Every finding on record at Lochearn Nursing Home, LLC

Based on observation, record reviews and interviews, it was determined that the facility failed to implement infection control practices to ensure oxygen equipment was dated when put into use. This deficient practice was evident for 2 (resident #37 and #135) of 3 residents reviewed for oxygen equipment during the annual survey.The findings include: 1. On 1/5/25 at 8:05 AM, Resident #37 was observed with an oxygen setup. The humidifier bottle and oxygen tubing attached to the resident's oxygen concentrator were noted to be in use but were not dated. At that time, the surveyor located Staff #4, who was identified as responsible for the care of Resident #37. Staff #4 confirmed the humidifier bottle and tubing were in use and acknowledged that they were not dated as required. Staff #4 then obtained a new humidifier bottle and oxygen tubing, placed them on the resident's concentrator, and marked both with the date. At 10:52 AM, the Nursing Home Administrator and Director of Nursing were informed of the surveyor's findings. 2. 01/05/2026 at 9:23 AM during initial observation, resident #135 was observed with nasal cannula intact and receiving 2L O2; however, O2 tubing was not labeled. On 1/5/2026 at 10:51 AM during an interview with DON staff #2, Regional Nurse staff #3 and NHA staff #1, this Surveyor shared the findings of no label on the Oxygen tubing in use; DON staff stated, 'the expectation is for all tubing to be labeled'. On 01/08/2026 12:39 PM during record review, it revealed the resident had a current order for 'Oxygen via Nasal Cannula at 2 LPM, every shift for Maintain POX above 90% for 7 Days AND as needed for Maintain POX above 90%; ordered 1/3/2026'.

Based on observations and interviews, it was determined that the facility failed to treat residents with dignity and respect as evidenced by staff standing over residents while assisting them to eat. This was evident for 1 (resident #52) out of 1 resident observed for dignity during the annual survey.Findings include:On 01/05/2026 at 9:29 AM Resident #52 was observed sitting in a wheelchair in the Activities room at the table with their breakfast tray in front of them. Geriatric Nursing Assistant (GNA) #16 was standing to the left of the resident with a fork in hand and feeding the resident. Additionally, observed seated at the table were 3 other residents in their wheelchairs, Activities Assistant Staff #25, and a vacant chair at the opposite end of the table. This Surveyor asked GNA #16 if the facility has a Feeder program and training; GNA staff #16 stated No. Then asked, was this resident designated to be assisted or fed; GNA staff #16 stated we encourage him/her to eat and we help sometimes. When asked if a chair is available to use while feeding the resident when needed, GNA staff #16 stated, yes, I should be seated, but this resident is not a Feeder, I'm just assisting them at times. On 1/5/2026 at 10:51 AM during an interview with DON #2, Regional Nurse staff #3 and NHA staff #1, this Surveyor shared the findings of, Resident #52 being fed by GNA #16 while standing, despite there being an available chair in the room. The Surveyor asked, is this the expectation of staff while feeding the residents; DON staff #2 stated No, that is not the expectation, staff should always be seated while feeding the resident.

Based on resident record reviews and staff interviews, it was determined that the facility failed to ensure the accuracy of the resident's Minimum Data Set (MDS). This was evident for 1 resident (Resident #3) out of 10 residents reviewed during the recertification survey.On 01/06/2026 at 1:06 PM, the surveyor reviewed Resident # 3's medical records. The resident record review revealed that, according to Resident # 3's January 2026 Medication Administration Record and current medication orders, Resident #3 did not receive insulin. It was documented in Resident #3's January 2026 Medication Administration Record and current medication orders that Resident #3 received a 50 mg tablet of Januvia, an oral anti-diabetic medication, each morning for type 2 diabetes.On 01/06/2026 at 1:32 PM, the surveyor asked the Assistant Director of Nursing staff #18 if Resident #3 received insulin. During the interview, staff #18 stated that Resident #3 did not receive insulin, and that Resident #3 received Januvia.On 01/06/2026 at 1:45 PM, the surveyor reviewed the resident's records. The resident record review revealed that, in the MDS, which has an ARD/Target date of 12/19/25, it is documented in Section N - Medications under N0350. Insulin, that Resident #3 received one insulin injection during the last 7 days or since admission/entry.On 01/08/2026 at 10:23 AM, the surveyor reviewed the resident's records. The resident record review revealed that, according to Resident # 3's discontinued medication orders, Resident #3 did not have any discontinued medication orders for insulin since being admitted to the facility on [DATE].On 01/08/2026 at 10:31 AM, the surveyor interviewed the Director of Nursing staff #2. During interview, the surveyor made staff #2 aware of the MDS discrepancy. Staff #2 agreed with the surveyor and stated that the MDS is wrong because Resident #3 did not receive insulin.

Based on review of resident medical records, observation and interviews, it was determined that the facility failed to perform appropriate revisions to resident care plan. This was evident for 1 resident (Resident #5) out of 10 residents reviewed during the survey. The findings include: Review of Resident #5's medical record on 01/08/2026 at 8:30 AM revealed a care plan with a problem area created on 08/04/2022, revised on 11/14/2025 stating that Resident #5 was an Elopement Risk with an approach to apply wanderguard: check placement Q shift and function Q Day. Further review of Resident #5's medical record revealed a Wandering Risk Scale - V3 assessment performed on 11/17/2025 with a score of 3 indicating that Resident #5 was a low risk of wandering. During observation rounds on 01/08/2026 at 9:15 AM Resident #5 was observed not wearing a wanderguard. During an interview on 01/08/2026 at approximately 10:10 AM the Director of Nursing confirmed and stated, [Resident #5's] current care plan was incorrect and needs to be updated, [Resident #5] is not a wander risk and should not be wearing a wanderguard.

Based on administrative records reviews and interviews it was determined that the facility failed to document and ensure that geriatric nursing assistants' (GNAs) human resources and clinical education records reflected the required 12 hours of annual clinical training/in-services as required. This was evident to be true for 5 out of 5 (GNA # 15, #16, #17, #21, #22 ) geriatric nursing aide clinical education and human resources records reviewed during the survey.The findings include: On 01/08/2026 at approximately 09:36 AM the surveyor requested the human resources records of six employees from the DON that held the job descriptions of geriatric nursing assistants. On 01/08/2026 the following GNA human resources and clinical education records were reviewed by the surveyor at 11:00 AM on : GNA # 15, #16, #17, 321, and #22. On 01/08/2026 12:34 PM The surveyor interviewed the ADON regarding the evidence/documentation/compliance requirements related to the annual clinical education and training for geriatric nursing assistant staff. The ADON stated that the annual hands on clinical training is provided to all clinical staff in October each calendar year. Also, the ADON stated the facility does have HealthStream online clinical training for nursing staff as well, however the completion of the online clinical education annually is non mandated at the present time. On 01/08/2026 at 12:15 PM the ADON brought additional documents that were printed from HealthStream however, these documents did include topics such as behavioral health, dementia training, or managing resident with traumatic stress disorder for example. The ADON stated that the staff have been resistant to completing the educational requirements online and there are currently no disciplinary consequences.On 01/08/2026 at 12:04 PM, the ADON stated that she was unable to provide any additional proof that the 5 GNA s selected by the surveyor had received the required 12 hours of annual clinical training required by federal and state requirements. The facility failed to provide any additional documentation of compliance with the required annual 12 hours of continuing education for the five GNAs educational records reviewed prior to the exit conference.These concerns were reviewed during the exit conference with the administrator, DON, and the corporate regional staff present on 01/08/2026.

Based on observations, interviews and review of facility documentation, the facility failed to properly store medications, biologicals and resident food items under proper temperature controls. This was evident for 2 out of the 4 medication, biologicals and resident food refrigerators observed during the annual survey. The findings include the following: During observation rounds, interview and review of facility documentation of the 3rd floor medication and resident food storage rooms on 01/07/2026 at 10:26 AM with staff # 4, refrigerator #1 was found to have several resident's food items. On the outside of this refrigerator was a Refrigerator Temperature Form for the month of January 2026 stating that temperatures must be between 38 and 42 degrees. On 01/07/2026 at 05:00 AM staff recorded that the refrigerator was 45 degrees Celsius. At the time of the observation the refrigerator reading was 45 Fahrenheit. A second refrigerator #2 was found to have several medications and biologicals for facility residents. On the outside of this refrigerator was a Refrigerator Temperature Form for the month of January 2026 stating that temperatures must be between 38 and 42 degrees. On 01/07/2026 at 01:00 AM staff recorded that the refrigerator was 20 degrees Celsius. Staff #4 stated, I will report this right now to the supervisor and confirmed reading of refrigerator #1 as well as the documented refrigerator reading for 01/07/2026 for both refrigerators. During an interview on 01/07/2026 at approximately 11:15 AM staff #3 was made aware of the refrigerator temperature findings and stated, We will be updating the form to indicate the correct temperature parameters and get maintenance to look at the refrigerators.

Based on observation, interview and document review, the facility failed to provide resident's rooms that measured at least 80 square feet per resident in 77 of 77 multi-resident rooms. Rooms 100, 102, 103, 104, 105, 107, 108, 109, and 110, measured 150 square feet. Rooms 300, 325, 326, 327, 331, 332, 333, 334, 335, 336, 337, 338, 341, 342, 346, 400, 411, 412, 421, 423, 424, 425, 426, 431, 432, 433, 435, 436, 437, 438, 441, 442, 444, 446, 447, 500, 511, 512, 523, 524, 525, 527, 531, 532, 535, 536, 544, 545, 547, 600, 611, 612, 621, 622, 623, 624, 625, 626, 627, 631, 632, 633, 634, 635, 636, 637, 641 and 642 measured 155 square feet. This failure had the potential for residents not to have reasonable privacy or adequate space.The findings include:On 1/5/2026 at 10:51, the NHA staff #1 provided an untitled document letter from the Centers for Medicare & Medicaid Services (CMS) dated 10/11/2024 which indicated the facility requested a waiver for the residents' room that did not measure 80 Square feet per resident in multi resident bedrooms and the waiver was granted for the rooms as listed: Rooms 100, 102, 104, 105, 107, 108, 109, and 110, measured 150 square feet. Rooms 300, 325, 326, 327, 331, 332, 333, 334, 335, 336, 337, 338, 341, 342, 346, 400, 411, 412, 421, 423, 424, 425, 426, 427, 431, 432, 433, 435, 436, 437, 438, 441, 442, 444, 446, 447, 501, 511, 512, 523, 524, 525, 527, 531, 532, 535, 536, 544, 545, 547, 600, 611, 612, 621, 622, 623, 624, 625, 626, 627, 631, 632, 633, 634, 635, 636, 637, 641 and 642 measured 155 square feet.During Initial Pool Resident observations and interviews, none of the residents residing in these rooms voiced any concern regarding the size of their rooms.Rooms 100, 102, 103, 104, 105, 107, 108, 109, and 110, measured 150 square feet. Rooms 300, 325, 326, 327, 331, 332, 333, 334, 335, 336, 337, 338, 341, 342, 346, 400, 411, 412, 421, 423, 424, 425, 426, 431, 432, 433, 435, 436, 437, 438, 441, 442, 444, 446, 447, 500, 511, 512, 523, 524, 525, 527, 531, 532, 535, 536, 544, 545, 547, 600, 611, 612, 621, 622, 623, 624, 625, 626, 627, 631, 632, 633, 634, 635, 636, 637, 641 and 642 measured 155 square feet. The prior CMS approval letter had listed room [ROOM NUMBER] which does not exist and should have been room [ROOM NUMBER], which measures 155 square feet. During an interview on 1/8/2026 at 11:30 AM with DON staff #2, NHA staff #1 and Regional Nurse staff #3, this Surveyor notified the facility they would need to submit a Waiver request for the above rooms.

Based on complaint, record review, and interview, it was determined that the facility staff failed to inform a resident's representative of a fall with injury and subsequent transfer to the hospital. This was evident for 1 (#7) of 12 residents reviewed for complaints during a complaint survey.The findings include: On 10/2/25 at 9:16 AM a review of complaints 326854 and 2561080 alleged that Resident #7 was transferred and sustained a fall with injury and that family were not notified On 10/2/25 at 9:16 AM Resident #7's medical record was reviewed and revealed a 6/6/25 at 13:01 (1:01 PM) nurse's note that documented, during care while attempting to place Hoyer pad under pt., pt. turned too far over rolling out of bed. The note continued, MD made aware of pt. fall. Review of a 6/6/25 at 13:09 (1:09 PM) change in condition note documented that the physician was aware of the fall and ordered an x-ray to the knee and pain medication. Review of a 6/6/25 at 22:05 (10:09 PM) change in condition note documented that the results of the x-ray were received and Resident #7 had a right knee distal fracture. The physician was made aware and ordered for the resident to be sent to the emergency room for evaluation. There was no documentation in the resident's medical record that the resident's family was made aware of the fall with injury and transfer to the hospital. On 10/8/25 at 11:20 AM the Assistant Director of Nursing (ADON) was interviewed and stated that if the resident has a BIMS (Brief Interview of Mental Status) of 15 and is their own RP (responsible party) then we don't notify the family unless the resident tells us to. On 10/8/25 at 1:20 PM an interview was conducted with Resident #7. Resident #7 was asked if the facility had permission to notify his/her daughter about any issues related to the resident and Resident #7 said, yes. On 10/8/25 at 1:45 PM the Director of Nursing (DON) was interviewed and stated, a patient that is cognitively intact is usually the responsible party for themselves. Anything going on with them we communicate with them. We do not communicate with family members. It depends on who is working with them if they can communicate with family. If the patient is going to the hospital for a fall, we will give them the bed hold policy, and they can communicate with families as they are responsible for self. It is only valid for patients responsible for self. The surveyor asked, even if a resident has a pain level of 8 with a fracture to the leg, you would not notify the family. The DON stated, not if the resident has a BIMS of 15 and is their own RP.

Based on review of a complaint, medical record review and interviews, it was determined the facility staff failed to ensure home health services were set up for a resident at discharge (Resident #19). This was evident for 1 of 3 residents reviewed for discharge during a complaint survey. The findings include:Review of Complaint 326835 was conducted on 10/2/25 for a concern Resident #19 was discharged without home health services.Review of Resident #19's medical record on 10/2/25 revealed the Resident was admitted to the facility in April 2024 following a hospitalization with a diagnosis to include POTS (Postural Orthostatic Tachycardia Syndrome). Review of the hospital Discharge summary dated [DATE] revealed the Resident received daily IV fluid bolus at home prior to admission.Further review of Resident #19's medical record revealed the Resident was receiving IV fluid daily in the facility.On 7/26/24 at 12:08 PM Staff #23, former Social Services, documented progress meeting held. Staff #23 also documented Resident plans to return home independently. Resident prefers to work with Home Health Agency [A,] but they do not take his/her insurance and was referred to Home Health Agency [B] who will provide PT (Physical Therapy), OT (Occupational Therapy), SLP (Speech Language Pathology), SW (Social Work), SN (Skilled Nursing) and aide.Review of Resident #19's closed paper medical record revealed a Post-Discharge Plan of Care document signed by the Resident on 8/6/24. On the document under Home Health Agency or Visiting Nurse was written PT, OT, SLP, SN, SW, aide and a phone number listed. The Surveyor called the phone number listed on 10/3/25 at 12:54 PM and it was answered with an automated message that identified the number was for Home Health Agency B. The Surveyor then spoke to Home Health Agency B Staff #27 who stated Resident #19 was referred to their agency by the facility. Home Health Agency B Staff #27 also stated the Agency did not take the Resident's insurance so they did not accept the Resident for home health services and notified the facility on 8/6/24.Interview with the Administrator on 10/3/25 at 1:30 PM confirmed the facility failed to ensure Resident #19 had home health services at discharge.

Based on observation, medical record review, and interviews, it was determined that facility staff failed to thoroughly evaluate and revise a resident's plan of care after each MDS (Minimum Data Set) assessment to reflect accurate and current interventions (Resident #17). This was evident for 1 of 19 residents reviewed during a complaint survey. The findings include: Minimum Data Set- The 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 A care plan is a guide that addresses each resident's unique needs. It is used to plan, assess, and evaluate the effectiveness of the resident's care. Review of Resident #17's medical record on 10/2/25 revealed the Resident was admitted to the facility in August 2024 with diagnosis to include spinal cord injury and quadriplegia. Further review of Resident #17's medical record revealed the staff conducted an MDS Quarterly Assessment on 9/18/25 and coded the Resident with a BIMS (Brief Interview of Mental Status) of 15 out of 15, indicating no cognitive impairment. Further review of Resident #17's 9/18/25 Quarterly MDS Assessment revealed in Section GG0130 Self-Care the facility staff coded the Resident as dependent for eating, oral hygiene, toileting, shower/bathe, dressing and personal hygiene. Dependent coding indicates the Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity. Review of Resident #17's care plans on 10/6/25 revealed a care plan titled: Self-care deficit related to musculoskeletal impairment as evidenced by weakness and spinal cord injury with approaches for bathing/showering, bed mobility, dressing and eating as independent. Observation of Resident #17 on 10/6/25 at 11:46 AM revealed the Resident in bed with heel protectors in place and bilateral fall mats next to the bed. During interview with the Resident at that time, the Resident was asked if he/she turns him/herself or do the staff turn the Resident. The Resident stated the staff turn him/her. The Resident also stated the staff bathe him/her and cut his/her nails. During interview with the Director of Nursing (DON) on 10/7/25 at 9:55 AM, the Surveyor reviewed Resident #17's Self-care deficit care plan and asked the DON if the Resident is independent or dependent. The DON stated the Resident is dependent and would follow up with the Surveyor regarding the care plan. Interview with the Director of Nursing on 10/7/25 at 2:00 PM confirmed the Resident is dependent on staff for bathing/showering, bed mobility, dressing and eating. The DON also stated the Self-care deficit care plan is not accurate and will be corrected to indicate the Resident as dependent.

Based on complaint, medical record review, and interviews, it was determined the facility staff failed to thoroughly assess a resident for pain after a fall with fracture. This was evident for 1 (#7) of 12 residents reviewed for complaints during a complaint survey.The findings include: Pain is often regarded as the fifth vital sign regarding healthcare because it is accepted now in healthcare that pain, like other vital signs, is an objective sensation rather than subjective. As a result, nurses are trained and expected to assess pain. A component of pain assessment-focusing on words to describe pain, intensity, location, duration, and aggravating or alleviating factors. On 10/2/25 at 9:16 AM a review of complaints 326854 and 2561080 alleged that Resident #7 was rolled out of bed during care and sustained a fall with injury. The complaint alleged that during a phone call Resident #7 was screaming in pain periodically during the call. The complaint alleged that Resident #7, laid with a broken leg for more than 6 hours before being transferred to the hospital. On 10/2/25 at 9:16 AM Resident #7's medical record was reviewed and revealed a 6/6/25 at 13:01 (1:01 PM) nurse's note that documented, during care while attempting to place Hoyer pad under pt., pt. turned too far over rolling out of bed. The note continued that the physician was made aware of the resident's fall, and a new order was obtained for x-ray and Tylenol for pain which was administered pending x-ray to the knee. Review of a 6/6/25 at 14:38 (2:38 PM) plan of care note documented, complained of pain to right knee, slight swelling noted, and resident was medicated for pain. The note ended, continue to monitor for effective pain management and make adjustments as needed. Review of a 6/6/25 at 22:05 (10:09 PM) change in condition note documented that the results of the x-ray were received and Resident #7 had a right knee distal fracture. The physician was made aware and ordered for the resident to be sent to the emergency room for evaluation. The note documented that the patient continued on extra strength Tylenol for pain which was administered with some relief. This note was written by the Assistant Director of Nursing (ADON) on 6/9/25, which was 3 days later. Review of Resident #7's medical record revealed under the vital sign section documentation of pain levels. On 6/6/25 at 12:54 PM the pain level was 8 out of 10. On 6/6/25 at 13:08 (1:08 PM) the pain level was 8 and on 6/6/25 at 20:55 (8:55 PM) the pain level was 8.Further review of Resident #7's medical record revealed there were no pain assessments between 1:08 PM and 8:45 PM when the resident arrived at the emergency room and received 2 mg. of IV morphine per emergency room records.Review of Resident #7's Medication Administration Record (MAR) was void of any pain medication being administered, including the Tylenol that a nursing note documented as given. There were no follow up assessments after the Tylenol was documented as given as to if it was effective. There were no additional pain assessments conducted. On 10/8/25 at 11:20 AM the ADON was interviewed and confirmed that the MAR did not have any documentation of Tylenol being administered. The ADON was asked if she was in the building the evening of the fall and saw the resident take the Tylenol and the ADON stated, no. The ADON was asked why her name was on the nursing note dated 6/6/25 at 22:09 that documented Tylenol was given. The ADON said she locked the note. The ADON was asked if she could confirm by looking at the medical record that pain assessments were done and that the resident was medicated for pain from the time of the fall until transport to the hospital. The ADON stated that she could not. On 10/8/25 at 1:20 PM an interview was conducted with Resident #7. Resident #7 was asked if he/she received pain medication after the fall. Resident stated he/she thought he/she got Tylenol but did not know how much. Resident #7 stated that it did not help the pain and that he/she was in pain until after he/she went to the hospital.On 10/8/25 at 2:30 PM the Director of Nursing and Nursing Home Administrator were informed of the concerns.

Based on medical record review and interview, it was determined the facility failed to maintain complete and accurate medical records in accordance with accepted professional standards (Resident #16). This was evident for 1 of 19 residents reviewed during a complaint survey. The findings include. A medical record is the official documentation of a healthcare organization. As such, it must be maintained in a manner that follows applicable regulations, accreditation standards, professional practice standards, and legal standards. All entries to the record should be legible and accurate. Review of Resident #16's medical record was conducted on 10/2/25 for Complaint 326847 in December 2024 related to the facility managing the Resident's diabetes. Review of the Resident's medical record revealed the Resident was admitted to the facility in January 2024 with a diagnosis to include Diabetes. Review of Resident #16's December 2024 Medication Administration Record revealed on 12/2/24 the facility staff documented the Resident's 12:00 PM blood sugar (BS) was 401 but failed to document the insulin given. On 12/12/24 at 11:00 AM the facility staff documented the Resident's blood sugar was 17 with no nurse's note. On 12/13/24 at 11:00 AM the facility staff failed to document the Resident's blood sugar. Interview with the Director of Nursing on 10/7/25 at 2:05 PM confirmed the facility staff failed to document the insulin given on 12/2/24 at 12:00 PM, failed to document an accurate blood sugar on 12/12/24 at 11:00 AM and failed to document the blood sugar on 12/13/24 at 11:00 AM for Resident #16.

Based on interview, record review, review of the Centers for Disease Control and Prevention (CDC) guidelines, and facility policy review, the facility failed to ensure five of five residents (Resident (R) 40, R158, R73, R7, and R96) reviewed for influenza vaccines had consents signed, including the risks and benefits explained to the resident and/or representative prior to the administration of the vaccine. The facility further failed to offer an additional pneumococcal vaccine to two of five residents (R73 and R96) reviewed for pneumococcal vaccines out of a total sample of 39 residents. The failure of not offering/providing the additional pneumococcal vaccine increased the risk for residents to contract pneumonia. The failure for not obtaining consents and providing education to the resident and/or representative prior to administering the influenza vaccine did not give the resident and/or representative the ability to make an informed decision prior to the vaccine being administered. Findings include: 1. Review of R40's electronic medical record (EMR) under the Med Diag tab revealed the resident was readmitted to the facility on [DATE] and was over [AGE] years of age. Review of R40's Immunization Record located in the EMR under the Immun tab revealed R40 received the influenza vaccine on 10/05/23. There was no evidence in the EMR to show that a consent had been signed or that any education was provided to the resident and/or representative prior to the administration of the vaccine. 2. Review of R158's EMR under the Med Diag tab revealed the resident was admitted to the facility on [DATE] and was over [AGE] years of age. Review of R158's Immunization Record located in the EMR under the Immun tab revealed R158 received the influenza vaccine on 10/05/23. There was no evidence in the EMR to show that a consent had been signed, or any educations was provided to the resident and/or representative prior to the administration of the vaccine. 3. Review of R73's EMR under the Med Diag tab revealed the resident was originally admitted to the facility on [DATE], readmitted on [DATE], and was over [AGE] years of age. Review of R73's Immunization Record located in the EMR under the Immun tab revealed R73 received the influenza vaccine on 10/05/23. There was no evidence in the EMR to show that a consent had been signed, or any education was provided to the resident and/or representative prior to the administration of the vaccine. Additionally, the Immunization Record revealed R73 received a pneumococcal vaccine (PPSV23) on 12/20/17 at a local hospital. Per CDC guidelines, R73 should have received one dose of PCV15 or PCV20 at least one year after the last dose of PPSV23. There was no evidence in the EMR that the resident and/or representative were offered an additional pneumococcal vaccine. 4. Review of R7's EMR under the Med Diag tab revealed the resident was admitted to the facility on [DATE], readmitted on [DATE], and was over [AGE] years of age. Review of R7's Immunization Record located in the EMR under the Immun tab revealed R7 received the influenza vaccine on 10/05/23. There was no evidence in the EMR to show that a consent had been signed, or any education provided to the resident and/or representative prior to the administration of the vaccine. 5. Review of R96's EMR under the Med Diag tab revealed the resident was admitted to the facility on [DATE] and was over [AGE] years of age. Review of R96's Immunization Record located in the EMR under the Immun tab revealed R96 received the influenza vaccine on 10/05/23. There was no evidence in the EMR to show that a consent had been signed, or any education provided to the resident and/or representative prior to the administration of the vaccine. Additionally, the Immunization Record revealed R96 had received a pneumococcal vaccine (PPSV23) on 04/27/22. Per CDC should have received one dose of PCV15 or PCV20 at least one year after the last dose of PPSV23. During an interview on 07/18/24 at 11:10 AM, the Assistant Director of Nursing (ADON) confirmed there was not a current consent signed, or any education provided to the resident and/or representative before the above five residents were administered the flu vaccine on 10/05/23. No additional information was provided prior to the survey exit to show that R73 was offered the CDC recommended pneumococcal vaccine in December 2018 (a year after the PPSV23 was administered). Additionally, no further information was provided prior to exit to show that R96 was offered the CDC recommended additional pneumococcal vaccine in April 2023 (a year after the PPSV23 was administered). Review of the facility policy titled; Influenza Vaccine revised 07/05/22 revealed . 3. Prior to the vaccination, the resident (or resident's legal representative) will be provided information and education regarding the benefits and potential side effects of the influenza vaccine. Provision of such education shall be documented in the resident's medical record. 4. A resident's informed consent for the influenza vaccine shall be documented on the Resident Immunizations Authorization Form and placed in the resident's paper medical record . Review of the CDC recommendations, revised on 06/27/24, indicated . CDC recommends pneumococcal vaccination for all adults [AGE] years or older . For adults [AGE] years or older who have only received PPSV23 [Pneumococcal polysaccharide vaccine], CDC recommends you. Give 1 dose of PCV15 or PCV20. The PCV15 or PCV20 dose should be administered at least 1 year after the most recent PPSV23 vaccination. Review of the facility policy titled; Pneumococcal Vaccines revised 07/05/22 revealed . All residents will be offered pneumococcal vaccine(s) to aid in preventing pneumonia/pneumococcal infections . 1. Prior to or upon admission, residents will be assessed for eligibility to receive pneumococcal vaccine(s) and when indicated, will be offered the vaccine(s) within thirty (30) days of admission to the facility unless medically contraindicated, or the resident has already been appropriately vaccinated. 2. Assessments of pneumococcal vaccination status will be conducted within five (5) working days of the resident's admission if not conducted prior to admission . 7. Administration of the pneumococcal vaccines or revaccinations will be made in accordance with current CDC recommendations at the time of the vaccination.

Based on record review and interview, it was determined that the facility failed to place a discharge summary on resident's medical record after discharge. This was evident for 2 (#919 and #923) of 89 residents reviewed during the survey. The findings include: 1) Review of resident #919's medical record on 7/19/24 at 9:30 AM revealed no evidence of a discharge summary after the resident discharged from the facility on 2/4/24. In an interview with the Director of Nursing (DON) on 7/19/24 at 10:42 AM, the surveyor told the DON that he/she was unable to locate the provider discharge summary after reviewing the resident's medical record. The DON reviewed the progress notes and agreed that the facility failed to place a discharge summary on the resident's medical record. 2) Review of resident #923's medical record on 7/19/24 at 7:51 AM revealed no evidence of a discharge summary after the resident from the facility on 4/29/22. In an interview with the DON on 7/19/24 at 10:42 AM, the surveyor told the DON that he/she was unable to locate the provider discharge summary after reviewing the resident's medical record. The DON reviewed the progress notes and agreed that the facility failed to place a discharge summary on the resident's medical record.

Based on review of the medical record and interview with staff it was determined the facility staff failed to maintain complete and accurately documented medical records. This was evident for 2 (#924 and #914) of 89 residents reviewed during the survey. The findings include: 1) A Facility Reported Incident regarding an allegation of abuse on 2/9/22 involving Resident #924 was reviewed on 7/15/24 at 11:52 AM. The facility investigated the allegation and was unable to conclude that abuse occurred. The facility's final report indicated a nursing assessment was done and the resident had no injuries. The report also identified a plan which included but was not limited to a psychiatry consult for Resident #924. Resident #924's medical record was reviewed on 7/15/24 at 1:00 PM. The surveyor was unable to find documentation that a psychiatry consult was obtained in response to the incident. The surveyor was also unable to find a documented nursing assessment for injury of Resident #924 after the allegation of abuse was made. Further review of the record revealed a physician progress note dated 1/4/22. The next physician note was dated 5/6/22. The record failed to reveal documentation that the resident's medical provider addressed the resident's allegation of abuse on 2/9/22. On 7/16/24 at approximately 8:00 AM the surveyor requested copies of a nursing assessment, physician progress note, and psychiatry consult, related to the alleged incident, from the Administrator, and made her aware that the surveyor was unable to find the requested documentation in Resident #924's medical record. At 10:36 AM the same day, the Assistant Director of Nursing (ADON) indicated that the nursing assessment was probably in the Risk Management tab. She confirmed that although the Risk Management tab was part of the electronic system it was not part of the resident's medical record. She then reviewed resident #924's medical record with the surveyor to locate a nursing assessment but none was found. The ADON was made aware at that time that no psych consult or provider progress notes were found in addition to the nursing assessment. On 7/19/24 at 8:05 AM the ADON confirmed that she was unable to find a physician's progress note, a psychiatry consult or a nursing assessment related to the alleged incident in Resident #924's medical record. 42886 2) Review of resident #914's medical records on 7/16/24 at 9:00 AM revealed a progress note from a provider that was dated on 5/30/24 at 1:00 AM. The note would have been created before the resident was in the facility. The resident was admitted to the facility on [DATE] at approximately 8:30 PM. In an interview with the Director of Nursing (DON) on 7/16/24 at 1:00 PM, the surveyor pointed out the time on a provider statement in resident #914's medical record. The DON was unable to provide information on why the note was dated prior to the resident's admission.

Based on observation, interview and document review, the facility failed to provide resident's rooms that measured at least 80 square feet per resident in 77 of 77 multi-resident rooms. Rooms 100, 102, 104, 105, 107, 108, 109, and 110, measured 150 square feet. Rooms 300, 325, 326, 327, 331, 332, 333, 334, 335, 336, 337, 338, 341, 342, 346, 400, 411, 412, 421, 423, 424, 425, 426, 427, 431, 432, 433, 435, 436, 437, 438, 441, 442, 444, 446, 447, 500, 511, 512, 523, 524, 525, 527, 531, 532, 535, 536, 544, 545, 547, 600, 611, 612, 621, 622, 623, 624, 625, 626, 627, 631, 632, 633, 634, 635, 636, 637, 641 and 642 measured 155 square feet. This failure had the potential for residents to not have reasonable privacy or adequate space. Findings include: On 07/17/24 at 5:17PM, the Regional Director of Operations provided an untitled document from the Centers for Medicare & Medicaid Services (CMS) dated 07/16/19 which indicated the facility requested a waiver for the residents' room that did not measure 80 Square feet per resident in multi resident bedrooms. The document indicated the following rooms: Rooms: 100, 102, 103, 104, 105, 107, 108, 109, 110 measured 150 square feet. Rooms: 300, 325, 326, 327, 331. 332, 333, 336, 337, 338, 341, 342, 346, 400, 411, 412, 421, 423, 424, 425, 426, 427, 431, 432, 433, 435, 436, 437, 438, 441, 442, 444, 446, 447, 501, 511, 512, 523, 524, 525, 527, 531, 532, 535, 536, 544, 545, 547, 600, 611, 612, 621, 622, 623, 624, 625, 626, 627, 631, 633, 634, 635, 636, 637, 641 and 642 measured 155 square feet. During an interview on 07/18/24 at 10AM, the Regional Director of Operations provided a revised list of rooms. He stated that he reviewed the document dated 07/16/19, observed each of the rooms, measured the rooms, and found that some of the rooms were not included in the list (334, 335, 500 and 632) and other rooms should have not been included on the list (103 and 501). He confirmed that rooms 334, 335, 500 and 632 measured 155 square feet and that the room size measurements were correct as listed on the 07/16/19 document. During the interview, the Regional Director of Operations confirmed that the facility had 77 semi-private rooms and 46 private rooms. He confirmed that the 77 semi-private rooms were certified for two residents in the room. During Initial Pool Resident Interviews, none of the residents residing in these rooms voiced out concerns regarding the size of their rooms.

Based on medical record review and interview, it was determined the facility staff failed to maintain the medical record in the most complete and accurate form for a resident. This was evident for 1 of 57 residents )Resident #69) selected for medical record review during the annual survey process. The findings include: A medical record is simply a record of a resident's health and medical history. Consistent, current and complete documentation in the medical record is an essential component of quality resident care. Medical record review revealed that on 11/15/2018 the physician ordered: audiology consultation as needed, and eye consultation as needed. Further record review revealed the physician ordered: dental consultation. Throughout the survey process, it was determined the facility staff failed to obtain the dental consultation. Interview with Resident #69 on 5/29/2019 at 12:30 PM revealed no concerns related to teeth. The resident denied any chewing difficulties. Interview with the Director of Nursing on 6/3/2019 at 10:00 AM revealed the facility staff entered the order incorrectly and it should have been entered as: dental consultation as needed; however, the facility staff failed to maintain the medical record in an accurate manner. The facility staff conducts a 24-hour chart check which gives the nursing staff the opportunity to detect any errors in order entry during that 24-hour period. The facility also conducts monthly turn over orders, another opportunity to detect and correct any medical record errors. Interview with the Director of Nursing on 6/4/2019 at 1:30 PM confirmed the facility staff failed to maintain the medical record for Resident #69 in the most accurate and complete form.

Based on observation and staff interview it was determined that 1.) Facility staff failed to maintain a safe environment. This was observed during the initial tour of the fifth floor during an annual recertification survey; and 2.) Facility staff failed to put a system in place to provide housekeeping and maintenance services necessary to maintain a sanitary, order and comfortable interior and wheelchairs for residents. This was found to be true for 3 of 6 resident floors during the environmental observations of the facility. The findings include: 1.) Facility staff failed to maintain a safe environment. During an observation of the fifth-floor west unit activity area on 05/30/2019 at 9:42 AM, the surveyor observed exposed wires coming from an electric wall fixture leading to the solarium air conditioner unit. The nursing unit manager was made aware of the observation and called the maintenance department manager. 2.) Facility staff failed to put a system in place to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior and wheelchairs for residents. Surveyor observation on 5/29/19 at 12:55 PM on the 6th floor revealed; rooms 6E 625 and 622 had broken drawers in the dressers. Observation on 5/29/19 at 12:40 PM, room [ROOM NUMBER]E 611 was observed with broken drawers in the cabinet. Surveyor also saw used gloves in the sink basin and excessive debris in the air conditioning unit. Observation of the 4th floor on 5/29/19 at 10:19 AM revealed room [ROOM NUMBER]E 427 had damage to the wall underneath the sink, exposing the drywall. On 5/29/2019 at 9:36 AM the 4th floor West solarium was observed being used as a storage area for resident wheelchairs. Wheelchairs labeled FCLH-72 and FCLH-79 had dried crumbs and sticky residue on the seats. Another wheelchair with a purple tag attached to the leg was observed with crumbs stuck to the arm rests and seat. A red geriatric chair was observed with several tears on the right arm rest and back which exposed the underlying foam and not easily cleanable. During a tour on 5/29/2019 at 9:53 AM on the 5th floor East solarium a wheelchair with a blue tag was observed with dried food and crumbs on the leg rests and groin pad. Surveyor observation on 5/30/19 at 10:46 AM of the 5th floor revealed: room [ROOM NUMBER]W 541 had broken top drawers in the closet as well as the bed side table. Observation on 5/29/19 at 9:58 AM revealed room [ROOM NUMBER]E 512 with a brown stain on the bathroom ceiling tile. The Administrator was made aware of these concerns on 6/4/2019 at 10:57 AM. An interview was conducted with the Director of Environmental Services on 6/4/2019 at 11:35 AM. It was revealed that the wheelchairs were expected to be washed on a weekly schedule and should have been wiped down after meals. The Director of Environmental Services and acknowledged surveyors' findings on 6/4/2019.

Based on medical record review and interview, it was determined the facility staff failed to: 1.) initiate a resident specific care plan with interventions for Resident #69 and 2.) failed to initiate a comprehensive care plan for Resident #174 to address dental needs. This was evident for 1 of 3 resident selected for review of [MEDICAL TREATMENT] and 1 of 4 residents selected for review of dental concerns during the survey process and 2 of 57 residents selected for review during the annual survey process. The findings include: The Minimum Data Set (MDS) is part of the federally mandated process for clinical assessment of all residents in Medicare and Medicaid certified nursing homes. This process provides a comprehensive assessment of each resident's functional capabilities and helps nursing home staff identify health problems. Care Area Assessments (CAAs) are part of this process and provide the foundation upon which a resident's individual care plan is formulated. MDS assessments are completed for all residents in certified nursing homes, regardless of source of payment for the individual resident. MDS assessments are required for residents on admission to the nursing facility, periodically, and on discharge. At the time of each MDS assessment, the expectation of the facility staff is to initiate a care plan or revise a current care plan to reveal current and appropriate interventions. A nursing care plan contains all the relevant information about a patient's diagnoses, the goals of treatment, the specific nursing orders (including what observations are needed and what actions must be performed), and a plan for evaluation. Over the course of the patient's stay, the plan is updated with any changes and new information as it presents itself. 1. The facility staff failed to initiate a resident specific care plan with interventions for [MEDICAL TREATMENT]. Medical record review for Resident #69 revealed the resident was admitted to the facility with [DIAGNOSES REDACTED]. Healthy kidneys clean the blood and remove extra fluid in the form of urine. They also make substances that keep the body healthy. [MEDICAL TREATMENT] replaces some of these functions when the kidneys no longer work. In [MEDICAL TREATMENT], a [MEDICAL TREATMENT] machine and a special filter called an artificial kidney, or a dialyzer, are used to clean the blood. To get the blood into the dialyzer, the doctor needs to make an access, or entrance, into the blood vessels. This is done with minor surgery, usually to the arm. On 6/4/2018 the facility staff initiated care plan included [MEDICAL TREATMENT] and an intervention on that care plan was: monitor intake and output. Further record review revealed on 1/31/2019 the facility staff initiated a care plan: Fluid overload or potential fluid volume overload related to kidney failure and an intervention on the care plan was: monitor and document intake and output as per facility policy. The process of monitoring intake and output is to document the amount of fluid the resident consumes and the amount of urine the resident excretes to determine the amount in and the amount out is closely the same numerically. During the survey process, the surveyor asked to review the intake and output record for Resident #69 and interview with the Director on Nursing on 5/30/2019 at 12:00 PM revealed the care plans initiated for Resident #69 were generic and Resident #69 had not displayed any evidence of fluid overload and therefore intake and output would not be appropriate intervention. Further record review revealed the facility staff assessed the resident and completed MDS assessments on: 6/19/2018, 6/26/2018, 7/7/2018, 10/26/2018, 1/23/2019 and 3/20/2019; however, failed to revise the care plan to indicate accurate and appropriate interventions for Resident #69. Interview with the Director of Nursing on 6/4/2019 at 1:30 PM confirmed the facility staff failed to initiate resident specific care plan for Resident #69. 2. The facility staff failed to initiate a dental care plan for Resident #174. Medical record for Resident #174 revealed on 2/13/2019 the facility staff assessed the resident and documented on the MDS Section l-Oral/Dental: L0200 D- obvious or likely cavity broken teeth as Yes. Review of Care Area Assessment (CAA) -Section V- revealed the facility staff indicated dental care triggered and a care plan would be initiated. The Care Area Assessment (CAA) process provides guidance on how to focus on key issues identified during a comprehensive MDS assessment and directs facility staff and health professionals to evaluate triggered care areas. Further record review revealed no evidence the facility staff initiated the dental care plan. Further record review revealed the facility staff assessed Resident #174 and completed MDS assessments on 2/23/2019, 3/9/2019, 4/6/2019,5/4/2019 and 5/17/2019; however, failed to initiate a care plan to address dental needs of the resident. Interview with the Director of Nursing on 6/4/2019 at 1:30 PM confirmed the facility staff failed to initiate a dental care plan for Resident #174.

Based on interview and observation, it was determined the nursing staff failed to provide a resident with the most dignified existence. This was evident for 1 of 1 resident (Resident #86) reviewed during the annual survey for dignity. The findings include: On 5/29/2019 at 10:34 AM Resident #86 who is dependent on facility staff for all care, including dressing, was observed sitting in his/her wheelchair wearing black sneakers with white soles. The sneakers had Resident #86's last name written in black marker on the lateral side of the sneaker and on the bottom. The name was clearly visible by anyone. Resident #86 also had 9 pairs of shoes piled up under the head of his/her bed that were covered in dust. On 6/03/2019 at 12:30 PM during interview and tour with Unit Manager #17 the 9 pair of shoes were still piled up under the head of Resident #86's bed and covered in dust. The black sneakers observed on 5/29/19 were by the bed with Resident #86's last name visible from the doorway. The facility failed to honor Resident #86's dignity and the Unit Manager #17 was made aware on 06/03/19.

Based on medical record review and interview, it was determined that the nursing staff failed to ensure [MEDICAL TREATMENT] occurred on the ordered date which then contributed to this resident' s decline and re-hospitalization or inform a physician that a resident did not receive [MEDICAL TREATMENT] in one of 32 sampled resident records in the Stage 2 review. [MEDICAL TREATMENT] (HD) is a life sustaining treatment. [MEDICAL TREATMENT] utilizes a machine that filters wastes, salts and fluid from the body when the kidneys are no longer healthy enough to do this. [MEDICAL TREATMENT] is the most common way to treat advanced, permanent kidney failure. [MEDICAL TREATMENT] requires you to follow a strict treatment schedule, food and fluid diet and take medications regularly. [MEDICAL TREATMENT] can help take over your kidneys' job by controlling the blood pressure and maintaining the proper balance of fluid and various chemicals - such as potassium and sodium - in your body. Complications that can stem from missing [MEDICAL TREATMENT] are electrolyte imbalances or fluid overload (fluid accumulation and swelling of the lungs). The findings included: Resident # 261 was admitted to the facility with multiple [DIAGNOSES REDACTED]. By way of history, this resident was hospitalized from [DATE] to 01/11/2011 with a discharge [DIAGNOSES REDACTED]. The hospital Discharge Summary dated 01/11/2011, states: " Arrangements will be made for transferring the patient to long-term care for subacute rehabilitation. The patient will continue his [MEDICAL TREATMENT] sessions Monday, Wednesday, Friday. " This resident was admitted to the facility on Tuesday, 01/11/2011, at approximately 7:00 p.m. Review of the medical record revealed the following nursing note: 01/11/2011 at 11:40 p.m.: " [MEDICAL TREATMENT] on Mon(day) - Wed(nesday) & Fridays, all admission orders [REDACTED]. " Review of the " PHYSICIAN ORDER [REDACTED]. 01/11/2011: " [MEDICAL TREATMENT] Monday - Wednesday & Friday. " Further review of the medical record revealed that at no time did this resident on Wednesday, 01/12/2011 receive [MEDICAL TREATMENT]. Interview with the Director of the [MEDICAL TREATMENT] Unit on 02/09/2011 at 2:15p.m. confirmed that this resident did not receive [MEDICAL TREATMENT] on Wednesday, 01/12/2011. Interview with the Director of Nursing on 02/10/2011 at 2:00 p.m. confirmed that this resident did not receive [MEDICAL TREATMENT] on Wednesday, 01/12/2011. Continued reviewed of the nursing notes revealed the following: 01/12/2011 at 5:30 p.m.: ... " Patient c/o (complained of) not feeling well. " ... 01/12/2011 at 9:30 p.m.: " c/o SOB (shortness of breath) and chest pain. Prn (as needed) neb(ulizer) administered. O2 (blood oxygenation - normal 95 - 100%) sat(uration) 64 - 71%. No change after neb RX (treatment) administered. MD made aware. Pt (patient) transferred to (hospital) ER (emergency room ) via 911. Left at 9:30 p.m. " Review of the hospital Admission Note states: " He actually presented to (name of) Hospital early this morning for a chief complaint from the nursing home for respiratory distress as per the nursing home staff. He actually was having increased shortness of breath, not relieved by nebulizer treatments and also found to be [MEDICAL CONDITION] (rapid heartbeat, typically greater than 100 beats per minute) and tachypnic (rapid breathing, typically greater than 40 breaths per minute) and therefore was subsequently transferred to the hospital. " The resident ' s admitting [DIAGNOSES REDACTED]. The resident was emergently dialyzed. By the nursing staff failure to ensure [MEDICAL TREATMENT] occurred on the ordered date and to inform a physician that a resident did not receive [MEDICAL TREATMENT] contributed to this resident ' s decline of shortness of breath, tachypnea, chest pain, [MEDICAL CONDITION] re-hospitalization .