Every finding on record at Nature Trail Health and Rehab

Based on interview, observation and record review the facility failed to provide three meals daily and the additional ordered protein for a resident with a diagnosis of severe protein calorie malnutrition and failed to provide ordered supplements and/or additional food items for 2 ( R52, and R57) of 9 residents reviewed for weight loss in a sample of 43. These failures resulted in R57 experiencing a severe weight loss of 25.6 pounds or a 14.83% weight loss in one month. Findings include:1. R57's admission record documents an admission date of 11/04/25 with diagnoses including spondylosis without myelopathy or radiculopathy, critical illness myopathy, severe protein calorie malnutrition, monoclonal gammopathy, dependence of renal dialysis, contusion of unspecified part of head, fall from chair, osteophyte, acute on chronic systolic heart failure, abnormal posture, muscle wasting and atrophy, and end stage renal disease. R57's minimum data set (MDS) dated [DATE] documents a brief interview of mental status (BIMS) score of 12 indicating moderately impaired. R57's eating ability is listed as independent. R57's order summary report documents a dietary order of liberal renal diet with regular texture and thin liquid consistency with an order date of 11/19/25 with an order status listed as active. The same order summary report documents dialysis treatments 3 times a week at 9:45 AM every Tuesday, Thursday, and Saturday. R57's care plan documents a focus area of: R57 is/may be at risk for altered nutritional status related to: diuretic use, end stage renal disease, heart failure, receives dialysis, therapeutic diet, perforation of esophagus, severe PCM (protein calorie malnutrition), and metabolic encephalopathy dated 11/07/25 with interventions including: food preferences: likes hot/cold cereals, bread, biscuit and gravy, salad, jelly with pancakes, provide meals/snacks, fluids based on R57's food preferences and physician orders, and provide nutritional supplement(s) if/as ordered by physician dated 11/07/25. R57's Nutritional Risk Assessment dated 11/12/25 documents: weight status: BMI (body mass index) 19-27% with no weight change. The comment section documents: hospital weight ranged low 170's, usual body weight is unknown, BMI 23.2 barely within normal limit for age. The additional comments section documents: [AGE] year-old male here for therapy. R57 has a therapeutic diet ordered. R57 is new to dialysis, he is tolerating it to date. R57 has no pressure areas, he is at risk for malnutrition consistent with active PCM diagnosis. R57 would likely benefit from adding double protein to all meals. Based on trends and labs, dietary changes are possible. Registered Dietician will follow. R57's Nutritional Assessment (mini) dated 11/23/25 at 2:05 PM documents R57's most recent weight as 171.6 pounds dated 11/22/25 at 5:00 PM, R57's height is 72 inches. This assessment documents R57 had no decrease in food intake and no weight loss in the last 3 months. R57's assessment documents he as a BMI of 23 or greater. R57's weight and vitals summary documents weights on: 11/04/25 as 167.8 pounds, 11/08/25 as 169.2 pounds, 11/12/25 as 171.2 pounds, 11/20/25 as 172.6 pounds, and 11/26/25 as 147.0 pounds. This document indicates R57 has had a 25.6 pound weight loss, indicating a 14.83 % weight loss in less than 30 days. On 12/03/25 at 2:23 PM, R57 stated he believes last time he was weighed he weighed about 147 pounds. On 12/03/25 at 2:40 PM, V6 (Certified Nurse Aide/CNA) weighed R57. R57 stood up and walked up on the scale, R57 weighed 146.2 pounds. The facility menu dated week one, day two, titled, Diet Spreadsheet documents lunch liberal renal: beef ravioli (no sauce) 8each/#16 scoop, cauliflower 4 ounces, bread or roll with margarine 1 each/1pat, and spiced peaches 4 ounces. On 12/01/25 at 12:38 PM, R57 received his lunch in his room, he did not receive double protein with his lunch. R57 received 8 each beef ravioli with no sauce, cauliflower 4 ounces, bread, and spiced peaches 4 ounces. R57's meal card documents double portion protein, regular diet, liberal renal diet. On 12/01/25 at 12:38 PM, R57 stated the ravioli with no sauce does not look appetizing, couldn't they put something on the pasta. R57 stated he does dialysis on Tuesday, Thursday and Saturday and he has to get his own ride to dialysis on Saturday. R57 stated his daughter comes up from Paducah to take him to dialysis on Saturday. R57 stated he leaves the facility around 9 am and doesn't get back until around 4 pm. R57 stated they don't send him a lunch to dialysis. R57 stated, they bring him something when he returns which is usually around 3:30 PM to 4:00 PM, but if he eats something then he won't eat anything for dinner because it is almost dinner time when he returns. R57 stated so he only has breakfast and dinner those days. R57 stated when he eats at the facility the food is cold by the time it gets to him and isn't always good. The facility menu dated week one, day four, titled, Diet Spreadsheet documents lunch liberal renal: low salt baked chicken breast with pasta 3 ounces + 4 ounces spoodle pasta, tossed salad with low salt/low fat dressing 1 cup/2 tablespoons, and fruit pie 1/8th pie. On 12/03/25 at 12:42 PM, R57's dietary ticket dated week one, day four: low salt chicken breast, tossed lettuce salad with a line through the tossed lettuce salad, pasta with no sauce, and fruit pie. Under these items is listed double protein. On 12/03/25 at 12:42 PM, R57 was sitting in his room, he did not receive double protein with his lunch. R57 received a 3 ounce low salt baked chicken breast with 4 ounces pasta with no sauce, and one square fruit pie for dessert. On 12/03/25 at 12:42 PM, R57 stated he does not know why he did not get the lettuce salad, he has had them before and he does not know why he didn't get the double protein or the bread. R57 stated, the pasta does not look appetizing without anything on it, it is just cold and a lump of pasta with no flavor. On 12/03/25 at 12:48 PM, V11 (Dietary Manager) stated R57 can have a salad, the computer might have crossed it out due to he does not like cucumbers. V11 stated, there were no cucumbers on the salad and the kitchen did not catch it and she does not know why he did not receive bread. On 12/04/25 at 9:10 AM, R57 while sitting in his room stated, the sausage was burnt and cold, the scrambled eggs were cold, and the pancake was cold so he did not eat much. At that time there was only approximately one bite of the sausage eaten and only about three bites of the pancake eaten. On 12/04/25 at 1:14 PM, V11 (Dietary Manager) stated they do not send food with R57 when he goes to dialysis. V11 stated, she has not spoken with R57 about sending food with him to dialysis, if he would like that or if he would prefer having something when he returns. V11 stated, 7.5 hours is not an appropriate timeframe to go without food and she would discuss lunch and dialysis with R57. On 12/04/25 at 2:25 PM, V11 stated R57 should have received double protein with his meal and the food should be an appetizing temperature even if he eats in his room. On 12/04/25 at 1:46 PM, V12 (Registered Dietician) stated she had been notified of R57's weight drop on 11/26/25 or 11/27/25 but they were supposed to call back to confirm that weight with her and she has not heard back from them yet. V12 stated, she would expect R57 to receive the double protein at all meals as directed. V12 stated, that is not beneficial for R57 not to have lunch or something to eat three days a week. V12 stated, she will have to discuss things with R57 and V11 (Dietary Manager). On 12/04/25 at 2:10 PM, V2 (Director of Nursing) stated, they save R57's tray for him when he goes to dialysis, but that is not long between lunch and dinner with it only being approximately an hour to an hour and a half when he would get his tray due to his return time from dialysis, they will have to talk with R57 about sending something with him to dialysis. V2 stated, he should be getting the double protein as recommended. V2 stated, R57's weight loss is not desired for R57. V2 stated, the physician and V12 were notified of R57's significant weight loss. On 12/04/25 at 1:21 PM, V21 (Dialysis Nurse) stated they monitor R57's fluids there and take the fluid gain off from between the treatments. V21 stated, they do not pull anything off extra from him due to his stage of renal failure they want to leave him wet they do not want to pull anything extra from him and dehydrate R57. V21 stated, the weight loss is not due to anything they are doing at dialysis. The facility policy dated 11/22/24 titled, Weight Assessment and Intervention documents: any weight change of 5% or more since the last weight assessment will be retaken the next day for confirmation. If the weight is verified, nursing will immediately notify the dietitian in writing. The section title, Interventions documents: interventions for undesirable weight loss shall be based on careful consideration of the following: resident choice and preferences and nutrition and hydration needs of the resident. Interventions for undesired weight gain should consider resident preferences and rights. A weight loss regimen should not be initiated for a cognitively capable resident without his/her approval and involvement. 2. R52's admission record dated 12/4/25 documents an admission date of 6/28/19. The same admission record documents diagnoses including but not limited to Alzheimer's disease, major depressive disorder, and gastro-esophageal reflux disease with esophagitis. R52's physician order statement dated 12/4/25 documents active orders including but not limited to an order for a regular diet with mechanical soft texture, with nectar consistency liquids with a start date of 10/15/25, health shake to be administered one time per day with start date of 11/13/25, Med Pass 2.0 120 milliliters (health supplement drink) three times a day for weight loss with a start date of 7/17/25, and super cereal in the morning at breakfast with a start date of 6/14/2025. R52's most recent care plan documents a focus area for R52 stating she is/may be at risk for nutritional deficit. Interventions for this focus area include but aren't limited to provide nutritional supplement(s) if/as ordered by physician. R52's most recent minimum data set (MDS) dated [DATE] documents a brief interview for mental status score of 5 indicating R52 is not cognitively intact. R52's MDS documents R52 is dependent for eating assistance. Same MDS documents R52 has a weight loss of 5% or more in the last month or loss of 10% or more in last 6 months and she is not on a physician prescribed weight loss program. R52's weights documentation dated 12/4/25 documents a weight loss of 4 pounds from 10/29/25 at 125 pounds to 121 pounds on 11/26/25 indicating a 3% weight loss in one month. Registered Dietician's Note dated 11/12/25 documents R52 has a significant weight loss and is at risk for malnutrition. Same Registered dietician's note documents a weight loss percentage of 11% in 6 months. On 12/1/25 at approximately 1:00 PM, observed while R52 was in the dining room she did not have a health shake administered with her lunch tray. On 12/2/25 at approximately 1:00 PM, observed while R52 was in the dining room she did not have a health shake at lunch. R52's diet card documents R52 should be administered a health shake with her lunch meal. On 12/3/25 at approximately 12:30 PM, observed R52 in the dining room being assisted by staff with eating. R52's diet card documents R52's lunch meal for today should include ground chicken and dumplings, chopped chilled steamed vegetables, fruit pie, milk beverage, nectar thick liquids and a health shake. All items were present except the health shake. On 12/03/2025 at 11:58 AM, V15 (Licensed Practical Nurse /LPN) stated R52 has a health shake that should be administered at lunch by the kitchen according to the orders. On 12/04/2025 at 12:28 PM, observed R52 being assisted by staff with her lunch meal in the dining room. There was no shake present at meal. On 12/04/2025 at 12:40 PM, while R52 was being assisted with eating in the dining room, R52's diet card documents R52's meal for lunch should contain beef goulash, chopped carrots, and mandarin orange gelatin nectar thick and health shake that is highlighted. R52 has all the items present except the health shake documented on the meal ticket. On 12/04/2025 at 12:02 PM, V17 (Certified Nurses Aide/CNA) stated she does know R52 was getting her health shakes for a while at lunch meals but hasn't seen them with her meal in sometime. On 12/04/2025 at 12:06 PM, V20 (CNA) stated she has not seen R52 get her health shakes in a while. V20 stated she doesn't know if she is still ordered to have health shakes anymore. On 12/04/2025 at 12:53 PM, when this surveyor showed V11, Dietary Manager R52's lunch meal she could not explain why R52 did not have a health shake present with it. V11 stated most of the time health shakes are ordered to go out with meals. V11 stated as far as she knows R52's health shake should go out with her lunch meal. V11 stated she could not explain why R52's health shake had not been present for the past 4 days at lunch meal. V11 stated if R52's is ordered a health shake to be given at lunch meal she should be getting it at each lunch. On 12/04/2025 at 1:17 PM, V12, Registered Dietician stated she doesn't believe R52's recent weight loss could be contributed to her not getting her health shakes at her noon meal because the health shakes were only ordered in the past approximately 3 weeks. V12 stated R52's main weight loss was back in June 2025. V12 stated she recommended the health shake after the weight loss. V12 stated R52's weights have been stable for the past month. V12 stated though if R52 is ordered a health shake she should be offered it at the ordered time. Facility's weight intervention and assessment policy dated revised 11/22/24 documents, The multidisciplinary team will strive to prevent, monitor, and intervene for undesirable weight loss for our residents.

Based on interview, observation and record review the facility failed to provide a call light activation system in the community bathrooms and shower rooms. This failure has the the potential to affect all 60 residents residing in the facility.Findings include:On 12/02/25 at 2:20 PM in the shower room on the 200 hall across from room [ROOM NUMBER], the call light string by the toilet was behind the toilet and reaches approximately 3 inches above the bottom of the toilet tank. In this same bathroom, there is no call light available from the shower stall area.On 12/02/25 at 2:23 PM in the shower room on the 200 hall across and between rooms [ROOM NUMBERS], did not have a call light accessible near the toilet or the shower stall area.On 12/02/25 at 2:29 PM in the shower room on the 300 hall there was no call light accessible from the shower stall area. On 12/02/25 at 2:30 PM in the second shower room on the 300 hall, there was no call light accessible from the toilet or the shower area.On 12/02/25 at 2:39 PM in the shower room on the 100 hall, there was no call light accessible from the shower stall.On 12/04/25 at 11:43 AM, V4 (Maintenance Director) stated the toilets and shower stalls should have call light strings available and in reach to utilize if a resident was to fall. V4 stated, he would get them back up today. The Long-term care facility application for Medicare and Medicaid dated 12/01/25 documents 60 residents residing in the facility.The facility policy dated 08/20/22 titled, Call Light Guidance documents: a call light activation device shall be kept within resident reach while in resident rooms and bathrooms.

Based on interview, observation and record review the facility failed to provide warm water in the resident's rooms for 4 (R7, R23, R26, R48) of 6 residents reviewed for warm water in a sample of 43. Findings include:1. R7's admission record documents an admission date of 09/29/25 with diagnoses including: spondylolisthesis, chronic obstructive pulmonary disease, type 2 diabetes mellitus, severe protein calorie malnutrition, major depressive disorder, disorder of thyroid, anxiety disorder, muscle wasting and atrophy, and unsteadiness of feet. R7's MDS dated [DATE] documents a BIMS score of 14 indicating cognitively intact. R48's admission record documents an admission date of 10/10/25 with diagnoses including: disorganized schizophrenia, vitamin D deficiency, and anxiety disorder. R48's MDS dated [DATE] documents a BIMS score of 14 indicating cognitively intact.Room roster dated 12/1/25 documents R7 and R48 are roommates. On 12/2/25 at 10:00 AM a metal stemmed thermometer was calibrated using ice point method, measured 32.5 Fahrenheit.On 12/02/25 at 12:54 PM, R7 stated the water in her room does not get warm at all. R7 stated, she has told V4 (Maintenance Director) about it and he has stated they need to let the water run longer. On 12/02/25 at 1:08 PM the water temperature from the sink in R7 and R48's bathroom sink was measured with a calibrated metal stemmed thermometer, after running for over 10 minutes, it tested to be 67.5 degrees Fahrenheit.On 12/03/25 at 3:10 PM, R48 stated, the water is cold in her room.2. R26's admission record documents an admission date of 12/06/23 with diagnoses including: simple chronic bronchitis, emphysema, chronic obstructive pulmonary disease, heart failure, major depressive disorder, chest pain, anemia, arthropathy, anxiety disorder, and restless legs syndrome. R26's minimum data set (MDS) dated 10/21//25 documents a brief interview of mental status (BIMS) of 15 indicating cognitively intact.R23's admission record documents an admission date of 03/02/22 with diagnoses including: chronic respiratory failure with hypoxia, type 2 diabetes mellitus with hyperglycemia, polyneuropathy, hypothyroidism, sleep apnea, shortness of breath, chronic pain syndrome, dyspnea, and muscle wasting and atrophy. R23's MDS dated [DATE] documents a BIMS score of 15 indicating cognitively intact. Room roster dated 12/1/25 documents R23 and R26 are roommates. On 12/02/25 at 2:41 PM, R26 stated the water in her room sink does not get warm at all. On 12/02/25 at 2:41 PM the water temperature from the bathroom sink in R26 and R23's room was measured with a calibrated metal stemmed thermometer, after the water was left running several minutes it tested to be 71.0 degrees Fahrenheit. On 12/02/25 at 2:43 PM, R23 stated the water does not get warm. On 12/04/25 at 11:48 AM, V4 (Maintenance Director) stated he does not know why those two rooms on the 100 hall do not have hot water. V4 stated, he is aware of the situation but does not know how to fix it. Facility policy dated 07/18/22 titled, Quality of Care -Homelike Environment documents: residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their belongings to the extent possible.

Based on interview, observation and record review the facility failed to provide food the was at an appetizing temperature for 4 (R7, R39, R57, and R58) of 4 residents reviewed for cold food in a sample of 43.Findings include: On 12/4/25 at 7:02 AM a digital metal stemmed thermometer used for taking temperatures for this survey was checked for accuracy using the ice-point method and was accurate within +/_ 2 degrees Fahrenheit. On 12/04/25 at 8:34 AM the items on a sample breakfast tray were temped with a metal stemmed thermometer; the pancake was 80.6 degrees Fahrenheit and the sausage was 80.0 degrees Fahrenheit. The pancake and the sausage tasted cold and were unappetizing. 1. On 12/01/25 at 2:32 PM, R7 stated the food is not always great, R7 stated, sometimes it is burnt and cold. R7 was alert to person, place and time.On 12/03/25 at 12:56 PM, R57 stated the breakfast sausage is always cold and the eggs are cold, R57 stated, he was told once if he wanted hotter food, he should eat in the dining room. 2. On 12/04/25 at 9:12 AM, R57 who was alert to person, place and time stated the sausage was burnt and cold today and the pancake was not that warm either. 3. On 12/04/25 at 8:42 AM, R58 stated she usually eats in her room and her food is not always hot, especially breakfast. R58 was alert and oriented to person, place, and time. 4. On 12/04/25 at 8:43 AM, R39 stated she usually eats in her room and sometimes the food is barely warm. R39 stated, today the sausage and the pancake were not good. R39 was alert and oriented to person, place, and time.On 12/04/25 at 2:20 PM, V11 (Dietary Manager) stated the food whether it be served in the dining room or the resident's rooms should be served hot, not 80 degrees Fahrenheit. V11 stated she is not sure on if they have a policy for cold food.

Based on observation, interview, and record review the facility failed to ensure hand hygiene was performed per current standards of practice for 3 of 3 residents (R8, R12, R24) reviewed for infection control in the sample of 43. Findings Include: 1.R24's admission Record with a print date of 12/3/25 documents R24 was admitted to the facility on [DATE] and includes diagnoses of Guillain-Barre Syndrome, neuromuscular dysfunction of bladder, and urinary retention. R24's MDS (Minimum Data Set) dated 10/2/25 documents a BIMS (Brief Interview for Mental Status) score of 15, indicating R24 is cognitively intact. R24's current Care Plan documents a Focus area of (R24) has a need for indwelling catheter r/t (related to) neuromuscular dysfunction. This same Focus area includes interventions of, Provide catheter care every shift and as needed. Date Initiated: 10/19/25. R24's Order Summary Report dated 12/3/2025 document a physician order dated 4/10/25 to provide foley catheter care every shift and ensure catheter strap is in place unless contraindicated. On 12/03/2025 at 11:15 AM, V5 (Certified Nursing Assistant/CNA) was observed providing catheter care for R24. Throughout the observation of V5 providing catheter care to R5 she changed her gloves after cleaning the insertion site, after washing the tubing, and after drying the area. V5 did not perform hand hygiene between each glove change. On 12/3/25 at 1:49 PM, V5 (CNA) stated she should have performed hand hygiene between glove changes. V5 stated it just slipped her mind. 2.R8's admission Record with a print date of 12/3/25 documents R8 was admitted to the facility on [DATE] with diagnoses that include chronic kidney disease, heart failure, kidney disorder, anxiety disorder, and restless leg syndrome. R8's MDS dated [DATE] documents a BIMS score of 15 indicating R8 is cognitively intact. R8's current Care Plan documents a Focus area of, (R8) has an ADL (activities of daily living) self-care performance deficit r/t (related to) recent surgery, obesity, osteoarthritis, osteoporosis, CHF (congestive heart failure), hx (history) of falls, myoclonus. This Focus area includes intervention of, Toileting: 2 Person Assist. On 12/3/25 at 10:50 AM, V7 (CNA) and V8 (CNA) were observed providing incontinence care using current standards of practice. Throughout this observation V7 and V8 changed gloves after washing R8's peri area, after drying the peri area, after washing R8's buttocks, and after drying R8's buttocks. V7 and V8 did not perform hand hygiene between glove changes. On 12/3/25 at 1:50 PM, V7 (CNA) stated she didn't perform hand hygiene between glove changes, and she wasn't sure why. V7 stated she had hand sanitizer in her pocket. On 12/3/25 at 1:51 PM, V8 (CNA) stated she had hand sanitizer in her pocket and forgot to use it. 3.R12's admission Record with a print date of 12/3/25 documents R12 was admitted to the facility on [DATE] with diagnoses that include benign prostatic hypertrophy and hydronephrosis with renal and ureteral calculus. R12's MDS dated [DATE] documents a BIMS score of 14, indicating R12 is cognitively intact. R12's current undated Care Plan documents a Focus area of, (R12) has a need for indwelling catheter r/t neuromuscular dysfunction of the bladder. This Focus area includes intervention of, Provide catheter care every shift and as needed. R12's Order Summary Report dated 12/03/25 includes a physician order with a start date of, 9/11/25 Foley Catheter Care Every Shift . On 12/03/25 at 1:35 PM, V9 (CNA) and V10 (CNA) provided catheter care to R12 using current standards of practice. V9 and V10 changed gloves after cleaning the insertion site, after cleaning the tubing, after cleaning R12's buttocks and drying R12's buttocks. V9 and V10 did not perform hand hygiene between glove changes. V9 and V10 both stated they did not have hand sanitizer in the room and that is why they didn't perform hand hygiene between glove changes. The undated Handwashing/Hand Hygiene policy documents, This facility considers hand hygiene the primary means to prevent the spread of infections 3. Hand hygiene products and supplies .shall be readily accessible and convenient for staff use to encourage compliance with hand hygiene policies .8. Hand hygiene is the final step after removing and disposing of personal protective equipment .

The facility failed to ensure activities of daily living were provided for 2 of 3 (R24 and R52) residents reviewed for activities of daily living in the sample of 43 Findings Include: 1. R52's admission record dated 12/4/25 documents an admission date of 6/28/19. Same admission record documents diagnosis including but not limited to Alzheimer's disease, blindness one eye, and dementia. R52's minimum data set (MDS) dated [DATE] documents a brief interview for mental status score of 5 indicating R52 is not cognitively intact. The same MDS documents R56 is dependent upon staff for all activities of daily living (ADLs) including toileting, toileting hygiene, showering, and all personal hygiene. R52's most recent care plan documents R52 has an ADL self-care performance deficit related to her diagnoses of Alzheimer's disease, anxiety, major depressive disorder, and blindness. Interventions for this focus area include but are not limited to assist with activities of daily living including but not limited to dressing, grooming, and personal hygiene. On 12/02/2025 at 9:19 AM, R52's fingernails were observed to be long and dirty with brown dirt, dead skin, and/or other unknown substances under nails. On 12/03/2025 at 2:22 PM, R52's nails remain long and yellowed with what appears to be dirt under them untouched from yesterday's observation. On 12/03/2025 at 2:26 PM, V13, Certified Nurse's Aide (CNA) stated nail care is provided every Thursday and a checkup done on every Tuesday and as needed to make sure no one is in need of nail care. On 12/03/2025 at 2:29 PM, V14, CNA stated nail care for residents is provided at every shower, as needed, and on manicure day through activities. On 12/03/2025 at 2:30 PM, V5, CNA stated nail care for residents is provided daily and as needed for nail trimming and cleaning. On 12/03/2025 at 3:56 PM, V2, Director of Nurses stated there is not a specific time nail care is to be performed or checked for the residents. V2 stated it is something that should be done as needed. V2 stated when this surveyor showed V2 R52's nails, V2 agreed R52's nails were too long and appeared dirty at this time. On 12/04/2025 at 10:45 AM, R52's fingernails had been clipped, but they were still dirty underneath with what appears to be the same brown buildup of substances of unknown origin. On 12/4/25 at 3:18 PM, V1, Administrator stated nail care for residents should be provided at least during showers but also as needed and when Activities perform manicures. V1 stated she would expect for all residents' fingernails to be kept clean and trimmed to the length the resident desires. V1 stated if R52's nails were in the state this surveyor reported to her then they were unacceptable and should have been cared for prior to this surveyor's observations. Facility's ADL policy dated revised 5/2/23 documents, Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. hygiene (bathing, dressing, grooming, and oral care). 2. R24's admission Record with a print date of 12/3/25 documents R24 was admitted to the facility on [DATE] with diagnoses that include major depressive disorder, morbid obesity, and Guillain-Barre syndrome. R24's MDS (Minimum Data Set) dated 10/2/25 documents a BIMS (Brief Interview for Mental Status) score of 15, indicating R24 is cognitively intact. This same MDS documents R24 is dependent on staff for bathing. R24's current Care Plan documents a Focus area of, (R24) has an ADL self-care performance deficit r/t (related to) impaired mobility. This Focus area includes the intervention of, Asist with activities of daily living (i.e.: dressing grooming, personal hygiene, locomotion, oral care, etc.) as needed. The current Care Plan does not specifically address bathing as an intervention of focus area. On 12/01/2025 at 10:15 AM, R24 stated he doesn't get assistance with bathing as he should. R24 stated he is supposed to get assistance with bathing on Wednesday and Saturday. R24 stated he didn't know why he didn't get assistance with bathing at times. R24's Documentation Survey Report v2 dated November 2025 documents under Shower/Bathe Self Wed/Sat Days R24 received assistance with bathing on 11/5, 11/8, 11/12, 11/15, 11/19, and 11/29. This same report documents an NA (not applicable) on 11/26/25. This indicates R24 did not receive assistance with bathing from 11/19 until 11/29 (9 days). On 12/4/25 at 10:30 AM, V2 (Director of Nurses) stated she didn't know what NA meant on 11/26/25 under the shower/bath task for R24. On 12/4/25 at 10:53 AM, V2 stated NA meant not applicable. At 11:29 AM, V2 stated R24 went 9 days without assistance with bathing and she didn't know why. V2 stated he should have received assistance and should not go 9 days without being offered a bath/shower. The facility Bathing Policy dated 4/25/22 documents, Purpose: To provide guidance to facility nursing staff regarding the expectation of resident bathing. Policy: It is the expectation of this facility that residents will be offered a means of bathing at a time/day of their preference and by means of their choosing (shower, tub bath, bed bath, etc.) at least two times a week. This facility recognizes that residents have the right to refuse cares as a personal choice.

Based on interview and record review the facility failed to provide an influenza vaccination for 1 (R57) of 5 residents reviewed for immunizations in a sample of 43. Findings include:R57's admission record documents an admission date of 11/04/25 with diagnoses including: spondylosis, critical illness myopathy, severe protein calorie malnutrition, monoclonal gammopathy, dependence on renal dialysis, osteophyte, acute on chronic systolic heart failure, major depressive disorder, Alzheimer's disease, muscle wasting and atrophy, pleural effusion, candidal stomatitis, atrioventricular block, paroxysmal atrial fibrillation, and chronic systolic heart failure. R57's Minimum Data Set, dated [DATE] documents a brief interview of mental status of 12 indicating cognition is moderately impaired.R57's Vaccine Informed Consent Form dated 11/05/25 documents: influenza vaccine: Influenza vaccine I accept to receive with yes marked.R57's Immunization Report documents the most current influenza vaccination as 12/19/2022.On 12/04/25 at 11:31 AM, V2 (Director of Nursing) stated R57 has not received a influenza vaccination while he has been at the facility. V2 stated, she does not know why he did not receive the vaccination.The facility policy dated 09/2015 titled, Immunizations: influenza (Flu) vaccination of residents and staff documents: guideline: the advisory committee on immunization practices recommends vaccinating persons who are at high risk for serious complications from influenza, including those [AGE] years of age and older, who are residents of nursing homes. The association for professionals in infection Control (APIC), the centers for disease Control and Prevention (CDC), the Immunization Action Coalition and the National Foundation for Infectious Disease all recommend that health care workers be immunized as well, because they work in close contact with residents. Administration procedure: current and newly admitted residents and al staff will be offered the influenza vaccine from October of each year through the end of March the following year (unless CDC extends the immunization season).

Based on interview and record review the facility failed to ensure a care plan meeting was conducted for 1 of 3 (R5) residents reviewed for care plan meetings in the sample of 43. Findings Include:R5's admission Record with a print date of 12/3/25 documents R5 was admitted to the facility on [DATE] with diagnoses that include heart failure, dysphagia, diabetes, and bipolar disorder. R5's Minimum Data Set, dated [DATE] documents a Brief Interview for Mental Status score of 13 this indicates R5 is cognitively intact. R5's current medical record did not document a signature sheet or progress notes indicating a care plan meeting was conducted for R5. On 12/01/25 at 11:00 AM, R5 stated he had not been invited to a care plan meeting. On 12/2/25 at 2:59 PM, V3 (Social Services) stated she couldn't find a signature sheet for the care plan meeting. V3 stated she was unable to locate documentation in R5's progress notes/medical records a care plan meeting had been conducted. The facility was unable to provide reproducible evidence a care plan meeting had been conducted for R5. The facility Care Plan policy dated 1/11/23 documents, Purpose: To provide guidance to the facility in developing, implementing and communicating the individualized plan of care of residents The resident, the resident's family and/or the resident's legal representative/guardian or surrogate are invited and encouraged to participate in the development of and revisions to the resident's care plan. 4. Every effort will be made to schedule care plan meetings at the best time of the day for the resident and family .

Based on observation, interview, and record review, the facility failed to ensure proper and safe administration of medications in accordance with facility policy for 2 (R1, R3) of 3 residents reviewed for pharmacy services in the sample of 13. Findings Include: 1. R1's Transfer/Discharge Report documented an admission date of 2/24/2025 and included diagnoses of bradycardia, heart failure, hypertension, type 2 diabetes mellitus with other circulatory complications, weakness and unsteadiness on feet. R1's Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15, which indicates R1 is cognitively intact. R1's Care Plan had no documentation of self-administration of medications being a goal or focus area for R1. V2 (Adult Protective Specialist) stated, she had direct care with R1 for the past year. V2 stated, R1 had been staying at this facility temporarily until another placement could be arranged. V2 stated, she came to visit R1 on 5/23/2025 around 8:00 am in the morning. V2 stated, when she walked into R1's room, she had been lying in her bed, covered up with blankets and a pillow resting over her head. V2 stated, R1 does prefer to sleep this way. V2 stated, when she entered R1's room, she noticed a medicine cup with medications sitting on R1's assistive device chair cushion. V2 stated, she woke R1 up and R1 stated, she did not know they had left her medications for her this morning, but they normally leave her medications for her because she does not like to get up in the mornings and go to the dining room. On 5/29/2025 at 10:57 AM, R1 stated she does get medication administered to her by the facility. R1 stated, the facility nurses will leave her medication, including eye drops at her bedside without telling her they are there. R1 stated, the nurses say she is too hard to wake up in the mornings. R1 stated V2 did come to visit her on 5/23/2025 sometime after 8:00 AM and woke her up. R1 stated, V2 did observe her medications in a medicine cup sitting on her assistive device cushion. R1 stated her nurse that morning was V6 (Registered Nurse/RN), and she did not wake her up to give her the medications. R1 stated, the facility nurses had been leaving her medication at her bedside more frequently than before. On 5/29/2025 at 12:39 PM, V6 (RN) stated she did work R1's hall on 5/23/2025. V6 stated, she did administer R1's medications to her that morning, signed them off in her electronic health record and does not remember leaving them at her bedside table. V6 stated, R1 is very hard to wake up in the mornings. R1's Medication Administration Record (MAR) documented on 5/23/2025 at 8:00 AM fenofibrate oral tablet 160 MG (milligrams) 1 tablet given by mouth one time a day, ferrous sulfate oral tablet 325 1 tablet by mouth one time a day, furosemide tablet 40 MG 1 tablet by mouth one time a day, glycoLax powder 1 scoop by mouth one time a day, losartan potassium oral tablet 100 MG give 1 tablet by mouth one time a day, protonix oral tablet delayed release 20 MG 1 tablet by mouth one time a day, tamsulosin oral capsule 0.4 MG 1 capsule by mouth one time a day, acetaminophen oral tablet 500 MG 2 tablets by mouth two times a day, azelastine ophthalmic solution 0.05 % instill 1 drop in both eyes two times a day, menthol topical analgesic the pain external gel 4% apply to right shoulder/neck and apply to top of feet and ankle topically two times a day, docusate sodium capsule 100 MG 100 mg by mouth two times a day, apixaban tablet 5MG 1 tablet by mouth two times a day, and pregabalin 50 MG 1 tablet by mouth two times a day, administered by V6 (RN). 2. R3's Transfer/Discharge Report documented an admission date of 2/10/2025 and included diagnoses of alzheimer's disease, chronic kidney disease, major depressive disorder, single episode, severe without psychotic features, and essential hypertension. R3's MDS assessment dated [DATE] documented a BIMS score of 11, which indicates moderate cognitive impairment. R3's Care Plan had no documentation of self-administration of medications being a goal or focus area for R3. On 5/29/2025 at 10:27 AM, R3 stated the nurses in the facility will leave her medications on her bedside table for her to take. R3 stated, she has her morning medications sitting in her room on her bedside table right now waiting for her to take them. R3 stated, V4 (Licensed Practical Nurse/LPN) brought them to her earlier this morning but she was not taking them until after she had her cigarette. On 5/29/2025 at 10:35 AM, R3's medication cup was observed on her bedside table with 4 pills in the cup. 1 pill was blue, 1 pill was green, 1 pill was white and round shaped and 1 pill was white and oval shaped. On 5/29/2025 at 10:37 AM, V4 (LPN) stated he did bring R3 her medications at 8:30 AM this morning, sat them on R3's bedside table and left the room. V4 stated, he is unaware if the facility has a policy that states medications cannot be left at the bedside. R3's Medication Administration Record documented on 5/29/2025 at 8:00 AM, amlopidine 10 mg (milligrams) 1 tablet by mouth one time a day, atorvastatin 40mg 1 tablet given in the morning, losartan potassium 100 mg tablet given in the morning, and sertraline 50 mg tablet administered by V4 (Licensed Practical Nurse/LPN). On 5/29/2025 at 10:39 AM, V3 (Director of Nursing/DON) stated, it is her expectation that medication should be administered as ordered and not left at the bedside table for any resident. V3 stated, if a resident is not able to take the medications at that time, then the nurse should take the medication back to the nurse's cart with them. On 5/29/2025 at 10:42 AM, V1 (Administrator) stated, it is her expectation that medications are not left at the bedside table for residents and staff should follow the facility's policy and procedures. The facility Medication Administration Policy/Procedure (revised 9/27/22) documented the purpose was To ensure proper administration of oral medications. Under Policy: Medications will be administered safely to residents within the facility by licensed nurses at the specified time/timeframe, following the recommended administration method and will be documented as required. Under Responsibility, the policy states It is the responsibility of all licensed nursing staff to safely administer medications to residents. The policy further documents: 5. Identify the individual and explain what is to be done .8. Follow the specific instructions listed for each type of medication to be given. Offer adequate fluids with medications .9. Ensure medication has been swallowed before leaving .a. If medication if refused, chart refusal and notify physician and family/power of attorney.

Based on interview and record review the facility failed to implement interventions to prevent falls for 1 of 6 (R122) residents reviewed for falls in a sample of 55. This failure resulted in R122 falling and sustaining a left intertrochanteric fracture and subsequent hospitalization . The Findings Include: R122's Admission Record documents an admitted [DATE] with diagnoses including unspecified dementia, weakness, and atrial fibrillation. R122's Admission Record documents a date of discharge og 1/14/25 to a local acute care hospital. R122's Order Summary Report with a print date of 1/31/25 documents an order for a bed alarm and chair alarm every shift with an order date of 1/8/25. R122's Care Plan has a focus area of being at risk for falls and injuries related to weakness, CVA (cerebral vascular accident), and Atrial Fibrillation. The goal for this focus area is to decrease risk of fall and/or minimize injuries form falls for 90 days. The interventions for the focus area include: assist to toilet prior to laying down with an initiation date of 1/13/25, bed and chair alarms in place with an initiation date of 1/8/25, and mat at bedside when in bed date with an initiation date of 1/13/25. R122's Minimum Data Set (MDS) 5 day assessment dated [DATE] Section J documents that R122 did not have a fall prior to admission. This same section documents R122 had one fall with a minor injury and one fall with a major injury after admission. The same MDS Section C documents a Brief Interview of Mental Status (BIMS) score of 11, indicating that he has moderately impaired cognition. R122's Progress Note dated 1/8/25 documents Resident is a high fall risk. New orders received for bed/chair alarm. Alarms in place at this time and functioning properly. R122's Progress Notes dated 1/11/25 document the following: 6:57 PM: notified POA (Power of Attorney), MD (Medical Doctor), and V2 (Director of Nursing/DON) of situation and R122 was being transferred to the local emergency room via EMS (Emergency Management Services) for evaluation. 7:04 PM: Resident had an unwitnessed fall while eating dinner in his room. Resident had small red mark on head back of head, roommate stated he witnessed him hit his head when he fell . Family called, DON notified, MD notified. Report called into (name of local hospital), and EMS notified. Report given to (name of nurse at local hospital), all information passed along and questions answered. EMS arrived as report to (name of local hospital) was finishing up. Resident was transferred via one assist on to gurney. Paperwork given to EMS, all information passed along and questions answered. Resident was secured and loaded into ambulance. R122's Unwitnessed Fall report dated 1/11/25 documents under the incident description: CNA's (Certified Nurse's Assistant) reported to nurse (self) that resident had fallen on the floor. Fall was not witnessed. Roommate stated resident hit head when he fell . Resident stated he was trying to get up but could not state why he was getting up. Resident was hoyered (used a mechanical lift) from floor 3x assist. Resident denied pain, but had a small red bump on head. Sent to hospital due to resident being on blood thinners for precautionary measures due to inability to judge confusion level due to resident's normal cognitive state. Resident stated he was trying to get up but could not remember why. Resident is unsure if he hit his head or not. This same document lists the root cause of the incident: R122 attempted to stand up out of bed unassisted and fell , hitting his head. Intervention is to assist R122 to toilet before assisting to bed. R122's Progress Note dated 1/13/25 at 5:34 PM it is documents: Resident slid out of his bed onto his bedroom floor at 0630 (6:30 AM) this morning. Resident received a head-to-toe assessment. VS (vital signs) and neuro (neurological checks) started per facility protocol. Resident was assisted back into his wheelchair with 2 staff. Resident denied any pain or discomfort at this time. Resident expressed pain and discomfort at approximately 1100 (11:00 AM) of L (left) hip. (MD) was notified and received orders for L hip and pelvic X-ray. Notified (name of mobile X-ray company) and waiting for call back. Resident c/o (complains of) pain to L should while doing PT (Physical Therapy). (MD) notified again, and received orders to add L shoulder to x-ray. Resident had x-ray completed at 1651 (4:51 PM). Awaiting results. Resident is currently resting in his room. R122's Progress Note dated 1/14/25 at 1:01 AM documents that a call was received with x-ray results indicating a left intertrochanteric fracture. A facility Incident Report dated 1/13/25 at 6:30 AM documents that R122 was oriented x1 and had no injury to report. The investigative statement on this report documents that R122 stated he was ready to get in his wheelchair. R122 stated then that he thought he could do it himself, and before he knew it he had slid onto the floor, sitting on his bottom. This report documents under actions: a fall assessment, skin assessment, a pain assessment were completed and diagnostic services ordered. On 1/30/25 at 2:31 PM, V4 (Certified Nurse Assistant/CNA) stated that she was the staff member who found R122 on the fall that occurred on 1/11/25. V4 stated that she heard a loud noise and ran to his room and found him on the floor. V4 stated that there was no fall mat observed in the room and R122 did not have an alarm sounding. V4 went on to state that he would not ever stay still and did not listen to reminders of not getting up to walk alone. V4 stated that she found him close to the doorway, and thinks he was likely getting up to go to the bathroom. V4 stated that he was refusing to want to use a mechanical lift to get up from the floor and did not want to go to the hospital, but she got help from the staff to assess him properly and R11 did go to the emergency room since they were unsure of whether he hit his head. On 1/30/25 at 2:38PM, V7 (CNA) stated on a telephone interview that she was the staff that found R122 on his fall that occurred on 1/13/25. V7 stated that she has just clocked out for the shift but was waiting to let her car warm up when she came back in the facility and walked by R122's room and saw him on the floor. V7 stated that she got staff to assist her with getting him assessed by the nurse and back in his chair. On 1/30/25 at 2:45PM, R44 who is alert to person, place and time stated that he was R122's roommate and the alarm did not sound for either of the falls. R44 stated that he remembers R122 getting up and being all wobbly and that he couldn't do anything to help him because he is unable to walk. On 1/30/25 at 2:55PM, V2 (Director of Nursing) stated that the CNA's check placement and function at the start of each shift of resident's bed/chair alarms. V2 stated that she is unsure why the alarm did not sound after each of the falls. V2 stated that all the alarms at the current time are working. V2 went on to state that the alarm should have been placed both in the chair and in the bed. On 1/30/25 at 2:55 PM, V1 (Administrator) stated that R122 was here a very short time and had a couple of falls. R122 stated that after the second fall he never returned to the facility as planned due to going on hospice and expiring at the hospital. On 1/20/25 at 3:38 PM, V5 (CNA) and V6 (CNA) stated that they check placement and function every shift for alarms. On 01/31/2025 at 12:44 PM, V17 (Licensed Practical Nurse) stated she was the nurse the night of 01/11/2025. V17 stated that she had just started her shift at 6:00 P.M. V17 stated that it had been reported to her that R122 had been restless for day shift and had gotten up and down all day from his bed and chair. V17 stated it was her understanding that R122's baseline is that he is confused. V17 stated that she was alerted by the CNA that R122 had fallen. R122's emergency room provider notes, dated 1/14/24 at 3:37 AM from the local hospital, documents under chief complaint that R122 is from the nursing home and presents with complaint of left hip pain. Per nursing home report patient had a fall this morning x-ray report this evening showing left hip fracture. History is limited by patient's mental status. It is unclear if he had any associated head or neck injury. Differential diagnosis includes likely hip fracture, less likely head or cervical spine injury. The hospital records document CT (Computed Tomography) results for the head and cervical spine dated 1/14/25 are negative for fractures. An Orthopedic Consult dated 1/14/25 documents a recommendation of surgical repair. A Brief Op (Operative) Note dated 1/15/25 documents that R122 had an Open Reduction Internal Fixation of the left hip/ trochanteric (fixation nail) performed.

Based on observation, interview, and record review the facility failed to provide services to increase and/or prevent further decrease of range of motion (ROM) for 5 (R23, R28, R3, R37, and R52) of 5 residents reviewed for decreased range of motion in the sample of 55. Findings Include: 1. R23's Admission Record documented R23 as a [AGE] year-old with an admitted to the facility of 03/16/2024. Diagnoses listed are hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, other immunodeficiencies, type 2 diabetes mellitus, essential hypertension, lymphedema, generalized anxiety disorder, hyperlipidemia, and embolism and thrombosis of superficial veins of left lower extremity. R23's Order Summary Report with a print date of 01/31/2025 does not document an order for any range of motion or restorative nursing program. R23's Quarterly Minimum Data Set (MDS) dated [DATE] noted that R23's Brief Interview for Mental Status (BIMS) score is 15 which indicates R23 is cognitively intact. Section GG documents for functional limitation in range of motion that R23 has impairment on one side for both upper and lower extremities. Section GG for self-care documents that R23 is dependent for shower/bathing, upper body dressing, lower body dressing, and putting on and taking off footwear. Section O of the same MDS documents R23 received 0 days of range of motion and 0 days of passive range of motion (with a look back period of 7 days.) R23's Care Plan, with a start date of 03/18/2023, documents a focus area of R23's Self-Care Deficit as evidenced by needs assistance with activities of daily living related to left sided weakness. Interventions listed include: encourage the resident to participate to the fullest extent with each interaction and encourage resident to discuss feelings about self-care deficit. The Focus area documents that R23 has hemiplegia/hemiparesis with interventions listed as bowel / bladder program, discuss the residents' concerns and fear, and give medications as ordered. R23's document titled Occupational Therapy (OT) Evaluation and Plan of Treatment dated 09/05/2024 under Musculoskeletal System Assessment documented right upper extremity range of motion within functional limits, left upper extremity impaired, left upper extremity hemiplegia - patient unable to perform active range of motion, but passive range of motion within functional limits for shoulder/elbow/forearm. Increased tone noted in left hand / wrist but 50% gross passive range of motion achieved in digits. Functional limitations as result of contracture left upper extremity hemiplegia contributing to left hand contracture risk and reduced ability to utilize left hand. R23's document titled Notice of Discharge From Therapy dated 10/2/24 documents that resident is to continue with restorative measures with a date of discharge from therapy of 10/4/24. On the bottom of this same form, it documents for R23 to do AROM (Active range of Motion) bilateral upper and lower extremities and utilize the bike for lower extremities. On 01/28/2024 at 10:50 A.M., R23 stated he does not receive any therapy or range of motion from the facility. R23 stated he was supposed to get therapy 3 times a week and he stated he doesn't get it at all. R23 stated he would like to go to therapy to lift weights and ride the bike, but the staff tell him he can't. R23 stated he would like to attempt to walk. R23 stated he feels like he is stiff as a robot. On 01/29/2025 at 1:23 P.M.V15 (Certified Nurse Assistant/CNA) was observed performing AROM to R23's right side. V15 asked resident to open and close hands, asked resident to move his foot up and down, asked resident to open and close his hand, asked resident to open and close arm at the elbow, and asked resident to move his head. There was no range of motion completed to the left side of R23's body. This observation ended at 1:27 P.M. 2. R28's Admission Record documented R28 as a [AGE] year-old with an admitted to the facility of 03/16/2024. Diagnoses listed are Parkinson's disease, unspecified dementia, chronic obstructive pulmonary disease, essential hypertension, major depressive disorder, and anxiety. R28's Order Summary Report with a print date of 01/31/2025 does not document an order for any range of motion or restorative nursing program. R28's Quarterly MDS with a date of 01/06/2025 noted that R28's BIMS score is 09 which indicates R28 has moderate cognitive impairment. Section GG documents for functional limitation in range of motion that R28 has impairment on one side for both upper and lower extremities. Section GG for self-care documents that R28 is dependent for oral hygiene, toileting hygiene, shower/bathing, upper body dressing, lower body dressing, and putting on and taking off footwear. Section O of the same MDS documents R28 received 0 days of range of motion and 0 days of passive range of motion (with a look back period of 7 days.) R28's Care Plan documents a focus area of R28 has an activity of daily living self-care performance deficit related to deconditioning. Interventions listed for the focus area include: R28 requires extensive assistance of one staff for bathing, extensive assist of one for turning and repositioning in bed, extensive assist of one for dressing, the resident required mechanical lift with two staff assistance for transfers and physical therapy (PT) / occupational therapy (OT) evaluation and treatment as per physician orders. R28's Occupational Therapy (OT) Evaluation and Plan of Treatment with a start date of 10/12/2023 documented under musculoskeletal system assessment upper extremity range of motion impairment on the right and left. On 01/29/2025 at 1:27 P.M. V15 performed AROM to R28. V15 asked resident to move both feet back and forth, asked resident to wiggle his toes, asked resident to move his legs up and down, asked resident to move his hand up and down, asked resident to move his arms up and down, and asked resident to move his head. Observation ended at 1:31 P.M. with CNA leaving room to go get R28 hot chocolate. On 01/30/2025 at 9:00 A.M., V3 (Physical Therapy Assistant) stated that after the resident is off therapy they leave the facility a restorative plan . V16 stated that the facility does not do PROM (Passive Range of Motion) as restorative therapy. She stated that the facility considers dressing a resident passive range of motion. V16 stated that dressing a resident may not prevent the decline in mobility in some residents. She stated that it all would depend on the resident. On 01/30/2025 at 9:42 A.M., V16 (Licensed Practical Nurse / MDS Nurse) stated that when she was trained to do MDS she was told that she cannot code section O0500 as anything but a 0 because they do not have a structured restorative program. 49664 3. R3's document titled Admission Record documents an admitted [DATE] with diagnoses including Intracranial Injury without loss of consciousness subsequent encounter, Chronic Obstructive Pulmonary Disease, Aphasia, Dysphagia, GERD, Paraplegia, Hypertension, and Contractures of the Right Knee, Left Ankle, Right Ankle, and Right Hip. R3's MDS dated [DATE] documents R3's cognition is severely impaired. Section GG documents under Functional Limited Range of Motion documents that R3 has impairment on both sides for upper and lower extremities and R3 is dependent for toilet hygiene, showers, upper body, and lower body dressing, putting on and taking off footwear, personal hygiene, rolling left to right, lying to sitting on side of bed, chair- chair transfer and toilet/shower transfer. R3's Care Plan documents a Focus area of R3 requires assistance with ADL's (Activity of Daily Living) related to paraplegia contractures, aphasia, pain, enteral feeding, TBI (Traumatic Brain Injury). R3's Goals document R3 will have ADL needs identified and met with staff assistance and interventions while maintaining highest level of independent function possible to review date every 90 days. Documented Interventions include: Head of Bed elevated 30 degrees always except brief ADL care, oral care every shift, provide assistance with required completion of ADL task, and up in specialized wheelchair as tolerated. R3's Occupational Therapy OT Evaluation and Plan of Treatment, authored by V3 (Therapy Director) documents a discharge date from therapy of 12/31/2024 with reason noted of Resident reached maximum potential. Under objective progress/short term goals R3 has a baseline date of 10/25/2024 with a target date of 11/7/2024, the patient will improve right upper extremity elbow hypertonicity with application of elbow extension split to reduce further progressing/development of contracture. On 1/30/2025 at 11:10 AM, V13 (Restorative Certified Nurse Assistant) stated she was the one that does all the restorative programs. V13 stated she does not have written programs and she just does what is needed for the residents. V13 was asked if she follows any guidelines as to how many reps are done on the affected joints, V13 stated no we do not have any guidelines like that. V13 stated she does see R3 on a regular basis for range of motion. V13 stated that R3 loves to be stretched out and by Friday he is usually much looser where he has contractures but then on Monday, we must start the process all over again. V13 was asked how she knew who to see for restorative purposes, V13 stated I usually see who needs to be seen and sometimes physical therapy will tell me to pick someone up after they complete therapy. V13 was asked if therapy gave her a plan of care to follow and she said they will tell me what needs to be done. V13 stated she sees R3 everyday Monday through Friday usually, but she has been off sick, and she doesn't think it was done while she was off sick. V13 stated R3 does not have splints. On 1/28/2025, 1/29/2025, and 1/30/2025, R3 was noted to be up in specialized wheelchair with noted contractures to right upper extremity, right lower extremity, right and left ankles. On 1/31/2025 at 9:45AM, V12 (Certified Nurse Assistant/CNA) stated she does not do PROM for R3, V12 stated the restorative duties are done by the restorative aid. On 1/31/2025 at 9:48AM, V10 (Certified Nurse Assistant/CNA) stated she care for R3 and is not responsible for any type of ROM because the restorative aid does all of that and the restorative CNA is V13. On 1/31/2025 at 2:22PM, V14 (Regional Clinical Director) stated he was not familiar with the Restorative Program and was unsure about the MDS. V14 stated he was not sure about the programs and who wrote the programs. V14 stated he was aware that a lot of companies are moving away from restorative programs due to financial issues. V14 stated there really were not programs written for the residents and most of the residents are on walk to dine programs. V14 stated there are only 2 contractures in the facility that she is aware of. V14 stated there are other residents with splints and devices like that. On 1/31/2025 at 10:15 AM, V13 (Restorative Certified Nurse Assistant) was observed doing PROM on R3 while R3 was in bed. V13 had placed warm compress to right shoulder and right knee. V13 did not do range of motion to right shoulder or right upper extremity. V13 did 5 reps of knee extension to right knee and 5 reps of rotation to right ankle were done. No PROM was completed to left ankle. 36384 4. R37's Admission Record documents an admitted [DATE] with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side, aphasia following cerebral infarction, and personal history of Transient Ischemic Attack. R37's December 17, 2024 quarterly MDS Section GG documents that under Functional Limitation Range of Motion is impaired on one side for both upper/lower extremity. This same MDS Section O0500 documents zero days of restorative nursing program for active/passive range of motion was completed in a look back period of 7 days. R37's care plan documents a focus area of: R37 has a self-care deficit as evidenced by needing assistance with ADL's related to hemiplegia. The goal for this focus area is: R37 will continue to perform current level of ADL function through review date. The Interventions for this goal include: PT/OT evaluation and treatment as physician orders. R37's OT Evaluation and Plan of Treatment dated 6/20-24-7/30/24 documents under the musculoskeletal assessment that R37 has a contracture of left hand will treat and address the impairment. R37's PT Evaluation and Plan of Treatment dated 6/19/24-7/29/24 documents under the musculoskeletal assessment that R37's left lower extremity range of motion is impaired. On 1/29/25 at 1:52 PM, V8 (Certified Nurse Assistant) stated that she works all three halls on any given day. V8 stated that she tries to work with residents if they have exercises posted in their room, or if she sees that they are having any problems straightening out any joints. V8 stated that not all residents necessarily receive daily active or passive range of motion whether they are receiving therapy services or not. V8 also stated that she doesn't really follow a program when doing any type of exercises, she just tries to work on what they can tolerate. On 1/28/25 at 9:30 AM, R37 who is alert to person, place and time stated that he does not get any type of daily exercises or therapy from the staff, but he would like to. R37 stated that no type of exercises are done on his left hand that he has a brace on it from a previous stroke. R37 stated that he does not usually participate in any of the activities, rather he enjoys being outside when the weather permits. R37's Notice of Discharge From Therapy dated 7/26/24 documents a discharge date from therapy of 7/30/24 and lists that the therapy recommends active range of motion on bilateral lower extremities. On 1/30/25 at 8:30 AM, V1 (Administrator) stated that they get rescreened after 30 days after discharge off therapy. They are not necessarily all receiving a restorative programs, other than group exercise activities and ADL's. On 1/30/25 at 8:32 AM, V3 (Therapy Director) stated that the residents are screened 30 days post discharge off therapy services and then at minimum every quarter on the MDS schedule. V3 went on to state that if there is a decline noticed by any nursing staff they can refer to therapy for a screening at any time. 4. R52's admission record documents an admitted [DATE]. This same documents includes the following diagnoses: spondylopathies cervical region, alcohol dependence, and PTSD. Review of R52's current Care Plan has a focus area for self-care deficit as evidence by: R52 needs assistance with ADL's related to complex medical factors. The goal for this focus area is: R52 will participate with ADL's daily and ADL status will improve by target date. Interventions for this focus area include: PT (Physical Therapy) and OT (Occupational Therapy) evaluation and treatment as per physician orders, with an initiations date of 9/16/24. R52's admission MDS dated [DATE] documents in section GG that no impairment on upper extremities and impairment on both sides for lower extremities. R52's Quarterly MDS dated [DATE] Section GG documents no impairment on upper extremities and impairment on both sides on lower extremity. The same MDS Section O0500 documents that he is not receiving any restorative nursing programs active or passive range of motion. R52's PT Evaluation with a certification period of 8/27/24-10/16/24 documents under musculoskeletal system assessment that bilateral lower extremities ROM and strength impaired. R52's Notice of Discharge From Therapy dated 11/4/24 documents a discharge date from therapy of 11/7/24 and that R52 should continue with restorative measures of bilateral upper/lower extremities with therapy exercises and active range of motion written in on the discharge form. Review of R52's current month physician orders does not include any restorative orders. On 1/28/24 at 10:30 AM, R52 who is alert to person, place, and time stated that since he has finished therapy he does not receive any types of exercises. R52 replied no when asked if the staff move his arms/legs/hands daily to ensure his joints are exercised and do not get stiff. R52 stated that he cannot stand, is in bed all the time, and chooses to not attend group activities or eat in the dining room. The facility policy titled Range of Motion with a date of 01/02/2022 documented range of motion exercises is critical to improve and maintain function in the joint and prevent contracture deformity. 1. Verify that there is a physician's order for this procedure. If there is no order for treatment, contact the attending physician to obtain treatment orders .4. Move each joint through its range of motion three times unless otherwise instructed .

Based on observation, interview, and record review the facility failed to provide the required 80 square feet of floor space per resident for 38 of 38 (R2, R16, R55, R8, R19, R5, R35, R20, R17, R50, R51, R26, R12, R43, R30, R31, R14, R1, R62, R56, R3, R48, R25, R41, R11, R24, R60, R40, R59, R61, R23, R46, R28, R18, R58, R47, R52, and R54) residents reviewed for room size in a sample of 55. The findings include: On 01/31/2025 at 9:28 A.M., V1 (Administrator) stated the waived rooms are 100-109, 111, 201-209 and 211, are certified 2 bed rooms, and measure less that 80 square feet per resident. On 01/31/2025 at 9:05 A.M., V9 (Maintenance) measured rooms [ROOM NUMBERS]. rooms [ROOM NUMBERS] measured 12 feet by 12 feet equaling 144 square feet which is approximately 72 square feet per resident bed. V9 stated that 100-109,111 and 201-209, and 211 are all the same size. Each room contained 2 beds, 2 dressers, and 2 nightstands. On 01/31/2025 at 9:10 A.M. R50 and R51 stated they both have no concerns with the room size. R50 and R51 are both alert and orientated to person, place, and time. On 1/31/2025 at 9:15 A.M. R56 stated he has no concerns with the room size. R56 is alert and orientated to person, place, and time. On 1/31/2025 at 9:18 A.M. R11 stated he has no concerns with the room size. R11 is alert and orientated to person, place and time. On 1/31/2025 at 9:20 A.M. R35 stated she has no concerns with the room size. R35 is alert and oriented to person, place and time. The facility daily rooster dated 01/27/2025 documents R2, R16, R55, R8, R19, R5, R35, R20, R17, R50, R51, R26, R12, R43, R30, R31, R14, R1, R62, R56, R3, R48, R25, R41, R11, R24, R60, R40, R59, R61, R23, R46, R28, R18, R58, R47, R52, and R54 reside in rooms 100-109, 111, and 200-209, and 211. Observations of the waived rooms were made from 01/28/2025 - 01/31/2025, showing these rooms provide adequate space to meet the medical and personal needs of these residents. The Resident Council Meeting Minutes from July 2024 through January 2025 documents no concerns regarding the size of resident rooms.

Based on interview and record review the facility failed to ensure a person-centered comprehensive care plan was developed with goals and interventions to address history of substance abuse for 1 (R1) of 3 residents reviewed for care planning in a sample of 3. Findings include: R1's face sheet documents an admitted [DATE] with diagnosis including: Pulmonary Hypertension, Stimulant use, Unspecified Stimulant - induced Disorder, Other Stimulant Abuse in remission, Tobacco use, Major Depressive Disorder, lower back pain, and Intervertebral Disc Degeneration lumbar region. R1's undated care plan does not contain a Focus area with goal and interventions for the concern area of Stimulant use, Stimulant induced Disorder, or Stimulant Abuse in remission. R1's hospital summary of care dated 01/18/2024 documents a diagnosis of methamphetamine abuse. On 04/15/24 at 3:45 PM, R1 stated he has been a methamphetamine user and has been trying very hard to keep from using. On 04/16/24 at 10:10 AM, V2 (Director of Nursing/DON) stated R1 went out on a community pass on the 9th and signed out, he did not return to the facility until the next morning, the nurse on duty V13 (Registered Nurse/RN) notified V10 (Medical Doctor) that R1 was out overnight. V10 gave an order that when R1 returned to the facility he was to be drug tested . V2 stated V10 knows R1's history with drug use and that is why he ordered the drug screen. V2 stated she believes he discharged from the facility AMA (against medical advice) because how the situation with the drug test was handled and he didn't think it was fair because he called and tried to let the facility know he was having trouble getting back but no one answered the phone. V2 stated, R1 was not told in advance that he would have to drug screen if he did not make it back to the facility before midnight or acted under the influence to her knowledge. On 04/16/24 at 3:45 PM, V10 (Medical Doctor) stated he ordered the drug screening for R1 upon return to the facility due to R1's history of drug use. R1's Physician Order Sheet dated 04/01/24 documents an order dated 04/10/24 stating: Upon arrival to facility do a urine screen: Hold pain meds (medications) until MD (medical doctor) notified of results. On 04/16/24 at 3:30 PM, V6 (Minimum Data Set Coordinator/Care Plan Coordinator) stated she did not know why they did not have anything in R1's care plan relating to R1's history of substance abuse problems. V6 stated they did not have anything care planned for drug screening or community passes, and he did not have a section relating to substance abuse. V6 stated they did not have anything in place to monitor R1 especially when he returned from community passes or if he returned late from a community pass. On 04/16/24 at 12:15 PM, V2 (DON) stated they did not have anything in place on R1's care plan in relation to his past history of drug use including anything with community passes or drug screening and they should have. On 04/16/24 at 1:29 PM, V8 (Licensed Practical Nurse) stated R1 returned to the facility from a community pass when she was on shift. V8 stated R1 came in and was going down the hall to his room and was talking about getting a flat tire and being stranded in the country. V13 (RN) told her there was an order for R1 to drug screen when he returned, so she went to his room and gave him the cup. He was not happy about having to drug screen. On 04/18/24 at 8:58 AM, V1 (Administrator) stated they do not have a care plan policy.

Based on interview, observation, and record review the facility failed to provide tracheostomy care per facility policy/professional standards of practice and failed to implement a care plan with appropriate interventions to provide tracheostomy care for 1 of 1 resident (R37) reviewed for tracheostomy care in a sample of 59. Findings include: Per R37's EHR (electronic health record) face sheet, R37 was admitted to this facility on 7/13/2021 with perinate diagnosis of Tracheostomy, Chronic Obstructive Pulmonary Disorder and Dementia. The MDS (Minimum Data Set) for R37 and dated 8/28/2023, documents R37 BIMS (Brief Interview for Mental Status) to be 00 out of a total of 15, which indicates R37 has severe cognitive impairment. R37's current physician's order sheet, dated 11/1/2023-11/31/2023, documents R37's doctor ordered R37 is to receive tracheostomy care every dayshift and every nightshift and as needed per nursing staff. On 11/15/2023 at 1:40 pm, V8 (Licensed Practical Nurse/LPN) performed tracheostomy care for R37, with V2 (Director of Nursing/DON) present. After performing hand hygiene, V8 donned non-sterile blue colored gloves from a wall dispenser in R37's room. V8 opened a sterile tracheostomy care kit, removed and set up all the sterile supplies with his non-sterile gloved hands, contaminating all items and placed the supplies on a covered bedside table. V8 then opened the package of sterile gloves that came out of the sterile tracheostomy care kit. V8 removed his blue colored gloves and handled the sterile gloves with his bare hand and touched multiple surfaces of the sterile gloves. V8 then attempted to pull the sterile gloves onto his hand, however the gloves were much too small to fit on V8's hands. V8 ripped the sterile gloves and did not replace the gloves and continued to provide the tracheostomy care with the contaminated and ripped gloves. Next, V8 removed R37's tracheostomy cannula for cleansing. R37's tracheostomy cannula was noted to be a medical grade stainless steel curved tube about four inches long and was crusted inside and out with yellowish brown matter. V8 used the contaminated supplies to clean the tracheostomy cannula. After cleansing, V8 attempted to re-insert the curved metal tracheostomy cannula upside down causing R37 to gag, cough and choke violently. V8 removed the cannula and attempted to insert it again upside down, which caused R37 to gag, choke and cough more violently. Surveyor verbally alerted V2 (DON) of R37's tracheostomy cannula being upside down, but V2 (DON) made no effort to correct V8's actions. V8 then turned the tracheostomy cannula the correct direction and the curved metal cannula slipped immediately into correct placement and R37 quickly recovered from gagging and coughing. V2 (DON) was asked why she did not intervene when surveyor expressed verbal concern about V8 putting in R37's curved metal tracheostomy cannula in upside down and V2 (DON) said I did not see what V8 was doing. V2 (DON) and V8 were asked if tracheostomy care was a sterile procedure and both said I don't know. V8 was asked if he had received tracheostomy care training and he said yes. V8 was asked how often he performs tracheostomy care and V8 said 4-5 times per week. During this tracheostomy care procedure, V8 did not have a stethoscope, never assessed R37's lung sounds and never assessed R37's oxygen levels during or after the procedure. V2 said V8 should have had a stethoscope, should have assessed R37's lung sounds and should have checked R37's oxygen levels after the tracheostomy care was performed. A document titled: In-service Monthly Attendance Form, dated 8/19/2022, Course Title: Trach (Tracheostomy) and Oxygen training with 12 names and signatures was presented as the most recent tracheostomy training received by the nursing staff, including V8. V2 (DON) is listed as the instructor. On 11/15/2023 at 2:15 pm, V14 (Corporate Nurse) said Yes, tracheostomy care is supposed to be a sterile procedure and We will re-educate the nursing staff on tracheostomy care procedures and move forward from here. R37's current care plan, initiation date of 7/14/2021, documents a focus area for R37 as: (R37) has a tracheostomy r/t (related to) impaired breathing mechanics. The goal for R37 is to have clear and equal breath sounds and R37 will have no abnormal drainage around trach (tracheostomy) site. Interventions listed in R37's care plan to help R37 achieve the goal are documented in part as: Resident performs own trach care. Staff to oversee and Monitor/document respiratory rate, depth and quality. Check and document every (q) shift/as ordered with initiation dates of 7/14/2021. The same Care Plan documents a focus are for R37 of (R37) has a self-care deficit as evidenced by: needs assistance with ADL's (Activities of Daily Living) related to deconditioning. Documented interventions include that R37 requires one-person physical assist with personal hygiene and oral/dental care with initiation dates of 7/14/2021. On 11/15/2023 at 1:15 pm, V8 (Licensed Practical Nurse/LPN) said he knows R37's care plan says she will perform her own tracheostomy care, however R37 cannot perform her own tracheostomy care. V8 said he observed R37 perform her own tracheostomy care, R37 pulled out the tracheostomy cannula, stuck it in her mouth, licked the cannula clean and places the cannula where it goes in her neck. V8 said he has not provided R37 with patient education on providing her own tracheostomy care and he feels R37 does not have the mental capability to be educated due to having dementia and severely impaired cognition. On 11/16/2023 at 12:30 pm, V20 (Social Service Director/Care Plan Coordinator) said she agrees R37 does not have the mental capacity to perform her own tracheostomy care and the intervention of Resident performs her own tracheostomy care with staff to oversee is a very inappropriate intervention for R37's tracheostomy care plan. V20 said she does not know why this is listed in place of nursing staff to perform the care. V20 agreed the inappropriate intervention is not patient centered and she will schedule a care plan meeting to get this corrected. A non-dated facility policy titled Tracheostomy Care Procedure, under General Guidelines documents: Aseptic (sterile) technique must be used A.) during cleaning and sterilization of reusable tracheostomy tubes, B.) During all dressing changes . C.) During tracheostomy tube changes, either reusable or disposable. Under Procedure Guidelines documents: Assess resident for respiratory distress: A.) Measure resident's oxygen saturation with pulse oximeter, B.) Listen to lung sounds with a stethoscope, C.) Observe for asymmetrical chest expansion. Maintain sterile field and document the procedure, condition of the site and the resident's response.

Based on interview and record review the facility failed to provide a SNF ABN Form (CMS-10055) for 1 of 3 residents (R26) reviewed for Beneficiary Protection Notification in the sample of 59. Findings include: R26's face sheet documents diagnosis including: Hemiplegia and Hemiparesis following cerebral infarction affecting left non-dominant side, Seizures, Central Pain Syndrome, Lymphedema, Anxiety Disorder, Pseudobulbar Affect, Type 2 Diabetes Mellitus with Hypoglycemia without coma and Morbid Obesity due to Excess Calories. R26's face sheet documents a admitted [DATE]. R26's SNF Beneficiary Protection Notification Review form documents a discharge from Medicare Part A services on 11/5/23, prior to exhaustion of his benefit day allotment. This form does not document that a written notice of the resident's potential liability for a non-covered stay (SNFABN - CMS-10055) form was provided to R26 to explain his right to appeal the decision of discharge from Medicare Part A services prior to exhaustion of his benefit days. On 11/16/23 at 11:45 AM, V1 Administrator stated they do not have the form (CMS-10055) for R26, it must have been missed. R26's Clinical records did not contain a CMS-10055 document. On 11/16/23 at 1:40 PM. R26 who was alert to person, place and time stated he does not remember if he received any forms about his therapy days.

Based on interview, observation, and record review, the facility failed to keep a resident requiring assistance with Activities of Daily Living hair clean and well groomed for 1 of 9 residents (R11) reviewed for Activities of Daily Living in a sample of 59. Findings include: Per the face sheet in R11's EHR (electronic health record) R11 was admitted to this facility on 6/28/2021 with pertinent diagnosis of Left sided hemiplegia and left sided hemiparesis following a Cerebral Infarction (Stroke ), left sided breast Cancer, Diabetes Mellitus type 2, Poly-Osteoarthritis and Dementia. An MDS (Minimum Data Set) in R11 EHR and dated 11/19/2023, documents R11's BIMS (Brief Interview for Mental Status) as being 03 out of 15 total, which indicates R11 has severe mental impairment and is not interviewable. This same MDS, under section titled H documents R11 is always incontinent of bowels and bladder and under section titled GG documents R11 has impairment to both upper and lower extremities on one side. The Care Plan in R11's EHR with initiation date of 6/29/2021 documents R11 has a Self-care Deficit of: Needs extensive assistance with ADL's (Activities of Daily Living) with goal of care documented as: (R11) will be clean, dry, well groomed and (R11) will participate with ADL's daily and ADL status will improve by target date of 1/30/2024. The care plan documents interventions to achieve R11's self-care deficit goals as: Bathing-One person physical assistance required. On 11/13/2023 at 11:30am, R11 was observed in the facility's dining room waiting for her noon meal to be served. R11 was noted to be appropriately dressed, however R11's hair looked very greasy and had not been recently combed. On 11/14/2023 at 8:45am, R11 was observed in the facility's dining room in her wheelchair. R11 was observed with greasy looking, non-combed hair. At 12:30 pm, R11 was observed in the facility's dining room waiting for her noon meal to be served. R11 was observed with greasy looking, non-combed hair again. A undated facility form titled Shower Schedule documents R11 is scheduled to receive showers on Wednesday and Saturday based on her assigned room number. On 11/15/2023, at 10:30 am, V19 (Licensed Practical Nurse) said residents are to receive two showers per week. V19 said showers are to be documented in the resident's EHR and if residents refuse showers, this information is to be documented in the resident's EHR. On 11/15/2023 at 9:00 am, V2 (Director of Nursing) said showers are not documented in the resident's EHR, but instead are documented on Shower Sheets and kept in the V2's office. V2 said shower refusals are also documented on Shower Sheets and kept in V2's office. Facility documents titled Shower Sheets for R11 documented the following care was given: On 10/4/23 R11 was showered and hair washed On 10/7/23 R11 was given a bed bath On 10/14/23 R11 was given a bed bath On 10/21/23 R11 was given a bed bath On 10/25/23 R11 was given a bed bath On 10/28/23 R11 was given a shower On 11/4/23 R11 was given a shower On 11/11/23, R11 was given a bed bath On 11/16/2023 at 10:00 am, V18 (Certified Nursing Assistant) said if the resident's Shower Sheet says they received a bed bath, then the resident did not get their hair washed. V18 said resident's get their hair washed when they are given a shower. V18 reviewed R11's shower sheets and agreed R11 did not have her hair washed when given a bed bath on 10/7/23, 10/14/23, 10/21/23, 10/25/23 and 11/11/23. V18 said R11 has not had her hair washed since being showered on 11/11/23 which was 5 days ago. V18 said showers or shower refusals are not documented in the resident's EHR, but instead are documented on Shower Sheets and turned into the nursing office. On 11/16/2023 at 10:55 am, V17 (Business Office Manager) reviewed R11's resident funds account and said no funds from R11's account have been used for beauty shop services since before September 6, 2023. On 11/16/2023 at 11:20 am, V1 (Administrator) said the facility has not had beautician services due to not having a person willing to come to the facility since September 18, 2023. 11/15/2023 at 3:00 pm, V2 said she gave the surveyors all the Shower Sheets for R11 that she could locate. A non-dated facility policy titled Bath or Shower Procedure, documents under the section labeled Purpose: The purpose of this procedure is to promote cleanliness, provide comfort to the resident and observe the condition of the resident's skin. Under the section labeled Documentation: Document procedure in the resident's electronic health record. Under the section labeled Reporting: Notify the supervisor if the resident refuses the shower/tub bath or any abnormalities noted to the resident's condition or skin integrity.

Based on interview, observation and record review, the facility failed to ensure nursing staff signed off medications they administered by using their own electronic signature and failed to provide tracheostomy care in accordance with professional standards of practice for 3 of 5 residents (R27, R41, and R37) reviewed for medication administration and tracheostomy care in a sample of 59. Findings include: 1. On 11/15/2023 at 7:50 am, V9 (Licensed Practical Nurse/LPN) said she was sorry she was slow and did not know the resident's medications very well. V9 said this was her first time passing meds (medications) at this facility. V9 said she works for the corporation that owns this facility and goes around to all their facilities helping out. V9 said today she is here at this facility helping out. V9 announced she would be preparing medications to administer to R27. V9 prepared R27's medications, administered the medications to R27 and signed the medications off electronically on R27's electronic MAR (medication administration record). Next, V9 announced she would be preparing medications to administer to R41. V9 prepared R41's medications, administered the medications and signed the medications off electronically on R41's electronic MAR. A review of R27's EHR under electronic MAR (medication administration record) documented the medications V9 (LPN) electronically signed off that she administered to R27, at 7:50 am, on 11/15/23. A review of R41's EHR, under the electronic MAR documented the medications V9 electronically signed off that she gave to R41 at 8:05 am on 11/15/2023. During this review, it was noted that V9 was using V8's (LPN) electronic signature to sign off the medications which erroneously indicated V8 (LPN) was the actual nurse administering the medications to R27 and R41. On 11/15/2023 at 9:10 am, V9 said when she arrived for duty this morning the facility's administration had neglected to provide her with her own electronic signature and access to the resident's EHR. V9 said she was temporarily using V8's until she received her own. On 11/15/2023 at 8:50 am, V1 (Administrator) and V2 (Director of Nursing) were informed of V9 signing off medications using V8's electronic signature. Both agreed V9 should not have been signing off medication administration using another nurse's electronic signature. Both V1 and V2 said it was their expectations for the nurses to administer the resident's medications, safely, correctly, and in accordance with the facility's policies. V1 said she agreed V9 using V8's electronic signature when passing medications was not in accordance with the facility's policy or professional standards of practice. A facility policy, with revision date of 11/21/2020, titled Charting and Documentation under bullet point #7 documents the following: Documentation of procedures and treatments will include care-specific details including: A.) The date and time the procedure/treatment was provided and B.) The name and title of the individual who provided the care. 2. Per R37's EHR (electronic health record) face sheet, R37 was admitted to this facility on 7/13/2021 with perinate diagnosis of Tracheostomy, Chronic Obstructive Pulmonary Disorder and Dementia. The MDS (Minimum Data Set) for R37 and dated 8/28/2023, documents R37 BIMS (Brief Interview for Mental Status) to be 00 out of a total of 15, which indicates R37 has severe cognitive impairment. R37's current physician's order sheet, dated 11/1/2023-11/31/2023, documents R37's doctor ordered R37 is to receive tracheostomy care every dayshift and every nightshift and as needed per nursing staff. On 11/15/2023 at 1:40 pm, V8 (Licensed Practical Nurse/LPN) performed tracheostomy care for R37, with V2 (Director of Nursing/DON) present. After performing hand hygiene, V8 donned non-sterile blue colored gloves from a wall dispenser in R37's room. V8 opened a sterile tracheostomy care kit, removed and set up all the sterile supplies with his non-sterile gloved hands, contaminating all items and placed the supplies on a covered bedside table. V8 then opened the package of sterile gloves that came out of the sterile tracheostomy care kit. V8 removed his blue colored gloves and handled the sterile gloves with his bare hand and touched multiple surfaces of the sterile gloves. V8 then attempted to pull the sterile gloves onto his hand, however the gloves were much too small to fit on V8's hands. V8 ripped the sterile gloves and did not replace the gloves and continued to provide the tracheostomy care with the contaminated and ripped gloves. Next, V8 removed R37's tracheostomy cannula for cleansing. R37's tracheostomy cannula was noted to be a medical grade stainless steel curved tube about four inches long and was crusted inside and out with yellowish brown matter. V8 used the contaminated supplies to clean the tracheostomy cannula. After cleansing, V8 attempted to re-insert the curved metal tracheostomy cannula upside down causing R37 to gag, cough and choke violently. V8 removed the cannula and attempted to insert it again upside down, which caused R37 to gag, choke and cough more violently. Surveyor verbally alerted V2 (DON) of R37's tracheostomy cannula being upside down, but V2 (DON) made no effort to correct V8's actions. V8 then turned the tracheostomy cannula the correct direction and the curved metal cannula slipped immediately into correct placement and R37 quickly recovered from gagging and coughing. V2 (DON) was asked why she did not intervene when surveyor expressed verbal concern about V8 putting in R37's curved metal tracheostomy cannula in upside down and V2 (DON) said I did not see what V8 was doing. V2 (DON) and V8 were asked if tracheostomy care was a sterile procedure and both said I don't know. V8 was asked if he had received tracheostomy care training and he said yes. V8 was asked how often he performs tracheostomy care and V8 said 4-5 times per week. During this tracheostomy care procedure, V8 did not have a stethoscope, never assessed R37's lung sounds and never assessed R37's oxygen levels during or after the procedure. V2 said V8 should have had a stethoscope, should have assessed R37's lung sounds and should have checked R37's oxygen levels after the tracheostomy care was performed. A document titled: In-service Monthly Attendance Form, dated 8/19/2022, Course Title: Trach (Tracheostomy) and Oxygen training with 12 names and signatures was presented as the most recent tracheostomy training received by the nursing staff, including V8. V2 (DON) is listed as the instructor. On 11/15/2023 at 2:15pm, V14 (Corporate Nurse) said Yes, tracheostomy care is supposed to be a sterile procedure and We will re-educate the nursing staff on tracheostomy care procedures and move forward from here. R37's current care plan, initiation date of 7/14/2021, documents a focus area for R37 as: (R37) has a tracheostomy r/t (related to) impaired breathing mechanics. The goal for R37 is to have clear and equal breath sounds and R37 will have no abnormal drainage around trach (tracheostomy) site. Interventions listed in R37's care plan to help R37 achieve the goal are documented in part as: Monitor/document respiratory rate, depth and quality. Check and document every (q) shift/as ordered. A non-dated facility policy titled Tracheostomy Care Procedure, under General Guidelines documents: Aseptic (sterile) technique must be used A.) during cleaning and sterilization of reusable tracheostomy tubes, B.) During all dressing changes . C.) During tracheostomy tube changes, either reusable or disposable. Under Procedure Guidelines documents: Assess resident for respiratory distress: A.) Measure resident's oxygen saturation with pulse oximeter, B.) Listen to lung sounds with a stethoscope, C.) Observe for asymmetrical chest expansion. Maintain sterile field and document the procedure, condition of the site and the resident's response.

Based on interview, observation and record review, the facility failed to ensure a medication error rate of less than 5%. There were 30 medication passing opportunities with 4 errors, resulting in a 13.33% error rate. The errors involved 1 of 4 residents (R27) reviewed during medication administration in the sample of 59. Findings include: On 11/15/2023 at 7:50 am, V9 (Licensed Practical Nurse) she would be preparing meds for R27. V9 gathered R27's medication cards and compared them to the meds listed in R27's EHR (electronic health record) that were to be given and stacked the med cards up together. V9 read the medications out loud and showed the surveyor the med cards before she popped the medication from the medication cards. The medications popped out by V9 to administer to R27 were as follows: Buspirone 5mg (milligram), 2 tabs (tablets), Calcium 600mg, 1 tab, Folic Acid 1 mg, 1 tab, Levetiracetam 1000mg, 1 tab, Potassium 20meq (millequivilants), 1 tab, Omeprazole 20mg, 1 cap (capsule), Multivitamin, 1 tab, Prednisone 10mg, 1.5 tabs, Quetiapine 300mg, 1 tab, Torsemide 20mg, 1 tab, Vitamin D 3000mg, 1 tab, Senna-Docusate Sodium 8.6/50mg, 1 tab, Paxlovid 150/100mg, 2 tabs. All medications are to be taken whole by mouth. V9 electronically signed off the medications, poured some cold water into a small cup and locked the med cart before going into R27's room to administer his medications. R27 orally took all the medications prepared by V9. V9 performed hand hygiene and preceded to prepare medications for the next resident due medications. A review of R27's EHR, under the MAR (Medication Administration Record) documented the medications V9 (LPN) electronically signed off as administered to R27, at 7:50am, on 11/15/23. R27's MAR documented V9 had omitted 3 of R27's prescribed medications, which were Pyridoxine 50mg (Vitamin B6), 1 tab, Polysaccharide Iron complex 150mg, 1 capsule and Ingrezza 40mg, 1 capsule. This same MAR documented R27 was to receive 3 tablets of Paxlovid 150/100mg, however V9 was observed only administering 2 tablets. On 11/15/2023 at 8:50am, V1 (Administrator) and V2 (Director of Nursing) were informed of the medication administration errors made by V9. Both V1 and V2 said it was their expectations for the nurses to administer the resident's medications, safely, correctly and in accordance with professional standards of practice. On 11/15/2023 at 9:00am, V9(LPN) said she reviewed the medications she administered to R27 and found 3 medication she omitted and she was supposed to give 3 tablets of Paxlovid but only gave 2. V9 said after the error was brought to her attention by V2 (DON) she went back and administered the omitted medications correctly. V9 said the omitted medications were in bottles in the top drawer of the med cart and the other medications were in med cards in the med storage drawer and this is how she missed the medications. A facility policy, with a revision date of 9/27/22, titled Medication Administration Policy/ Procedure under Policy it documents the following: Medications will be administered safely to residents within the facility by licensed nurses at the specified time/ timeframe, following the recommended administration method and will be documented as required. Under Oral Medications, step #4 documents compare the medication record with the label to make sure they correlate. If there is a discrepancy, clarify with the physician before giving the medication.

Based on interview, observation, and record review the facility failed to develop and implement a person centered comprehensive care plan for tracheotomy care for 1 of 1 residents (R37) reviewed for care plans in a sample of 59. Findings include: Per R37's EHR (electronic health record) face sheet, R37 was admitted to this facility on 7/13/2021 with pertinent diagnosis of Tracheostomy, Chronic Obstructive Pulmonary Disorder, Dementia with Agitation, Delusional Disorders and Visual Hallucinations. The MDS (Minimum Data Set) for R37 dated 8/28/2023, documents R37 BIMS (Brief Interview for Mental Status) to be 00 out of a total of 15, which indicates R37 has severe cognitive impairment. R37's current physician's order sheet, dated 11/1/2023-11/31/2023, documents R37's doctor ordered R37 to receive tracheostomy care every dayshift and nightshift. R37's current care plan, initiation date of 7/14/2021, documents a focus area for R37 as: (R37) has a tracheostomy r/t (related to) impaired breathing mechanics. The goal for R37 is to have clear and equal breath sounds and R37 will have no abnormal drainage around trach (tracheostomy) site. Interventions listed in R37's care plan to help R37 achieve the goal are documented in part as: Resident performs own trach care. Staff to over see (dated 7/14/2021). On 11/15/2023 at 1:15 pm, V8 (Licensed Practical Nurse/LPN) said he knows R37's care plan says she will perform her own tracheostomy care, however R37 can not perform her own tracheostomy care. V8 said he observed R37 perform her own tracheostomy care, R37 pulled out the tracheostomy cannula, stuck it in her mouth, licked the cannula clean and places the cannula where it goes in her neck. V8 said he has not provided R37 with patient education on providing her own tracheostomy care and he feels R37 does not have the mental capability to be educated due to having dementia and severely impaired cognition. On 11/16/2023 at 12:30 pm, V20 (Social Service Director/Care Plan Coordinator) said she agrees R37 does not have the mental capacity to perform her own tracheostomy care and the intervention of Resident performs her own tracheostomy care with staff to over see is a very inappropriate intervention for R37's tracheostomy care plan. V20 said she does not know why this is listed in place of nursing staff to perform the care. V20 agreed the inappropriate intervention is not patient centered and she will schedule a care plan meeting to get this corrected.

Based on observation, interview, and record review, the facility failed to accurately document the administration of medication for 2 of 4 residents (R27 and R41) reviewed for medication administration in a sample of 59. Findings include: On 11/15/2023 at 7:50 am, V9 (Licensed Practical Nurse/LPN) said she was sorry she was slow and did not know the resident's medications very well. V9 said this was her first time passing meds (medications) at this facility. V9 said she works for the corporation that owns this facility and goes around to all their facilities helping out. V9 said today she is here at this facility helping out. V9 stated she would be preparing medications to administer to R27. V9 prepared R27's medications, administered the medications to R27 and signed the medications off electronically on R27's electronic MAR (Medication Administration Record). Next, V9 stated she would be preparing medications to administer to R41. V9 prepared R41's medications, administered the medications and signed the medications off electronically on R41's electronic MAR. A review of R27's EHR under electronic MAR documented the medications V9 (LPN) electronically signed off that she administered to R27, at 7:50 am, on 11/15/23. A review of R41's EHR, under the electronic MAR documented the medications V9 electronically signed off that she gave to R41 at 8:05 am on 11/15/2023. During this review, it was noted that V9 was using V8's (LPN) electronic signature to sign off the medications which erroneously indicated V8 (LPN) was the actual nurse administering the medications to R27 and R41. On 11/15/2023 at 9:10 AM, V9 said when she arrived for duty this morning the facility's administration had neglected to provide her with her own electronic signature and access to the resident's EHR. V9 said she was temporarily using V8's until she received her own. On 11/15/2023 at 8:50 am, V1 (Administrator) and V2 (Director of Nursing) were informed of V9 signing off medications using V8's electronic signature. Both agreed V9 should not have been signing off medication administration using another nurse's electronic signature. Both V1 and V2 said it was their expectations for the nurses to administer the resident's medications, safely, correctly, and in accordance with the facility's policies. V1 said she agreed V9 using V8's electronic signature when passing medications was not in accordance with the facility's policy or professional standards of practice. A facility policy, with revision date of 11/21/2020, titled Charting and Documentation under bullet point #7 documents the following: Documentation of procedures and treatments will include care-specific details including: A.) The date and time the procedure/treatment was provided and B.) The name and title of the individual who provided the care. A facility policy, with a revision date of 9/27/22, titled Medication Administration Policy/ Procedure under Policy it documents the following: Medications will be administered safely to residents within the facility by licensed nurses at the specified time/ timeframe, following the recommended administration method and will be documented as required. Under bullet point #12 it documents the following: Chart the medication administered on the electronic medication administration record.

Based on interview, observation and record review the facility failed to utilize a gait belt to safely transfer a resident for 1 of 3 residents (R1) reviewed for transfers in the sample of 3. This failure resulted in R1 experiencing a large hematoma causing acute anemia that resulted in a blood transfusion and a six-night hospital stay. This past non-compliance occurred between 10/27/23 and 10/31/23. Findings include: R1's Face Sheet documents Diagnosis to include: Hemiplegia and Hemiparesis following Cerebral Infarction affecting right dominant side, Aphasia following Cerebral Infarction, Chronic Obstructive Pulmonary Disease, Polyneuropathy, Anxiety Disorder, Contracture Right hand, Acute Pulmonary Edema and Contusion of Right Shoulder. R1's MDS (Minimum data set) dated 08/23/23 section C documents a BIMS (Brief Interview of Mental Status) as 6 indicating cognition level is severely impaired, section GG documents R1's chair/bed to chair transfer as 2 (substantial/maximal assistance) - helper does more than half the effort. Helper lifts, holds trunk or limbs and provides more than half the effort, toilet transfer is documented as 3 (Partial/moderate assistance) - helper does less than half the effort, helper lifts, holds or supports trunk or limbs, but provides less than half the effort. R1's care plan dated 03/11/23 documents: R1 has a self-care deficit as evidenced by: needs (extensive) assistance with ADL's (activities of daily living) related to impaired mobility and cognition, weakness, hemiplegia and CVA (cerebral vascular accident) with an initiated date of 03/01/23 and documents R1 is a 1 assist transfer. R1's PT (Physical Therapy) discharge summary documents: Transfers chair/bed to chair transfer = partial/moderate assistance, dated 10/11/23 by V4 (PT). On 11/06/23 at 10:00 AM, R1 stated, she has a large bruise and it hurts bad. She stated she did not have a fall. R1 indicated it happened during a transfer. R1 started breathing very quickly with short shallow breaths when asked about her bruise. R1 moved the neck of her blouse to show the bruise and then started rubbing it. R1's bruise was dark purple under her right armpit area. The bruise was approximately 10 inches long by approximately 5 inches wide. On 11/08/23 at 2:30 PM, R1 was lying in bed whining while rubbing the bruised area under her arm. When asked if it hurts, she shook her head yes. On 11/08/23 at 9:55 AM, V9 (Family) stated, she saw V3 (Assistant Director of Nursing/ADON) and V7 (Certified Nurse Aide/CNA) transfer R1 inappropriately, the evening of 10/27/23. V9 stated she saw them transfer R1 under her arm. She stated, she heard R1 yell out when they transferred her to her bed. V3 and V7 put her into bed and put her feet up, due to her blood pressure was low. V9 stated, they did not use a gait belt to transfer R1 at that time and she has seen them (staff in general) transfer R1 several times without a gait belt. V9 stated she has had to remind them several times to use a gait belt. V9 stated R1 has a large bruise under her arm along her side to under her breast on her paralyzed side. She also stated R1 also has a knot under her bruise that was a blood clot and they had to give her more blood than usual at the hospital. V9 stated R1 was in the hospital six nights. V9 stated she thought her shoulder looked dislocated but she believes it turned out to be a knot after the X-rays. V9 stated, R1 still has a lot of pain with the injury and rubs it all the time. On 11/08/23 at 3:46 PM, V7 (Certified Nurse Aide/CNA) stated, she and V6 (CNA) took R1 to the bathroom and put her on the toilet on 10/27/23 just after 3:00 PM. Then V6 got busy doing something different so she and V3 (ADON) transferred R1 from the toilet back to her chair, then to her bed. V7 stated they did not use a gait belt. V7 stated V3 was on R1's paralyzed side and held her under her arm and the back of her pants. V7 stated when V3 grabbed her under her arm and transferred her, R1 yelled out in pain. V3 stated she didn't grab her under her armpit but she did. V7 stated, she feels V3 grabbed her harder than she thinks she did. V7 stated, she knows she was on the left side because she was not comfortable with being on her paralyzed side, no one at the facility had given her specific instructions on how to transfer R1 but she knows you are not supposed to mess with the weak side unless you have a gait belt. V7 stated she has never seen anyone use a gait belt with R1 except PT (Physical Therapy). On 11/06/23 at 1:15 PM, V6 (Certified Nurse Aide/CNA) stated on 10/27/23 she did put R1 on the toilet and told V7 (CNA) that she had to go do something else and that R1 was on the toilet. V6 stated, R1 is an easy transfer, she can assist you with the transfer most of the time, she just is paralyzed on her right side due to her stroke. V6 stated she got R1 up for supper but when she was putting R1 to bed after supper she saw the bruise and told V2 (DON). V6 stated a standard transfer would be with a gait belt. On 11/08/23 at 12:15 PM, V3 (Assistant Director of Nursing/ADON) stated, she was working on the floor that day and V7 (CNA) told her that R1 was on the toilet. V7 told her R1 was not acting right and she was clammy. V3 stated she went down to assist V7 with getting R1 off the toilet. They got her off the toilet and she called V10 (Medical Doctor). V3 stated, R1 was not completely unresponsive. R1 had a large BM (bowel movement) on the toilet and thought that could be why she was somewhat unresponsive. They got R1 into bed and raised her feet. R1's blood pressure came up. V3 stated she wanted a pain pill prior to the toilet but they did not give her a pain pill due to her blood pressure being low, around 3:45 PM R1's blood pressure came back up. When they got R1 off the toilet they transferred her with a two-person transfer. V7 was on the right side, R1's weak side. During the transfer from her wheelchair to her bed she was on her weak side and they did not have a gait belt. V3 stated, she used her pants but did not pull on her arm. V3 stated she did not yell out or anything because her blood pressure was low. She doesn't remember how V7 transferred her. On 11/08/23 at 11:30 AM, V5 (Physical Therapy Manager) stated, the standard transfer with residents is with a gait belt. In her opinion R1 should be transferred with a gait belt due to her right-side paralysis, it would just be safer that way. On 11/06/23 at 10:45 AM, V4 (Physical Therapy) stated, a standard transfer is with a gait belt. V4 stated, R1 is an easy transfer if you tell her what you are going to do, you just put the gait belt around her waist area because you don't want it to get too high with her paralysis, and lift, she will assist, she has strength, her balance is just not great and she leans due to the right-side paralysis. On 11/08/23 at 1:45 PM, V2 (Director of Nursing/DON) stated on the evening of 10/27/23 R1 told her her arm was broke and was flopping it up and down. V2 stated, she told her, your arm hasn't worked for years. R1 then started pointing to her shoulder area. V2 asked R1 if her shoulder injury happened today and R1 shook her head yes, when she asked if it was around the time they took her to the bathroom and she shook her head yes. V2 then stated R1 was utilizing hand motions to describe V3 (ADON) and pointed to the area with the bruise. V2 stated V7 (CNA) stated R1 had an episode on the toilet, and that she (V7) and V3 transferred R1. V3 stated, R1 was kind of limp and was not as responsive as usual. V2 stated, V9 (family) was at the facility. V2 stated V9 (family) told her V3 (ADON) transferred R1 and R1 yelled out in pain. V2 stated, if it was her with R1 she would have tried to get a hold of her pants to assist her. V2 stated typically R1 can pretty much stand on her own, but she does have problems with her balance and leaning to the right. V2 stated, the safest way to transfer R1 would be with a gait belt but it was a more urgent situation. V10's MD (Medical Doctor) note dated 11/02/23 at 13:39 (1:39 PM) documents: R1 was recently hospitalized for the following diagnoses: UTI (Urinary tract infection) chest wall hematoma. R1 was recently hospitalized for weakness and diagnosed with UTI along with acute shoulder pain with workup showing no fractures of shoulder or ribs. CT showed a large hematoma of the axilla and anterior chest most likely due to pectoralis muscle tear. Injury uncertain. R1 is still having pain in the area of swelling and nurses note it is hard to gauge her pain because she always has pain. She (R1) points to the right chest as area of pain and withdrawals prior to me touching her. R1's hospital notes document an admitted [DATE] and a discharge date of [DATE] with an admitting diagnosis of Anemia. R1's hospital History and Physical dated 10/28/23 documents: Chief Complaint: Right arm injury after lift assistant nursing home. Bruising in the right armpit and discomfort. R1's weight was documented as 135 pounds on 10/28/23. R1's Hospital preliminary report dated 10/27/23 documents: Clinical indication: Per EMS (Emergency Medical Service) pt (patient) (R1) had an episode in which the nursing home is unsure of how but right arm became bruised. Pt (R1) has bruise under right arm. HX (history) of stroke and is normally contracted on this side. V9 (family) at bedside and stated the nursing home pulls on this arm and doesn't use a gait belt and she thinks it is an injury from being pulled on. Limited movement with contracted right arm. R1's Hospital's Preliminary Report section - X-ray shoulder 3 views right shoulder 10/27/23 at 8:10 PM documents: there is a slight superior displacement of the distal right clavicle with respect to the adjacent acromion. The findings are consistent with mild AC joint separation, age indeterminate. R1's hospital notes dated 10/30/23 at 7:29 PM document: Imaging - Results - Other CT (computed tomography) chest wo (without) contrast dated 10/29/23. Indication: Hemorrhage, Unspecified injury of right shoulder and upper arm, sequela, chest pain, and localized swelling, mass and lump, trunk. CT examination of the chest: Indication: [AGE] year-old female nursing home resident, post cerebrovascular accident and right - sided weakness, a fascia, with bruising over the right upper extremity, anemia. Findings: There is a large right subpectoral hematoma, measuring at least 11.9 x 6.1 x 11.8 cm extending caudally from the right anterior shoulder along the right lateral chest wall and axilla. There are edematous changes in adjacent extrathoracic fat, extending into the right upper extremity , not included on these images. Impression: large right subpectoral hematoma with edematous changes extending into the adjacent extrathoracic fat. R1's hospital notes dated 10/29/23 at 4:30 AM document: progress notes lab called with Hgb (hemoglobin) drop 10/27 - 8.3 and now 10/28 - 5.7. Upon looking at admission photo the area around R1's pectoral on the right side is very swollen and firm. R1's hospital Discharge summary dated 11/02/23 at 1:40 PM documents: Discharge Diagnoses: 1) Acute anemia 2/2 (secondary to) large subpectoral hematoma d/t (due to) shoulder injury prior to admission, 2) Acute Cystitis, 3) HTN (Hypertension), 4) Troponin elevation 2/2 demand ischemia. Hospital Course: Patient (R1) presented with acute blood loss anemia, d/t (due to) subpectoral hematoma. The patient's Eliquis was held and she was given blood transfusion as needed to keep Hgb (hemoglobin) >8, d/t (due to) demand ischemia 2/2 anemia. The patient's hgb (hemoglobin) stabilized after 2 days of holding Eliquis. She was discharged on ce hgb (hemoglobin) stable. She will hold Eliquis on discharge for 1 week. The facility document titled, Witness Statement dated 10/27/23 documents a witness statement by R1. Statement documents: My arm is broke. Hurts. They, R1 demonstrated placing left hand underneath right axillae while stating hurt, signed per V2 (DON). The facility document titled, Witness Statement dated 10/27/23 documents a witness statement by V7 (Certified Nurse Aide/CNA). It documents: 10/30/23 at 1:56 PM, I V7 took R1 to the bathroom. R1 couldn't stand so I asked V6 (CNA) to help. V6 ended up transferring R1 by herself. I stood in the bathroom until she was done. When she finished I got V3 (ADON) to help me. After getting R1 in her chair she went unresponsive. V3 and I laid her down and put her feet up. R1 started to get better. R1 did scream out during the transfer but I didn't see a bruise until V6 showed me. Signed by V1 (Administrator) with the witness line signed with Via Phone signed and dated 10/30/23. The facility document titled, Witness Statement dated 10/27/23 documents a witness statement by V6 (Certified Nurse Aide/CNA). It documents: 10/30/23 I was asked by V7 (CNA) to transfer R1 to the toilet. R1 helped with the transfer using the left arm and I held on to her pants to secure her and transferred her to the toilet. Signed by V6 dated 10/30/23. The facility document titled, Witness Statement dated 10/27/23 documents a witness statement by V3 (Associate Director of Nursing). Documents: Alerted by CNA (V7) that R1 was clammy and didn't seem right. This nurse investigated to find R1 to be clammy and B/P (blood pressure) low. This nurse (V3) assisted CNA (V7) with transfer of R1 to chair. Alerted the MD. Then assisted the CNA (V7) with changing the resident out of the damp shirt. CNA (V7) then buttoned up shirt and we transferred R1 into bed. Blood pressure being so low had caused this nurse (V3) to hold pain pill R1 had requested and MD notified of this as well. R1 BP came up after this nurse (V3) reassessed R1. This nurse (V3) did not notice a bruise when changing or transferring R1, signed by V3 and dated 10/30/23. The facility document dated 10/27/23 titled, Bruise/Skin Resident: R1: Incident Description: V6 CNA summoned this nurse (V2 DON) to room. Upon entering R1 behind the privacy curtain sitting in wheelchair with blouse off and gown draped across the breast area to cover for privacy. Bruise noted to Right upper anterior arm and right chest to upper rib cage that is in the axilla area. R1 c/o (complaints of) pain to area. Area to chest in this area was also swollen and hard to touch. R1 is contracted to right arm and unable to use. R1 reports bruising is from staff who place their arm underneath her right axillae when transferring. R1 is not a lift assist and able to bear weight. R1 leans to one side so assist is needed by guiding R1 or assisting R1 with balance. The section titled, Resident Description documents: my arm broke. Hurts. R1 demonstrated by placing her good hand Left hand under the right armpit stating like this. R1's Order Summary Report (Physician Order Sheet) documents: Monitor hematoma to R (right) shoulder until resolved every shift for monitoring report any worsening sx (symptoms) to MD V10 (Medical Doctor) dated 11/06/23. The facility document with the subject documented as Transfer Policy dated 05/19/22 documents: Policy: To promote safe transfer for the residents, as well as the staff. Gait belts, Hoyer lifts and/or sit to stand lifts will be used, unless otherwise specified. Responsibility: It is the responsibility of all nursing staff to ensure the use of safe transfer techniques when transferring a resident. Prior to the survey date, the facility took the following actions to correct the deficient practice: A. An Ad Hoc QAPI (Quality Assurance and Performance Improvement) meeting was held with nursing and CNA staff which included the following: Identified Opportunity for Improvement/Deficient Practice: Proper transfer and reporting bruises. 1) Immediate Corrective Action for those affected by the deficient practice: Transfer assessments completed on all residents. Staff education on proper transfer of residents. Care plans reviewed for all residents on transfer status. Staff education on abuse policy with focus on reporting bruising of unknown origin. Skin assessment completed on all residents. 2) Process/Steps to identify others having the potential to be impacted by the same deficient practice: All residents could be affected by the deficient practice. 3) Measures put in to place/systematic changes to ensure the deficient practice does not recur: All licensed nursing staff were educated on transfers. All staff educated on the abuse policy. 4) Plan to monitor performance to ensure solutions are sustained: DON/designee will review twice weekly that skin assessments are completed and then randomly thereafter. All results will be reviewed at the monthly QA meeting and will make revisions as needed to ensure compliance. DON and/or designee will observe 3 residents 3 times weekly and then twice weekly times 2 weeks and then randomly thereafter to audit transfers. All audits will be reviewed in the monthly QA meeting and will make revisions as needed to ensure continued compliance. B. In-service sign in sheets were provided documenting Nursing and CNA staff were trained on the gait belt policy by V1 and V2 on 10/30/23 and 10/31/23. In-service sign in sheets were provided documenting Nursing staff were trained on abuse reporting and abuse of bruises by V1 and V2 on 10/30/23 and 10/31/23. In-service sign in sheets were provided documenting Nursing and CNA staff were trained on the proper transfer of residents with gait belts by V1 and V5 on 10/30/23.

Based on record review, observation, and interview, the facility failed to follow a providers orders to begin ear irrigation and to bring the resident as scheduled for follow up treatment for one (R2) of three residents reviewed for following providers orders in the sample of four. This failure resulted in R2's impacted cerumen causing eardrum perforation and infection, and a delay in R2 being evaluated for hearing aids. Findings include: R2's Office Visit Provider Progress Notes documented: 12/18/20: Bilateral ear canals impacted with cerumen. Unable to see Tympanic Membrane(s) .Start [MEDICATION NAME] 2 drops to each ear twice daily for 7 days. 01/07/21: (R2) presents to have ears flushed, was here 3 weeks ago for the same thing, and was ordered [MEDICATION NAME] and was supposed to return in 1 week. Right ear completely impacted, left ear has a minimal amount of cerumen.Instructions: [MEDICATION NAME] Sodium(DS) 5 drops into both ears nightly, return in 7 days for ear flushing. 01/22/21: Ear irrigation was performed on bilateral ears. Exam: Right ear: Tympanic Membrane is perforated, large amount of purulent drainage noted in canal. Left ear: Tympanic membrane is [DIAGNOSES REDACTED]tous and bulging.Impression: Acute Otitis Media of right ear with (eardrum) perforation. Start Bactrim 800-160 micrograms one tablet twice daily(for infection). R2's December 2020 Medication Administration Record(MAR) documented an order for [REDACTED]. R2's January 2021 MAR indicated [REDACTED]. On 01/26/21 at 10:05am, V6, Nurse Practitioner, stated R2 was seen for initial visit on 12/18/20. V6 stated R2's presenting complaint was impacted cerumen in both ears. V6 stated that R2 stated she had seen an audiologist to be fitted with new hearing aids but was told the exam could not be done until impacted cerumen in both ears was removed. V6 stated both R2's ears were severely impacted with cerumen. V6 stated R2 was ordered [MEDICATION NAME] instill 2 drops in each ear twice daily for 7 days, to start immediately, and for R2 to return to the clinic in one week.V6 stated R2 did not return until 01/07/21, and R2 was noted to have no thinning of cerumen in either ear. V6 stated R2 was then ordered a stronger agent, [MEDICATION NAME] Sodium(DS) liquid 50 milligrams per 15 milliliters, give 5 drops in each ear at bedtime for 7 days, to start immediately, and return to the clinic in 7 days. V6 stated R2 did not return until 1/22/21, and again there had been no improvment to either ear. V6 stated she had to manually remove the hardened cerumen. V6 stated when the right ear canal was cleared, she noted the eardrum was perforated and there was an excessive amount of purulent drainage indicative of infection. V6 stated it is her professional opinion that the cerumen caused pressure on the eardrum, causing it to rupture, setting up an [MEDICAL CONDITION] infectious process. V6 stated the left ear showed evidence of the cerumen causing pressure on the eardrum and it was bulging and reddened but not perforated. V6 stated she prescribed Bactrim 800-160 micrograms one tablet twice daily for the infection, and to follow up with R2's GP(General Practitioner). V6 stated R2's inflammation and infection will need to be resolved before she can be evaluated for new hearing aids. On 01/26/21 at 11:45am, V2, Director of Nurses, stated when V9, Transporter/Certified Nursing Assistant, returned from R2's appointments on 12/18/20 and 01/07/21, V9 gave written instructions and orders to V8, Licensed Practical Nurse. V2 stated on 12/18/20, V8 did not input orders into the computer system so the [MEDICATION NAME] was not started until the error was noted on 12/29/20, at which time the [MEDICATION NAME] was started. V2 stated on 01/07/21, V8 again did not input the orders for DS. V2 stated the error was not caught until 01/14/21 at which time the DS was obtained over the counter and immediately started. V2 stated V8 has since quit.V2 stated if R2 was not taken for return visits with V6 in a timely manner, it was an error on V9's part as she is solely responsible for scheduling visits. V7, Pharmacist, stated they received the order for DS on 01/07/21 and called V6's office to confirm it as they were unfamiliar with otic use of this drug. V6 confirmed the order, they ordered the medication, and received it on 01/08/21. They notified the facility that day that the medication was in, but had been flagged as not approved for payment by the facility's corporation. V7 stated this occurs when it is possible that the medication might be cheaper to purchase elsewhere, in this case, over the counter. V7 stated they heard nothing back until 01/14/21, when V2 called and stated they obtained the medication over the counter. On 01/26/21 at 10:30am, R2 was interviewed in her room. R2 was alert to person and place but not time. R2 was observed to require the use of a communication board for all communication and could not hear the surveyor at all. R2 stated she has hearing aids but does not wear them because they don't help. R2 stated she is going to be fitted for new hearing aids when her ear infection clears up. R2 stated she is not sure when that will be. On 01/27/21 at 10:10am, V9 stated she took R2 to be fitted for new hearing aids on 12/08/20 and was told by the audiologist that R2 had an accumulation of ear wax in both ears and this would need to be removed before they could test her hearing. V9 stated various providers to provide this were contacted, all of whom were scheduled several weeks out. V9 stated V6's practice was identified as being a walk in clinic with immediate availability, so she took R2 there, and her initial visit was on 12/18/20. V9 stated when she brought R2 back from the above referenced appointments, she gave the written instructions to whomever was charge nurse on that hall that day, V9 stated she can't remember who the staff members were. V9 stated she is told by nursing staff when residents need appointments, and in this case was told R2 needed to go back after each medication had been administered for seven days.V9 stated her responsibilty is to transport residents and sort out scheduling issues but it is the responsibility of nursing staff to determine who needs to be seen and how soon they need to be seen. V9 stated she cannot remember in either instance which nurse instructed her to take R2 for follow up. R2's Minimum Data Set((MDS) dated [DATE] documented that R2 has moderate difficulty with hearing and requires the use of hearing aids. The same MDS documented that R2 felt down, depressed, or hopeless from 7 to 11 days of the previous two week reporting period. R2's Care Plan dated 01/22/21 documented problem areas of difficulty hearing in noisy settings, depression, and little to no activity involvement. According to the National Institute of Health, 08/14/19, Depression in elderly patients with hearing loss: Current perspectives, @www.ncbi.nim.nih.gov, 'Hearing loss in older adulthood negatively impacts the quality of life and is associated with unipolar depression among older adults'. The facility's Physicians Orders Policy with a revision date of November 2017 documented, Physicians orders are obtained to provide clear direction regarding the care of the resident. Orders given by a physician or state permitted healthcare professional must be accepted by a licensed nurse and documented in the residents medical record .After noting the order, the receiving nurse enters it into the electronic health record and ensures it is active.

Based on record review, interview, and observation, the facility failed to provide adequate perineal cleansing for one resident (R2) of three residents sampled for perineal care in the sample of 3. This failure resulted in R2 complaining for two weeks about his penis becoming very painful and ulcerated due to a fungal infection. Findings include: R2's Minimum Data Set ((MDS) dated [DATE] indicated R2 requires extensive assistance from at least one staff person for hygiene and bathing. The same MDS listed R2's Brief Interview for Mental Status Score as 5, indicating R2 has severe cognitive deficits, and indicated R2 is always incontinent of bowel and occasionally incontinent of bladder. R2's hospital record Admission assessment dated [DATE] showed R2 is at high risk for skin breakdown. This Admission record also showed R2 had a many whitened, malodorous lesion on his penis with inflamed surrounding tissue. A Progress Note from the hospital dated 8/15/14 stated "penile [MEDICAL CONDITION]-[MEDICAL CONDITION] Simplex negative, Rapid Plasma Reagin non-reactive-likely fungal.' On 8/14/14 at 9 am, R2's family member Z1, stated that she told staff R2 complained of pain in his penis, and had been complaining of this for approximately two weeks. Z1 stated that to her knowledge, staff did not examine R2's penis. E2, Director of Nurses, stated on 8/14/14 at 11 am that she was not aware of R2 having anything wrong with his penis. E4, Certified Nursing Assistant.stated R2 would not allow her to retract the foreskin and cleanse his penis. E5, Certified Nursing Assistant, stated that she had a good working relationship with R2 and he would frequently allow her to give his care when he refused other staff. E5 stated she did not work very often on R2's hall. On 08/15/14 at 10:30 am, E3, Assistant Director of Nurses stated, "We are considering assigning (E5) to (R2's) hall since he is more cooperative with her." On 08/19/14 at 8 am, R2 stated his penis is very sore and painful, and "They told me at the hospital its caused by a fungus. I think maybe its because I wasn't kept very clean." At the time of that interview R2 was oriented to person, place and purpose, but not time. On 08/19/14 a 8 am, R2 was observed to have three light yellow areas, each one approximately 0.5 centimeters in diameter, on the head of his penis, with surrounding tissue appearing red and inflamed.

Based on record review, observation and interview, the facility failed to identify a defective pressure relieving device causing pressure; failed to obtain a physician order [REDACTED]. Findings Include: 1. According to his current face sheet, R3 was originally admitted to the facility on [DATE]. R3's [DIAGNOSES REDACTED]. R3's most recent Minimum Data Set (MDS), dated [DATE], documents that he does not ambulate; is dependent on staff for all activities of daily living; requires the extensive assistance of two or more staff members and a mechanical lift for transfers; has short and long term memory problems, and severely impaired cognitive skills for daily decision making. R3's care plan documents "turn and reposition while in bed frequently for comfort and pressure reduction". The facility "Weekly Pressure Ulcer Log" documents that R3 was readmitted from the hospital on [DATE] with a stage II pressure sore on his right heel and a stage I pressure sore on his left heel. A "Change of Condition" form was faxed to R3's physician documenting that on [DATE] an open area was found on R3's left gluteal. The form documents, "Noted a 4 centimeter (cm) by 4 cm area to left gluteal. Resident's wheelchair cushion had a worn area where a board was present. The area rubbed against his buttock causing a pressure area. I suggest new orders: Area cleansed with wound cleanser, skin prep applied around area then [MEDICATION NAME] applied. Change every 3 days and as needed. If you need something else, please let us know". This form is signed by E11, Licensed Practical Nurse (LPN). R3 does not have a physician's orders [REDACTED]. There is no documentation present in R3's clinical record that shows that his physician was ever notified of the open area to his left gluteal area. E1, Administrator, and E2, Director of Nursing (DON), were interviewed on [DATE] at 1:55 PM. Both E1 and E2 stated that "Change of Condition" forms are completed by the Facility nurse on duty then faxed to the physician. Both confirmed that there is no confirmation that R3's physician got the fax or was notified of the open area to R3's left gluteal area. E2 said that the nurse who originally reported the area on R3's left gluteus is no longer employed by the Facility. E1 said that an air mattress was placed on R3's bed on [DATE]. The "Weekly Pressure Ulcer Log" documents that on [DATE], a 3.2 cm x 2 cm x .4 cm in depth pressure sore was found on R3's left buttock. On [DATE], the area measured 4.7 cm x 3.5 cm x .5 in depth. On [DATE], it measured 2 cm x 2.1 cm x .5 in depth with no staging. The first physician order [REDACTED]. Cleanse wound prior. [DATE], Treatment to buttock with Max Orb Silver rope and [MEDICATION NAME] okay. Prior to dressing, prep surrounding skin with no sting skin prep and pack wound with Max Orb Silver rope. Cover with [MEDICATION NAME]". R3 was sent to the hospital on [DATE]. The hospital "Consultation Report" documents "He has significant decubitus on the right buttock and we were asked to see him for that. On the right side down over the ischial tuberosity on the left there was a 4 cm decubitus. I debrided this and there was a large amount of purulent material evaluated and necrotic tissue. This extended the depth of 8 cm centrally and 2 cm superiorly. There is a large amount of necrotic debris irrigated but this was by no means a complete debridement. We were able to get to the base and I was concerned that there were perhaps some bone exposed. Ultimately if we can get this cleaned we may try a wound vac although I have some concerns that this may heal. I am not sure that this will ever heal in this poor gentleman but we will be aggressive at this point". The [DATE] "Weekly Pressure Ulcer Log" documents that the area on R3's left coccyx (the facility referred to R3's area of the pressure sore as both coccyx and gluteal on different documents) measured 1.2 cm x 2.7 cm with unknown depth. R3 was seen all days of the survey lying in bed on a low air loss mattress. During interviews with E1 and E2, on [DATE], it was stated that R3 developed a pressure sore in-house which required surgical debridement. Both of those interviewed could not confirm if R3's physician had ever been notified about the pressure sore. 2. During an interview on [DATE] at 11:40 a.m. E2 Director of Nurses (DON) reported R2 was admitted to the facility with a decubitus ulcer on her coccyx and knew of pressure areas on her heels which developed while she was a resident in the facility. E2 said the care plans in use do not specify any frequency for turning and positioning and could not explain what the intervention of "turn and reposition frequently to decrease pressure" means in relation to how often a resident is to be turned. E4 LPN and Minimum Data Set Coordinator, agreed with E2 that the care plans do not specify frequency for turning and repositioning. The Physician order [REDACTED]. The Nursing Admission Assessment Integumentary page indicates R2 had a Stage II Decubitus Ulcer of the coccyx and 4 small scabbed areas on the right lower leg. R2's Pressure Ulcer Care Plan dated [DATE] indicated 8 pressure areas including areas on the buttocks, coccyx, and both heels. Observation of R2 could not be made as she was transferred to the hospital on [DATE] and expired on [DATE]. E2 (Director of Nursing) and E4 (LPN) were interviewed on [DATE] at 11:40 a.m. related to the practice of turning and position for their residents. When asked if the facility has a policy regarding turning and position they both indicated they did not. When asked to explain the meaning of the intervention marked on the care plan for R2, "turn and reposition frequently to decrease pressure", E2 was unable to explain how often the word "frequently" meant. When asked if E2 recalled how often R2 was turned and repositioned she stated "NO." When E2 was asked if the Certified Nurse Aides or LPN's document when they turn and reposition residents she stated there was no specific documentation of times residents are turned. E2 was asked if she recalled R2's skin condition related to decubitus ulcers or pressure areas. E2 reported she recalled R2 came to their facility with a decubitus on her coccyx and knew it was staged at a 2 but she felt it was at a stage 3. She reported she was aware R2 had other areas on her heels while she was in the facility but could not recall details. E2 reported R2 expired in the hospital after she was transferred for [MEDICAL CONDITION]. 3. The medical records of R1 and R5 documents that their care plans were marked for interventions which included "turn and reposition frequently to decrease pressure" but fail to indicate how frequently each resident is to be turned, depending on their individual needs. The facility listings for residents requiring T/P (turn and position) and the listing for residents with pressure ulcers document that R1 and R5 had either a history of pressure ulcers or received treatment in the facility for pressure ulcers and were unable to reposition themselves without assistance.