs and charge nurses to report and document accordingly. The surveyor informed the DON and ADON of this concern, and both acknowledged receipt.

Based on medical record reviews and staff interviews, it was determined that facility staff failed to ensure the accuracy of Minimum Data Set (MDS) assessments. This was evident for 1 of 3 residents reviewed for unnecessary medications (Resident #14) during the annual survey. The findings include: The Minimum Data Set (MDS) is a federally mandated assessment tool used by nursing home staff to gather information on each Resident's strengths and needs. Information collected drives resident care planning decisions. MDS assessments must be accurate to ensure that each Resident receives the care they need. An active diagnosis documented on the MDS assessment are attending provider-documented diagnoses in the last 60 days that have a direct relationship to the resident's current functional status, cognitive status, mood or behavior, medical treatments, nursing monitoring, or risk of death during the 7-day look-back period. A record review was completed for Resident #14 on 11/20/25 at 6:44 AM for an Unnecessary Medications Review. The review noted that Resident #14 was admitted to the facility on [DATE]. His/her diagnoses included anxiety, as documented in the attending provider's note dated 10/24/2025 at 2:46 PM.On 11/20/25 at 7:00 AM, further review of Resident #14's Medication Administration Record (MAR) for the period of 11/1/2025-11/20/2025 revealed that the resident had an order for buspirone HCl 5 mg, to be given orally once daily for anxiety.Further review of the records on 11/20/25 at 7:15 AM revealed that the MDS assessment completed on 10/27/2025 did not include the diagnosis of anxiety in Section I - Active Diagnoses.On 11/21/25 at 12:58 PM, an interview was conducted with the MDS Coordinator, who stated that the process for diagnosis coding on the MDS assessment requires that a diagnosis be active and documented by the physician within the past 60 days. When asked how diagnoses are coded when a resident is admitted on a medication associated with a particular condition, she stated that the diagnosis is added to the admission assessment.During an interview on 11/21/25 at 1:15 PM, the surveyor requested that the MDS Coordinator verify whether the resident's diagnosis of anxiety was coded on the admission or Modification MDS assessment. She confirmed that the resident is prescribed buspirone for anxiety; however, the diagnosis of anxiety was not coded on either the admission or Modification assessment. She further stated, The diagnosis was not coded, and it was missed on both assessments.On 11/21/25 at 1:20 PM the surveyor informed the MDS Coordinator of the above concern, and she acknowledged receipt.On 11/24/25 at 12:14 PM review of the medical record revealed that the MDS assessment was modified on 11/21/25 following the surveyor's intervention.

Based on medical record review, staff interviews, and review of the facility's discharge practices, it was determined that the facility failed to: 1) provide the resident and/or resident representative with written notification of the bed-hold policy, and 2) notify the Ombudsman of the resident's transfer. This was evident for 1 (Resident #120) of 2 residents reviewed for hospitalization during the annual survey.The findings include:Review of the medical record for Resident #120 on 11/24/25 at 9:57 AM revealed that on 9/24/25, the resident was transferred from a nephrology appointment to the emergency room (ER) due to a change in condition. On 11/24/25 at 10:15 AM further review of the medical record revealed that on 9/24/25 at 11:59 PM, the nurse's notes documented that a call was placed to the hospital and confirmation was received that Resident #120 had been admitted with fluid overload related to congestive heart failure (CHF). No documentation was found in either the paper or electronic record to indicate that the resident or resident representative had been provided with written notice of the bed-hold policy. On 11/25/25 at 6:33 AM during an interview with the Director of Nursing (DON), she stated that she was unsure whether a bed-hold notice had been provided to the resident and that she would look for a copy. She also indicated that the notice may be kept in a location outside of the medical record. On 11/25/25 at 6:46 AM an interview was conducted with the DON regarding the process for Ombudsman notification. The DON stated, I am not sure; I will get back with you. On 11/25/25 at 8:46 AM the DON and Assistant Director of Nursing (ADON) reported that the facility failed to provide the resident and/or resident representative (RP) with the bed-hold policy notice after confirming that Resident #120 had been admitted to the hospital. On 11/25/25 at 10:12 AM the DON and ADON reported to the surveyor that there was no documentation verifying that the Ombudsman was notified. Both confirmed that the facility failed to notify the Ombudsman of the resident's transfer to the hospital. On 11/25/25 at 10:15 AM the surveyor informed both the DON and ADON of the above concerns, and both acknowledged receipt.

Based on record review and interview, it was determined that the facility failed to thoroughly investigate an allegation of abuse. This deficient practice was identified for 1 out of 1 facility-reported incidents reviewed during the annual survey.The findings include:On 11/19/2025 at 2:59 PM, this surveyor reviewed the facility-reported incident investigation regarding an allegation of sexual abuse involving Resident #101 and housekeeping staff member #19. The resident reported that the staff member had touched him/her inappropriately. Review of the file showed that during the investigation only residents on the Arcadia Unit were interviewed, and only female residents were included. There was no documentation that male residents or residents on other units were interviewed or observed for potential signs of abuse.On 11/20/2025 at 10:25 AM, this surveyor interviewed the Director of Nursing (DON) and Assistant Director of Nursing (ADON) regarding the scope of the investigation. During the interview, it was confirmed that the Licensed Practical Nurse (LPN) #17 who conducted the investigation interviewed only female residents. The DON explained this was done because the alleged employee was located on the female side of the unit at the time of the alleged incident.It was discussed with the DON and ADON that this approach was insufficient because the employee had clocked in earlier that morning (at 8:23am) and could have had access to male residents prior to the alleged incident time (approximately 9:30am). Additionally, it was discussed that the employee was not permanently assigned to the Arcadia Unit and worked on other floors, giving access to other residents throughout the facility.Since the investigation did not include interviews or observations of male residents or residents on other units, the facility did not ensure that all potentially affected residents were assessed for signs or symptoms of abuse and therefore did not conduct a thorough investigation. The DON and ADON acknowledged that male residents were also at risk for sexual abuse and recognized the concern raised by this surveyor.

cite Based on record reviews and staff interviews, it was determined that the facility failed to ensure adequate monitoring for residents receiving antipsychotic medications. This was evident for 3 (Residents #14, #5 #1) out of 3 residents reviewed for Unnecessary Medications during the annual survey.The findings include:1) During the medical record review on 11/20/2025 at 6:44 AM for Resident #14, it was noted that the resident had a physician's order for busPIRone HCl 5 mg oral tablet, to give 1 tablet by mouth once daily for anxiety.2) On 11/20/25 at 10:30 AM review of Resident #5's medical record revealed a physician's order for bupropion HCl ER (XL) 300 mg oral tablet, to be administered by mouth once daily for depression.3) On 11/20/25 at 10:40 AM review of Resident #1's medical record revealed a physician's order for ARIPiprazole Oral Tablet 10 MG (Aripiprazole) Give 1 tablet via PEG-Tube one time a day for BIPOLAR DISORDER. 2) TraZODone HCl Tablet 100 MG Give 1 tablet via PEG-Tube at bedtime for DEPRESSION.Further review of the medical records on 11/20/25 at 11:00 AM for Residents #14 and #5, #1 revealed that there were no orders in place for behavior monitoring, side effect monitoring, or non-pharmacological interventions for either residents.During an interview on 11/21/25 at 9:24 AM, the Assistant Director of Nursing (ADON) stated that psychiatric and attending physicians review residents' medications and make changes as needed; families are informed; and residents are monitored through non-pharmacological interventions, behavior monitoring, side-effect monitoring documented on flow sheets, completion of AIMS assessments, and verification of medication indications by the physician On 11/21/25 at 9:34 AM the surveyor requested that ADON provide documentation of behavior monitoring, side effect monitoring, and non-pharmacological intervention assessments for Residents #14, #5, and #1.On 11/21/25 at 11:46 AM the Assistant Director of Nursing (ADON) reported that behavior monitoring, non-pharmacological interventions, and side-effect monitoring had not been initiated for Residents #14, #5, and #1, and stated that she would follow up.On 11/21/25 at 12:05 PM the surveyor notified DON and ADON of the above concerns, and both acknowledged receipt.On 11/22/25 at 4:00 PM record review revealed that orders for non-pharmacological interventions, behavior monitoring, and side effect monitoring had been added to the medical records of Residents #14, #5 and #1 after the surveyor's intervention.

Based on record reviews and facility staff interviews, it was determined that the facility failed to ensure a resident received a beneficiary notification. This was found to be evident for 1 (Resident #16) of 3 residents reviewed for Beneficiary Notifications during the recertification survey.The findings include: The Advance Beneficiary Notice (ABN) provides information to residents/beneficiaries that services may no longer be covered by Medicare and addresses the resident's liability for payment should they wish to continue receiving the skilled services. The Notice of Medicare Non-Coverage (NOMNC) informs the beneficiary of his or her right to file an appeal of the decision for non-covered services and their right to an expedited review of Medicare non-coverage of services. On 11/25/2025 at 08:30 AM, record review of resident # 16, confirmed that the facility had stopped billing for Medicare part A on 05/27/2025. On 11/25/2025 at 9:30 AM, information and copies for the Advanced beneficiary notice (ABN) and Notice of Medicare Non-Coverage (NOMNC) forms were requested for Resident #16 from the facility's business Office. The Assistant Business Office Manager was unable to locate the two requested forms for Resident #16. On 11/25/2025 at 10:20 AM, the requested record for Resident #16 were reviewed using the Skilled Nursing Facility Beneficiary Protection Notification Review form (FORM CMS-20052) and found to be missing the ABN and NOMNC forms. Resident #16 was noted to not have exhausted all the Medicare Part A Services benefit Days. On 11/25/2025 at 11:15 AM, interview with Social Services Director confirmed that a NOMNC and ABN should have been issued to resident #16 when they transferred to the skilled nursing unit. The Social Services Director also confirmed that the facility does not have record of either form for Resident # 16.

Based on interviews, observations, and record reviews, it was determined that the Facility failed to ensure a resident's choices were honored. This was evident for 1 (Resident #61) of 3 residents reviewed for choices during the recertification survey.The findings include: On 11/17/2025 at 11:05 AM, during an interview with Resident #61, the Resident stated can't get up, can't do anything, no GNA,I would like to get up and can't get up every day, I have not been out of bed in 2 weeks. The resident reported that when he/she requested to get out of bed, a staff member advised the facility had low staff and there was not anyone to assist the resident in getting out of bed. The Resident further reported he/she was dependent on staff to transfer him/her out of the bed and into a chair using a hoyer lift. ADL care means Activities of Daily Living care, which refers to the support provided for basic self-care tasks. This can include assistance with activities like bathing, dressing, eating, toileting, and moving around. The level of ADL care needed is determined by a person's ability to perform these fundamental tasks independently.During multiple observations conducted on 11/18/2025 at 3:00 PM and 11/19/2025 at 9:20 AM, Resident #61 was observed in bed, in a gown, and had not received ADL care. On 11/19/2025 at 10:00 AM, review of the Resident #61's 30-day ADL care look back period for showers revealed that the resident received 2 showers in 30 days: 10/21/25 and 10/28/25. On 11/19/2025 at 10:55 AM, an interview with the Assistant Director of Nursing (ADON) confirmed that if a resident missed their shower yesterday (11/18/25) due to the hot water being temporarily turned off, a makeup shower would be offered to the resident today (11/19/25). The ADON stated that if a resident refused a shower, it would be documented in the electronic record and on the shower sheet. She also went on to state it is the facility's process to have the Geriatric Nursing Assistant (GNA) report the refusal of a shower to the nurse and if it is a regular occurrence the resident would then be care planned for bed baths only. On 11/19/2025 at 11:51 AM, a review of the shower binder, kept at the nurse's station, showed only 1 shower sheet for Resident #61 for 10/07/2025 for the last 30-days. It was not documented on the sheet if a shower was completed. On 11/19/2025 at 11:53 AM, review of resident #61's care plan revealed the resident is not care planned for just bed baths or to only get out of bed on certain days. On 11/19/2025 at 1:50 PM, interview with the Licensed Practical Nurse (LPN) #2 confirmed that residents have routines that they follow. If a resident does not want to get up every day, then they have specific orders for the resident. LPN #2 explained that the facility policy is to get all bed bound residents out of bed daily unless the Resident requested to only get out of bed on certain days. Getting the residents out of bed is part of their daily routine. When LPN #2 was questioned about Resident #61, LPN #2 stated that Resident #61 does not refuse showers or care and that they are up out of bed every day. LPN #2 further stated that on Monday 11/17/25 residents were not able to get out of bed due to low staffing. During an interview conducted on 11/19/25 at 1:59 PM, the Assistant Director of Nursing (ADON) stated that it is the facility's expectation to get all residents out of bed as part of their daily routine of care. She also stated that an order was not required to get the resident out of bed however sometimes there is an order if the resident requested to get out of bed on certain days. During the continued interview, the Director of Nursing (DON) stated that if a bedbound resident refused to get out of bed the staff are expected to turn and reposition. On 11/20/2025 at 02:00 PM, Resident #61 was observed to be in their bed in a gown. On 11/21/2025 at 10:00 AM, an interview with Resident #61 confirmed they did not receive their shower on Tuesday or Wednesday. The resident stated that he/she was supposed to get a shower today and would like to receive a shower today and get out of bed. On 11/21/2026 at 10:15 AM, review of Resident #61 record for showers showed that over the last 90 days Resident #61 only received 11 showers of the 28 showers that they were scheduled to receive. There was one documented refusal in the chart for the 90-day period. 11/21/2025 at 10:20 AM, an interview with GNA # 11 confirmed she did not shower Resident #61 on 11/18/2025 or 11/19/2025. GNA #11 then stated she would not be showering Resident #61 today on his/her scheduled shower day. She stated she does not have enough time to shower everyone and stated a good bed bath gets the resident just as clean. 11/25/2025 at 12:30 PM, The Director of Nursing (DON) was informed of the findings and no evidence was provided to refute the finding prior to exit.

Based on medical record review and interviews with the resident and staff, the facility was found to have failed in ensuring the resident's right to participate in planning care. This was evident for 1 (Resident #5) of 1 resident reviewed for care plan during the annual survey.The findings include:On 11/18/25 at 1:07 PM Resident #5 reported that he/she did not receive an invitation to his/her care plan meeting. Instead, staff came to him/her room on the day of the meeting to inform her. He/she reported that the Social Worker stated the invitation had been sent to a family member who is not his/her responsible party, and that the family member received it the day after the meeting. The resident stated, I told them I am alert and oriented; why didn't you come and tell me? I'm the patient. He/she further stated, I was not happy about that, and I told the Social Worker.Review of Resident #5's medical record on 11/19/25 at 11:20 AM revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident is cognitively intact. Further review of the record revealed that the resident is his/her own responsible party for making medical decisions. On 11/19/25 at 12:07 PM an interview was conducted with the Social Services Coordinator (SSC) regarding care plan invitations. The SSC stated that invitations are sent via mail to the resident and/or the Responsible Party (RP) if the resident is capable. To verify receipt, a follow-up call is placed to the resident or family one week prior to the care plan meeting. However, for Resident #5, the invitation was sent on 10/16/25 to his/her family member, who is not the RP.On 11/19/25 at 12:20 PM the Social Services Coordinator (SSC) and the Regional Social Worker confirmed that the facility's expectation is to notify the resident of care-plan meetings unless the residents lack the capacity to make their own decisions. The SSC stated that the resident was unhappy about not being notified and apologized to him/her. The Regional Social Worker noted that notifying a family member who is not the responsible party is not the facility's practice. They further confirmed that Resident #5 is his/her own responsible party and that the invitation should have been sent to the resident, not to a family member who is not the Responsible Party.On 11/19/25 at 12:37 PM the surveyor informed the Regional Social Worker and the Social Services Coordinator of the above concern, and both acknowledged receipt.

Based on observation, record review, and interview of facility staff, it was determined the facility failed to: 1) ensure medications and hazardous items were safely and securely stored and limit access to authorized personnel only. This was evident for two of three units observed; 2) investigate the root cause of the falls and initiate nursing interventions to prevent further falls, and 3) assess resident's fall risk regularly before actual fall incidents. This was evident for two (Resident #38 and # 323) of five residents reviewed for falls during the annual survey. As a result of the findings of unsecured medications and hazardous items, a state of immediate jeopardy was declared on 1/12/24 at 4:45 PM and communicated to the facility Administrator at 4:48PM. An immediate jeopardy summary tool was provided to the facility at 4:51PM. The facility submitted a plan to remove the immediacy on 1/12/24 at 6:59PM that was rejected; another plan at 10:04PM that was rejected; another plan at 11:03PM that was rejected; another plan at 11:21PM that was rejected; and another plan was presented at 11:31 PM and was accepted by the state agency 11:59 PM on 1/12/2024. After removal of the immediacy, the deficient practice remained with a scope and severity of E. The findings include: 1. On 1/12/24 at 9:53 AM Staff #8, Unit Manager, 2nd floor, Licensed Practical Nurse, showed the surveyor to a room labeled the central supply room located on floor 2, on the Independence hallway and proceeded to push the door open and enter the room without use of the keycode pad located on the front of the door. Staff #8 verbalized to the surveyor that this room was the medication room. On 1/12/24 at 9:53 AM the surveyor observed various medications and supplies in the room labeled the central supply room located on floor 2, on the Independence hallway; including but not limited to: aspirin, acetaminophen, naproxen, guaifenesin oral solution, vitamin C, vitamin B, vitamin D, vitamin E, milk of magnesia, Dakin's solution, calcium tablets, povidone iodine 10% solution, multivitamins, multivitamins with iron, Claritin, senna, aspercreme, fexofenadine, carbamide peroxide, bacitracin zinc ointment, hydrogen peroxide 3%, simethicone, acetaminophen suppositories, melatonin, iron, folic acid, bisacodyl, sodium chloride tablets, calcium citrate, cetirizine, insulin needle supply, hypodermic needle supply, tuberculin syringes, packages of twin blade shaving razors supply, and bandage scissors. On 1/12/24 at 9:56AM the surveyor observed Staff #16, Staffing Coordinator, immediately open the door to the room labeled the central supply room located on floor 2, on the Independence hallway without use of the keypad. On 1/12/24 the surveyor observed Resident #91 utilizing their wheelchair to leave the [NAME] Wing Unit hall. Upon record review the resident was noted to have a history of stroke, and dementia diagnosis documented in the medical record on 10/6/23 as well as a BIMS (brief interview of mental status, an assessment of cognitive impairment) score of 9 out of 15, indicating moderate cognitive impairment. On 1/12/24 at 10:11AM surveyors conducted a dual observation of the contents of the central supply room located on floor 2, on the Independence hallway. On 1/12/24 at 10:12AM surveyors observed all units for medication storage. On 1/12/24 at 10:20AM surveyors approached the first-floor medication room door and found the door had not been shut and was left ajar, allowing the door to easily be pushed open for entry. Upon entry to the room, surveyors observed the medication refrigerator with a padlock hanging on the left side which was unlocked and able to be opened. Upon opening the refrigerator, surveyors observed it to contain the following: insulins, lidocaine injection, pneumovax, flu vaccines, TB test solution, triamcinolone, and bags of intravenous intralipids 20%. On 1/12/24 at 10:36AM surveyors approached the first-floor supply room door which was observed to be shut, with a keypad present, however, the door handle freely allowed entry to the room without use of the keypad, allowing entry. Surveyors observed the following supplies within the room: syringes, blood test tubes/vacutainers, bag containing heparin lock flushes 50 USP units/5ml, and needles On 1/12/24 at 11:23AM the surveyor conducted another observation of the door to the 2nd floor central supply room on the Independence hallway, which did not require keypad use to open the door despite the door being tightly shut. The keypad was observed to light up when keys were pressed, however, the door was unable to lock. On 1/12/24 at 12:25PM the surveyor conducted an interview with, Licensed Practical Nurse (LPN) #9, who reported that Resident #69, was among other residents on the unit who have the ability to ambulate, required supervision due to cognitive deficits. Upon record review Resident #69 was noted to have a BIMS score of 0 out of 15 indicating severe cognitive impairment as documented in the medical record on 12/28/23. On 1/12/24 at 12:33PM the surveyor observed the 2nd floor maintenance log which revealed on 6/27/23 the keypad to the 2nd floor central supply room was reported as not working. On 1/12/24 at 12:40PM the surveyor conducted another interview with LPN #9 who confirmed they reported the request in the maintenance log. LPN #9 reported to the surveyor that the 2nd floor central supply room door had not been locking for approximately two months. On 1/12/24 at 12:45PM the surveyor observed Resident #69 ambulating without the use of an assistive device into the central bath/shower room. The unlocked central supply room was accessible at this time in the adjacent hallway. On 1/12/24 at approximately 3:19PM, surveyors observed Resident #88 ambulating in the hallway near the central supply storage room. Upon review of the medical record, Resident #88 was noted as an elopement/wander risk with impaired cognitive functioning, dementia diagnosis, and a BIMS score of 5 out of 15 indicating severe cognitive impairment , whose room was found to be located near the central supply room. On 1/12/24 at 4:54PM the Director of Nursing (DON) communicated to the surveyors that the facility had decided to use the 2nd floor medication room instead of the central supply room for medication storage. As a result of these findings, a state of immediate jeopardy was declared on 1/12/24 at 4:45PM. The provision of the plan to remove the immediacy had a completion date of 1/14/24 and included: a A 100% audit of all medication rooms and supply rooms have been conducted by the Administrator, Maintenance Director and DON to ensure medications and hazardous items were safely and securely stored. This was completed on 01.12.2024. b. The lock to the central supply room on the 2nd floor located on Independence unit has been replaced with a new code by maintenance staff on 01.12.2024 and is currently secured. Only authorized staff will be allowed access to this room. c. The nurse managers immediately removed all the over-the-counter medications from the central supply room on Independence unit and secured them in the 2nd floor medication room nearest to the nurses' station on 01.12.2024. d. All insulin needles, hypodermic needles, tuberculin syringes, twin blade shaving razors, and bandage scissors are all currently safely secured in the 2nd floor central supply room on the Independence unit as of 01.12.24. e. The door to the 1st floor medication room has been repaired and is secured. Education with all licensed nurses has been initiated effective 01.12.24 and will be completed by 01.14.24. Training is being conducted by the Staff development nurse, ADON, and DON to ensure the refrigerator is kept locked when not in use. f. The door to the 1st floor supply room across from rehab gym is repaired, locked, and code changed. Education with all licensed nurses has been initiated effective 01.12.24 and will be completed by 01.14.24. Training is being conducted by the Staff development nurse, ADON, and DON to ensure the supply room is kept locked when not in use. g. As a result of the findings of the audit conducted by the facility staff on 01.12.24, a Staff member was immediately stationed outside each door that did not lock appropriately until the repairs were completed by maintenance. h. Training with licensed nurses, housekeeping staff, and Maintenance staff was initiated by the Staff Development nurse on 01.12.24 to make certain that the staff pulls the door shut when exiting to ensure all medications and hazardous items are kept safe and secure, and to notify the Administrator and Maintenance director immediately if any door is identified as in need of repair. This will be completed by 01.14.24. i. The Administrator and Maintenance director will validate all supply rooms and medication room doors are repaired and secured effective 01.12.24. j. The Unit managers and nursing supervisors will inspect all supply rooms and medication rooms to ensure all medications and hazardous materials are properly secured and in compliance every shift X 7 days, then daily X30 days. k. Results of the audits will be submitted to the QAPI committee for further review and recommendations as needed. After on-site confirmation of the completion of the facility's plan of removal on 1/18/2024, the Immediate Jeopardy was removed on 1/14/2024. 43096 2. Reviewing Resident #38's medical record on 02/01/24 revealed that the facility documented a form named 72 hours. Post fall documentation on 10/11/23. The form indicated that Resident #38 had a fall from a bed on 9/24/23 at 6 AM. Further review of the resident's progress note revealed that a Licensed Practical Nurse (LPN) documented that Resident was noted with an open area and swelling to the left upper cheek close to the eye area and opening to the left knee on 9/24/23 at 10:30 AM. However, no documentation was found to indicate the cause of Resident #38's swelling and openings near the eyes. During an interview with the Director of Nursing (DON) on 2/05/24 at 9:25 AM, the DON stated that a night shift nurse who initially found Resident #38's changes on 9/24/23 did not report a fall. The DON explained, When a day shift nurse brought this issue to me, I contacted the night nurse and confirmed that the resident had a fall which resulted in swelling to the left cheek to the knee on 9/24/23. Also, the DON added that whoever has a fall, the facility would do a fall assessment, notify the provider and responsible party, and document details. However, there was no documentation to support this injury caused by a fall and/or investigation of the fall incident and interventions to prevent possible falls. 3. A review of Resident #323's medical record on 02/02/24 revealed that Resident #323 was found by nursing staff on 3/29/23 around 6:45 PM lying face down on the floor noted with left forehead bump and a small laceration on the right upper-end eyebrow with small amount of blood. Further review of Resident #323's medical records revealed that the facility assessed the resident's fall risk with a tool named Morse falls scale as below: On 2/25/22, the score was 35 as a moderate risk for fall On 5/25/22, the score was 35 as a moderate risk for fall. On 7/16/22, the score was 50, which was a high-risk fall. On 8/03/22, the score was 20, which was a low-risk fall. On 8/18/22, the score was 20, which meant it was a low-risk fall. On 12/12/22, the facility assessed Resident #323 with a form named falls risk tool. This form included the resident's medication category, orthostatic changes with vital signs, admitted , and date of last fall. However, the form did not list mobility status, unsafe behavior, and fall risk level or score. During an interview with the Director of Nursing (DON) on 2/02/24 at 10:30 AM, the DON stated that the facility staff assessed each resident's fall risk quarterly and documented it under electronic medical records. On 2/05/24 at 9:30 AM, the surveyor reviewed Resident #323's fall assessments with the DON. The most recent fall assessment prior to the fall incident (3/29/23) was 12/12/22, which did not indicate the level of fall risk and/or the resident's health condition, which could affect the resident's fall risk. The surveyor asked DON how the facility staff recognized Resident #323's fall risk from the 12/12/22 fall assessment. The DON stated, We did fall assessment quarterly, but the form name changed. The surveyor pointed out that the assessment date was 12/22/22, and the incident occurred on 3/29/23 (more than 3 months ago). No additional documentation was submitted to the surveyor team, and the DON validated the surveyor's concerns regarding the lack of fall assessment for Resident #323.

Based on record review, and interview with the resident and staff it was determined the facility staff failed to ensure all residents were free from abuse and mistreatment. As a result of this deficient practice, Resident #18 experienced actual harm as evidenced by a laceration requiring 6 sutures to the forehead. This was evident for 1 (#18) of 28 residents reviewed for abuse. The findings include: During an interview on 1/09/24 at 11:04 AM Resident #18 stated that he/she was hit by a receptionist with a phone and had to go to the hospital to get stitches in his/her head. The resident explained that he/she was trying to call the police because we needed our cigarette break to happen, and no one was coming. Review of facility investigation documentation on 1/25/24 at 11:00 AM revealed that on 10/28/23 at approximately 5:00 PM, Resident #18 was in the first-floor dining room attempting to call 911 using the wall phone, in response to a delay in the scheduled smoke break. Staff #29 a receptionist entered the dining room and asked Resident #18 what he/she was doing. The resident indicated that he/she was calling the police. Staff #29 approached Resident #18 and attempted to stop the resident from completing the call. Resident #18 allegedly struck Staff #29. Staff #29 in return struck Resident #18 and an altercation ensued. During the altercation, Resident #18 sustained a laceration on the left forehead as a result of being struck with the phone handset by Staff #29. The resident was assessed by the nursing supervisor on duty and was sent to the hospital emergency room for further evaluation. Resident #18 received 6 stitches to a laceration on the left forehead and returned to the facility. Review of the medical record on 1/25/24 at 11:00 AM revealed a Change in Condition Progress Note written by Staff # 34 a Licensed Practical Nurse (LPN) at 5:26 PM indicated Resident #18 was observed wheeling himself/herself to the nurses station with a bloody face more on left top side of scalp the note described the resident as yelling, cursing and inconsolable. Emergency personnel were on site for an unrelated call. The primary Care Provider was notified and recommended to send the resident via 911 to hospital for evaluation and care. First aid was provided and the resident was sent to the emergency room . Another Change in Condition Progress Note by Staff #66 a Registered Nurse (RN) indicated left forehead laceration measure 4.0cm(centimeters) x 1.0cm draining to bright red blood moderate in amount pressure dressing applied. unable to measure depth. patient refused whole body assessment. The facility investigated the incident and obtained statements from residents and staff. Staff #30 an environmental services assistant supervisor was present in the dining room during the event and witnessed the altercation. In a documented interview on 10/31/23 he reported that Resident #18 entered the dining room to use the phone, speaking loudly, he/she indicated that he/she was going to call the police. Staff #29 entered the dining room to buy something from the vending machine, asked Resident #18 what they were doing. When Resident #18 informed her that he/she was calling the police, Staff #29 said Resident #18 should wait and attempted to unplug the phone. Resident #18 hit Staff #29 who hit Resident #18 back. Staff #30 indicated that during the tussle he told Staff #29 to let it go and allow Resident #18 to call whomever he/she wanted to call. He asked her to stop, and she eventually walked away. Witness #2 and #3 who were not identified by the facility due to their requests to remain anonymous, and provided statements that they were present in the dining room and witnessed Resident #18 and Staff #29 striking each other. In a written statement dated 10/28/23 Staff #29 indicated that Resident #18 approached her requesting to go out to smoke. Staff #29 indicated she responded that she could not leave the front desk. As she walked down the hall, Resident #18 started to dial 911. Staff #29 asked the resident to stop and when she tried to unplug the phone Resident #18 struck her on the head with the phone and scratched her arm. She indicated that as Resident #18 stood up to strike Staff #29 again, the resident hit his/her head on the phone and started bleeding. She indicated that Resident #18 then started saying that Staff #29 hit him/her. Staff #29 denied hitting Resident #18. Staff #30 was interviewed on 1/26/24 at 10:12 AM. He stated that he recalled the above events and when asked, described the above events as per his initial report. He confirmed when asked that Resident #18 sustained the laceration to the forehead as a result of Staff #29 striking him/her with the phone. He indicated that he attempted to intervene and repeatedly told Staff #29 to stop and just allow Resident #18 to call. He added that Resident #18 called 911 frequently and stated: that's part of what he/she does, he/she calls the police for everything like if his/her medications were late. The Administrator and Director of Nursing were made aware of these findings on 1/29/24 at 11:32 AM.

Based on record review and interview, it was determined that the facility failed to prevent an avoidable accident with injury to Resident #9 during a transfer from the wheelchair to the bed. The facility failed to implement interventions, including adequate supervision that was consistent with the resident's needs, care plan and current professional standards of practice in order to reduce the risk of an accident. As a result, Resident #9 suffered a fall with harm (injury to the face resulting in sutures). This was evident for 1 (#9) of 5 residents reviewed for complaints during a complaint survey. The findings include: In the State Operations Manual, Appendix PP last updated 11/28/17, the Centers for Medicare and Medicaid Services (CMS) indicated that an avoidable accident means that an accident occurred because the facility failed to identify environmental hazards and/or assess individual resident risk of an accident, including the need for supervision and/or assistive devices; and/or the facility failed to evaluate/analyze the hazards and risks and eliminate them, if possible, or, if not possible, identify and implement measures to reduce the hazards/risks as much as possible. Review of complaint MD 016 on 3/3/22 at 10:10 AM revealed a statement by the complainant that stated, Resident #9 was to be a 2 person transfer but the facility used a 1-person transfer. The resident fell and required 30 to 40 stitches across the forehead and nose. The facility's fall report, dated 10/5/21 at 7:30 PM, was reviewed on 3/3/22 at 10:10 AM. The report revealed documentation that Geriatric Nursing Assistant (GNA) #27 stated Resident #9 fell during care while transferring from the wheelchair to the bed. Per GNA #27, he transferred Resident #9 with little assistance. Resident #9 was seated on the edge of the bed and GNA #27 was trying to move the wheelchair out of the way so he could pull the resident up in bed. The resident fell forward and hit [his/her] head on the floor. The fall report also documented that Resident #9 stated [he/she] was not sitting properly at the edge of the bed after the transfer and that the GNA had one glove on his hand and he had let go of the resident to move the wheelchair. When he did that, the resident fell forward and hit [his/her] head. Resident #9 was sent out 911 due to a laceration to the face. GNA #27 was removed from the unit and staff was in-serviced about transfer and body mechanics. A written statement, dated 10/5/21 at 7:30 PM by Registered Nurse (RN) #26, documented, At about 7:15 PM, this writer was in the hallway passing medications. Resident #9 called that [he/she] needed to be changed. GNA #27 was called to the room. Explained to the GNA that resident can stand and can take few steps with assistance and will need two staff to transfer from wheelchair to bed. Writer told GNA to go and get brief so writer can assist with transfer. Writer went to Rm 107 to answer call light. At about 7:30 PM, writer was called to (Resident #9) room by GNA that [he/she] was on the floor. Upon arrival, resident was noted on the floor face down. A call was placed to RN #26 on 3/4/22 at 10:29 AM. RN #26 failed to return the surveyor's call. In an interview on 3/4/22 at 12:50 PM, GNA #27 (agency GNA) stated that it was the second time he had worked at the facility and it was the first time he had worked with Resident #9. GNA #27 stated that the nurse on duty walked him around and told him the resident was independent and could walk. He said Resident #9 was in a wheelchair and he stood the resident up and turned the resident by himself. GNA #27 stated, I put the wheelchair close to the bed and then was moving the wheelchair out of the way to put the resident closer to the edge of the bed so I wouldn't be stressing [him/her] by pulling [him/her] up in bed. [He/she] was sitting on the edge of the bed. [He/she] was not secure because I needed to get [him/her] up in the bed further. GNA #27 stated Resident #9 fell to the floor and it happened in seconds. GNA #27 was asked if he had access to Resident #9's care plans and he said, no. GNA #27 stated, the nurse just said to change the resident's diaper and put to bed, that [he/she] could walk. GNA #27 stated, I have not been there since. They sent me home immediately. The Director of Nursing (DON) said to go home. In an interview on 3/3/22 at 1:45 PM of the Director of Rehab, it was revealed that the therapist that worked with Resident #9 no longer worked at the facility. The surveyor called and left a message for the therapist with no return call. The Director of Rehab reviewed the therapy note of 10/4/21 that documented the resident was a sit to stand with supervision, chair to bed supervision or touch assist, gait distance 100 feet with a 2-wheel walker. Review of the medical record failed to produce documentation that the physical therapist gave instruction to the staff to only use supervision with the resident or how to safely assist the resident with transfers. In an interview of GNA #10 (day shift GNA that worked with the resident frequently) on 3/4/22 at 1:10 PM, GNA #10 stated that Resident #9 was a 2 person transfer due to the resident's weight. GNA #10 was asked if she looked at resident care plans and she stated, a little bit. Do not look at it much. The previous DON (Staff #16) was interviewed on 3/4/22 at 10:40 AM and was asked why GNA #27 was immediately sent home after the fall. Staff #16 stated, I called the agency to get his training information. I did not get it so I held off bringing him back to the building until I get those requirements. Staff #16 was asked if she should have had that information before agency staff worked at the facility. Staff #16 reiterated what she stated above. Staff #16 continued the conversation by stating, the resident can walk. I saw [him/her] walk in therapy. The care plan, we had put 2 staff for transfer based on the initial assessment, weight, confusion, shortness of breath. Two staff is always the safest. When in therapy [he/she] improved. When asked why they did not change the care plan to 1-person assistance, Staff #16 responded, we can't until [he/she] has fully progressed, but the patient also fluctuated during the day. The safest is a 2-person transfer. As time goes by, they progress. We were going to update the care plan but it was not due yet. We update the care plan if there is a significant change. [He/she] was still working with therapy. Review of Resident #9's medical record, on 3/3/2022 at 10:10 AM, revealed Resident #9 had diagnoses which included, but were not limited to, COVID-19, pneumonia due to COVID-19, shortness of breath, [CONDITION(S)], altered mental status, hypertension and a history of falls with a fracture of a rib on the right side. Review of Resident #9's admission MDS (minimum data set) with an assessment reference date of 9/17/2021 revealed the resident required extensive assistance with at least 2 people for transfers and was not steady during transitions and walking and was only able to stabilize with staff assistance. The MDS is part of the Resident Assessment Instrument that was federally mandated in legislation passed in 1986. The MDS is a set of assessment screening items employed as part of a standardized, reproducible, and comprehensive assessment process that ensures each resident's individual needs are identified, that care is planned based on these individualized needs, and that the care is provided as planned to meet the needs of each resident. Further review of Resident #9's medical record revealed care plans that were initiated on 9/13/21 that stated, I am at risk for falls r/t (related to) deconditioning, gait/balance problems and I have an ADL (activities of daily living) self-care performance deficit r/t disease process which had the interventions, bed mobility: The resident is totally dependent on (2) staff for repositioning and turning in bed and transfer: The resident requires mechanical lift with (2) staff assistance for transfers. The resident also had a care plan, pain r/t fracture, closed fracture of multiple ribs of right side, hx (history) of recent fall. Continued review of the medical record on 3/3/22 revealed a Morse Falls Scale (a fall risk assessment tool that predicts the likelihood that a patient will fall) dated 9/13/21. The fall scale documented a score of 50, which indicated Resident #9 was a high risk for falling. On 3/3/22 at 1:45 PM, a review of the occupational therapy (OT) notes, dated 10/5/21, revealed, pt. has a fear of falling. Has deficits in safety awareness. Poor standing tolerance. A 10/3/21 physician's note documented, neurological: positive weakness, positive difficulty walking, abnormal strength, abnormal coordination. On 3/4/22 at 1:39 PM Staff #16 provided the surveyor with a copy of Staff Development Program attendance records dated 10/29/21 which had the topic, change of shift huddle. The change in shift huddle stated, both outgoing and incoming nurses will have a meeting on the nurse's station with the GNAs and go over and discuss any changes for the last 24 hours. This is to prevent further occurrences (rehospitalization , sudden deaths, fall, wounds, weight loss). It's a quick 15-minute huddle. This way the GNAs/incoming nurses are aware who needs to be monitored closely.