Every finding on record at Pershing General Hospital SNF

Based on observation, interview and document review, the facility failed to remove a personal food item stored in a refrigerator designated for resident food, ensure a cook on tray line was not wearing a dangling earring, ensure hair coverings fully covered all hair and facial hair, and ensure a kitchen aide performed hand hygiene before returning to tray line. These deficient practices had the potential to affect the entire facility census due to improper food storage, possible cross contamination, and an increased likelihood of foodborne illness. Findings include: Personal Food Item On 06/08/2026 at 10:12 AM, an 8.4 ounce unopened can of Red Bull original, was located in the refrigerator by the three-compartment sink. The can was undated and unlabeled. On 06/08/2026 at 10:13 AM, the Dietary Manager confirmed the Red Bull was not dated or labeled and belonged to a facility employee. The Dietary Manager verbalized having been unaware employee personal food items were not to be stored with resident food items. The facility policy titled, Nutrition Room Refrigerators, reviewed 02/25/2026, documented resident refrigerators located in Long Term Care and in nutrition rooms were reserved for resident food only and no employee food was to be stored in resident refrigerators. Earring On 06/09/2026 at 11:17 AM, the [NAME] had a black lightning bolt earring dangling below the right earlobe. The earring was approximately one inch in length. On 06/09/2026 at 12:08 PM, the Dietary Manager confirmed the [NAME] was wearing a dangling lightning bolt earring in the right earlobe while on tray line. The Dietary Manager verbalized all jewelry over a quarter of an inch should not be worn in the kitchen. The facility policy titled, Dress Code and Personnel Appearance, dated 04/01/2026, documented jewelry shall not pose a safety risk and dangling jewelry shall not be worn. Hair Coverings On 06/09/2026 at 11:18 AM, the Cook's left and right sideburn hair was uncovered and down the sides of the Cook's cheeks approximately two inches. On 06/09/2026 at 11:20 AM, the Dietary Aide/Cook had an uncovered moustache and goatee. The goatee hung approximately one inch from the Dietary Aide/Cook's chin. On 06/09/2026 at 11:23 AM, the Dietary Aide/Cook was on the tray line and prepared a cheese quesadilla for a resident. The Dietary Aide/Cook's moustache and goatee were uncovered. On 06/09/2026 at 11:24 AM, Dietary Aide #1's left and right sideburn hair was uncovered and down the sides of the Dietary Aide's cheeks approximately three inches. The sideburn hair was thick and curly. On 06/09/2026 at 12:09 PM, the Dietary Manager confirmed the Cook, the Dietary Aide/Cook and Dietary Aide #1 all had uncovered sideburns or facial hair. The Dietary Manager confirmed all hair including sideburns and facial hair should have been covered while in the kitchen. The facility policy titled, Maintenance of Sanitary Conditions, reviewed 02/25/2026, documented employees engaged in meal preparation or handling food products were to use hair nets, covering the hair line at all times. The facility policy lacked language on the use of hair nets or hair coverings for facial hair. Hand Hygiene On 06/09/2026 at 11:28 AM, Dietary Aide #2 returned to the kitchen after delivering food trays and entered the tray line prior to washing hands. On 06/09/2026 at 11:29 AM, the Dietary Manager confirmed Dietary Aide #2 returned to the tray line without washing hands and instructed Dietary Aide #2 to wash hands before returning to the tray line. On 06/09/2026 at 12:10 PM, the Dietary Manager confirmed kitchen staff were to wash hands each time before returning to the tray line. The facility policy titled, Hand Hygiene, reviewed 03/21/2026, documented all staff were to perform effective hand hygiene by washing hands with soap and water before, during and after preparing food.

Based on observation, interview, clinical record review, and document review, the facility failed to ensure 1) hand hygiene was performed per facility policy during a dressing change on a gastric tube insertion site for 1 of 13 sampled residents (Resident #4), 2) a staff member's personal belongings were not stored in a drawer of the medication cart on top of tissues for resident use for 1 of 1 medication carts, and 3) personal protective equipment (PPE) was worn when touching a soiled mop pad and hand hygiene was performed prior to touching a housekeeping cart and a nutrition room door handle. This deficient practice had the potential to result in a resident developing a health care associated infection from poor hand hygiene during a dressing change and the transmission of infection from staff and environmental surfaces to residents with weakened immune systems with the potential for actual harm to residents such as sepsis or death. Findings include: Gastric Tube Resident #4 Resident #4 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including dysphagia following cerebral infarction and cerebellar stroke syndrome. An Order Summary Report for Resident #4 documented the following: Complete tube site care every day. The start date for the order was 12/05/2025. On 06/09/2026 at 2:36 PM, the Registered Nurse (RN) for Resident #5 removed the dressing from the resident's gastric tube insertion site. The RN cleaned the area around the insertion site, dried the area with dry gauze, and applied a new dressing. The RN did not perform hand hygiene or change gloves in between removing the old dressing and applying the clean dressing. The RN confirmed the RN should have performed hand hygiene and changed gloves in between removing the old dressing and applying a clean dressing. The RN confirmed the RN had not performed hand hygiene or changed gloves. On 06/09/2026 at 4:17 PM, the Director of Nursing (DON) verbalized the correct process for changing a dressing was to remove the dressing, perform hand hygiene and don new gloves and then apply the clean dressing to avoid contaminating the insertion site with bacteria from the old dressing. The facility policy titled Enteral Feeding Tube Exit Site Care, Gastrostomy and Jejunostomy, revised 12/14/2025, documented because the tube exited through the abdominal wall it required careful skin care to prevent infection. Site care included performing the following steps: Remove old dressing Remove and discard gloves. Perform hand hygiene. Put on gloves. Medication Cart On 06/11/2026 at 9:40 AM, during a medication cart observation with the DON, the top drawer of the medication cart had a tissue box for resident use and use with dispensing medications. A staff member's cell phone and lip balm were laying on top of the tissues. The DON confirmed the items should not have been stored in the medication cart or near any items intended for resident use. The DON verbalized the personal items in the medication cart had the potential to spread bacteria or infection to residents. The Licensed Practical Nurse (LPN) confirmed the cell phone and lip balm in the top drawer of the medication cart were on top of a box of tissue for resident use and the personal items belonged to the LPN. The facility policy titled Medication Storage, reviewed 10/28/2024, documented all areas were drugs where stored would be kept dry, clean, and neat at all times. Housekeeping On 06/11/2026 at 8:29 AM, a Housekeeper was mopping the floor in room [ROOM NUMBER], the Housekeeper was not wearing gloves. The Housekeeper finished mopping floor around the resident bed closest to the door, exited the room, removed the mop pad from the mop handle, placed the pad in a plastic bag on a housekeeping cart, grabbed the cart handle, opened a binder located on top of the cart, grabbed the handle on the door to the nutrition room and opened the door. The Housekeeper did not perform hand hygiene after touching the soiled mop pad and prior to touching the cart, binder, or nutrition room door handle. On 06/11/2026 at approximately 8:35 AM, the Housekeeper verbalized the Housekeeper usually wore gloves when touching soiled mop pads and would perform hand hygiene after removing the gloves. The Housekeeper confirmed the Housekeeper was not wearing gloves when the Houskeeper removed the soiled mop pad from the mop handle and did not perform hand hygiene prior to touching the housekeeping cart, binder on the cart, and the nutrition room door handle. On 06/11/2026 at 10:19 AM, the Infection Preventionist (IP) and the DON verbalized hand hygiene was required to be performed when going in and out of resident rooms, before performing a task, after performing a task, and any time staff came in contact with a resident or object in the resident's environment. The IP's expectation of housekeeping staff when mopping floors in resident rooms included switching the mop pad between resident areas and performing hand hygiene. The IP confirmed a Housekeeper would be expected to wear gloves when removing a soiled mop pad from the mop handle and would be expected to perform hand hygiene after touching a soiled mop pad with bare hands, prior to touching any other surface. The IP explained if staff did not wear gloves when touching soiled mop pads and did not perform hand hygiene afterward, infectious organisms could be transmitted to other people and surfaces. The facility policy titled Hand Hygiene, reviewed 03/21/2026, documented all staff who came into contact either directly with patients, or indirectly through equipment or the environment, would perform effective hand hygiene practices to minimize the risk of cross-infection to other patients, staff and visitors. Hand hygiene was the single most important activity for preventing the spread of infection. Circumstances indicating or recommended to perform hand hygiene included but were not limited to before and after exiting resident rooms and after contact with patient's surroundings.

Based on observation, interview, clinical record review and document review, the facility failed to ensure staff followed the facility's policy related to inventorying of residents' personal belongings and a resident was allowed to retain and use personal possessions when a fish tank was removed from the resident's room without the resident's permission and placed in a common area of the facility for 1 of 13 sampled residents (Resident #12). This deficient practice had the potential to result in emotional distress and psychosocial harm to the resident.Findings include:Resident #12Resident #12 was admitted to the facility on [DATE], with diagnoses including rheumatoid arthritis, unspecified and major depressive disorder, recurrent, unspecified.Resident #26Resident #26 was admitted to the facility on [DATE], with diagnoses including unspecified dementia, unspecified severity, with other behavioral disturbances, major depressive disorder, recurrent, unspecified, and age-related physical debility. Resident #26 was discharged from the facility on 09/25/2025.On 06/08/2026 in the afternoon, Resident #12 verbalized a facility staff member had removed an aquarium from the resident's room without the resident's permission.On 06/09/2026 at 11:01 AM, Resident #12 pointed to a large cylindrical fish tank in the activities room. The fish tank contained several small faux fish, was secured to the wall, and was unplugged. Resident #12 verbalized the fish tank had been removed from the resident's room a few months prior when the Activity Director (AD) had maintenance take it out and the resident wanted the fish tank back. The resident explained the fish tank previously belonged to the resident's roommate (Resident #26) and was kept in the residents' room. When the former roommate passed away, the roommate's family member gave the fish tank to Resident #12 because Resident #12 loved it. Resident #12 verbalized the fish tank was typically turned off because the noise bothered other residents.An Activity Participation Note dated 04/21/2026, documented Resident #12 was upset about the fish tank. The AD explained to Resident #12 the facility set the rules, and the resident had too many belongings in the room to fit the fish tank. It was placed in the common area for everyone to enjoy. Resident #12 was refusing to participate in activities because of this.On 06/10/2026 at 2:25 PM, the Social Worker (SW) verbalized tracking and inventorying of residents' personal items was a shared responsibility. Activities staff typically would help residents place orders for new items and once items arrived at the facility, the SW would take the items to the Unit Secretary (US) who would log the items.The SW confirmed the SW was familiar with Resident #12. The SW recalled there was a fish tank in the resident's room which originally belonged to Resident #26, who had passed away. Resident #12 asked Resident #26's family member if the resident could keep the fish tank and the family member agreed. When Resident #12 got a new roommate, facility staff let the resident know if the resident was able to find space for the fish tank and it remained safe for the resident to get in and out of bed, the fish tank could remain in the room. The SW recalled the fish tank remained in Resident #12's room from the time Resident #26 passed away in September 2025, until a new roommate moved in in April 2026.On 06/10/2026 at 2:37 PM, the US verbalized resident belongings were tracked on inventory sheets. The US confirmed the US was familiar with Resident #12 and verbalized there was a lot of debate about the fish tank. The US confirmed Resident #12 asked Resident #26's family member for the fish tank after Resident #26 passed away. The US denied having any documentation of Resident #12 taking possession of the fish tank and denied having any documentation of the disposition of Resident #26's belongings after the resident passed.On 06/11/2026 at 11:58 AM, the Director of Nursing (DON) verbalized staff tried to make the facility feel as close to home as possible. Residents deserved respect and were allowed to keep personal items, however; the facility could not accommodate all items. If there was a safety risk staff would explain this to the resident, explain why the facility could not accommodate the item, ask the resident if there was something else the facility could get for the resident or something else the facility could do to try to accommodate the request. The DON explained the facility would usually document the conversation if an item was not safe and had to be removed.The DON confirmed the DON was familiar with Resident #12 and verbalized the DON had previously spoken to Resident #12 about the fish tank. The fish tank belonged to Resident #12's former roommate who had passed away and was given to Resident #12 by the roommate's family member. There was concern due to some residents who wandered, and staff were afraid the fish tank would get knocked over. The DON recalled the fish tank remained in Resident #12's room for a while and the DON did not know who had removed it or when it had been removed.On 06/11/2026 at 12:15 PM, during an interview with the AD and the DON, the AD verbalized maintenance had removed the fish tank from Resident #12's room at the AD's request. The AD verbalized staff provided Resident #12 with some boxes in order to remove some items from the resident's room to make room for the fish tank. The AD denied being present for a conversation with Resident #12 or having any knowledge of the resident agreeing to have any items removed from the room. The AD confirmed the fish tank was in the activities room and verbalized it was unplugged due to it making a lot of noise.On 06/11/2026 at 12:42 PM, the DON, the AD and two Certified Nursing Assistants (CNAs) denied having any documentation related to the disposition of the fish tank when Resident #26 passed away, the conversation with Resident #12 regarding the safety concerns related to the fish tank, removing the fish tank from Resident #12's room, and any offers of alternatives such as a different tank or removal of other items to make room for the tank. The DON, the AD, and the CNAs confirmed the resident brought up the fish tank in conversation and voiced being upset about the fish tank being removed every few weeks. The DON acknowledged Resident #12 and Resident #26 were close and verbalized the DON thought the fish tank may have reminded Resident #12 of Resident #26.The facility document titled Resident's [NAME] of Rights, undated, documented residents had the right to be treated with consideration, respect, and dignity, to have security of possessions, and to reasonable accommodation of one's needs and preferences.The facility policy titled Patient Belongings and Property, reviewed 04/20/2026, documented upon admission, nursing staff were to complete a resident property inventory form. Residents could retain and use personal items unless the item presented a safety risk, created an infection control concern, was prohibited by law, or interfered with care or treatment. Upon a resident's death, two staff members were to inventory belongings. The property would be secured and be released only to the legally authorized individual.

Based on interview, clinical record review, and document review, the facility failed to ensure the results of a facility reported incident (FRI) abuse investigation were reported to the State Agency (SA) within five days of the initial report for 1 of 13 sampled residents (Resident #6) and an initial FRI report for potential neglect was submitted to the SA within 24 hours of facility staff becoming aware of the allegations for 1 of 13 sampled residents (Resident #5). This deficient practice had the potential to result in an allegation of abuse and/or neglect not being investigated and reported in a timely manner and one or more residents experiencing harm from late or incomplete investigations. Findings include: Resident #6 Resident #6 was admitted to the facility on [DATE], with diagnoses including acquired absence of left foot and acquired absence of right leg below knee. A FRI initial report for potential neglect of Resident #6, dated 03/03/2026, documented the resident had attempted to self-transfer and fell. Post fall the resident had a change in mentation. The resident was sent to the emergency room for evaluation and treatment. The initial report documented a final report with a description of the investigation would be completed when the resident returned from the Emergency Room. The FRI did not include a final report with the results of the facility investigation. On 06/11/2026 at 9:05 AM, the Director of Nursing (DON) verbalized the final investigation report had not been sent to the State Agency. The facility policy titled Abuse/Neglect Prevention and Prohibition Long Term Care, reviewed 05/12/2026, documented it was the policy of the facility to report and investigate all allegations of actual or suspected abuse or neglect. Allegations of abuse would be reported to the State Agency and the results of all investigations of alleged violations would be reported within five working days of the incident. FRI 2793790 Resident #5 Resident #5 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including type two diabetes mellitus without complications and presence of artificial hip joint. A FRI initial report for potential neglect of Resident #5 was submitted to the SA on 03/24/2026 at 7:37 AM. The report documented Resident #5 informed a nurse the night shift Certified Nursing Assistants (CNAs) were rough with the resident and refused to take the resident's Vital Signs (VS). On 06/11/2026 at 11:26 AM, the DON, who was also the facility's Abuse Coordinator (AC), verbalized abuse was anything which was detrimental to a resident. Abuse could be physical, verbal, psychological or financial. Neglect was the act of refusing to provide care or services to a resident which the resident was required to have. The DON/AC confirmed the DON/AC was familiar with the FRI report involving Resident #5 and recalled Resident #5 informed the nurse on Saturday, 03/21/2026, the CNAs were rough and refused to check the resident's VS. The nurse emailed the DON/AC and the Assistant DON (ADON) around 3:00 AM on 03/23/2026 to report the resident's concerns. The DON/AC explained the allegations should have been reported to the DON/AC immediately and the DON/AC would have needed to submit an initial FRI to the SA within two hours of when staff became aware of the allegation. The DON/AC confirmed the initial FRI was submitted to the SA beyond the required reporting timeframe and the alleged perpetrators were not suspended immediately due to delay in staff reporting. The facility policy titled Abuse/Neglect Prevention and Prohibition Long Term Care, reviewed 05/12/2026, documented suspicions of abuse/neglect were to be reported immediately. The DON/AC was to be contacted via phone. Once a report was received and the resident's safety was verified via phone call, the AC or designee would submit a state report. If the alleged perpetrator was a staff member, the staff member would be relieved of duty, replaced with an appropriate staff member, and placed on administrative leave pending investigation. FRI 2962442

Based on clinical record review, interview and document review the facility failed to ensure a Minimum Data Set 3.0 (MDS) assessment was transmitted timely for one discharged resident reviewed for resident assessment (Resident #26). This deficient practice had the potential to result in delayed submission of resident assessment data affecting the accuracy of the facility's quality measures and reimbursements. Findings include:Resident #26 Resident #26 was admitted to the facility on [DATE], with diagnoses including unspecified dementia, unspecified severity, with other behavioral disturbances, major depressive disorder, recurrent, unspecified, and age-related physical debility. A progress note dated [DATE] at 4:40 PM, documented Resident #26 passed away while in the facility. Resident #26's MDS assessment dated [DATE], Section A, documented the resident passed away while in the facility. The MDS assessment documented having been completed by the MDS Registered Nurse (RN) on [DATE] at 7:15 AM. The MDS assessment submission validation report for Resident #26, documented the MDS assessment dated [DATE] was submitted to the Centers for Medicare and Medicaid (CMS) on [DATE] at 10:17 AM. The report documented the record had been submitted late and should have been submitted within 14 days of the resident's death. On [DATE] at 8:50 AM, the MDS RN confirmed having completed the MDS assessment after Resident #26's death on [DATE], but had not submitted the assessment until [DATE], more than a month after the resident's death. The MDS RN confirmed the record should have been submitted within 14 days of the resident's passing. On [DATE] at 8:52 AM, the MDS RN verbalized the facility did not have a policy related to MDS submission validation reporting and only used the Resident Assessment Instrument 3.0 (RAI) Manual for instructions and guidance. The Long-Term Care RAI 3.0 Manual, version 1.20.1, effective [DATE], documented assessment records related to deaths in the facility were to be transmitted to CMS no later than 14 calendar days after the date of death .

Based on observation, interview, clinical record review and document review, the facility failed to ensure a controlled medication was documented in the controlled drug record at the time the medication was administered for 1 of 13 sampled residents (Resident #5). This deficient practice had the potential to result in inaccurate record keeping of the administration of controlled substances with the potential to result in misappropriation of a resident's medications and a resident's symptoms not being managed effectively.Findings include: Resident #5 Resident #5 was admitted to the facility on [DATE], with diagnoses including anxiety disorder, unspecified and borderline personality disorder. A medication order and the June 2026 Medication Administration Record for Resident #5 documented the following:Ativan oral tablet 1 milligram (mg). Give 1 mg by mouth three times a day for fidgeting, agitation, restlessness related to anxiety disorder, unspecified. On 06/11/2026 at 9:39 AM, during an observation of the narcotic drawer in the medication cart with the Director of Nursing (DON), a Licensed Practical Nurse (LPN) retrieved the controlled substance log from the medication cart and verbalized the LPN needed to document in the log. On 06/11/2026 at 9:40 AM, the LPN confirmed the LPN had administered Ativan to Resident #5 at 9:31 AM but had not documented the administration and current count for the medication in the controlled substance log. On 06/11/2026 at 9:41 AM, the DON verbalized a controlled substance, such as Ativan, should have been documented in the controlled substance log at the time the medication was administered so the medication count was accurate, and the nurse administering could ensure the current medication count was accurate prior to administration. The facility policy titled, Medication Administration, reviewed 05/01/2026, documented documentation of medication administration would be completed after administering the medication to the resident.

Based on clinical record review, interview and document review, the facility failed to provide documented evidence residents and/or residents' representatives were provided opportunity to change their decision regarding acceptance or declination of the influenza (flu) vaccine prior to administration of the vaccine for 2 of 5 residents sampled for vaccinations (Residents #4 and #23). This deficient practice had the potential to result in residents and their representatives not being given the opportunity to make informed decisions before accepting or declining the vaccination.Findings include:Resident #4Resident #4 was admitted to the facility on [DATE], with a diagnosis of aphasia following cerebral infarction. A Record of Vaccination Acceptance and Declination Form signed by Resident #4's representative on 07/24/2025, documented the resident's provider notified the resident and/or responsible party the Centers for Disease Control and Prevention (CDC) recommended vaccinations for the resident and the resident was to be informed when the vaccination was due. The provider had offered risk versus benefits of receiving the recommended vaccinations. The flu vaccine was documented as accepted on 07/24/2025 with an administration due date of 2025. Additionally, the form documented the resident and/or representative understood the resident and/or representative had the right to change their mind and accept or decline any of the recommended vaccinations at any time. An Influenza Vaccination Consent and Documentation form documented the flu vaccine was administered to Resident #4 on 09/29/2025. The form included vaccination contraindication screening questions, a statement indicating the resident/representative had been given the opportunity to decline the vaccine and had consented to the vaccine being administered to the resident. The patient signature line and the parent/guardian signature lines were left blank. The form lacked documented evidence the screening was completed with the resident/representative and consent was obtained at the time of administration.Resident #23Resident #23 was admitted to the facility on [DATE], with a diagnosis of unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety.A Record of Vaccination Acceptance and Declination Form signed by Resident #23's representative on 06/04/2025, documented the resident's provider notified the resident and/or responsible party the CDC recommended vaccinations for the resident and the resident was to be informed when the vaccination was due. The provider had offered risk versus benefits of receiving the recommended vaccinations. The flu vaccine was documented as accepted on 06/04/2025 with an administration due date of 2025. Additionally, the form documented the resident and/or representative understood the resident and/or representative had the right to change their mind and accept or decline any of the recommended vaccinations at any time. An Influenza Vaccination Consent and Documentation form documented the flu vaccine was administered to Resident #23 on 10/12/2025. The form included vaccination contraindication screening questions, a statement indicating the resident/representative had been given the opportunity to decline the vaccine and had consented to the vaccine being administered to the resident. The patient signature line and the parent/guardian signature lines were left blank. The form lacked documented evidence the screening was completed with the resident/representative and consent was obtained at the time of administration.On 06/11/2026 at 10:19 AM, during an interview with the Director of Nursing (DON) and the Infection Preventionist (IP), the DON verbalized the facility followed CDC guidelines and would review WebIZ (an online, statewide immunization information system) to determine if residents were eligible for vaccines offered by the facility. Eligibility for vaccines was reviewed upon admission and at least annually for all residents. The facility Record of Vaccination Acceptance or Declination Form was intended for residents and/or resident representatives to say which vaccines the resident was interested in. The DON verbalized people could change their mind, and staff were to ask the resident and/or representative if the resident/representative still wanted the vaccine at the time it was due. A separate form was to be filled out at the time of administration.The DON and IP acknowledged the Influenza Vaccination Consent and Documentation Forms for Residents #4 and #23 lacked documented evidence consent was obtained at the time of administration and the resident and/or representative were given the opportunity to change their mind regarding receipt of the vaccine. The DON verbalized both residents were not their own responsible parties. The DON and IP explained when a resident was not their own responsible party, staff usually administered vaccines based on the Record of Vaccination Acceptance or Declination Form as staff did not often get a response from the representative/Power of Attorney (POA). The DON confirmed the DON's expectation was staff would obtain informed consent and complete an individual consent form prior to administration of each vaccine. If the resident had a representative and/or POA, the representative/POA could sign the vaccine-specific consent form, or two nurses could obtain verbal consent over the phone. If verbal consent over the phone was obtained, both nurses were to document on the consent form. The DON acknowledged failure to obtain consent at the time of administration denied the resident/representative the opportunity to decline the vaccine.The facility policy titled Influenza Vaccination Program, reviewed 12/01/2025, documented the facility would provide, promote, and document annual influenza vaccination for all eligible healthcare personnel and residents in compliance with regulations.The facility policy titled Standards of Care, reviewed 08/06/2025, documented each shift documentation would include but was not limited to: care, treatment, and interventions provided, notifications of guardian or family, and any resident or caregiver education including level of understanding.

Based on clinical record review, interview and document review, the facility failed to provide documented evidence residents and/or residents' representatives were provided opportunity to change their decision regarding acceptance or declination of the Covid-19 vaccine prior to administration of the vaccine for 2 of 5 residents sampled for vaccinations (Residents #24 and #4). This deficient practice had the potential to result in residents and their representatives not being given the opportunity to make informed decisions before accepting or declining the vaccination.Findings include:Resident #24Resident #24 was admitted to the facility on [DATE], with diagnoses including other sequelae of cerebral infarction and vascular dementia, severe, with anxiety. A Record of Vaccination Acceptance and Declination Form signed by Resident #24 on 06/04/2025, documented the resident's provider notified the resident and/or responsible party the Centers for Disease Control and Prevention (CDC) recommended vaccinations for the resident and the resident was to be informed when the vaccination was due. The provider had offered risk versus benefits of receiving the recommended vaccinations. The Covid-19 vaccine was documented as accepted on 06/04/2025 with an administration due date of Fall 2025. Additionally, the form documented the resident and/or representative understood the resident and/or representative had the right to change their mind and accept or decline any of the recommended vaccinations at any time. Two facility Vaccination Administration Forms documented the Covid-19 vaccine was administered to Resident #24 on 01/17/2026 and 04/22/2026. The form lacked documented evidence consent was obtained from the resident and/or resident representative at the time of administration, and staff verified if the resident and/or representative had changed their mind regarding acceptance or declination of the vaccine prior to administration. Resident #4Resident #4 was admitted to the facility on [DATE], with a diagnosis of aphasia following cerebral infarction. A Record of Vaccination Acceptance and Declination Form signed by Resident #4's representative on 07/24/2025, documented the resident's provider notified the resident and/or responsible party the CDC recommended vaccinations for the resident and the resident was to be informed when the vaccination was due. The provider had offered risk versus benefits of receiving the recommended vaccinations. The Covid-19 vaccine was documented as accepted on 07/24/2025 with an administration due date of Fall 2025. Additionally, the form documented the resident and/or representative understood the resident and/or representative had the right to change their mind and accept or decline any of the recommended vaccinations at any time. A facility Vaccination Administration Form documented the Covid-19 vaccine was administered to Resident #4 on 01/16/2026. The form lacked documented evidence consent was obtained from the resident and/or resident representative at the time of administration, and staff verified if the resident and/or representative had changed their mind regarding acceptance or declination of the vaccine prior to administration. On 06/11/2026 at 10:19 AM, during an interview with the Director of Nursing (DON) and the Infection Preventionist (IP), the DON verbalized the facility followed CDC guidelines and would review WebIZ (an online, statewide immunization information system) to determine if residents were eligible for vaccines offered by the facility. Eligibility for vaccines was reviewed upon admission and at least annually for all residents. The facility Record of Vaccination Acceptance or Declination Form was intended for residents and/or resident representatives to say which vaccines the resident was interested in. The DON verbalized people could change their mind, and staff were to ask the resident and/or representative if the resident/representative still wanted the vaccine at the time it was due. A separate form was to be filled out at the time of administration.The DON and IP acknowledged the Vaccine Administration Forms for Residents #4 and #24 lacked documented evidence consent was obtained at the time of administration and the resident and/or representative were given the opportunity to change their mind regarding receipt of the vaccine. The DON verbalized both residents were not their own responsible parties. The DON and IP explained when a resident was not their own responsible party, staff usually administered vaccines based on the Record of Vaccination Acceptance or Declination Form as staff did not often get a response from the representative/Power of Attorney (POA). The DON confirmed the DON's expectation was staff would obtain informed consent and complete an individual consent form prior to administration of each vaccine. If the resident had a representative and/or POA, the representative/POA could sign the vaccine-specific consent form, or two nurses could obtain verbal consent over the phone. If verbal consent over the phone was obtained, both nurses were to document on the consent form. The DON acknowledged failure to obtain consent at the time of administration denied the resident/representative the opportunity to decline the vaccine.The facility policy titled COVID-19 Vaccination Policy - Long Term Care, reviewed 05/2026, documented the facility would maintain a COVID-19 vaccination program to include vaccine education, vaccine offering or assistance with access, documentation of acceptance/refusal/contraindication, and required reporting. The facility would provide each resident or resident representative education regarding COVID-19 vaccination and offer the vaccination when available unless the resident was up to date or the vaccination was medically contraindicated. The resident or representative may accept, refuse, or later change vaccination decision. Documentation was to be maintained in residents' medical records, vaccine administration records, and declination or contraindication forms.

Based on personnel record review, interview and document review, the facility failed to ensure elder abuse prevention training was completed timely for 1 of 20 sampled employees (Employee #10). This deficient practice had the potential for the employee to be unprepared to recognize, prevent and report abuse thereby placing residents at risk for abuse and neglect. Findings include:Employee #10 Employee #10 was hired by the facility on 05/24/2018, as a Speech Therapist Contractor. Employee #10's personnel record documented elder abuse training had been completed on 01/20/2025. Employee #10's personnel record lacked documentation of annual elder abuse prevention training having been completed in 2026. On 06/11/2026 at 7:52 AM, the Administrator confirmed Employee #10 had not completed annual elder abuse prevention training for 2026, but should have. The facility policy titled, Abuse/Neglect Prevention and Prohibition Long Term Care, reviewed 05/12/2026, documented employees were to have completed abuse and neglect prevention training upon employment and annually thereafter.

Based on observation, interview, and document review, the facility failed to ensure the posted nurse staffing data included the actual hours worked per shift for licensed and unlicensed staff responsible for resident care for 4 of 4 days observed. This deficient practice had the potential to result in residents and visitors to the facility not being able to view accurate and complete staffing data.Findings include: On 06/08/2026, 06/09/2026, 06/10/2026, and 06/11/2026, the posted nurse staffing data did not include the actual hours worked per shift by licensed and unlicensed nursing staff directly responsible for resident care. On 06/11/2026 at 9:19 AM, the Director of Nursing (DON) verbalized the DON was unaware of the requirement to include actual hours worked on the posted nurse staffing data and confirmed the actual hours worked were not included in the facility's posting.

Based on clinical record review, interview and document review, the facility failed to ensure the accuracy of Minimum Data Set 3.0 (MDS) assessments for 2 of 12 sampled residents (Resident #1 and #9). This deficient practice had the potential to deprive the residents of person-centered care plans and the associated interventions relative to their current health management needs. Findings include: Resident #1 Resident #1 was admitted to the facility on [DATE], and readmitted on [DATE], with a diagnosis of major depressive disorder, recurrent, unspecified. Resident #1's quarterly MDS assessment dated [DATE], Section N0415 (Medications-High-risk Drug Classes: Use and Indication, C. Antidepressant), documented Resident #1 had been administered an antidepressant medication within the prior seven-day look-back period. A physician's order dated 04/22/2024, documented SEROquel oral tablet 25 milligrams (mg), give 25 mg by mouth at bedtime for anxiety, paranoid ideation, agitation related to major depressive disorder, recurrent, unspecified. The medication had a discontinue date of 09/10/2024. Resident #1's physician orders lacked documentation an antidepressant medication was currently ordered. Resident #9 Resident #9 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including aphasia following cerebral infarction, unspecified intellectual disabilities, other abnormalities of gait and mobility, and a history of falling. Resident #9's quarterly MDS assessment dated [DATE], Section P0200 (Restraints and Alarms: Alarms, C. Floor mat alarm), documented a floor mat alarm had been used daily within the prior seven-day look-back period. Resident #9's physician orders lacked documentation a floor mat alarm had been ordered. On 04/16/2025 at 1:51 PM, Resident #9 was in bed with the bed in a low position. The floor and area around the bed was absent of any floor mats or floor mat alarms. On 04/16/2025 at 2:04 PM, the Director of Nursing (DON) confirmed Resident #1 had not been currently ordered or administered an antidepressant. The DON confirmed Resident #9 did not have a floor mat alarm, and verbalized the facility did not have any, nor had they every used floor mat alarms. The DON confirmed the MDS entries for each resident's last quarterly assessment had been coded incorrectly and the facility followed the Resident Assessment Instrument Manual to complete the assessment process. The facility policy titled, Comprehensive Assessment and Reassessment, reviewed 10/30/2024, documented assessments would be individualized to meet the needs of the resident and must accurately reflect the resident's status.

Based on observation, clinical record review, interview and document review the facility failed to ensure 1) an order was obtained for the application of pressure redistribution/heel protector boots (heel boots) prior to applying heel boots and 2) failed to ensure the heel boots were correctly applied with the potential to cause a pressure injury (PI) or deep tissue injury (DTI) to the resident's heels for 1 of 12 sampled residents (Resident #14). Findings include: Resident #14 Resident #14 was admitted to the facility on [DATE], with diagnoses including unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, and anxiety, foot drop, unspecified foot, and pain in left lower leg. On 04/14/2025 at 1:52 PM, Resident #14 was resting in bed with a pair of heel boots placed under the resident's feet. The heel boots were not fastened to help ensure appropriate placement and the resident's heels were resting on the inner surface of the heel boots and were not positioned over the pressure redistribution opening in the heel of the boot. On 04/16/2025 at 3:41 PM, Resident #14 was resting in bed with a pair of heel boots placed under the resident's feet. The heel boots were not fastened and the resident's heels were not aligned with the pressure redistribution opening in the heel of the boots. Resident #14's clinical record did not include an order for the use and monitoring of heel boots. The resident's Treatment Administration Record (TAR) did not include monitoring for the use of heel boots and the resident's clinical record lacked documented evidence the resident's heels had been assessed/monitored for PI/DTI related to the use of the heel boots. On 04/16/2025 at 3:44 PM, a Registered Nurse (RN) verbalized due to a past trauma Resident #14's feet were very sensitive and the resident could not tolerate anything touching the tops of the resident's feet and did not like to have the heel boots fastened. The RN explained the heel boots were used prophylactically to prevent PI/DTI due to the resident was in bed most of the time. On 04/16/2025 at 3:46 PM, The RN verbalized both nurses and Certified Nursing Assistants applied the heel boots. The RN explained to apply the boots staff raised up the resident's leg and place the heel boots under the resident's feet. The heel boots were left unstrapped because the resident did not like to have the heel boots fastened due to sensitivity in the resident's feet. The RN verbalized the use of the pressure redistribution heel boots required a physician's order and confirmed Resident #14's clinical record lacked documented evidence of an order for the use of the heel boots. On 04/16/2025 at 3:53 PM, the Director of Nursing (DON) verbalized the facility required orders for all equipment used for resident care including the heel boots. The DON confirmed Resident #14's clinical record did not include an order for the use of pressure redistribution boots and confirmed an order should have been in place prior to the application of the heel boots. On 04/16/2025 at 3:58 PM, the DON explained heel boots were generally used when residents were in bed to protect the resident's heels from skin break down including PI and DTI. The DON confirmed when heel boots were applied, the resident's heel were to be positioned over the opening in the heel of the boot. On 04/16/2025 at 4:19 PM, Resident #14 was resting in bed with heel boots placed under the resident's feet, the boots were not fastened, and the resident's heels were not resting within the opening of the heel boots. The resident's heel and foot was resting on the inner surface of the boots. The DON confirmed the heel boots were not correctly applied. On 04/16/2025 at 4:28 PM, the DON confirmed Resident #14's clinical record did not include an order for the use of heel boots and confirmed a physician's order should have been obtained prior to the use of the heel boots. The DON verbalized the correct application of the boots required the resident's heels to be placed in the opening of the heel of the boots. The DON confirmed the heel boots had not been correctly applied for Resident #14. The DON confirmed when a resident's heels were not correctly aligned within the opening of the heel of the boots, pressure was being applied to the resident's heels and had the potential to cause the resident to develop a PI or DTI. The facility policy titled Skin Integrity and Injury Prevention, dated 03/15/2022, documented pressure injury prevention included managing pressure. Pressure was managed by providing appropriate support surfaces an off-loading heels by using pillows or positioning boots. The facility policy titled Written, Verbal, Electronic Physician Orders, reviewed 10/28/2024, documented orders for resident treatment were carried out only when given by a qualified physician or other duly licensed person authorized to prescribe. All orders for treatment included the type of treatment, specific requirements, and frequency of the treatment. The healthcare professional implementing the order documented the order was implemented in the appropriate section of the resident's clinical record.

Based on personnel record review, interview and document review, the facility failed to ensure initial behavioral health care training was completed timely per facility policy for 1 of 20 sampled employees (Employee #9). This deficient practice had the potential to prevent residents with behavioral health care needs from attaining or maintaining their highest practicable physical, mental and psychosocial well-being. Findings include Employee #9 Employee #9 was hired as the Minimum Data Set 3.0 Registered Nurse on 02/25/2025. Employee #9's personnel record lacked documented evidence of behavioral health care training. On 04/16/2025 at 11:05 AM, the Human Resources Director confirmed Employee #9's start date of 02/25/2025, and Employee #9 had not yet completed behavioral health care training. The Human Resources Director verbalized all employees were to have completed the training per the facility's policy. On 04/16/2025 at 11:41 AM, the Administrator verbalized not having been aware Employee #9 was required to complete the training. The facility policy titled, Employee Compliance, revised 06/28/2023, documented new employees were required to complete behavioral health training within 40 hours of the candidate's start date.

Based on observation, interview, clinical record review, and document review, the facility failed to ensure a care plan was developed to address side effects and necessary monitoring for a resident with bilateral lower extremity edema for 1 of 12 sampled residents (Resident #5). This deficient practice had the potential for the resident to suffer adverse health outcomes because of staff caring for the resident being unaware of the need to monitor for signs of leg swelling. Findings include: Resident #5 Resident #5 was admitted to the facility on [DATE], and readmitted on [DATE], with a diagnosis of bilateral primary osteoarthritis of knee. On 10/15/2024 at 11:48 AM, Resident #5 verbalized Resident #5 had swelling in both legs. Resident #5 verbalized Resident #5 was not wearing compression stockings. Resident #5's clinical record lacked documented evidence a care plan had been developed for the resident's diagnosis of bilateral primary osteoarthritis of knee and the management of the resident's bilateral leg edema. A physician's order dated 06/06/2024, documented compression stockings to bilateral limbs as needed for occasional swelling associated with bilateral primary osteoarthritis of knee. On 10/17/2024 at 11:51 AM, the Director of Nursing (DON) confirmed Resident #5's clinical record did not include a care plan for the resident's bilateral primary osteoarthritis of knee and the management of the resident's edema. The DON verbalized the compression stockings should be care planned as an intervention for the diagnosis since the hose were being placed on the resident to provide an intervention for the bilateral leg edema. The facility policy titled Baseline and Comprehensive Care Plan, revised 04/13/2023, documented the facility shall provide an individualized, interdisciplinary plan of care for all residents appropriate to the resident's needs, strengths, rules of diagnostic testing limitations and goals. The care plan shall describe the services to be furnished to attain or maintain the resident's highest practical physical well-being.

Based on interview, clinical record review, and document review, the facility failed to ensure comprehensive care plans were revised to include the physician identified behaviors for the administration of a psychotropic medication for 1 of 12 sampled residents (Resident #2) and new interventions for the prevention of falls for 2 of 12 sampled residents (Resident #23 and #25). Findings include: Resident #2 Resident #2 was admitted on [DATE], and readmitted on [DATE], with diagnoses including major depressive disorder, recurrent, unspecified and vascular dementia, moderate with mood disturbances. Resident #2's psychotropic physician's orders dated 02/15/2024, documented the following: -Seroquel Oral Tablet 25 milligrams (mg), give one tablet by mouth in the afternoon for low mood, anxiety, paranoid ideation related to major depressive disorder, recurrent, unspecified. -Cymbalta Oral Capsule Delayed Release Particles 30 mg, give one capsule by mouth two times a day for low mood, anxiety, paranoid ideation related to major depressive disorder, recurrent, unspecified. Resident #2's care plans documented the following focus areas related to psychotropic medications: -Resident #2 had a behavior history of self-isolation, sense of doom, crying/tearful episodes, anxious related to (r/t) major depressive disorder, initiated 03/05/2023 and revised 10/09/2024. -Resident #2 used psychotropic medications r/t major depressive disorder with behaviors. Resident #2 had a history of fearfulness, crying, tearfulness, anxious, self isolation, sense of doom and agitation, initiated 09/13/2023 and revised 10/09/2024. Resident #2's care plans lacked evidence of the paranoid ideation indicated in the physician ordered psychotropic medications. On 10/17/2024 at 3:45 PM, the Director of Nursing (DON) confirmed the behaviors indicated by the physician on the psychotropic medication orders did not match the behaviors documented by the nurses on the care plan for Resident #2 and the care plans lacked paranoid ideation as a behavior exhibited by the resident. The facility policy titled Baseline and Comprehensive Care Plan, last reviewed 04/13/2023, documented any resident receiving any type of psychotropic medication shall have a resident specific care plan which includes identification of resident specific targeted behaviors Cross reference F tag 758 Resident #23 Resident #23 was admitted to the facility on [DATE], with diagnoses including unspecified dementia, unspecified severity, with other behavioral disturbances and major depressive disorder, single episode, severe without psychotic features. On 10/15/2024 at 10:50 AM, Resident #23 recalled having fell off the bed and the resident's knees hurt from the fall. On 10/16/2024 at 2:15 PM, Resident #23 stood up from the resident's bed, physically moved a wheelchair out of the way, walked around the bed from the left side to the right side while bracing self with right hand on the bed, retrieved the resident's walker and ambulated to the bathroom. Resident #23's Progress Notes documented the following: -10/08/2024 The resident was impulsive and forgetful and had poor safety awareness. The resident was on the edge of the bed, moved forward and slid from the bed with no injury . consistent reminders offered to resident to ask for assistance. -10/09/2024 Interdisciplinary Team (IDT) and Root Cause analysis, resident was in room and slid from bed, no injury, all parties notified. Root cause resident was impulsive and had intermittent confusion and was ambulatory but overestimates abilities at times. Resident was educated and verbalized understanding of call light use and safety but was non-compliant. Will attempt to discuss grip strips with maintenance as resident at times had slipper socks on but the grip did not prevent sliding, care plan would be reviewed, no injury or pain noted. On 10/18/2024 at 8:50 AM, Resident #23's room lacked grip strips on the floor as indicated in the IDT progress notes. Resident #23's comprehensive care plan initiated and revised on 09/17/2024, documented a focus area for high risk for falls r/t confusion, conditioning, gait/balance problems, poor communication/comprehension, unaware of safety needs and history of falling. On 10/18/2024 at 9:12 AM, the DON explained Resident #23 had attempted to self transfer out of bed when the resident fell . The resident had leaned forward and slipped because the grip on the resident's socks was not enough to prevent sliding. The resident had difficulty with safety awareness. The facility had not applied grip tape as indicated by the IDT as a possible intervention and confirmed the tape was not available at the facility and had not been ordered. On 10/18/2024 at 9:19 AM , the DON verbalized the facility should have updated Resident #23's care plan with new interventions or revised past interventions after the fall on 10/08/2024. The DON confirmed new interventions had not been initiated or revised on the care plan to prevent future falls. Resident #25 Resident #25 was admitted to the facility on [DATE], with a diagnosis of major depressive disorder, recurrent, unspecified. Resident #25's Progress Notes documented the following: -09/14/2024 Post Fall Evaluation Fall Details: Date / Time of Fall: 09/14/2024 2:20 PM, Fall was not witnessed. Fall occurred in the resident's room. Activity at the time of fall: Resident cannot recall activity at time of fall. The reason for the fall was not evident .Resident was heard screaming down the hall and was found laying next to the resident's bed, on the ground, with head towards foot of the bed. Resident with no visible injuries. Denied hitting head but cannot recall how the resident fell or what the resident was doing . Bed alarm was not going off and call light was not on. New bed alarm placed. Resident returned to bed, educated and reminded to use the call light for assistance .Resident was not using cane/walker as instructed. Resident was not wearing oxygen as prescribed at time of fall . -09/25/2024 Post Fall Evaluation Fall Details: Date / Time of Fall: 09/25/2024 2:05 PM, Fall was not witnessed. Fall occurred in the resident's room. Resident was attempting to self toilet at time of the fall. The reason for the fall was not evident .Fall Details Note: Resident with unwitnessed fall in room. Resident found face down on the ground, head towards foot of the bed. Resident was assessed by Registered Nurse (RN) and DON for injures or any deformities. No visual sign of injury. Resident assisted back into bed by RN and Certified Nursing Assistant (CNA.) Resident denied hitting head. Reported no pain. Resident attempted to self-transfer out of bed and admitted to needing to use the restroom. Vital signs within defined limits. Bed alarm in place. Contributing Factors: .Footwear at time of fall: Socks. Resident was not using cane/walker as instructed. Resident was not wearing oxygen as prescribed at time of fall .-10/06/2024 Post Fall Evaluation Late Entry: Date / Time of Fall: 10/06/2024 6:30 PM, Fall was not witnessed. Fall occurred in the resident's room. Activity at the time of fall: Resident stated was trying to get self back to bed from sitting at side of bed eating dinner. Reason for the fall was evident. Reason for fall: Resident tried to get self back into bed. Resident denied utilizing call light for assistance . Contributing factors note: Patient denied utilizing call light for staff assistance when they were finished with meal. -10/07/2024 Fall Root cause analysis and IDT: Resident was impulsive and had poor safety awareness .The resident overestimated abilities and often became anxious and impatient during care provision .The resident denied any pain related to fall and stated the resident will attempt to be more patient and ask for assistance due to cognitive decline related to resident's condition, staff will continue to offer frequent reminders on safety past fall follow up indicated this fall was not the result of abuse or neglect. The care plan had been reviewed and updated to reflect interventions to assist in fall prevention for the resident. Resident #25's comprehensive care plan initiated on 04/30/2024 and revised on 07/02/2024, documented a focus area for high risk for falls r/t gait/balance problems and history of falling. The care plan contained one intervention post falls in September, initiated 09/17/2024: Physical Therapy/Occupational Therapy (PT/ OT) evaluate and treat as ordered or as needed (PRN.) Resident #25's Alert Note dated 10/09/2024, documented the prior Director of Nursing initiated potential to utilize trapeze as an intervention for the resident related to falls, upon reviewing this with therapy and nursing staff and the resident, it had been determined this was an ineffective intervention and the resident would not receive any benefit related to bed mobility with a trapeze, this is an ineffective intervention. Therapy did not have a suggestion for equipment related to fall intervention, to assist in fall will have staff provide frequent checks and encourage resident to be in visual areas while awake to assist in fall prevention at this time. On 10/18/24 at 9:28 AM, the DON explained Resident #25 had impulse control problems and had quite a few falls. It was almost behavioral, the resident gets impatient and tries to get out of bed. On 10/18/2024 at 9:35 AM, the DON confirmed implementing new interventions after the 10/06/2024 fall. The previous DON wanted to do a trapeze as an intervention after one of the falls in September but did not get an evaluation from PT/OT. The current DON had a verbal meeting with PT/OT and they said no, the trapeze was not approriate and had no other interventions. The intervention for the trapeze was not on the care plan. The care plan did not reflect interventions post falls from 09/14/2024 and 09/25/2024 to prevent future falls. The PT/OT eval, post fall, did not derive new interventions. The facility policy titled Falls and Fall Prevention, last revised 05/2024, documented extra measures were to be on the care plan for fall prevention. The facility policy titled Baseline and Comprehensive Care Plan, last reviewed 04/13/2023, documented all staff using the plan of care shall be responsible for interdisciplinary collaboration to establish goals and appropriate interventions as well as ongoing evaluation and revisions. Cross reference F tag 689

Based on interview, clinical record review and document review, the facility failed to ensure fall prevention interventions were initiated post-fall as a result of the root cause analysis of the falls for 2 of 12 sampled residents (Resident #23 and #25). This deficient practice had the potential for a resident to fall with serious injury. Findings include: Resident #23 Resident #23 was admitted to the facility on [DATE], with diagnoses including unspecified dementia, unspecified severity, with other behavioral disturbances and major depressive disorder, single episode, severe without psychotic features. On 10/15/2024 at 10:50 AM, Resident #23 recalled having fell off the bed and the resident's knees hurt from the fall. On 10/16/2024 at 2:15 PM, Resident #23 stood up from the resident's bed, physically moved a wheelchair out of the way, walked around the bed from the left side to the right side while bracing self with right hand on the bed, retrieved the resident's walker and ambulated to the bathroom. Resident #23's Progress Notes documented the following: -10/08/2024 The resident was impulsive and forgetful and had poor safety awareness. The resident was on the edge of the bed, moved forward and slid from the bed with no injury . consistent reminders offered to resident to ask for assistance. -10/09/2024 Interdisciplinary Team (IDT) and Root Cause analysis, resident was in room and slid from bed, no injury, all parties notified. Root cause resident was impulsive and had intermittent confusion and was ambulatory but overestimates abilities at times. Resident was educated and verbalized understanding of call light use and safety but was non-compliant. Will attempt to discuss grip strips with maintenance as resident at times had slipper socks on but the grip did not prevent sliding, care plan would be reviewed, no injury or pain noted. On 10/18/2024 at 8:50 AM, Resident #23's room lacked grip strips on the floor as indicated in the IDT progress notes. Resident #23's comprehensive care plan initiated and revised on 09/17/2024, documented a focus area for high risk for falls related to (r/t) confusion, conditioning, gait/balance problems, poor communication/comprehension, unaware of safety needs and history of falling. On 10/18/2024 at 9:12 AM, the Director of Nursing (DON) explained Resident #23 had attempted to self transfer out of bed when the resident fell . The resident had leaned forward and slipped because the grip on the resident's socks was not enough to prevent sliding. The resident had difficulty with safety awareness. The facility had not applied grip tape as indicated by the IDT as a possible intervention and confirmed the tape was not available at the facility and had not been ordered. On 10/18/2024 at 9:19 AM , the DON verbalized the facility should have updated Resident #23's care plan with new interventions or revised past interventions after the fall on 10/08/2024. The DON confirmed new interventions had not been initiated or revised on the care plan to prevent future falls. On 10/18/2024 at 9:21 AM, the DON confirmed the Morse scale evaluation had not been completed post fall for Resident #23. The DON explained the Morse scale evaluation would be used to determine if the resident had a decline and why the resident had fallen. The facility would complete another evaluation quarterly to determine if increase in functionality had occurred and to ensure no functional issue or decline had occurred. The Morse scale evaluation was required to be completed post fall. Resident #25 Resident #25 was admitted to the facility on [DATE], with a diagnosis of major depressive disorder, recurrent, unspecified. Resident #25's Progress Notes documented the following: -09/14/2024 Post Fall Evaluation Fall Details: Date / Time of Fall: 09/14/2024 2:20 PM, Fall was not witnessed. Fall occurred in the resident's room. Activity at the time of fall: Resident cannot recall activity at time of fall. The reason for the fall was not evident .Resident was heard screaming down the hall and was found laying next to the resident's bed, on the ground, with head towards foot of the bed. Resident with no visible injuries. Denied hitting head but cannot recall how the resident fell or what the resident was doing . Bed alarm was not going off and call light was not on. New bed alarm placed. Resident returned to bed, educated and reminded to use the call light for assistance .Resident was not using cane/walker as instructed. Resident was not wearing oxygen as prescribed at time of fall . -09/25/2024 Post Fall Evaluation Fall Details: Date / Time of Fall: 09/25/2024 2:05 PM, Fall was not witnessed. Fall occurred in the resident's room. Resident was attempting to self toilet at time of the fall. The reason for the fall was not evident .Fall Details Note: Resident with unwitnessed fall in room. Resident found face down on the ground, head towards foot of the bed. Resident was assessed by Registered Nurse (RN) and DON for injures or any deformities. No visual sign of injury. Resident assisted back into bed by RN and Certified Nursing Assistant (CNA.) Resident denied hitting head. Reported no pain. Resident attempted to self-transfer out of bed and admitted to needing to use the restroom. Vital signs within defined limits. Bed alarm in place. Contributing Factors: .Footwear at time of fall: Socks. Resident was not using cane/walker as instructed. Resident was not wearing oxygen as prescribed at time of fall . -10/06/2024 Post Fall Evaluation Late Entry: Date / Time of Fall: 10/06/2024 6:30 PM, Fall was not witnessed. Fall occurred in the resident's room. Activity at the time of fall: Resident stated was trying to get self back to bed from sitting at side of bed eating dinner. Reason for the fall was evident. Reason for fall: Resident tried to get self back into bed. Resident denied utilizing call light for assistance . Contributing factors note: Patient denied utilizing call light for staff assistance when they were finished with meal. -10/07/2024 Fall Root cause analysis and IDT: Resident was impulsive and had poor safety awareness .The resident overestimated abilities and often became anxious and impatient during care provision .The resident denied any pain related to fall and stated the resident will attempt to be more patient and ask for assistance due to cognitive decline related to resident's condition, staff will continue to offer frequent reminders on safety past fall follow up indicated this fall was not the result of abuse or neglect. The care plan had been reviewed and updated to reflect interventions to assist in fall prevention for the resident. Resident #25's comprehensive care plan initiated on 04/30/2024 and revised on 07/02/2024, documented a focus area for high risk for falls r/t gait/balance problems and history of falling. The care plan contained one intervention post falls in September, initiated 09/17/2024: Physical Therapy/Occupational Therapy (PT/ OT) evaluate and treat as ordered or as needed (PRN.) Resident #25's Alert Note dated 10/09/2024, documented the prior Director of Nursing initiated potential to utilize trapeze as an intervention for the resident related to falls, upon reviewing this with therapy and nursing staff and the resident, it had been determined this was an ineffective intervention and the resident would not receive any benefit related to bed mobility with a trapeze, this is an ineffective intervention. Therapy did not have a suggestion for equipment related to fall intervention, to assist in fall will have staff provide frequent checks and encourage resident to be in visual areas while awake to assist in fall prevention at this time. On 10/18/2024 at 9:28 AM, the DON explained Resident #25 had impulse control problems and had quite a few falls. It was almost behavioral, the resident gets impatient and tries to get out of bed. On 10/18/2024 at 9:35 AM, the DON confirmed implementing new interventions after the 10/06/2024 fall. The previous DON wanted to do a trapeze as an intervention after one of the falls in September but did not get an evaluation from PT/OT. The current DON had a verbal meeting with PT/OT and they said no, the trapeze was not approriate and had no other interventions. The intervention for the trapeze was not on the care plan. The care plan did not reflect interventions post falls from 09/14/2024 and 09/25/2024 to prevent future falls. The PT/OT eval, post fall, did not derive new interventions. The facility policy titled Falls and Fall Prevention, last revised 05/2024, documented extra measures were to be on the care plan for fall prevention and Morse scale completed post fall. Cross reference F tag 657

Based on interview and personnel record review, the facility failed to ensure a Certified Nursing Assistant (CNA) had an annual performance evaluation completed timely for 3 of 4 CNAs employed greater than one year, sampled for personnel record review (Employee #3, #8 and #9). Findings include: Employee #3 Employee #3 was hired as the Activity Director/CNA with a start date of 02/08/2018. Employee #3's personnel record documented the CNA had an annual performance evaluation last completed on 05/22/2023. Employee #3's personnel record lacked documented evidence a performance evaluation was completed in May 2024. Employee #8 Employee #8 was hired as a CNA with a start date of 07/20/2022. Employee #8's personnel record documented the CNA had an annual performance evaluation last completed on 04/28/2023. Employee #8's personnel record lacked documented evidence a performance evaluation was completed in April 2024. Employee #9 Employee #9 was hired as a CNA with a start date of 04/17/2013. Employee #9's personnel record documented the CNA had an annual performance evaluation last completed on 06/03/2023. Employee #9's personnel record lacked documented evidence a performance evaluation was completed in June 2024. On 10/16/2024 at 11:32 AM, the Human Resources Director was unable to provide evidence Employee #3, #8 and #9 had an annual performance evaluation completed for 2024 and verbalized the CNA annual performance evaluations were to be completed annually by the anniversary date of hire. The Human Resources Director confirmed the CNA annual performance evaluations were not completed for Employee #3, #8 and #9 annually for 2024. The facility policy titled Long Term Care Staff Continuing Education, last reviewed 04/13/2024, documented CNAs would receive annual evaluation.

Based on observation, interview, clinical record review, and document review the facility failed to ensure ordered medications were available for 1 of 5 residents observed for medication administration (Resident #6) and have a procedure in place for the safe procurement of drugs and biologicals. Findings include: Resident #6 Resident #6 was admitted to the facility on [DATE], with diagnoses including dry eye syndrome of bilateral lacrimal glands and abnormal results of other function studies of the eye. Resident #6's October 2024 Medication Administration Record (MAR) documented Restasis Ophthalmic Emulsion, instill one drop in both eyes two times a day for cataract inflammation. The order date was 09/10/2024. The medication was documented as 9 on the following dates for the 8:00 AM medication pass: -10/11/2024 -10/16/2024 -10/17/2024 The medication was documented as 9 on the following dates for the 8:00 PM medication pass: -10/10/2024 -10/12/2024 -10/13/2024 -10/14/2024 -10/15/2024 -10/16/2024 The MAR chart code documented a 9 equated to other, see progress notes. Resident #6's Orders Administration Notes documented the following: -Effective date 10/10/2024, Restasis Ophthalmic Emulsion, instill one drop in both eyes two times a day. On order. -Effective date 10/11/2024, Restasis Ophthalmic Emulsion, instill one drop in both eyes two times a day. Awaiting medication delivery. -Effective date 10/12/2024, Restasis Ophthalmic Emulsion, instill one drop in both eyes two times a day. On order, awaiting delivery. -Effective date 10/13/2024, Restasis Ophthalmic Emulsion, instill one drop in both eyes two times a day. Awaiting delivery. -Effective date 10/14/2024, Restasis Ophthalmic Emulsion, instill one drop in both eyes two times a day. Still awaiting pharmacy delivery. -Effective date 10/15/2024, Restasis Ophthalmic Emulsion, instill one drop in both eyes two times a day. On order. -Effective date 10/16/2024, Restasis Ophthalmic Emulsion, instill one drop in both eyes two times a day. Awaiting medication delivery. -Effective date 10/17/2024, Restasis Ophthalmic Emulsion, instill one drop in both eyes two times a day. Awaiting pharmacy delivery. On 10/18/2024 at 8:30 AM, during an interview with the Director of Nursing (DON) and a Registered Nurse (RN), the DON confirmed Resident #6 had not received ordered doses of Restasis Ophthalmic Emulsion eye drops due to the medication being unavailable in the facility and on order from the pharmacy. The DON explained the DON was aware the Restasis eye drops were not available in the facility and had contacted the facility's pharmacy multiple times to request a refill of the medication. The RN reviewed Resident #6's clinical record and explained the medication had been unavailable in the facility since 10/10/2024. On 10/18/2024 at 11:40 AM, during an interview with the Administrator and the DON, the Administrator explained the facility did not have a documented policy or procedure in place for the safe procurement of drugs and biologicals for residents. The facility document titled Consultant Pharmacist Agreement, effective 10/01/2024, documented the consultant pharmacist was to assist the facility with the implementation of policies and procedures for the safe procurement of drugs and biologicals. Cross reference F tag 759

Based on interview, clinical record review, and document review, the facility failed to ensure behaviors monitored were associated with the specific condition indicated by the physician for the use of psychotropic medications for 1 of 12 sampled residents (Resident #2) and physician ordered psychotropic medications had a specific condition documented for indication of use associated with the diagnoses for 5 of 12 sampled residents (Resident #23, #25, #5, #12, and #24). Findings include: Resident #2 Resident #2 was admitted on [DATE], and readmitted on [DATE], with diagnoses including major depressive disorder, recurrent, unspecified and vascular dementia, moderate with mood disturbances. Resident #2's psychotropic physician's orders, dated 02/15/2024, documented the following: -Seroquel oral tablet 25 milligrams (mg), give one tablet by mouth in the afternoon for low mood, anxiety, paranoid ideation related to major depressive disorder, recurrent, unspecified. -Cymbalta oral capsule delayed release particles 30 mg, give one capsule by mouth two times a day for low mood, anxiety, paranoid ideation related to major depressive disorder, recurrent, unspecified. Resident #2's care plans documented the following focus areas related to psychotropic medications: -Resident #2 had a behavior history of self-isolation, sense of doom, crying/tearful episodes, anxious related to (r/t) major depressive disorder, initiated 03/05/2023 and revised 10/09/2024. -Resident #2 used psychotropic medications r/t major depressive disorder with behaviors. Resident #2 had a history of fearfulness, crying, tearfulness, anxious, self isolation, sense of doom and agitation, initiated 09/13/2023 and revised 10/09/2024. An intervention included to monitor for effectiveness by charting every shift behavior monitoring in Point of Care (POC) and/or additional behavior monitoring in progress notes of electronic Medication Administration Record (eMAR). Resident #2's behavior monitoring in the eMAR instructed the nurse to document behavior monitoring every day and night shift related to major depressive disorder, recurrent, unspecified. On 10/15/2024, the resident had behaviors twice on the day shift. The documentation was indicated with yes. On 10/17/2024 at 2:29 PM, the Director of Nursing (DON) verbalized the behavior monitoring on the eMAR was not personalized to each resident for the specific psychotropic medication. On 10/17/2024 at 3:45 PM, the DON confirmed Resident #2 did not have any documented evidence of the behaviors exhibited on 10/15/2024 or the behaviors monitored were related to the behaviors identified for the administration of the psychotropic medications. The behavior monitoring was entered by nurses in the eMAR and the physician signed after it was entered. The nurses had been using the diagnosis on the psychotropic medication as the behavior to be monitored and did not add specific behaviors related to the medication, as identified by the physician. The facility policy titled Psychotropics Medications, reviewed 04/14/2023, documented daily monitoring of psychotropic medications were to include the presence and frequency of resident-specific targeted behaviors. Resident #23 Resident #23 was admitted to the facility on [DATE], with diagnoses including unspecified dementia, unspecified severity, with other behavioral disturbances and major depressive disorder, single episode, severe without psychotic features. Resident #23's psychotropic physician's order dated 09/12/2024, documented the following: -Venlafaxine Hydrochloric Acid (HCl) extended release oral tablet 24 hour 75 mg, give 75 mg by mouth, one time a day related to major depressive disorder, single episode, severe without psychotic features. -Divalproex Sodium oral tablet delayed release 250 mg, give 250 mg by mouth, two times a day related to other headache syndrome and major depressive disorder, single episode, severe without psychotic features. Resident #25 Resident #25 was admitted to the facility on [DATE], with a diagnosis of major depressive disorder, recurrent, unspecified. Resident #25's psychotropic physician's order dated 05/01/2024, documented Citalopram Hydrobromide oral tablet 20 mg, give 20 mg by mouth, one time a day related to major depressive disorder, recurrent, unspecified. 40377 Resident #5 Resident #5 was admitted to the facility on [DATE], and readmitted on [DATE], with a diagnosis of depressive disorder, recurrent, unspecified. Resident #5's psychotropic physician's order dated 10/05/2024, documented Mirtazapine 15 mg oral tablet, give 15 mg by mouth at bedtime related to depressive disorder, recurrent, unspecified. Resident #12 Resident #12 was admitted to the facility on [DATE], and readmitted on [DATE], with a diagnosis of unspecified psychosis not due to a substance or known physiological condition. Resident #12's psychotropic physician's order dated 07/23/2024, documented Olanzapine 2.5 mg oral tablet, give 2.5 mg by mouth at bedtime related to unspecified psychosis not due to a substance or known physiological condition. 49557 Resident #24 Resident #24 was admitted to the facility on [DATE], with a diagnosis of major depressive disorder, recurrent, unspecified. Resident #24's psychotropic physician's order dated 01/22/2024, documented Fluoxetine HCl oral capsule 40 mg, give 40 mg by mouth at bedtime related to major depressive disorder, recurrent, unspecified. On 10/17/2024 at 3:23 PM, the Director of Nursing (DON) explained physician orders for psychotropic medications were required to include the specific behaviors and/or symptoms the medication was ordered for. On 10/17/2024 at 3:45 PM, the DON confirmed the physician had not been identifying specific behaviors related to the administration of the psychotropic medications. Nurses were entering behaviors on care plans however, the physician had not indicated the targeted behaviors identified for the need for the specific psychotropic medications. The facility policy titled Psychotropics Medications, reviewed 04/14/2023, documented psychotropic medications were drugs effecting brain activities associated with mental processes and behavior. The interdisciplinary team would determine the lowest possible effective dose in managing identified behaviors. The provider's order would include the reason for the psychotropic being ordered.

Based on observation, interview, clinical record review, and document review the facility failed to ensure medications were administered with an error rate of less than five percent (%). There were 29 opportunities and two medication errors. The medication error rate was 6.9%. Findings include: Resident #6 Resident #6 was admitted to the facility on [DATE], with diagnoses including heart failure, unspecified, dry eye syndrome of bilateral lacrimal glands, and abnormal results of other function studies of the eye. On 10/17/2024 at 8:08 AM, a Registered Nurse (RN) began preparing medications for Resident #6. The RN verbalized the physician ordered Restasis Ophthalmic Emulsion eye drops were not available in the facility and were on order from the pharmacy. The RN verbalized Resident #6's physician ordered medications for the morning medication pass included Metoprolol 12.5 milligrams (mg). The RN compared the bubble pack containing Metoprolol to the physician order on the Medication Administration Record (MAR) then placed the bubble pack back in the medication cart. The RN did not remove the medication from the bubble pack. On 10/17/2024 at 8:14 AM, the RN locked the medication cart, grabbed the medication cup containing Resident #6's prepared medications, and began to move toward Resident #6 to administer the medications. The RN was asked to verify the number of tablets in the medication cup. After counting the number of tablets in the medication cup, the RN verbalized Resident #6's Metoprolol was not in the cup. The RN then retrieved the Metoprolol from the medication cart, placed the medication in the medication cup and administered the medications to Resident #6. On 10/17/2024 at 8:27 AM, the RN explained the RN's usual process when administering medications to residents was to retrieve the medication from the medication cart, compare it to the order on the resident's MAR, remove the medication from the medication card, and placed the medication in a medication cup. The RN verbalized the RN forgot to place Resident #6's Metoprolol in the medication cup during the morning medication pass because the RN was nervous about being observed during medication administration. Resident #6's MAR documented the following: -Restasis Ophthalmic Emulsion, instill one drop in both eyes two times a day for cataract inflammation. The order date was 09/10/2024. -Metoprolol Tartrate oral tablet 25 milligrams (mg), give one half tablet by mouth two times a day related to heart failure, unspecified and tachycardia unspecified. The order date was 09/10/2024. On 10/18/2024 at 8:30 AM, the DON explained the DON's expectation of nursing staff when administering medications to residents was to check the physician's order, verify the medication against the order, assure the resident was within parameters if applicable, punch/remove the tablet from the medication card (bubble pack), administer the medication, and document the administration. The DON confirmed medication errors included failure to administer an ordered medication (omission). The facility policy titled Medication Error Prevention and Investigation, Adverse Drug Reactions, dated 09/27/2007, documented all medications were to be administered to residents in a safe manner, according to physician's orders. Medication errors included omitting a prescribed medication. Cross reference F tag 760