Every finding on record at Lillian Carter Health Center by Harborview

Based on observation, interview, record review, review of the Food and Drug Administration (FDA) guidelines and review of Manufacturer's Instructions for Use (MIFU), the facility failed to ensure bed frames and bed rails, if present, were inspected and maintained per the Manufacturer's Instructions For Use (MIFU) to minimize the risks of bed malfunction or resident injury for five Residents (R) (R5, R7, R21, R23, and R25) identified as having bed rails in the sample of 37 residents.Findings include: Review of the facility's policy titled Side Rail Policy and Guidelines dated 1/16/2023 revealed, Policy Statement, Side rails are adjustable metal or rigid plastic bars that attach to the bed. They are available in a variety of types, shapes, and sizes ranging from full to one-half, one-quarter, or one-eighth lengths. The facility will attempt to use appropriate alternatives prior to installing a side rail. If a side rail is used, the facility must ensure correct installation, use, and maintenance of the side rail, including but not limited to the following elements. Evaluate the resident for risk of entrapment from side rails prior to installation.Ensure the bed's dimensions are appropriate for the resident's size and weight. Follow the manufacturer's recommendations and specifications for installing and maintaining side rails. Review of the Food and Drug Administration guidance (FDA https://www.fda.gov/regulatory-information/search-fda-guidance-documents/hospital-bed-system-dimensional-and-assessment-guidance-reduce-entrapment) recommendations for rail entrapment revealed.Potential Zones of Entrapment, This guidance describes seven zones in the hospital bed system where there is a potential for patient entrapment. Entrapment may occur in flat or articulated bed positions, with the rails fully raised or in intermediate positions. Descriptions of the seven entrapment zones appear on pages 15-21 in this guidance.The seven areas in the bed system where there is a potential for entrapment are identified in the drawing below: Zone 1: Within the Rail, Zone 2: Under the Rail, Between the Rail Supports or Next to a Single Rail Support, Zone 3: Between the Rail and the Mattress, Zone 4: Under the Rail, at the Ends of the Rail, Zone 5: Between Split Bed Rails, Zone 6: Between the End of the Rail and the Side Edge of the Head or Foot Board, Zone 7: Between the Head or Foot Board and the Mattress End.Dimensional Limits for Identified Entrapment Zones 1-4, FDA is recommending dimensional limits for zones 1 through 4 at this time because we believe the majority of the entrapments reported to FDA have occurred in these zones. We based these recommended limits upon the body parts entrapped in these individual zones identified through adverse event reports and entrapment scenarios described in the reports. Review of R5, R7, R21, R23, and R25 for bed rail usage revealed these residents were observed using bed rails when in bed and had a physician's order for the use of the bed rails. 1. Review of R5's admission Record in the electronic medical record (EMR) Profile tab revealed diagnoses that included but not limited to, mood disorder, chronic respiratory failure, polyneuropathy, and metabolic encephalopathy. Review of Physician Orders in the Orders tab of the EMR revealed, 1/4 assist rails to assist with bed mobility, transfers, and/or define bed parameters dated 4/3/2025. Observation of R5's bed on 9/9/2025 at 12:09 pm showed bilateral upper bed rails with an air mattress. Observation on 9/11/2025 at 3:39 pm, R5 was observed asleep in bed with both bed rails in the up position and on 9/12/2025 at 9:55 am, R5 was observed in bed awaiting wound care with bilateral upper bed rails in place. 2. Review of R21's admission Record in the EMR Profile tab revealed diagnoses that included but not limited to, congestive heart failure (CHF), history of heart attack, diabetes, peripheral vascular disease, chronic kidney disease, and panic/anxiety disorder. Review of Physician Orders in the Orders tab of the EMR revealed, 1/4 assist rails x 2 to assist with bed mobility, transfers, and/or define bed parameters dated 4/17/2024. During an observation on 9/9/2025 at 12:05 pm, R25 was noted to have bilateral upper bed rails with an air mattress. Observation on 9/11/2025 at 3:36 pm, R25 was noted to be in bed with bilateral upper rails in place. Observation on 9/12/2025 at 9:25 am, R25 was receiving wound care showed bilateral upper rails in place. 3. Review of R25's admission Record in the EMR under the Profile tab revealed diagnoses that included but not limited to, brain hemorrhage, cerebral infarction, diabetes, anxiety, and a vegetative state. Review of Physician Orders in the Orders tab of the EMR revealed, 1/4 assist rails x 2 to assist with bed mobility, transfers, and/or define bed parameters dated 4/3/2025. During an observation on 9/9/2025 at 12:05 pm, R25 was noted to have bilateral upper bed rails with an air mattress. Observation on 9/11/2025 at 3:36 pm, R25 was noted to be in bed with bilateral upper rails in place. Observation on 9/12/2025 at 9:25 am, R25 was receiving wound care showed bilateral upper rails in place. 4. Review of R23's admission Record, located in the EMR under the Profile tab, revealed R23 was admitted to the facility with a diagnosis that included but not limited to, cerebral infarction (stroke). Review of R23's Orders tab of the EMR revealed a Physician order dated 6/5/2025 for 1/4 assist rails x 2 to assist with bed mobility, transfers, and/or define bed parameters. During an observation on 9/9/2025 at 11:15 am, R23 was in bed with bilateral 1/4 assist rails in place on his bed. 5. Review of R7's admission Record, located in the EMR under the Profile tab, revealed R7 was admitted to the facility with diagnosis that included but not limited to, cerebral infarction . Review of R7's Orders tab of the EMR revealed a Physician order dated 7/2/2024 for 3/4 assist rails to assist with bed mobility, transfers, and/or define bed parameters. During an observation on 9/9/2025 at 11:20 am, R7 was in bed with bilateral upper 1/2 side rails pulled up and bilateral lower 1/2 side rails not utilized in low position. During an interview on 9/12/2025 at 1:16 pm, the Director of Nursing (DON) revealed that she expected residents to be checked for risk of entrapment. During an interview on 9/11/2025 at 2:35 pm, the Administrator was asked for the facility's bed rails inspection/maintenance records. The Administrator stated We don't have anything. The Administrator stated that he called corporate and they said there is nothing in TELs [maintenance software program for facilities] and then the Maintenance Supervisor [name] called back and said there wasn't anything.

Based on interview, record review, and review of the Resident Assessment Instrument (RAI) Manual, the facility failed to ensure four out of 37 sampled Residents (R) (R3, R5, R6, and R27) Minimum Data Set (MDS) assessments were accurately coded. Specifically, the facility failed to accurately code the MDS assessment for (R3) related to falls, (R5) related to (Level II Preadmission admission Screening and Resident Review (PASARR), and (R6 and R27) related to weight loss. This failure had the potential to affect the care planning and provision of needed services.Findings include: 1. Review of R3's admission Record in the electronic medical record (EMR) Profile tab revealed a facility admission date of 4/23/2025 with diagnoses that included cerebral infarction, difficulty walking, legal blindness, and muscle weakness. During an interview on 9/10/2025 at 8:28 am, R3 related she had a fall that caused a cracked tooth and fractured orbital bone. Review of R3's EMR Care Plan tab revealed R3 had a fall on 7/21/2025 and was also diagnosed with a subarachnoid hemorrhage. Review of R3's significant change of status assessment (SCSA) MDS with an assessment reference date (ARD) of 7/30/2025 revealed R3 was coded for having no falls since the previous MDS assessment. During an interview on 9/11/2025 at 10:29 am, the MDS Coordinator (MDSC) reviewed R3's fall dated 7/21/2025 and the SCSA MDS dated [DATE] and stated, It is coded no, and she did have a fall. I missed that and I had it in my notes. During an interview on 9/11/2025 at 10:36 am, the Administrator stated the facility did not have a policy on MDS accuracy and they use the RAI Manual as their guide. Review of the October 2024 RAI Manual revealed: On page J-37,Steps for Assessment .3. Review all available sources for any fall since the last assessment, no matter whether it occurred while out in the community, in an acute hospital, or in the nursing home. Include medical records generated in any health care setting since last assessment. All relevant records received from acute and post-acute facilities where the resident was admitted during the look-back period should be reviewed for evidence of one or more falls. 4. Review nursing home incident reports and medical record (physician, nursing, therapy, and nursing assistant notes) for falls and level of injury. 5. Ask the resident, staff, and family about falls during the look-back period. Resident and family reports of falls should be captured here, whether or not these incidents are documented in the medical record. 6. Review any follow-up medical information received pertaining to the fall, even if this information is received after the ARD.and ensure that this information is used to code the assessment. 2. Review of R5's admission Record from the EMR Profile tab revealed an admission date of 7/16/2020, readmission on [DATE], with medical diagnoses that included a mood disorder. The survey software triggered R5 due to a mental health diagnosis but had not had a level II PASARR completed. Review of R5's EMR Miscellaneous tab revealed a level II PASARR completed 4/24/2024. Review of R5's annual MDS with an ARD of 2/5/2025 revealed that section A was coded as no level II PASARR having been completed. Review of R5's EMR Care Plan tab showed: [R5's name] has been evaluated for serious mental illness (SMI) and/or intellectual disability (ID)as required by law and has been given a Level II value and has been approved for nursing home level of care r/t dx of mood disorder. Date Initiated: 4/8/2024 During an interview on 9/11/2025 at 10:2025 am, the MDSC verified only the comprehensive assessments (annual, SCSA, etc.) would capture the PASARR level II. MDSC reviewed R5's MISC tab in the EMR which showed R5's PASARR level II completed. The MDSC reviewed R5's last comprehensive assessment dated [DATE] and stated, I have it coded as no for PASARR II, and it should have been coded yes. Review of the October 2024 RAI Manual revealed: On page A-30: Individuals who have or are suspected to have MI or ID/DD, or related conditions may not be admitted to a Medicaid-certified nursing facility unless approved through Level II PASRR determination. Those residents covered by Level II PASRR process may require certain care and services provided by the nursing home, and/or specialized services provided by the State. A resident with MI or ID/DD must have a Resident Review (RR) conducted when there is a significant change in the resident's physical or mental condition. Therefore, when an SCSA is completed for a resident with MI or ID/DD, the nursing home is required to notify the State mental health authority, intellectual disability or developmental disability authority (depending on which operates in their State) in order to notify them of the resident's change in status. On page A-32: Code 1, yes: if PASRR Level II screening determined that the resident has a serious mental illness and/or ID/DD or related condition, and continue to A1510, Level II Preadmission Screening and Resident Review (PASRR) Conditions. Review of the RAI Manual dated 10/1/2024 revealed the definitions for weight loss in coding the MDS To determine a five percent (%) weight loss in 30 days: Start with the resident's weight closest to 30 days ago and multiply it by .95 [or 95%]. The resulting figure represents a 5% loss from the weight 30 days ago. If the resident's current weight is equal to or less than the resulting figure, the resident has lost more than 5% body weight. To determine 10% weight loss in 180 days: Start with the resident's weight closest to 180 days ago and multiply it by .90 [or 90%]. The resulting figure represents a 10% loss from the weight 180 days ago. If the resident's current weight is equal to or less than the resulting figure, the resident has lost 10% or more body weight. 3. Review of R6's admission Record in the EMR under the Profile tab revealed R6 was admitted to the facility on [DATE] with diagnoses which included diabetes and heart failure. Review of R6's Weight Summary located in the EMR under the Wts/Vitals tab revealed the following weights: On 8/12/2025, R6 weighed 157.0 pounds (lbs.) The weight closest to 30 days prior was 153.0 lbs., which reflected that R6 had gained weight. The weight closest to 180 days prior was 153.0 lbs. on 2/7/2025, which reflected that R6 had gained weight. Review of R6's quarterly MDS with an ARD of 8/18/2025 in the EMR under the MDS tab indicated a BIMS score of five out of 15, which indicated she had severe cognitive impaired. R6 weighed 157 lbs. and had weight loss of five percent or more in the last month or loss of 10% or more in the last six months. During an interview on 9/9/2025 at 11:51 am, R6 reported she was unaware of any recent weight loss. 4. Review of R27's admission Record located in the EMR under the Profile tab revealed R27 was admitted to the facility on [DATE] with diagnoses which included dysphagia (difficulty swallowing). Review of R27's Weight Summary located in the EMR under the Wts/Vitals tab revealed the following weights: On 3/5/2025-202.0 LBS.; 4/4/2025-202.0 lbs.; 5/6/2025-191.0 lbs.; 6/6/2025, 7/4/2025, and 8/5/2025, R6 weighed 190.0 lbs. On 2/7/2025, R27 weighed 201.4 lbs., which meant R27's weight loss was 5.66% in six months. Review of R27's annual MDS with an ARD of 8/2/2025 and located in the EMR under the MDS tab indicated R27 had a BIMS score of six out of 15, which indicated she had severe cognitive impairment. R27 weighed 190 lbs. and had weight loss of five percent or more in the last month or loss of 10% or more in the last six months. During an interview on 9/10/2025 at 1:47 pm, the Dietary Manager (DM) reported she filled out Section K of the MDS concerning weights. The DM stated she looked for the weight warnings which appeared when there was a weight loss of five percent of greater in one month or 10% or greater in six months. The DM verified R6 had no weight loss as of the MDS dated [DATE] at one or six months but had greater than five percent weight loss in June, which was why she coded the MDS with weight loss. R27 had a greater than five percent weight loss in May which carried over to the August MDS, although there was no significant weight loss at one month or at six months. During an interview on 9/10/2025 at 2:10 pm, the Registered Dietician (RD) reviewed R6's weights and stated she had a weight loss of 6.3% in June but had no weight loss at one or six months as of 8/18/2025. The RD was unfamiliar with coding the MDS so was unable to say if R6's or R27's MDSs were coded correctly. During an interview on 9/11/2025 at 11:49 am, the MDSC stated she completed Section K of the MDS if the DM was unable. The MDSC reviewed R6's and R27's weights and stated that while R27 had lost greater than five percent of her body weight in six months, neither resident had a weight loss of five percent in one month or 10% in 6 months from the ARD date of the MDS assessment. During an interview on 9/12/2025 at 1:05 pm, the Director of Nursing (DON) stated she expected staff to follow the RAI Manual when they completed the MDS assessment. Review of the RAI Manual dated 10/1/2024 revealed the definitions for weight loss in coding the MDS To determine a five percent (%) weight loss in 30 days: Start with the resident's weight closest to 30 days ago and multiply it by .95 [or 95%]. The resulting figure represents a 5% loss from the weight 30 days ago. If the resident's current weight is equal to or less than the resulting figure, the resident has lost more than 5% body weight. To determine 10% weight loss in 180 days: Start with the resident's weight closest to 180 days ago and multiply it by .90 [or 90%]. The resulting figure represents a 10% loss from the weight 180 days ago. If the resident's current weight is equal to or less than the resulting figure, the resident has lost 10% or more body weight.

Based on observation, interview, record review, and review of the facility's policy titled Side Rail Policy and Guidelines, the facility failed to ensure alternatives were attempted prior to the use of bed rails for five out of 48 Residents (R) (R5, R7, R21, R23, and R25) identified with bed rails. This failure had the potential to increase accidental entrapment or injury from bed rail usage when an alternate assistive device may have been effective.Findings include: Review of the facility's policy titled Side Rail Policy and Guidelines dated 1/16/2023 revealed, Policy Statement, Side rails are adjustable metal or rigid plastic bars that attach to the bed.The facility will attempt to use appropriate alternatives prior to installing a side rail. 1. Review of R5's admission Record in the electronic medical record (EMR) Profile tab revealed the resident admitted to the facility with diagnoses that included but not limited to, mood disorder, chronic respiratory failure, polyneuropathy, and metabolic encephalopathy. Observation of R5's bed on 9/9/2025 at 12:09 pm showed bilateral upper bed rails with an air mattress. On 9/11/2025 at 3:39 pm, R5 was observed asleep in bed with both bed rails in the up position and on 9/12/2025 at 9:55 am, R5 was observed in bed awaiting wound care with bilateral upper bed rails in place. Review of Physician Orders in the Orders tab of the EMR revealed, 1/4 assist rails to assist with bed mobility, transfers, and/or define bed parameters dated 4/3/2025. Review of R5's EMR Miscellaneous tab showed ten bed rail assessments back to July 2023 with the most recent assessment dated [DATE], however, none of the evaluations addressed what alternatives were attempted prior to the bed rail installation and use. Review of R5's EMR Care Plan tab indicated a focus of ADL [Activities of Daily Living] self-care performance deficit r/t [related to] weakness with intervention 1/4 assist rails x 2 to assist with bed mobility, transfers, and/or define bed parameters dated 7/7/2023. 2. Review of R21's admission Record in the EMR Profile tab revealed the resident was admitted to the facility with diagnoses that included but not limited to, congestive heart failure (CHF), history of heart attack, diabetes, peripheral vascular disease, chronic kidney disease, and panic/anxiety disorder. Review of Physician Orders in the Orders tab of the EMR revealed, 1/4 assist rails x 2 to assist with bed mobility, transfers, and/or define bed parameters dated 4/17/2024. During an interview on 9/10/2025 at 2:10 pm, R21 stated he used the bilateral bed rails for mobility and was advised of the risks and benefits. During an observation on 9/12/2025 at 9:10 AM, R21 was asleep in bed with the bilateral bed rails in place. Review of R21's EMR Miscellaneous tab indicated bed rail assessment dated [DATE] and no alternatives was mentioned. The assessment only indicated, 1/4 assist/enabler bar. 3. Review of R25's admission Record in the EMR revealed the resident was admitted to the facility with diagnoses that included but not limited to, brain hemorrhage, cerebral infarction, diabetes, anxiety, and a vegetative state. Review of Physician Orders in the Orders tab of the EMR revealed, 1/4 assist rails x 2 to assist with bed mobility, transfers, and/or define bed parameters dated 4/3/2025. During an observation on 9/9/2025 at 12:05 pm, R25 in bed with bilateral upper bed rails with an air mattress. Observation on 9/11/2025 at 3:36 pm, R25 was noted to be in bed with bilateral upper rails in place. Observation on 9/12/2025 at 9:2025 am, R25 was receiving wound care and bilateral upper rails in place. Review of R25's EMR Care Plan tab showed a focus area of being at risk for falls related to impaired mobility with an intervention of 1/4 assist rails x2 to assist with bed mobility, transfers, and/or define bed parameters dated Initiated: 3/31/2025 Created on: 4/3/2025. During an interview on 9/19/2025 at 3:35 pm, the Administrator provided consent forms for R5, R21, and R25 and stated, Corporate said they only had to do these [consents], have the nurse assess [for bed rail use], and get the physician order. The Administrator stated no alternatives were attempted prior to bed rail use. 4. Review of R23's admission Record located in the EMR under the Profile tab revealed R23 was admitted to the facility 6/3/2025 with diagnosis of cerebral infarction (stroke). Review of R23's Consent for Use of Side Rails located in the EMR under the Documents tab revealed it was signed on 6/2/2025, the day before R23 was admitted to the facility, with a note that indicate phone consent by R23's responsible party. The consent recommended bilateral upper 1/4 partial rails for bed mobility. Review of R23's Initial Assist Device Evaluation [Side Rails] dated 6/3/2025 at 4:20 pm and located in the EMR under the Evaluations tab revealed, Every resident should start with a bed that does not have a side rail and then from the evaluation decide if a side rail is needed and then that will be placed on the bed. The facility must attempt to use appropriate alternatives prior to installing a side or bed rail. The document indicated that the resident or the responsible party requested side rails. It did not indicate whether side rails were recommended or not recommended. Evaluations of Alternatives that were checked included call light within reach, average bedtimes around six to seven hours for sleep only, restorative nursing, and low bed; however, the resident admitted the day of the evaluation. Review of R23's Orders tab of the EMR revealed an order dated 6/5/2025 for 1/4 assist rails x 2 to assist with bed mobility, transfers, and/or define bed parameters. Review of R23's admission Minimum Data Set (MDS) with an ARD of 6/9/2025 and located in the EMR under the MDS tab indicated R23 had a Brief Interview of Mental Status (BIMS) score of five out of 15, which indicated R23 had severe cognitive impairment. R23 needed partial/moderate assistance to roll and sit up from a lying position. Review of R23's Care Plan tab of the EMR revealed a focus area [R23] uses 1/4 assist rails x 2 to assist with bed mobility, transfers, and/or define bed parameters dated 6/27/2025 with intervention of 1/4 assist rails for bed mobility dated 6/27/2025. During an observation on 9/9/2025 at 11:15 am, R23 was in bed with bilateral 1/4 assist rails in place on his bed. During an interview on 9/12/2025 at 7:55 am, Licensed Practical Nurse (LPN)1 stated R23 sometimes assist with rolling in bed; it depended on his mood. During an interview on 9/12/2025 at 11:27 am, Admissions reported she reviewed the consent form for assist rails when she completed the admission paperwork with the family. Admissions stated the side rails were offered, but the family or resident was made aware it depended on the doctor orders and the nursing assessment, whether the resident received side rails. R23's consent was signed the day before he was admitted to the facility with family aware he would be assessed when he arrived. 5. Review of R7's admission Record located in the EMR under the Profile tab revealed the resident was admitted to the facility with diagnoses that included but not limited to, cerebral infarction (stroke). Review of R7's Initial Device Evaluation [Side Rails] dated 6/15/2023 and Quarterly/Annual Assist Device Evaluation [Side Rails] dated 4/18/2024 and located in the EMR under the Evaluations tab revealed R7 had 1/4 assist/enabler rails on his bed. Review of R7's Consent for Use of Side Rails located in the EMR under the Documents tab revealed it was signed by Admissions and the Assistant Director of Nursing (ADON) on 7/2/2024 with verbal consent from R7's responsible party for bilateral 3/4 rails were recommended for mobility and security. Review of R7's Orders tab of the EMR revealed an order dated 7/2/2024 for 3/4 assist rails to assist with bed mobility, transfers, and/or define bed parameters. Review of R7's Care Plan tab of the EMR revealed a focus of ¾ side rails x 2 for bed mobility and the intervention dated 7/2/2024: 3/4 assist rails x 2 to assist with bed mobility, transfers, and/or define bed parameters. Review of R7's quarterly MDS with an ARD of 6/19/2025 in the EMR under the MDS tab indicated R7 had a BIMS score of five out of 15, which indicated severe cognitive impairment. R7 was dependent on staff for bed mobility and transfers. During an observation on 9/9/2025 at 11:20 am, R7 was in bed with bilateral upper 1/2 side rails pulled up and bilateral lower 1/2 side rails not utilized in low position. During an interview on 9/12/2025 at 11:35 am, the ADON stated she and Admissions spoke to residents or their families about side rails on admission and obtained consent. They looked at what beds were available and what was in the room and had the consent form reflect that. The 3/4 rails looked like 1/2 rails, but the corporate nurse said they were 3/4 rails. The ADON was unsure why R7 changed from 1/4 rails to 3/4 rails, but it was likely because the bed with the 1/4 rails was broken, such as the remote stopped working, and they had to use what was available. During an interview on 9/12/2025 at 1:16 pm, the Director of Nursing (DON) stated a nursing evaluation was completed when residents were admitted . The ADON filled out the consent form and determined needs for rails based on mobility. R7 likely switched beds, possibly because of his height, and so received a bed with 3/4 rails instead of his initial 1/4 rails. She expected staff to offer alternatives to side rail use and follow the guidance on the Initial Assist Device Evaluation [Side Rails] form.

Based on interviews, record review, and review of the facility's policy titled, Abuse Prohibition Policy and Procedures, the facility failed to ensure allegations of abuse were reported timely for two of two Residents (R) (R20 and R23) reviewed for abuse out of a total sample of 37 residents. The facility failed to report resident-to-resident abuse within two hours to the state survey agency (SSA). Facility staff failed to report an allegation of physical abuse between R20 and R23 to the Administrator. Failure to report resident-to-resident altercations could potentially lead to continued abuse and neglect.Findings include:Review of the facility's policy titled, Abuse Prohibition Policy and Procedures dated January 2017 revealed, Once a complaint or situation is identified involving alleged mistreatment, neglect, or abuse, including injuries of unknown source and misappropriation of resident property the incident will be immediately reported. If it is an allegation of abuse, it should be reported to the state within 2 hours.1. Review of R20's admission Record in the electronic medical record (EMR) under the Profile tab revealed R20 was admitted to the facility on [DATE].Review of R20's quarterly Minimum Data Set (MDS, with an Assessment Reference Date (ARD) of 8/11/2025 in the EMR under the MDS tab indicated R20 had a Brief Interview Mental Status (BIMS) score of five out of 15, which indicated R20 had severe cognitive impaired.2. Review of R23's admission Record located in the EMR under the Profile tab revealed R23 was admitted to the facility on [DATE].Review of R23's admission MDS with an ARD of 6/9/2025 in the EMR under the MDS tab indicated R23 had a BIMS score of five out of 15, which indicated R23 had severe cognitive impairment.Review of a written statement by Certified Nurse Aide (CNA) 4 dated 8/25/2025 and provided by the facility revealed that R20, seated in a wheelchair, and R23, seated in a Geri chair (a padded, reclinable chair with wheels) were near the dining room when R23 yelled out. R20 told R23 to shut up and attempted to hit him. CNA4 separated the two residents. Later in the shift, R20 approached R23, who was seated in his Geri chair at the nurse's station, and grabbed his neck in front of CNA4 and Licensed Practical Nurse (LPN) 3, who separated them.Review of a facility-provided email from the SSA dated 8/26/2025 revealed the SSA had received the Facility Incident Report regarding R20 and R23 was received on 8/26/2025 at 11:06 am.During an interview on 9/11/2025 at 2:05 pm, the Administrator stated she was the facility's Abuse Coordinator. No one reported the 8/25/2025 resident-to-resident altercation to her. It occurred during the 3:00 pm to 11:00 pm shift. The Director of Nursing (DON) brought it to her attention the next morning. The Administrator reported the abuse allegation to the SSA on 8/26/2025 at 11:06 am.During an interview on 9/11/2025 at 2:18 pm, the DON reported nursing staff did not report the resident-to-resident altercation which occurred on 8/25/2025 to her. The DON became aware of the two residents arguing when, prior to the facility's daily meeting, she read the Behavior Note written on 8/26/2025 at 12:55 am. The DON immediately reported the note to the Administrator.During an interview on 9/11/2025 at 3:17 pm, CNA1 reported she worked with CNA4 on 8/25/2025 during the 3:00 pm to 11:00 pm shift. CNA4 reported to CNA1 during the shift that R20 put his hands around R23's neck, sometime after the evening meal. The two residents were kept apart during the shift, and the next shift moved R20 to a different room. CNA1 stated she felt what was reported to her by CNA4 reflected abuse, and it was to be reported right away to the nurse. CNA1 believed CNA4 reported the abuse to LPN3.During an interview on 9/11/2025 at 4:05 pm, the Administrator stated she expected staff to report all abuse concerns to either her or the DON immediately so she could report to the SSA within two hours.During a phone interview on 9/12/2025 at 8:08 am, LPN2 stated when she arrived at work on 8/25/2025 around 11:00 pm, R23 was seated at the nurse's station in his Geri chair. CNA4 reported that R20 and R23 had been verbally and physically fighting throughout the shift. R20 told R23 to shut up and at some point R20 had put his hands around R23's throat. LPN3 confirmed CNA4's report. LPN2 stated that Abuse concerns were reported immediately to the Administrator, who was the abuse coordinator. LPN2 spoke to the DON the morning of 8/26/2025 after the resident-to-resident altercation but now knew she was to report right away, even if she believed someone else reported it.During an interview on 9/12/2025 at 12:53 pm, the DON reported she expected staff to report any allegation of abuse to herself or the Administrator immediately.

Based on interview, record review, record review, and review of the facility document titled Hospice Nursing Home Agreement, the facility failed to maintain onsite, the hospice medical records for one Resident (R) (R9) out of 37 sampled residents. This had the potential to interfere with the continuity of care between the facility and hospice.Findings include:Review of the facility document titled Hospice Nursing Home Agreement dated 10/22/2024 indicated that services provided by hospice will providing the facility with a copy of the Interdisciplinary Plan of Care, shall furnish the facility with a copy of the Patient/Family Assessment and a copy any modifications to the patient plan of care and shall be provided to the facility within 72 hours.Review of the facility's policy titled Hospice Services dated 3/2016 indicated that the facility goal is to collaborate with the Hospice provider. Review of R9'sadmission Record located under the Profile tab of the Electronic Medical Record (EMR) revealed R9 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including cerebral infarction, dysphasia, Alzheimer, kidney failure, vascular dementia, and depression.Review of R9's significant change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/16/2025 located under the MDS tab documented that R9 had a condition which resulted in a life expectancy of six months or less and was placed on hospice care.Review of the EMR revealed a physician order dated 1/7/2025 admitting R9 to hospice. Review of R9's EMR Care Plan located under the Care Plan tab documented that R9 has been placed under hospice care with the diagnosis of Alzheimer's disease related to a decline in health status with less than six months to live. The approaches included, Care Plans and decisions and plans will be integrated with the facility, hospice, resident and family.Review of the EMR revealed there was no hospice care plan, no hospice notes, or assessments available. During an interview on 9/10/2025 at 1:35 pm, the Director of Nursing (DON) stated that they do not keep the hospice care plans, or the hospice care notes on site. The DON stated that they do not have any access to the hospice notes or care plan. The DON stated that they use their care plan to provide care, and they coordinate care by calling hospice if they have any questions.During an interview on 9/11/2025 at 8:38 am, Certified Nursing Assistant (CNA)5 stated that they do not have access to any nursing notes or any hospice notes. CNA 5 stated she has never seen R9's hospice care plan. CNA 5 stated that if she has questions about the care for R9 she will ask their nurse, and they will call hospice.During an interview on 9/12/2025 at 10:34 am, the Administrator stated that hospice has never left their notes with the facility. The Administrator stated that she can see how access to the hospice notes could contribute to the continuity of care. The Administrator stated verbal communication can be lost if there are not written records to refer to.

Based on observations, interviews, record review, and review of the facility's policy titled, Encouraging and Restricting Fluids, the facility failed to ensure a physician-ordered fluid restriction was followed for one of one Residents (R) (R6) reviewed for fluid restriction out of a total sample of 37 residents. Failure to limit fluids in the presence of an order for a fluid restriction has the potential to cause symptoms of fluid overload.Findings include:Review of the facility's policy titled, Encouraging and Restricting Fluids dated 3/24/2017 revealed, Verify that there is a physician's order for this procedure. Follow specific instructions concerning fluid intake or restrictions. Be accurate when recording fluid intake. Record fluid intake if ordered by the physician. Review of R6's admission Record, located in the electronic medical record (EMR) under the Profile tab, revealed R6 was admitted to the facility on [DATE] with diagnosis of heart failure.Review of R6's Care Plan tab of the EMR revealed that she was on a fluid restriction and had an intervention Provide fluids per fluid restriction parameters Dated 6/27/2025Review of R6's quarterly MDS, with an Assessment Reference Date (ARD) of 8/18/2025 and located in the EMR under the MDS tab, indicated R6 had a Brief Interview Mental Status (BIMS) score of five out of 15, which indicated she had severe cognitive impaired.Review of R6's Orders tab of the EMR revealed orders dated 8/21/2025 for Fluid Restriction 1200 ml [milliliters] daily-Breakfast 240 ml; Lunch 240 ml; Dinner 240 ml [480 ml Nursing; 720 ml Kitchen] every shift.Review of R6's Medication Administration Records (MARs) dated August 202025 and September 2025 and located in the EMR under the Orders tab revealed that in the 19 days from 8/22/2025 to 9/9/2025, R6 received greater than the ordered 480 ml by nursing on nine days: 9/4/2025 (510 ml) and 9/6/2025 (540 ml) and 9/7/2025 (540 ml) and 9/9/2025 (515 ml) 8/22/2025 (515 ml), 8/24/2025 (540mL), 8/25/2025 (510 ml), 8/28/2025 (500 ml), 8/31/2025 (540 ml).During an observation on 9/9/2025 at 12:34 pm, R6 ate in her room, and her tray included two large glasses, filled with Kool-Aid and water (20 ml).During an observation on 9/10/2025 at 12:29 pm, a Certified Nurse Aide (CNA) took a meal tray from a cart in the hall, brought it to R6's room, and placed it in front of R6.The tray contained a large glass of water, a large glass of tea, and a 120 ml container of ice cream (24 ml). R6's meal card did not document fluid restriction.During an interview on 9/10/2025 at 1:00 pm, R6 reported she was on a fluid restriction because she had an echocardiogram of her heart which showed too much fluid around her heart. R6 stated she did not keep track of the fluids she consumed. I just drink what they give me.During a concurrent observation and interview on 9/10/2025 at 1:06 pm, CNA3 came into R6's room to remove the tray. The glass of tea was empty. The container of ice cream was empty, and R6 had drank a few sips of the water. CNA3 asked R6 if she wanted the water and left it on the tray table before removing the tray. When asked the size of the large glasses, CNA3 reported she was unsure if they were 6 ounces (oz) or 8 oz. When asked about R6's fluid restriction, CNA3 stated she served what was provided by dietary for meals and was unable to provide any additional fluids without consulting with the nurse.During a simultaneous interview on 9/10/2025 at 1:35 pm, a Cook, Dietary Aide (DA) 1 and DA2 reported they were unaware of any fluid restriction for R6. They said fluid restriction was indicated on the meal cards. During an interview on 9/10/2025 at 1:37 pm, the Dietary Manager (DM) stated R6 was on fluid restriction, but there was no option for documenting it on her meal card. Dietary staff knew residents were on a fluid restriction because the breakdown of allotted fluid amounts by meals was posted in the kitchen. The DM retrieved R6's Fluid Restriction Instruction Sheet from the wall inside the entrance door to the kitchen. The sheet did not include R6's name or any identifying information, and the 1000ml fluid restriction amounts were highlighted instead of the 1200mL restriction that was ordered for R6. The DM acknowledged R6's name was not on the sheet, and the wrong amounts were highlighted. The DM stated the size of the large glasses used at meals was 10oz (300ml). The DM stated R6 was to receive two small glasses of fluid at meals to total 240mls for each meal. Two 10oz glasses were over her meal allowance, and the ice cream added an additional 120mls.During an interview on 9/10/2025 at 2:18 pm, the Registered Dietitian (RD) reported staff were expected to provide fluids based on the facility's Fluid Restriction Instruction Sheet. The RD stated the 10oz glasses held 8oz (240 ml) of fluid comfortably and ice took away some space as well.During an interview on 9/10/2025 at 2:2025 pm, the [NAME] stated for a 1200ml fluid restriction staff were to provide two-four oz glasses for a total of 8oz (240ml) for each meal.During an interview on 9/10/2025 at 2:36 pm, Licensed Practical Nurse (LPN) 1 stated R6 had fluid restriction orders because of her heart failure and referred to a Fluid Restriction Instruction Sheet at the desk. Nursing was allotted a set amount of fluids during a 24-hour period and documented those intakes on the MAR. R6 used to resist the fluid restriction but received education on the consequences of fluid overload. Staff were to document if she refused to follow her fluid restriction orders. LPN1 reviewed R6's MAR and reported nursing sometimes provided more than their allotted amount. LPN1 stated nursing did not document the fluid intakes from meals but did monitor what R6 received and removed fluids if she received too much.During an interview on 9/12/2025 at 1:10 pm, the Director of Nursing (DON) stated fluid restriction orders were broken down between nursing and dietary. The DON expected nursing to provide no more than their allotted amount for 24 hours and dietary not to exceed their allotted amount on the meal trays. The DON reviewed the tasks tab of R6's EMR and stated she did not see documentation of R6's fluid intakes at meals.

Based on interviews, record review, review of Centers for Disease Control (CDC) guidelines, and review of the facility's policy titled Pneumococcal Vaccine, the facility failed to ensure three of five Residents (R) (R3, R28, and R44) reviewed for immunizations had been provided with education and received an updated pneumococcal conjugate vaccine. This failure had the potential to affect the resident's ability to decrease the possibility of a serious pneumococcal infection and potential hospitalization.Findings include: Review of the facility's policy titled Pneumococcal Vaccine dated 9/5/22 revealed: Policy Statement All residents will be offered pneumococcal vaccines to aid in preventing pneumococcal infections. Policy Interpretation and Implementation.7) Administration of the pneumococcal vaccines or revaccinations will be made in accordance with current Centers for Disease Control and Prevention (CDC) recommendations at the time of the vaccination. 1. Review of R3's admission Record in the electronic medical record (EMR) Profile tab revealed, an admission date of 4/23/2025, age of 62 and diagnoses of chronic kidney disease, heart failure, and type II diabetes. Review of R3's EMR Immunization tab showed the receipt of the Pneumococcal Polysaccharide Vaccine (PPSV) 23 on 5/5/2019. No other pneumococcal vaccines were noted as received. No declination with education was found in the EMR. According to the CDC PneumoRecs recommendations dated 10/26/2024 showed that R3 should receive either the PCV15, PCV20 or PCV21. 2. Review of R28's admission Record in the EMR Profile tab revealed an admission date of 4/23/2024, age [AGE] and diagnoses of adult failure to thrive, history of COVID, and cancer. Review of R28's EMR Immunization tab showed no pneumococcal vaccines had been administered. No declination with education was found in the EMR. Review of the CDC PneumoRecs recommendations dated 10/26/2024 showed that R28 should receive PCV20 or PCV21. 3. Review of R44's admission Record in the EMR showed an admission date of 1/24/2022, age [AGE] and diagnoses of malnutrition and epilepsy. Review of R44's EMR Immunization tab showed the PPSV23 was administered on 1/24/2022. No other pneumococcal vaccines were shown as administered. No declination with education was found in the EMR. Review of the CDC PneumoRecs recommendations dated 10/26/2024 that R44 should receive PCV15, PCV20, or PCV21 vaccine. During an interview on 9/12/2025 at 1:06 pm, the Infection Preventionist (IP) was asked about education and declinations for the recommended PCV vaccines. At 2:00 pm, the IP advised that R3's Representative Party (RP) had signed for vaccines but had not checked which vaccines on the form. The IP stated that both R28 and R44 had signed consents for the pneumococcal vaccines, but the vaccines had never been administered. The IP confirmed R28 and R44 should have received the vaccines. During an interview on 9/12/2025 at 2:21 pm the Director of Nursing (DON) stated the expectation that pneumococcal vaccines for residents if they want it, they should get it.

Based on observations and staff interviews, the facility failed to maintain an effective infection control program related to labeling and storage of personal care equipment on one of four halls in six bathrooms. The facility census was 53 residents. Findings include: Observation on 3/8/2024 at 8:47 am revealed in the shared bathroom between rooms [ROOM NUMBERS] had four unlabeled, un-bagged wash basins stored stacked on the floor. Observation on 3/8/2024 at 8:58 am revealed in the shared bathroom between rooms [ROOM NUMBERS] urinal sitting inside of specimen hat, inside of bed pan on floor. None were labeled or bagged. An additional two wash basins were stacked unlabeled, un-bagged on the floor. Observation on 3/8/2024 at 9:05 am revealed in the shared bathroom between rooms [ROOM NUMBERS] a bedpan unlabeled and un-bagged. Interview on 3/8/2024 at 9:10 am with Assistant Director of Nursing confirmed the above findings and revealed resident care equipment should be labeled with the resident room number and bed and placed in a bag after each use. Interview on 3/9/2024 at 10:33 am with the Director of Nursing revealed her expectation is for the staff to place wash basins, urinals, and any other resident care items in a plastic bag after use.

Based on staff interviews, and record review the facility failed to ensure a Preadmission Screening/Resident Review Level II referral was made to ensure that individualized care and services were offered to meet resident needs for one resident (R 45) of 25 sampled residents. Findings: Review of the electronic medical record revealed diagnoses (dx) that included (but not limited to) Major Depressive Disorder, Anxiety, and Post Traumatic Stress Disorder (PTSD). Review of Level 1 does not indicate dx of a serious mental illness. Review of the care plan for R45 revealed a potential for psychosocial well-being problem related to anxiety, depression, and PTSD. Further review of the medical record revealed the following behaviors: 1. A Behavior Note dated 10/10/2023 indicated behaviors of yelling and cussing by R45 due to Certified Nursing Assistants (CNAs) coming into room to assist because the call light was on. 2. A second Behavior Note dated 10/10/2023 R45 sat dinner tray outside of room door and when told not to sit the tray outside R45 then kicked the tray further into the hallway. 3. There were several Behavior Note dated 2/3/2024 which revealed R45 getting up and talking loudly as he told war stories and waking up other residents due to the loud talking, R45 talking loudly and yelling at a housekeeper in the dining room while waiting for breakfast, and later in the morning R45 was noted to yell at the housekeeper again while at the nursing station in addition to yelling at another resident that was in the area. 4. There were two Behavior Note date 2/5/2024 which revealed an incident in the morning in which R45 yelled, cursed, and made threats towards a CNA who asked him to stop turning the dining room light on and off. There was a second incident later that night in which R45 continuously walked to the nursing station making forceful/aggressive remarks and questioning staff if they were threatened by him. 5. There was a Behavior Note dated 2/6/2024 in which R45 was documented yelling loudly at a resident in the hallway. 6. On 2/7/2024 there was a Behavior Note regarding an incident in which R45 began yelling at the nurse after responding to the call light being on. R45 is then documented as getting out of bed, coming into hallway, and again yelling at the nurse. 7. On 2/15/2024 there was a Behavior Note related to R45 coming out of his room yelling and cursing at CNA who had passed by his room. During an interview with the Social Services Director (SSD) on 3/9/2024 at 2:08 pm it was reported that information is put into the system (unnamed) and it determines if a Level II is needed and a referral would then be made. SSD reported that R45 needs a Level II but his Physician has verbalized in the past that he did not think the Level II would be beneficial. SSD denied that there was no documentation to support the conversation with the Physician. SSD acknowledged that R45 is currently receiving some psych services. During an interview with R45's Physician on 3/10/2024 at 10:51 am it was reported that conversations have been had about a Level II for R45 but without looking at the details in the medical record he could not explain why the referral was not sent. The Physician reported that R45 is lucid most of the time. PASARR/Level II policy requested but was not received as it was reported that the facility does not have a policy related to PASARR/Level II.

Based on observations, staff interviews, record review, and review of the facility policy titled, Care Plan-Comprehensive the facility failed to develop and implement a comprehensive, person-centered care plan for three resident's, resident (R) R30 for pain, R36 for diabetes and insulin usage, and R37 for implementing monitoring of behaviors while on psychotropic medications. The sample size was 25 residents. Findings included: Review of facility policy titled, Care Plan-Comprehensive with revised date 4/18/2017 revealed, under Policy Interpretation and Implementation number 3. Each resident's comprehensive care plan is designed to: a. Incorporate identified problem areas. numbers 6. Identifying problem areas and their causes and developing interventions that are targeted and meaningful to the resident care interdisciplinary processes that require careful data gathering, proper sequencing of events and complex clinical decision making. 8. Assessments of residents are ongoing and care plans are revised as information about the resident and the resident's condition change. 9. c. and d. The care planning/interdisciplinary team is responsible for the review and updating of care plans when the resident has been readmitted to the facility from a hospital stay; and at least quarterly. 1. R30 was an [AGE] year-old male who admitted [DATE], Basic Interview of Mental Status (BIMS) score 05 indicating cognitive impairment, with pertinent diagnoses that included but not limited to, unspecified osteoarthritis with unspecified site, and back pain. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed sections C-Cognitive pattern, BIMS 05. Section J-Received scheduled but not prn (as needed) pain meds (medications), and section N-Received opioid medications. Physician orders included but not limited to, Tramadol 50 mg (milligrams) po (by mouth/orally) bid (twice a day), and Tylenol 500 mg for back pain, give with Tramadol 50 mg bid, Colace 100 mg po bid for constipation, Divalproex Sodium bid for anxiety, evaluate resident for pain every (q) shift and record on the Medication Administration Record (MAR), indicate pain using numerical scale 0-10. Review of the care plan revealed there was no care plan with problem, goal, or interventions for pain, pain assessment, or pain medication usage. Observation on 3/9/2024 at 7:30 am, and on 3/9/2024 at 12:43 am of R30 sitting up in bed eating, no complaints of pain or other concerns. Interview on 3/9/2024 at 8:11 am with the Registered Nurse (RN) weekend supervisor confirmed R30 did not have behaviors or complaints of pain, he took pain medications, he used oxygen, he was a good resident, he kept to himself inside his room and called for help when needed. Interview on 3/10/2024 at 9:47 am with the Licensed Practical Nurse (LPN) MDS coordinator revealed they determine what care area was needed to be on the care plan by looking at the resident, talking with staff and family, and looking at the resident's medical chart. If there was a new issue or change in condition, they find out during morning meeting, they talk to staff and family, review the 24-hour report, get all the information they can and update the care plan. She looked at R30's physician orders in the electronic record and confirmed R30 did take scheduled pain medications bid, and confirmed she could not find a care plan for pain, pain medication usage, or pain assessments. Interview on 3/10/2024 at 9:53 am with the RN MDS coordinator confirmed she did not find anything where pain was care planned and did not find any other care areas that included pain or pain medication as interventions. A review of discontinued medication orders with the RN MDS Coordinator, she confirmed R30 had pain medication orders going back to at least April 2023, and they should have caught it doing the quarterly MDS assessment review because they review medications. She revealed there was always so much going on with R30 and they just missed it. She revealed the care plan should be person-centered and should include pain since R30 took it routine bid along with Tylenol. 36200 2.Review of the medical record for R 36 revealed a readmitted [DATE] with a diagnosis that included type 2 diabetes without complications. Further review revealed an order for Humalog to be administered subcutaneously before meals and at bedtime for diabetes. Review of the quarterly Minimum Data Set (MDS) dated [DATE] in section N indicated medications that included injections, insulin, antidepressant, opiod, and hypoglycemic. There was not a care plan identified for diabetes and insulin usage. During an interview on 3/10/2024 at 9:47 am with Minimum Data Set (MDS) Licensed Practical Nurse (LPN) and MDS Registered Nurse (RN) it was reported that each resident's chart is reviewed to determine what the resident's needs are that will be reflected on the care plan. MDS LPN explained that they also discuss changes during the morning meetings in addition to interviews with residents and staff. MDS RN acknowledged that the facility had a care plan for hyperglycemia and thought this would be sufficient because hyperglycemia is associated with diabetes. She also reported that an intervention for hyperglycemia included medications as ordered. MDS RN later acknowledged that a person does not have to have diabetes to experience a hyperglycemic episode. It was further reported that she would typically include information about the actual diagnosis and usage of injections on the care plan and would update R36's care plan to include the diabetes diagnosis and usage of insulin. 3.Review of the medical record for R37 revealed diagnoses that included but was not limited to unspecified psychosis not due to a substance or known physiological condition, depression, and anxiety. Review of the care plan for R37 revealed R37 is at risk for adverse effects of antidepressant medication with an initiation date of 10/20/2023. There was an intervention to monitor/document side effects and effectiveness q-shift. Review of the care plan for R37 revealed R37 is at risk for adverse effects of anti-anxiety medication with an initiation date of 6/2/2023.There was an intervention to monitor for side effects and effectiveness every shift. During an interview with the Director of Nursing (DON) on 3/10/2024 at 11:41 am it was reported that nursing staff are to monitor and document behaviors on the MAR each shift. DON reviewed the eMAR for March 2024 but was unable to find any documentation for behavior monitoring or documented side effects of medications for R37.

Based on observations, staff interviews, and record review, and review of the facility policy titled, Tracheostomy Care, the facility failed to ensure the provision of respiratory services in accordance with professional standards for one of one resident (R) (R9) reviewed for tracheostomy (trach) care. Specifically, the facility failed to provide tracheostomy care supplies to include one size as ordered, and one smaller tracheostomy tube in emergency tracheostomy supplies at bedside. This failure increased R9's risk for compromise airway and respiratory distress. Findings include: Review of the facility policy titled, Tracheostomy Care dated 3/24/2017, under general Guidelines number 6. A replacement tracheostomy tube must be available at the bedside at all times. Review of Admission Record for R9 located in the Electronic Medical Record (EMR), revealed R9 was admitted to the facility with multiple diagnoses including but not limited to encounter for attention to tracheostomy, chronic obstructive pulmonary disease, and aphasia following unspecified cerebrovascular disease. Review of the most recent Quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 99, which indicated R9 was unable to complete the interview due to cognitive deficits. Review of the care plan for R9 revealed a tracheostomy related to respiratory difficulties. Observations made on 3/8/2024 at 9:58 am revealed R9 lying in bed with head of the bed elevated. R9 was non-verbal. Tracheostomy was in place and secured with ties. Oxygen (O2) via trach collar at 2 liters (L)/minute (min). Observation revealed there was no same size trach or smaller size trach at the bedside. Further observations revealed there was not an artificial manual breathing unit (AMBU) bag at the bedside. Review of Physician's Orders for R9 in the EMR revealed no order for the size trach, and no order for an emergency tracheostomy kit at the bedside. Interview on 3/8/2024 at 9:44 am with the Assistant Director of Nursing (ADON) and Licensed Practical Nurse (LPN) AA revealed the ADON and LPN AA verified that there was no same size trach or smaller size trach at the bedside, and there was not an artificial manual breathing unit (AMBU) bag at the bedside. Neither the ADON nor LPN AA could verbalize what trach supplies were needed at the bedside. When asked what would either do if R9's trach became dislodged, the ADON stated that they would be in trouble. LPN AA stated that they used to have a respiratory therapist but that was months ago. She stated that the nurses are now responsible for providing trach care. Interview on 3/8/2024 at 10:07 am with the Administrator revealed, the administrator verified that there was no same size trach or smaller size trach at the bedside, and there was not an artificial manual breathing unit (AMBU) bag at the bedside. The administrator stated that they were getting the supplies together. Administrator stated that she expects that emergency trach supplies should be at the bedside. Administrator further stated that she expected the nurses and the ADON to know what trach supplies are needed at the bedside for a resident with a trach. Interview on 3/10/2024 at 7:55 am with the Director of Nursing (DON) revealed they do not have a respiratory policy to address what is needed at the bedside. DON confirmed that there was no order for the size of trach for R9. DON stated that R9 has a size 6 trach in. DON stated that there should be at the bedside same size trach and a smaller size trach at the bedside. DON further stated that she expects the ADON along with the nurses to know what is needed at the bedside of a resident with a trach.

Based on staff interviews, clinical record review, and review of facility policy titled, Depression - Clinical Protocol, the facility failed to monitor behaviors and side effects of psychotropic medications for one resident (R37) of five residents reviewed for unnecessary medications. Findings: Review of the facility policy titled, Depression - Clinical Protocol dated 3/23/2017 Monitoring and Follow-up 2. The staff and physician will monitor the resident carefully for side effects specific to each class of medication as well as interactions between antidepressants and other classes of medications. Review of the medical record for R37 revealed diagnoses that included but was not limited to unspecified psychosis not due to a substance or known physiological condition, depression, and anxiety. Review of the Annual Minimum Data Set (MDS) dated [DATE] in Section N revealed medication usage that included antianxiety and antidepressants. There was an order for Effexor XR Oral Capsule Extended Release 24 Hour 37.5 MG (Venlafaxine HCl). Give 1 capsule by mouth one time a day for depression with a start date of 10/28/2023. There was an order for Lorazepam Oral Tablet 0.5 MG (Lorazepam). Give 1 tablet by mouth two times a day for Anxiety with a start date of 7/1/2023. Review of the March 2024 electronic Medication Administration Record (eMAR) did not reveal any behavior monitoring or documentation of side effects of psychotropic medications. During an interview on 3/10/2024 at 11:32 am Licensed Practical Nurse (LPN) DD regarding R37 it was reported that behavior monitoring, and medication usage side effects are documented in the eMAR. LPN DD was able to find some documentation related to behaviors in notes but was unable to find any documentation addressing the side effects of medications. During an interview with the Director of Nursing (DON) on 3/10/2024 at 11:41 am it was reported that nursing staff are to monitor and document behaviors on the MAR each shift. DON reviewed the eMAR for March 2024 but was unable to find any behavior monitoring for R37. DON then reviewed the orders for R37 and acknowledged seeing an order for anti-anxiety side effects.

Based on observations, record review, staff interviews, and review of the facility policy titled, Infection Control Recommendations the facility failed to properly store suctioning equipment for two of three residents (R) (R#12 and R#63) with tracheostomies. Findings include: Review of facility policy titled, Infection Control Recommendations (not dated) revealed under section 'Suction Machines: suction tubing should be changed when soiled; Suction catheters are to be changed after use; discarded when soiled; Suction [MEDICATION(S)] are to be discarder when soiled; Equipment should be bagged when not in use. Observation on 5/17/22 at 9:39 a.m. of R#12 revealed in room [ROOM NUMBER] next to bed 'A' and 'B' revealed suction machines sitting on bedside table with tubing extending from the suction machines into a drawer. The cannisters on the suction machines had a large amount of cloudy watery substance. Observation on 5/18/22 at 8:33 a.m., 11:07 a.m., and 2:19 p.m. of R#63 revealed the residents suction tubing was lying uncovered on the bedside table and the suction cannisters had large amount of cloudy watery substance. The suction machines were partially covered with a plastic bag. Observation and interview on 5/19/22 at 10:10 a.m. with the Director of Nursing and Respiratory Therapist revealed the suction cannister should be cleaned after each use and all supplies should be changed at least monthly. Further revealed the suction equipment should be stored in a plastic bag when not in use. Both confirmed the suction machines and tubing were not stored properly.

Based on record review and Family and staff interviews the facility failed to document weekly wound assessments and treatment administration for two of three residents (R) (R#2 and R#3) reviewed for pressure ulcers. Findings include: Review of the facility's policy and procedure titled Clinical Documentation dated 2/2019, revealed an intent that progress clinical documentation should be maintained for each patient. It further noted the clinical documentation reflects the patient's progress and response to his/her care plan, medications, diet, etc. 1. Record review revealed R#2 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the 10/18/2021 Wound Report documented that R#2 was admitted to the facility with a Stage 4 pressure ulcer to the coccyx and a Stage 2 to the left hip. The coccyx measured 17 centimeters (cm) x 13 cm x 3.5 cm with slough and non-granulating pink tissue. It also noted the wound extended to the rectum. The left hip measured 2 cm x 2 cm with no description of the wound bed. There was no further documentation of wound measurements or assessments of the pressure ulcers after 10/18/2021 until after surveyor inquiry on 12/1/21. On 11/3/21 a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the November 2021 Treatment Administration Record (TAR) revealed staff failed to document the treatments were done for the entire month. Further review of the clinical record revealed although there was not a TAR for the month of October 2021, there was some documentation in the Nurse's Notes on 10/15/21, 10/23/21, 10/27/21 and 10/30/21 as treatment provided to the sacrum and both hips. During an interview with the resident's family member on 12/1/21 at 4:00 p.m., she stated the resident's wounds had improved since he has been in the facility and she has never found old dressings on the resident's wounds. 2. Record review revealed R#3 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Wound Report documented the resident was admitted with a Stage 3 pressure ulcer to the left heel, an unstageable pressure ulcer to the right heel and a Stage 3 to the coccyx. Weekly wound assessments were assessed and documented each week through 10/6/21. However, review of the 10/6/21 Wound Report revealed there was no documentation the pressure ulcer to the coccyx was assessed. Further review of the 2021 Wound Report revealed there were no weekly wound assessments documented for three weeks in October 2021 and there were no assessments documented for November 2021. The TAR's for September, October and November of 2021 were incomplete. During an interview with the Regional Nurse on 12/2/21 at 11:25 a.m., she stated they had identified problems with the lack of documentation on the wounds.

Based on record review, staff interviews, and review of the Performance Improvement Plan (PIP) the Quality Assurance and Performance Improvement Committee failed to effectively develop, implement, and monitor a corrective action plan related to documentation omissions for wound care two of three residents (R) (R#2 and R#3) that were reviewed for pressure ulcers. Findings include: Review of the Performance Improvement Plan (PIP) dated 8/4/2021 documented an Objective of: Assure we have acknowledged through our documentation that we have provided the care and services necessary to deliver the highest quality of care for our patients. 4. Prepare a QI Improvement Data Collection rid with the following indicators and completed weekly x 4 weeks or until substantial compliance is achieved. a. Are weekly skin assessments completed timely? b. Braden assessments are completed timely: c. Pressure Ulcer Assessments is completed timely? d. Weekly wound documentation is completed timely? 1. Record review revealed R#2 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the 10/18/2021 Wound Report documented that R#2 was admitted to the facility with a Stage 4 pressure ulcer to the coccyx and a Stage 2 to the left hip. The coccyx measured 17 centimeters (cm) x 13 cm x 3.5 cm with slough and non-granulating pink tissue. It also noted the wound extended to the rectum. The left hip measured 2 cm x 2 cm with no description of the wound bed. There was no further documentation of wound measurements or assessments of the pressure ulcers after 10/18/2021 until after surveyor inquiry on 12/1/21. Review of the November 2021 Treatment Administration Record (TAR) revealed staff failed to document the treatments were done for the entire month. Further review of the clinical record revealed although there was not a TAR for the month of October 2021, there was some documentation in the Nurse's Notes on 10/15/21, 10/23/21, 10/27/21 and 10/30/21 as treatment provided to the sacrum and both hips. 2. Record review revealed R#3 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Wound Report documented the resident was admitted with a Stage 3 pressure ulcer to the left heel, an unstageable pressure ulcer to the right heel and a Stage 3 to the coccyx. Weekly wound assessments were assessed and documented each week through 10/6/21. However, review of the 10/6/21 Wound Report revealed there was no documentation the pressure ulcer to the coccyx was assessed. Further review of the 2021 Wound Report revealed there were no weekly wound assessments documented for three weeks in October 2021 and there were no assessments documented for November 2021. The TAR's for September, October and November of 2021 were incomplete. During an interview with the Regional Nurse on 12/2/21 at 11:25 a.m., she stated they had identified problems with the lack of documentation on the wounds. These concerns were placed in the Performance Improvement Project (PIP) 8/4/21 and 9/15/21. Although, there was a PIP in place since 8/4/2021, record review revealed that QAPI was ineffective to monitor and ensure that wound assessments and wound care were documented as being completed.

Based on record review, staff interview and a review of the facilities Patient's Plan of Care procedural guidelines, the facility failed to develop comprehensive care plans for Activities of Daily Living (ADL) for two of four residents reviewed (R) (R#3 and R#23). Findings include: A review of the facilities Patient's Plan of Care procedural guidelines dated (YEAR) revealed, It is the intent of this center to develop and maintain an individualized plan of care for each patient. The compents of the guidelines consist of a problem statement - Problems, imitations, needs, behaviors, possibilities for improvement, and risks should be identified. Goal - should lead to an outcome and Interventions - should be specific individualized approaches that staff will take to assist the resident to achieve the identified goal. 1. Review of R #23's clinical record revealed that he had [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set ((MDS) dated [DATE] for R#23 revealed that he had a Brief Interview for Mental Status (BIMS) score of 03 (a BIMS score of 00 to 07 indicates severe cognitive impairment); extensive assistance for and dressing, total dependence for transfers and bathing. Review of R #23's care plans revealed that one was not seen for ADL's as related to dressing, transfers or bathing. Further review of his care plans revealed that a care plan for self-care deficit addressed the family making physician appointments. Review of a Care Plan Review dated 2/28/19 and 5/29/19 revealed the IDT (interdisciplinary team) met for his plan of care meeting. Further review of this note revealed that R #23 was unable to mention any goals at this time. An interview on 4/30/19 at 1:29 p.m. with the family of R#23 revealed, he had a stroke, we don't expect him to be walking up and down the halls. They sent a staff person by herself in the room to transfer/pivot him. During an interview on 5/01/19 at 2:45 p.m. until 3:05 p.m. with the Registered Nurse (RN) Care Plan Coordinator BB, she confirmed the self-care deficit plan of care for R#23 stated the following: his family makes appointments and does not let the staff know. Care Plan Coordinator BB further revealed; it seems like there should be another care plan. There should be another self-care deficit care plan for the staff to provide personal care, bathing, and hygiene, I am not seeing it. During an interview on 5/02/19 at 10:37 a.m. the Administrator stated that staff find out what a resident's preferences are for bathing and provide as they desire; this is incorporated as part of their Resident Rights. When a resident refuses care, the facility honors that refusal as a preference/choice; patient centered care, honor their choices and refusing is a choice. She expects refusal of care to be care planned. It is something she is trying to implement. Policy on bathing, care plans, resident rights/preferences, ADL documentation, refusal of care. During an interview on 5/02/19 at 11:44 a.m. the Director of Nursing (DON) revealed the facility has no bathing policy. She also stated on 2/28/19 the staff had a meeting with a mix of all nursing staff related to developing the care plan, the DON further stated all licensed nursing staff are expected to complete the care plan. On 5/02/19 at 12:11 p.m. a further interview with the Administrator revealed the expectation would be that a resident's self-care deficit care plan would reflect his care needs, even if the Certified Nursing Assistants (CNA's) could see that care plan it wouldn't help them. 2. R#3 admitting [DIAGNOSES REDACTED]. The annual Minimum Data Set (MDS) a resident assessment instrument (RAI) with an assessment reference date of 8/3/18 reflects a Brief Interview for Mental Status (BIMS) score of three (3) out of a possible 15 indicating severe cognitive dysfunction. The annual MDS also reflects that R#3 requires limited assistance with toileting and dressing activities and physical assistance of one staff person with bathing. A review of the comprehensive care plan for R#3 reveals no care area or problem related to a self-care deficit or activities of daily living including bathing, dressing or grooming. An interview conducted on 5/2/19 at 10:15 a.m. with the MDS Coordinator AA confirmed there is no care plan for R#3's self-care deficit even though she requires assistance with bathing by the staff. .

Based on observation, staff interview, and policy review the facility failed to label and date food items upon receipt. This had the potential to effect 78 of 88 residents that receive an oral diet. Findings include: Review of the policy Skilled Inpatient Services: Storage Areas revealed that it was the intent of this center to store food that maintained quality and safety. Under Bullet 1 the policy revealed that all items would be inspected for quality and temperature control upon receipt. The policy stated that items would be covered, sealed, labeled, and dated appropriately. Interview on 5/1/19 at 8:55 a.m. with the Kitchen Supervisor CC revealed that she used a first in-first out rotation system, that food items have a one-year shelf-life and that they use received by, use by and opened dates to verify that a food item was still suitable for consumption. Observation with the Kitchen Supervisor CC revealed a 1/3 of a tub of individual packets of saltines (more than 50 packets), four cans of pimentos with no received by date or use by date and four cans of sweet potatoes with the received by month and day but no year. The Kitchen Supervisor confirmed these findings and stated that she would have no way of knowing when the food items were received except that she knew that the food delivery truch delivered weekly on Fridays. She stated that the reason this happened was because there was such a high turnover of staff.

Based on record review, resident and staff interviews, the facility failed to provide quarterly account statements for one (1) residents (R#115) of four (4) residents and to provide one (1) resident the correct account balance after taking resident liability from a sample of thirty-five (35). Facility manages eighty-seven (87) residents' accounts. Findings include: Interview on 3/07/2017, at 9:41 a.m., with R#115 stated no they don't tell or send a statement. Review of R#115 trust funds account for the past six (6) months, revealed that resident's account was owed $18 from the month of October, 2016. Interview on 3/09/2017, at 3:19 p.m., with staff EE stated that residents' statements are printed out quarterly. Staff reported that quarterly statements are mailed to responsible parties, but quarterly statements for in-house cognitive residents are placed into a binder and kept in his/her office. Staff further reported that some residents do not wish to receive their statements, but no refusals are documented. Interview on 3/09/2017, 3:21 p.m., with staff FF revealed that R#115 account balance was incorrect due to facility not placing the entire $50 into resident's account once resident liability was extracted. Interview with staff also revealed that resident's account was owed $18 from the month of October, 2016. Staff reported that the error was not discovered until surveyor brought error to his or her attention.

Based on observation, interview and record review, the facility failed to ensure two residents (#28 and #45) of 35 sampled residents, were treated with dignity and respect. Specifically: - Resident was called by undignified label, feeder. - Staff failed to respond timely to Resident's call light. Findings include: 1. Record review for R#28 revealed an Annual Minimum Data Set (MDS) assessment dated [DATE] that indicated admission to the facility on [DATE]. Active [DIAGNOSES REDACTED]. Section C- Cognitive patterns, documented that the resident had a Brief Interview for Mental Status (BIMS) summary score of three (3), indicating severe cognitive impairment. Section G- Functional Status documented the resident required one (1) person total dependence with eating. During an interview regarding [MEDICAL TREATMENT] and nutritional care of the resident, Certified Nursing Assistant (CNA) DD referred to R#28 as a feeder. When questioned about the terminology used, CNA DD repeated feeder. During an interview on 3/9/17 at 1:42 p.m. regarding [MEDICAL TREATMENT] and nutritional care of the resident, Licensed Practical Nurse (LPN) CC referred to R#28 as a feeder. Interview with the Director of Nursing (DON) on 3/9/17 at 3:36 p.m. revealed that staff should never refer to the resident's as feeders. DON informed that the staff do not call the resident's feeders to their face. Review of the Patients' Rights Policy reviewed and updated July 2014 revealed Procedural Guidelines- a Comprehensive Patients' Rights Program includes dignity and respect. 2. During an observation on 3/6/17 starting at 4:00 p.m. of call light response time for R#45, Respiratory Therapist (RT) BB walked past the resident's room at 4:09 p.m. without acknowledging the resident's call light being on. RT BB walked back by the resident's room again at 4:11 p.m. with no response to the resident's call light. Interview with the Administrator on 3/9/17 at 2:11 p.m. revealed that she expects all staff to respond to the call light no matter what the circumstances. Administrator stated that non-nursing staff are instructed that if unable to provide assistance to the resident; never turn off a call light until the appropriate staff arrive. Interview RT AA on 3/9/17 at 2:34 p.m. revealed her expectation is that RT's answer the call lights if needed. Review of the Record of Training Inservice dated 3/4/17 through 3/6/17 revealed education provided to the nursing staff related to answering the call lights timely; no in-services documentation available indicating that RT's received education related to answering call lights. Review of the corporate Policy Our Performance Standards revised February 2015 documented all call lights will be answered in a way that demonstrates the care, courtesy, and respect our patients deserve.

Based on observation, interview, and record review, the facility failed to maintain an effective program to ensure that bed bolsters were in good repair for three out of 10 residents (#20, #32, and #54) with bed bolsters. The census sample size was 35. Findings include: Observation on 3/9/17 at 12:20 p.m., 12:25 p.m., and 12:30 p.m. revealed bed bolsters to be in disrepair in rooms 4A (R#54), 6P (R#20), and 15A (#32); torn and cracked along the edges causing a scratchy surface. Observation with administrator and Director of Nursing (DON) from 1:00 p.m. to 1:15 p.m. on 3/9/17 confirmed the above mentioned bolsters with torn areas and in disrepair. Interview with the administrator on 3/9/17 at 1:59 p.m. revealed that anyone (mostly housekeeping who cleans the bolsters and Certified Nursing Assistant's working with residents) should be identifying a bolster in disrepair and should report it immediately to central supply to obtain a new one for that resident. Review of the Preventative Maintenance Calendar revealed personal equipment checked annually and due in August 2017. Interview with the DON on 03/09/2017 at 4:45 p.m. revealed there is no policy related to bolsters or maintenance of bolsters and no residents have ever been injured from the torn bolsters.