Every finding on record at Pruitthealth - Austell

Based on observations, staff and resident interviews, record review, and review of the facility's policy titled Care Plans, the facility failed to develop and implement comprehensive, person-centered care plans for two of 47 sampled residents (R) (R62 and R117) related to transfer needs for R62 and accommodation of needs for call light access for R117. This deficient practice resulted in actual harm to R62 on 12/5/2025 when staff improperly transferred the resident without using a gait belt.Findings included:A review of the facility's policy titled Care Plans, reviewed 1/21/2025, revealed under the section admission Comprehensive Plan of Care, Step 3: The comprehensive person-centered care plan is developed to include measurable goals and timeframes to meet a patient/resident's medical, nursing and psychosocial needs, the services that are to be furnished to attain or maintain the resident's highest practical physical, mental and psychosocial needs that are identified in the comprehensive assessment. Further review of this section, step 4: The care plan approach serves as instructions for the patient/resident's care and provides continuity of care by all partners. Short and concise instructions, which can be understood by all partners, should be written and have a relationship to the problem and goal(s) . Some interventions require all disciplines to be involved in the implementation, while others may only involve specific team members. When approaches that involve the CNA (Certified Nursing Assistant) have been added to the care plan, those approaches should also be included on the CNA Care Record or Resident Profile/Care Plan. 1. A review of the Electronic Medical Record (EMR) revealed R62 was admitted to the facility on [DATE] and pertinent diagnoses, including but not limited to right tibial shaft fracture (subsequent encounter), morbid obesity, generalized muscle weakness, and lack of coordination. Observation and interview on 12/5/2025 at 12:10 pm with R62 revealed a 3×3 bandage on her right knee. She reported falling earlier that morning between 10:00 and 11:00 am while transferring from her bed to her wheelchair. R62 reported that she attempted to scoot into the wheelchair using her left leg, as she was non-weight-bearing on her right leg, when her left leg gave out and she began to fall. The CNA present did not provide hands-on assistance and only attempted to grab R62's pants, which were loose, failing to prevent the fall. R62 fell onto her right knee, causing a laceration, and then struck her head. She reported that her nurse bandaged the knee. R62 stated that physical therapy always uses a gait belt with hands-on assistance, but nursing staff and CNAs typically do not, and she had not refused assistance; in fact, she asked for it. A gait belt was visible and accessible in her room. R62 became tearful during the interview, expressing concern about her knee injury delaying recovery and stating she just wants to go home. A review of R62's progress note dated 12/5/2025 at 12:17 pm indicated that the Certified Nursing Assistant (CNA) notified staff that the resident was on the floor. The nurse responded and obtained vital signs. A body audit revealed a swollen area in the middle of the head and a wound on the right knee. The resident denied pain or discomfort. The nurse notified the Nurse Practitioner (NP), who ordered an X-ray of the right knee and instructed staff to monitor for any changes and report immediately. The resident's son was notified and stated he was on his way to the facility. Neuro-checks were initiated. A review of R62's Census entry dated 12/5/2025 at 1:35 pm indicated that the resident was transported to the hospital. This event was documented solely in the electronic medical record Census, with no accompanying progress note entered. A review of the written statement of the event, submitted by CNA TT after being interviewed by the surveyor, read: When I walked in the room, she asked for help to be transferred into the wheelchair. I went to help her in the chair I was standing on the left side of the resident the wheelchair was locked and next to the bed she went to stand up I grab her pants and she turned to sit in chair and her leg buckle went to the floor very quickly face forward, I rolled her over and place a pillow under head and went and got the nurse. The statement does not explicitly indicate that CNA TT provided hands-on physical assistance to R62 during the transfer, despite R62 asking for help. Additionally, the statement describes that CNA TT moved R62 after the fall by rolling her over and placing a pillow under her head before notifying the nurse, which is contrary to facility policy requiring a licensed nurse to assess a fallen resident before any movement. By moving R62, CNA TT potentially placed the residents at further risk of injury. A review of R62 admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 15, which indicated R62 was cognitively intact, and that R62 had impairment of the lower extremities. A review of the Care Area Assessment (CAA) on the admission MDS dated [DATE] indicated R62 was identified with problems in the areas of functional status, falls, mobility, pain, and chronic disease conditions. A review of R62's care plan dated 9/17/2025 indicated a problem of risk for falls related to generalized weakness, impaired physical mobility related to recent hospitalization, and potential for pain related to a right tibial fracture. Goals included, but were not limited to, preventing injury related to falls. Interventions included, but were not limited to, assisting with transfers and toileting as needed. An interview on 12/5/2025 at 12:47 pm with CNA TT revealed she was present in the room when R62 attempted to transfer from the bed to the wheelchair. She stated R62 was sitting on the side of the bed, with the wheelchair wheels locked, and as R62 stood and attempted to transfer, she buckled. Reported that she reached toward R62 by grabbing her pants, but the pants came up and R62 landed on the floor. She confirmed that she did not make contact or provide physical assistance prior to the resident beginning to fall. When asked whether R62 had refused assistance or indicated she wanted to transfer independently, she stated, No, she did not say anything like that. She is the type who needs to do it herself, and we always do that with her. An interview on 12/5/2025 at 1:42 pm with the Director of Nursing (DON) revealed that CNAs are expected to follow the care plan when assisting residents with transfers. 2. A review of the admission record revealed that R117 was admitted to the facility on [DATE] with diagnoses that included, but were not limited to, nontraumatic intracerebral hemorrhage, acquired absence of right upper limb above elbow, acquired absence of left upper limb below elbow, acquired absence of right leg above knee, and acquired absence of left leg above knee. A review of the quarterly Minimum Data Set (MDS) assessment for R117, dated 10/2/2025, revealed she presented with a Brief Interview for Mental Status (BIMS) score of nine, indicating moderate to severe cognitive impairment, and that R117 required total assistance for all care to include eating, oral hygiene, toileting, bathing, and dressing. A review of the care plan dated 8/22/2025, revealed that R117 had no indication or problem statement regarding R117's inability to use the upper extremities to activate the call light. Care plan approaches noted keep call light in reach at all times. An observation and interview on 12/2/2025 at 12:30 pm with R 117 revealed she was lying on her bed, alert and oriented, watching television. The call light placement on the bed was about six inches out of reach. R 117 confirmed she did not need any assistance at the time, but could not reach the call light if she did need assistance. During an observation on 12/3/2025 at 2:20 pm, R117 was sitting in a reclining position in her wheelchair in her room, watching television. During the interview, R117 was asked if she was able to use her call light to get assistance from staff. R117 demonstrated she was not able to, as the call light was placed on her bed and out of reach. The call light was observed lying in the middle of the bed, at least one foot from R 117. When asked how she gets assistance if she can't use the call light, she stated, I scream out loud even though I know I'm not supposed to do that. During an observation on 12/4/2025 at 10:00 am, certified nursing assistant (CNA) RR was observed providing care for R117. Before leaving the R117's room, CNA RR left the call light on a table at the foot of the bed, out of reach of R117. During an interview with CNA RR at that time, she confirmed that she did not leave the call light within reach for use by the R117, and she returned to R117's room to place the call light within reach. During an interview on 12/4/2025 at 12:15 pm, Nurse Unit Manager NN confirmed that R117 had difficulty activating the nursing call system. Nurse NN confirmed that R117 could benefit from using a more reliable call light device because R117 moves around in the bed, which could easily shift the call light pad, making it difficult to activate it. Nurse NN stated she will report this to the Director of Nursing (DON) so that a breathcall call light device could be ordered for R117. During an interview on 12/4/2025 at 3:30 pm, the DON confirmed that a breathcall call light system was being ordered for R117 to assure she has a reliable means to call for assistance. The DON confirmed he was not aware of R117's inability to activate the call light system using the call pad.

Based on observations, staff and resident interviews, record review, and review of the facility policies titled Occurrences, Gait (Transfer) Belts, and Assistance with Transfers, the facility failed to follow established transfer procedures when assisting one of 42 sampled residents (R) (R62). This deficient practice resulted in actual harm to R62 on 12/5/2025 when staff improperly transferred the resident without using a gait belt.Findings included:A review of facility policy titled Occurrences reviewed 11/17/2025, revealed under the policy statement that The healthcare center recognizes that due to the frailty of the patients/residents served, there is an increased risk of occurrences that may result in injury to the patient/resident and/or others. To prevent occurrences, each patient/resident will be observed and assessed for risks. Appropriate, realistic interventions will be implemented in accordance with their plan or care. Further review of the Assisting Occurrence Victim section revealed Do not move the victim until he/she has been examined by a licensed nurse for possible injuries. Only move the injured person out of harm's way, to a treatment area or bed after a licensed nurse has evaluated them.A review of facility policy titled Gait (Transfer) Belts reviewed 3/6/2025, revealed under the policy statement that A gait belt will be utilized with patients/residents who require assistance with transfers and ambulation. To promote safety from injury for both patients/residents and nursing staff.A review of facility policy titled Assistance with Transfers, issued September 2012, revealed the following procedures: step 8: Be sure you have a good footing, stand with legs apart, bend your knees, keep arms and back in proper alignment. Step 9: Use your arms to support the resident and legs to stabilize and support, not your back. Step 11: Be sure you have a firm and secure, but gentle grip before moving the resident. Avoid using fingertips or grabbing limbs with your hand. Step 13: To avoid injury to yourself or the resident, be sure to get help if the person is too heavy for you alone.A review of the Electronic Medical Record (EMR) revealed R62 was admitted to the facility on [DATE] and pertinent diagnoses, including but not limited to right tibial shaft fracture (subsequent encounter), morbid obesity, generalized muscle weakness, and lack of coordination.A review of R62 admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 15, which indicated R62 was cognitively intact, and that R62 had impairment of the lower extremities.A review of the Care Area Assessment (CAA) on the admission MDS dated [DATE] indicated R62 was identified with problems in the areas of functional status, falls, mobility, pain, and chronic disease conditions.A review of R62's care plan dated 9/17/2025 indicated a problem of risk for falls related to generalized weakness, impaired physical mobility related to recent hospitalization, and potential for pain related to a right tibial fracture. Goals included, but were not limited to, preventing injury related to falls. Interventions included, but were not limited to, assisting with transfers and toileting as needed. On 12/5/2025, the care plan was updated to include a new problem of abrasion to the right knee related to a fall earlier that day. Short-term goals included healing of the abrasion without complications by 12/31/2025. Interventions included handling the resident with care during direct care and monitoring for signs of localized infection (swelling, redness, pain, tenderness, heat, purulent drainage, or loss of function) every shift. The fall risk interventions were also updated to indicate one-person assist with one-person standby.A review of the Physician Orders for R62 included, but was not limited to:Order dated 9/25/2025 for AP and Lateral X-ray of the right knee due to tibial fracture and pain; special instructions: wheelchair bound.Order dated 12/5/2025 for wound care related to a right knee abrasion from the fall: cleanse with normal saline, pat dry, apply Xeroform, cover with protective dressing, 3x/week and PRN.Order dated 12/5/2025 for X-ray of the right knee due to fracture.Observation and interview on 12/5/2025 at 12:10 pm with R62 revealed a 3x3 bandage on her right knee. She reported falling earlier that morning between 10:00 and 11:00 am while transferring from her bed to her wheelchair. R62 reported that she attempted to scoot into the wheelchair using her left leg, as she was non-weight-bearing on her right leg, when her left leg gave out and she began to fall. The Certified Nursing Assistant (CNA) present did not provide hands-on assistance and only attempted to grab R62's pants, which were loose, failing to prevent the fall. R62 fell onto her right knee, causing a laceration, and then struck her head. She reported that her nurse bandaged the knee. R62 stated that physical therapy always uses a gait belt with hands-on assistance, but nursing staff and CNAs typically do not, and she had not refused assistance; in fact, she asked for it. A gait belt was visible and accessible in her room. R62 became tearful during the interview, expressing concern about her knee injury delaying recovery and stating she just wants to go home.A review of R62's vital signs indicated the resident weighed 205.2 lbs. (pounds) on admission.A review of R62 physical therapy evaluation and plan of treatment dated 9/18/2025 indicated that R62 was referred for skilled physical therapy following a right tibial fracture, generalized weakness, and decreased functional mobility. Precautions included non-weight-bearing on the right leg, right knee injury, and fall risk. Therapy focused on improving lower extremity strength, bed mobility, transfers, and wheelchair skills to support a safe return home. The patient actively participated, demonstrated good rehabilitation potential, and responded well to interventions, with primary barriers being medical conditions and weight-bearing restrictions.A review of R62's physical therapy note dated 12/4/2025 indicated that R62 received skilled physical therapy for bilateral lower extremities. Precautions included non-weight-bearing on the right leg, right knee injury, and fall risk. The resident actively participated, with no barriers or contraindications identified. Pain management was addressed by nursing.A review of R62's progress note dated 12/5/2025 at 12:17 pm indicated that the CNA notified staff that the resident was on the floor. The nurse responded and obtained vital signs. A body audit revealed a swollen area in the middle of the head and a wound on the right knee. The resident denied pain or discomfort. The nurse notified the Nurse Practitioner (NP), who ordered an X-ray of the right knee and instructed staff to monitor for any changes and report immediately. The resident's son was notified and stated he was on his way to the facility. Neuro-checks were initiated.A review of R62's Census entry dated 12/5/2025 at 1:35 pm indicated that the resident was transported to the hospital. This event was documented solely in the electronic medical record Census, with no accompanying progress note entered.A review of the written statement of the event, submitted by CNA TT after being interviewed by the surveyor, read: When I walked in the room, she asked for help to be transferred into the wheelchair. I went to help her in the chair I was standing on the left side of the resident the wheelchair was locked and next to the bed she went to stand up I grab her pants and she turned to sit in chair and her leg buckle went to the floor very quickly face forward, I rolled her over and place a pillow under head and went and got the nurse. The statement does not explicitly indicate that CNA TT provided hands-on physical assistance to R62 during the transfer, despite R62 asking for help. Additionally, the statement describes that CNA TT moved R62 after the fall by rolling her over and placing a pillow under her head before notifying the nurse, which is contrary to facility policy requiring a licensed nurse to assess a fallen resident before any movement. By moving R62, CNA TT potentially placed the residents at further risk of injury.An interview on 12/5/2025 at 12:25 pm with both Physical Therapist (PT) SS and Therapy Outcome Coordinator VV revealed they both oversee and participate in R62's therapy plan of care. They stated R62 is non-weight-bearing and unable to transfer safely without staff assistance. They reported it is their expectation that nursing staff, including CNAs, use a gait belt when assisting with transfers, and that therapy had provided training on gait belt use. They stated that, at a minimum, staff should provide hands-on physical contact when assisting R62. They reported they were not informed that R62 had sustained a fall and expressed concern regarding the possible impact on her recovery.An interview on 12/5/2025 at 12:47 pm with CNA TT revealed she was present in the room when R62 attempted to transfer from the bed to the wheelchair. She stated R62 was sitting on the side of the bed, with the wheelchair wheels locked, and as R62 stood and attempted to transfer, she buckled. Reported that she reached toward R62 by grabbing her pants, but the pants came up and R62 landed on the floor. She confirmed that she did not make contact or provide physical assistance prior to the resident beginning to fall. When asked whether R62 had refused assistance or indicated she wanted to transfer independently, she stated, No, she did not say anything like that. She is the type who needs to do it herself, and we always do that with her.An interview on 12/5/2025 at 1:42 pm with the Director of Nursing (DON) revealed that CNAs are expected to follow the care plan when assisting residents with transfers. He stated staff should ensure the bed height is appropriate, assist the resident to sit up, position the wheelchair correctly, use proper body mechanics, and provide the level of assistance indicated in the care plan to ensure resident safety. An interview on 12/5/2025 at 1:42 pm, the Regional Nurse Consultant revealed that CNAs should ask residents if they want assistance with transfers, and if assistance is accepted, support the resident's weak side, position the chair correctly, and provide help as needed. She stated that refusals should be reported to the nurse and witnessed. She stated the CNA should not have allowed the resident to transfer without assistance and that she would have provided hands-on help throughout the transfer.

Based on staff interviews, resident interviews, record review, and review of the facility's policies titled Care Plans, the facility failed to coordinate a quarterly care plan conference for one of 47 sampled residents (R) (R21).Findings included:A review of the facility's policy titled Care Plans, dated/revised 10/21/2025, revealed that during all care plan meetings other than the admission Comprehensive Care Plan that was conducted during a Post admission Care Conference, care plan meetings including IDT (Interdisciplinary Team), patient/resident, and/or patient/resident representative attendance should be documented in the Care Conference Notes. Comprehensive care plans should be reviewed not less than quarterly according to the OBRA MDS (Omnibus Budget Reconciliation Act Minimum Data Set) schedule, following completion of the assessment.A review of R21's electronic medical record (EMR) revealed R21 was admitted to the facility on [DATE], and pertinent diagnoses included, but were not limited to epilepsy, muscle weakness, and cognitive communication deficit.A review of R21's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 13, which indicates R21 was cognitively intact. A review of R21's EMR revealed no documentation of a care plan conference, including a care plan conference upon admission.An interview on 12/3/2025 at 11:51 am with R21 revealed that she does not remember having a care plan conference meeting since she moved into the facility. She stated that her family may have been involved.A phone interview on 12/3/2025 at 12:10 pm with the family of R21 revealed that a care plan meeting was held when R21 was admitted to the facility, and that was the only one. Since admission, he has had to initiate calls with the Unit Manager to discuss R21's care, and he would have to get lucky getting someone on the phone. R21's family expressed concerns regarding communication with the facility and stated that he has not received an invitation for a formal care plan conference meeting. An interview on 12/4/2025 at 12:06 pm with the Social Services Director (SSD) revealed she has been working at the facility for three months. She stated that long-term residents have quarterly care plan conferences, and the MDS nurse will give her a schedule to know which quarterly meetings are needed. Family and residents are informed a month prior to the care plan conference that the resident is due for a quarterly meeting, and the facility will also mail out a letter as a reminder. When asked about R21's care plan conferences, the SSD stated that R21 would have had a care plan conference in July 2025, which would have been the initial one completed at admission. The SSD confirmed that R21 was due for a quarterly care plan conference in October, but she does not see that it was completed. The SSD further confirmed that the only care plan conference that was completed was the initial one on admission. The SSD further stated that care plan conferences are important to keep the resident and family updated to assess any changes that have been going on with the resident, changes the family and resident would want to include, and address any concerns the resident or family may have.An interview on 12/5/2025 at 10:38 am with the Administrator revealed that she expects the care plan conferences to be done timely on admission, upon change of condition, quarterly, and annually.

Based on record reviews, observations, resident and staff interviews, and facility policy titled Patient/Resident Rights, Accommodation of Needs, the facility failed to ensure the call light provided was appropriate for the physical condition of one of 47 sampled residents (R) (R117). The facility was unable to ensure that R117 could obtain help when needed using the call light provided. This failure placed R117 at risk of accident, injury, and/or unmet needs related to an inability to use the call light system provided to call for staff assistance. Findings included:A review of the facility's policy titled Patient/Resident Rights, Accommodation of Needs revealed that, unless indicated in the care plan, each patient/resident, when in their room or in bed, must have the call light placed within reach at all times, regardless of staff assessment of the patient/resident's ability to use it. When the patient/resident is in bed, the call bell should be fastened to the side rail he/she is facing. When out of bed, the call bell is to be draped across the bed so it is accessible from a wheelchair or bedside chair.A review of the admission record revealed that R117 was admitted to the facility on [DATE] with diagnoses that included, but were not limited to, nontraumatic intracerebral hemorrhage, acquired absence of right upper limb above elbow, acquired absence of left upper limb below elbow, acquired absence of right leg above knee, and acquired absence of left leg above knee. A review of the quarterly Minimum Data Set (MDS) assessment for R117, dated 10/2/2025, revealed she presented with a Brief Interview for Mental Status (BIMS) score of nine, indicating moderate to severe cognitive impairment, and that R117 required total assistance for all care to include eating, oral hygiene, toileting, bathing, and dressing. A review of the care plan dated 8/22/2025, revealed that R117 had no indication or problem statement regarding R117's inability to use the upper extremities to activate the call light. Care plan approaches noted keep call light in reach at all times, teaching reinforced on the use of call light for assistance.An observation and interview on 12/1/2025 at 12:42 pm revealed R117 was alert and oriented, lying in her bed. The resident was observed to be a quadruple amputee. She stated that she has been a resident at the facility for almost ten years, and since she has no arms, it is a challenge to push the call light to request staff assistance. A round call light pad in the bed was observed.An observation and interview on 12/2/2025 at 12:30 pm with R117 revealed she was lying on her bed, alert and oriented, watching television. The call light placement on the bed was about six inches out of reach. R117 confirmed she did not need any assistance at the time, but could not reach the call light if she did need assistance.During an observation on 12/3/2025 at 2:20 pm, R117 was sitting in a reclining position in her wheelchair in her room, watching television. During the interview, R117 was asked if she was able to use her call light to get assistance from staff. R117 demonstrated she was not able to, as the call light was placed on her bed and out of reach. The call light was observed lying in the middle of the bed, at least one foot from R117. When asked how she gets assistance if she can't use the call light, she stated, I scream out loud even though I know I'm not supposed to do that.During an observation on 12/4/2025 at 10:00 am, Certified Nursing Assistant (CNA) RR was observed providing care for R117. Before leaving the R117's room, CNA RR left the call light on a table at the foot of the bed, out of reach of R117. During an interview with CNA RR at that time, she confirmed that she did not leave the call light within reach for use by the R117, and she returned to R117's room to place the call light within reach.During an interview on 12/4/2025 at 11:28 am, the Therapy Outcome Coordinator revealed that it is routine for the therapy staff to evaluate all residents for needs and abilities. She confirmed that R117 uses a flat round call light pad for use to call for assistance. She confirmed that she was not aware that R117 could not use the call light pad. During an interview on 12/4/2025 at 12:15 pm, Nurse Unit Manager NN confirmed that R117 had difficulty activating the nursing call system. Nurse NN confirmed that R117 could benefit from using a more reliable call light device because R117 moves around in the bed, which could easily shift the call light pad, making it difficult to activate it. Nurse NN stated she will report this to the Director of Nursing (DON) so that a breathcall call light device could be ordered for R117. (A Breathcall call light is a pneumatic nurse call device for residents with limited motor skills, activated by a gentle puff of air into a disposable straw/filter, not pressing a button, making it easy to use when movement is difficult. It features a flexible gooseneck with a clamp for mounting and connects to the existing nurse call system, providing a lifeline for those who can't operate standard call cords.)During an interview on 12/4/2025 at 3:30 pm, the DON confirmed that a breathcall call light system was being ordered for R117 to assure she has a reliable means to call for assistance. The DON confirmed he was not aware of R117's inability to activate the call light system using the call pad.

Based on observations, staff and resident interviews, record review, and review of the facility policy titled Physician Orders, the facility failed to ensure timely coordination and follow-up of physician/Nurse Practitioner (NP) recommendations for one of 47 sampled residents (R) (R9). Specifically, the facility failed to schedule or track urology specialist appointments, failed to document completed visits or follow-up outcomes, and failed to act on prior NP recommendations. These deficient practices resulted in prolonged pain, delayed evaluation and treatment of ongoing urinary symptoms, and lack of oversight of the resident's urologic care, placing the resident at risk for worsening complications.Findings included: A review of the facility policy titled Physician Orders, reviewed 2/3/2025, revealed under the section Verbal and Telephone Orders, Step 1: All verbal and telephone orders will be immediately transcribed in the medical record by the licensed professional taking the order. Further review of this section indicated under Step 3: The licensed professional will sign and date the order, will indicate the name of the physician giving the order, and will document 'read back' as proof of verification of orders.A review of the electronic medical record (EMR) revealed that R9 was admitted to the facility on [DATE] with pertinent diagnoses including, but not limited to, urinary tract infection, benign prostatic hyperplasia (BPH) with lower urinary tract symptoms, neuromuscular dysfunction of the bladder, other specified disorders of the bladder, and dysuria. R9 also has type 2 diabetes mellitus, which increases the risk of urinary infections and chronic Foley catheter dependence as documented under his bladder-related diagnoses. A review of R9's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14, indicating the resident was cognitively intact. Section GG (functional status) revealed that R9 required extensive assistance to total dependence for activities of daily living (ADL) care. A review of Section H (bowel and bladder) revealed that the resident had an indwelling urinary catheter in place during the assessment period and was not on any bladder toileting program. The resident was always incontinent of bowel.A review of R9's care plan, initiated 05/28/2025 and last revised 10/27/2025, indicated multiple problems, including risk for urinary tract infection (UTI) due to a chronic indwelling catheter, neuromuscular bladder dysfunction, and stool incontinence. Goals included, but were not limited to, preventing complications associated with catheter use, maintaining urinary comfort, and preventing infections. Interventions included, but were not limited to, coordinating follow-up with specialists, including urology. A review of the Physician's Orders for R9 included, but was not limited to:Order dated 6/13/2025 for urology consult for neurogenic bladder/BPH with chronic Foley (catheter to drain urine from the bladder).A review of R9's EMR revealed an open-ended urology referral order from June 2025. Documentation regarding follow-up was inconsistent and incomplete. A printout of abnormal urine analysis (UA) results dated 11/13/2025 included a handwritten note dated 11/20/2025, which indicated the need for a urology appointment; but had no initials or signature identifying the author, and staff were unable to determine who wrote it. No subsequent orders or documentation were found in the EMR confirming that follow-up with the urologist had been scheduled or completed, or that the resident or their representative had been notified of the need for the follow-up. There were also no uploaded documents or visit notes verifying that R9 had attended any urology appointments.An observation and interview on 12/1/2025 at 12:20 pm revealed that R9 was waiting to be taken to the emergency room (ER) due to a UTI. He stated that he could feel the infection and pointed to his pubic area to indicate where he was feeling pain. R9 was seated in a reclining wheelchair with a Foley catheter in place, but tubing was visible with dark blood present.During an interview on 12/2/2025 at 1:23 pm, R9 reported that he had been in pain for about a month. An observation and interview on 12/3/2025 at 3:55 pm with R9 revealed he was lying in bed and continued to experience discomfort. He recalled seeing the urologist the previous month, but could not recall the date.An interview on 12/4/2025 at 3:55 pm with R9's wife via telephone she expressed continued frustration regarding poor communication at the facility and noted that the facility was responsible for arranging transportation for R9 to medical appointments. She stated she planned to visit the facility that evening to speak with the Director of Nursing (DON) to address communication concerns and ensure that follow-up appointments were managed appropriately. An interview on 12/2/2025 at 4:32 pm with NP HH via telephone emphasized the importance of follow-up with a urologist as previously recommended.An interview on 12/4/2025 at 3:46 pm with the Urology Center revealed that a staff member from the facility contacted their practice to schedule an appointment for R9, and it is scheduled for 12/17/2025. Further stated that R9 was seen on 10/7/2025 for leakage of the catheter and had a CT and labs, and again on 11/4/2025 for Blood in urine and urinary retention, and a Cystoscopy (procedure to view the inside of your bladder and urethra with a scope) was done. They have been trying to get R9 to return to the practice for a follow-up to discuss the results of the cystoscopy since 11/17/2025, with no success. They have been calling and calling with no answer. An interview on 12/4/2025 at 4:33 pm with the Assistant Director of Nursing (ADON) revealed that all nurses on the floor are responsible for following up on NP recommendations and writing orders for specialist visits. She confirmed the open-ended urology referral from June 2025 and acknowledged that records of R9 visits on 10/7/2025 and 11/4/2025 were missing from the EMR. An interview on 12/4/2025 at 5:15 pm with the facility Administrator revealed that staff were expected to follow through on physician-ordered referrals and ensure appointments are scheduled and completed. She emphasized that failure to follow up may result in delayed care. She stated that the responsible staff must ensure all follow-up is completed and that any issues should be discussed during IDT (Interdisciplinary Team) meetings, and families should be notified. An interview on 12/4/2025 at 5:35 pm with the DON revealed that the facility is responsible for ensuring residents are appropriately scheduled for referrals and specialist appointments. Nurses, unit managers, or the nurse receiving the order may initiate physician consultations and follow up on results. Nursing staff are expected to track outcomes of specialist visits, including any required follow-up. Even if a resident returns without information from the physician/specialist visit, it remains the responsibility of the nurses to contact the provider to obtain documentation of what occurred during the visit and any recommendations or follow-up needed. Failure to properly schedule or follow up on appointments could result in declines in the resident's health and negatively impact overall care.

Based on observations, staff and resident interviews, record review, and review of the facility policy titled Oxygen Administration, the facility failed to ensure oxygen (O2) was administered as ordered for two of 12 residents (R) (R123 and R62) who used oxygen. Specifically, the facility failed to administer oxygen at the correct ordered setting for R123 and failed to ensure oxygen was not administered without a physician's order for R62. These deficient practices placed both residents at increased risk for respiratory complications and adverse clinical outcomes.Findings included:A review of the facility policy titled Oxygen Administration, dated 11/17/2025, revealed under the Procedure section that Oxygen will be administered by licensed personnel only when ordered by the physician, PA, or NP. Further review of this section indicated, under Step 4, that staff are to Regulate liter flow to ordered/desired flow rate.1. A review of the electronic medical record (EMR) revealed R123 was admitted to the facility on [DATE] and pertinent diagnoses including but not limited to chronic obstructive pulmonary disease (COPD), chronic respiratory failure with hypoxia, hypertensive heart disease with heart failure, chronic diastolic (congestive) heart failure (CHF), and atrial fibrillation.A review of R123 quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 14, which indicated R123 was cognitively intact. Section GG, functional status, revealed wheelchair use requiring substantial/max assist with activities of daily living (ADLs). Section O revealed oxygen therapy. A review of R123 care plan dated 11/25/2025 indicated a problem of COPD and CHF. Goals included but not limited to maximizing oxygen levels, maintaining optimal breathing and oxygenation within the limits of COPD. Interventions included, but were not limited to, administering oxygen as ordered, and monitoring oxygen saturation per protocol. A review of the Physician's Order for R123 included but were not limited to: Order dated 8/12/2025 for Oxygen at 2 LPM (Liters Per Minute) via nasal cannula (NC) continuous.An observation and interview on 12/1/2025 at 12:37 pm revealed, R123 was wearing his oxygen via NC and the O2 concentrator (machine that produces oxygen) was running at the setting of 1.5 LPM. An observation on 12/2/2025 at 1:27 pm revealed, R123 was wearing his oxygen via NC and the O2 concentrator was running under 2 LPM. An observation and interview with Licensed Practical Nurse (LPN) II on 12/2/2025 at 3:20 pm confirmed, the O2 concentrator setting was set below 2 LPM, which was the ordered setting. The LPN initially did not observe the concentrator at eye level but corrected the setting once she did. She stated that she had checked the settings earlier that morning and it is the expectation for them to reflect the physician's orders.2. A review of the EMR revealed R62 was admitted to the facility on [DATE] and pertinent diagnoses including but not limited to chronic respiratory failure with hypoxia, COPD, atherosclerotic heart disease of native coronary artery without angina pectoris, and anemia. A review of R62 admission MDS assessment dated [DATE] revealed a BIMS of 15, which indicated R62 was cognitively intact. Section GG, functional status revealed impairment of lower extremity and use of a wheelchair requiring substantial assist with ADLs. Section O revealed oxygen therapy. RA rview of R62 care plan dated 9/17/2025 indicated the care plan did not address any respiratory conditions until 12/2/2025, when it was discovered during the survey that there were no physician orders for oxygen on record. At that time, a problem of COPD was added to the care plan. Goals included but not limited to maintaining optimal breathing and oxygen levels within the constraints of the terminal diagnosis and maximizing oxygen levels over the next 90 days. Interventions included, but were not limited to, administering oxygen as ordered, monitoring oxygen saturation as ordered, allowing ample time for activities of daily living, and notifying the physician of any changes.A review of the Physician's Orders for R62 revealed that there were no orders for oxygen prior to 12/2/2025. On 12/2/2025, an order was added for oxygen at 2 LPM via nasal cannula (NC) continuous.An observation and interview on 12/1/2025 at 12:45 pm revealed, R62 was wearing her oxygen via NC and the O2 concentrator was running at the setting of 2 LPM. An observation on 12/2/2025 at 2:03 pm revealed, R62 was wearing her oxygen via NC and the O2 concentrator was running at the setting of 2 LPM. An observation and interview with LPN II on 12/2/2025 at 2:58 pm confirmed that she was unable to locate any oxygen orders in the EMR despite searching for approximately 20 minutes. When asked what she had referenced earlier that morning when she reported checking the resident's oxygen settings, she stated that she did not know. This raised concern regarding the basis of her assessment in the absence of any physician orders.An interview with the Administrator on 12/4/2025 at 5:15 pm indicated that residents requiring oxygen must have proper physician orders, and nurses are expected to follow these orders. An interview with the Director of Nursing (DON) on 12/4/2025 at 5:35 pm indicated that every resident receiving oxygen must have a physician order, and oxygen must be administered and monitored according to the frequency specified in the order, which may be every shift. If a resident is admitted with existing oxygen orders, these must be transcribed accurately, and care must reflect the physician's instructions. If a resident is receiving oxygen without an order, the physician must be notified. Failure to follow orders could result in adverse outcomes, such as shortness of breath, depending on the resident's diagnosis.

Based on observations, record review, staff interviews, and review of the facility's policies titled Medication Administration: General Guidelines, the facility failed to ensure accurate administration of medications for two of 28 medication opportunities observed, resulting in a medication error rate of 7.14%. This deficient practice has the potential to negatively impact residents leading to complications of current health status. The facility census was 97.Findings included:A review of the facility's policies titled Medication Administration: General Guidelines reviewed 7/28/2025 revealed under the Procedure step 2. Medications are administered in accordance with written orders of the attending physician.An observations of medication administration were conducted on 12/3/2025 on two medication carts across two halls (West-A and West-B) with two Registered Nurses (RNs) during three administration times. An observation on 12/3/2025 at 5:30 pm on West-B hall with RN BB, it was observed that R54 had physician orders for Omega-3 (fish oil) 300 mg (120 mg-180 mg)-1,000 mg, two capsules orally twice daily, and Voltaren Arthritis Pain (diclofenac sodium) 1% gel, 2 grams topically to the shoulder and lower back four times daily. The nurse administered only one capsule of fish oil, despite the physician's order for two capsules. The nurse then dispensed the Voltaren gel by squeezing an unmeasured amount into a medication cup, rather than measuring the ordered 2 grams. The nurse applied the gel to the resident's shoulders but did not apply it to the lower back as ordered.An interview on 12/3/2025 at 5:40 pm with RN BB reported that he did not see a specified amount for the Voltaren (diclofenac) gel in the electronic record. This was stated after the surveyor asked what dosage he was referencing, as he had been observed squeezing an unmeasured amount of the gel into a medication cup without using a measuring tool.An interview on 12/4/2025 at 5:15 pm with the Administrator indicated that the facility maintains a zero-tolerance standard for medication errors. She stated that staff are required to follow all physician orders, implement new orders promptly, and notify the physician as indicated.An interview on 12/4/2025 at 5:35 pm with Director of Nursing (DON) indicated that the facility expects a zero medication-error rate to ensure resident safety. He stated that nurses are responsible for reviewing physician orders and administering medications exactly as ordered.

Based on observations, staff interviews, review of manufacturer package inserts, the list titled Expiration Dates for the Following Medications After Opening, and review of the facility policy titled Medication Storage in Healthcare Centers, the facility failed to ensure medications were stored in a safe and secure manner for two of five medication carts (West A and [NAME] B) observed. Specifically, one medication cart contained two expired ophthalmic (eye) drops, one nutritional supplement bottle that was soiled, stored in a bag with a crystallized substance, and had an expiration date that was no longer visible, and a loose unlabeled pill and capsule. In addition, the controlled substance book on that cart contained multiple pages that were torn, loose, and no longer secured within the binder. On a second medication cart, an additional loose unlabeled capsule was found. These deficient practices demonstrate that the facility failed to maintain a safe and secure medication storage system, placing residents at risk of receiving expired, incorrect, or unaccounted-for medications.Findings included:A review of the facility's policy titled Medication Storage in Healthcare Centers, revised 11/11/2025, revealed under the Procedures section Step 3: Nurses . are required to check all medications for deterioration and expiration before administration. Nursing staff . who administer medications are responsible for the cleaning and organization of medication carts and storage areas. Further review of this section revealed Step 12: . ophthalmic and otic preparations . are to be dated (when opened). Except where manufacturer recommendations require a shorter expiration date, . with the exception of latanoprost, will expire according to the manufacturer's expiration date. Further review also revealed Step 13: A daily audit and checklist by a medication/treatment nurse will be completed for all medication carts. Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication destruction, and reordered from the pharmacy.A review of the facility's list titled Expiration Dates for the Following Medications After Opening, undated, revealed that for ALL OTHER EYE, EAR, NOSE, INHALERS, the list directs to follow MANUFACTURER EXP (expiration) DATE. A review of the Combigan (brimonidine tartrate/timolol maleate) ophthalmic solution package insert, page 10, section 17, revealed the instruction: Do not use the product after the expiration date marked on the bottle.A review of the Cosopt (dorzolamide hydrochloride-timolol maleate) ophthalmic solution package insert, page 36, under How should I store dorzolamide hydrochloride-timolol maleate ophthalmic solution? revealed the instruction: Do not use your medicine after the expiration date on the bottle.An observation and interview on 12/3/2025 at 10:50 am of the nurse's medication cart with Registered Nurse (RN) FF on West-A hall revealed the following:Controlled Substance Record Book: Multiple pages were torn, loose, and no longer secured within the binder. During inspection, these pages easily fell out, creating a risk for inaccurate or incomplete controlled substance accountability. Active Liquid Protein, Sugar-Free 30 FL Oz bottle: expiration date no longer visible; was soiled, stored in a bag with a crystallized substance.Combigan Sol 0.2/0.5% ophthalmic drops: opened 9/28/2025, expired 11/28/2025.Dorzolamide/Timolol Sol 2-0.5% ophthalmic drops: opened 10/22/2025, expired 11/30/2025.Loose unidentified medications: One tablet and one capsule were found outside of any packaging inside a medication drawer. The nurse was unable to identify the medication or determine which resident(s) they were prescribed to. An observation and interview on 12/3/2025 at 11:59 am of the nurse's medication cart with Licensed Practical Nurse (LPN) JJ in the West-B Back hall revealed the following:Loose unidentified medication: One capsule was found outside of any packaging inside the medication drawer. The nurse immediately reached for it and discarded it into the sharps container. The nurse was unable to identify the medication or determine which resident it was prescribed to. Interview on 12/3/2025 at 11:24 am with RN FF and the Assistant Director of Nursing (ADON) confirmed the presence of expired medications/supplements, loose/unlabeled medications, and unsecured pages in the Controlled Substance Record Book, on the nurse's medication cart. They both explained that expired medications should not be administered, as they may be ineffective. This concern also extends to any supplements for which the expiration date is not visible, as they may also be ineffective. They further noted that the presence of loose, unidentified medications creates a risk that residents may not receive their prescribed medication. Similarly, if pages in the Controlled Substance Record Book are loose, torn, or unsecured, this could result in medications not being administered properly or according to orders. The ADON and RN emphasized that all nurses were responsible for monitoring their medication carts to ensure that medications did not expire. They ADON reported that the expired medications would be discarded, replacement medications would be ordered per current orders, and the loose pages in the Controlled Substance Record Book would be secured after being uploaded into the medical records system.An interview on 12/3/2025 at 12:10 pm with LPN JJ and the ADON confirmed the presence of loose, unlabeled medication on the nurse's medication cart. LPN JJ stated that this could result in a resident not receiving their prescribed medication. She further noted that education was required for staff, and it was the responsibility of the nurse to notify management of such findings. An interview on 12/4/2025 at 5:15 pm with the Administrator revealed the facility's expectations regarding medication management and accuracy. She stated that nursing staff were responsible for ensuring that expired medications were not present, medication carts remained clean and free of loose pills, and carts were cleaned at the end of each shift. She further emphasized that controlled substance logs must remain intact, without rips or tears, to ensure proper documentation and accountability.

Based on observations, staff and resident interviews, record review, and review of the facility's policy titled Diagnostic and Laboratory Services: Procedure for Processing, the facility failed to notify the physician/ Nurse Practitioner (NP) of abnormal laboratory results for one of 47 sampled residents (R) (R9). This deficient practice had the potential to cause delayed assessment and treatment of abnormal clinical conditions.Findings included:A review of the facility policy titled Diagnostic and Laboratory Services: Procedure for Processing revised 1/3/2024 revealed under the section Laboratory Results and Communication with the Provider and Responsible Party Step 4: The licensed nurse is responsible for communicating patient/resident laboratory results to the provider as: Outside of Normal Limits: When test results are outside of normal limits, the licensed nurse will notify the resident's provider of the laboratory results and document the notification in the clinical record. Further review of this section indicated under Step 5: The licensed nurse will communicate laboratory test results to the patient/resident and/or responsible party at the time a new provider order is received related to the test results. The licensed nurse will document the notification in the clinical record.A review of the electronic medical record (EMR) revealed that R9 was admitted to the facility on [DATE] with pertinent diagnoses including, but not limited to, urinary tract infection, benign prostatic hyperplasia (BPH) with lower urinary tract symptoms, neuromuscular dysfunction of the bladder, other specified disorders of the bladder, and dysuria. R9 also has type 2 diabetes mellitus, which increases the risk of urinary infections and chronic Foley catheter dependence as documented under his bladder-related diagnoses. A review of R9's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14, indicating the resident was cognitively intact. Section GG, functional status, revealed that R9 required extensive assistance to total dependence for activities of daily living (ADL) care. Review of Section H revealed that the resident had an indwelling urinary catheter in place during the assessment period and was not on any bladder toileting program. The resident was always incontinent of bowel.A review of R9's care plan, initiated 5/28/2025 and last revised 10/27/2025, indicated multiple problems, including risk for urinary tract infection due to chronic indwelling catheter, neuromuscular bladder dysfunction, and stool incontinence, as well as risk for dehydration related to history of urinary tract infection (UTI), diabetes, and metabolic encephalopathy. Goals included, but were not limited to, preventing complications associated with catheter use, maintaining urinary comfort, preventing infections, and ensuring hydration and nutritional stability. Interventions included performing lab tests as ordered.A review of the Physician's Orders for R9 included, but was not limited to:Order dated 5/27/2025 for an indwelling urinary catheter #20 French (FR), 10 Cubic Centimeters (cc) bulb.Order dated 5/27/2025 for catheter: neurogenic bladderOrder dated 5/27/2025 for catheter care every shift.Order dated 5/27/2025 for catheter care PRN (as needed) for leakage, obstruction, or dislodgement.Order dated 5/27/2025 to monitor and record intake and output every shift, noting urine characteristics and lab specimen submission.Order dated 5/27/2025 for Foley catheter monthly change on the 26th.Order dated 12/2/2025 for urinalysis with reflex to culture/sensitivity.A review of R9's urinalysis (UA) results dated 11/13/2025, finalized 11/18/2025, revealed abnormal results that reflected a culture, showing Greater than 2 organisms recovered, none predominant. The printout included a handwritten note dated 11/20/2025, with no initials or signature identifying the author, and the staff were unable to determine who wrote it or how to track the author. The note read: Over 2 strains, which indicates contamination, would have to see the urology soon, and they will know what/if they want to treat. A review of R9's UA results dated 12/2/2025 revealed abnormal results with a handwritten note dated 12/3/2025, again with no identifying initials or signature, stating: NP Notified, No New Orders, Sensitivity Pending. A review of R9's EMR did not contain documentation showing that the physician or Nurse Practitioner (NP) was notified of the abnormal urine culture results from 11/13/2025 or the abnormal urinalysis results from 12/2/2025. There was no documentation showing that the resident or responsible party was notified of the abnormal laboratory results as required by policy. Two handwritten notes on the printed lab reports were unsigned and unidentifiable, and no provider response or follow-up orders were documented.An observation and interview on 12/1/2025 at 12:20 pm revealed that R9 was waiting to be taken to the emergency room (ER) due to a Urinary Tract Infection (UTI). He stated that he could feel the infection and pointed to his pubic area to indicate where he was feeling pain. R9 was seated in a reclining wheelchair with a Foley catheter in place, but tubing was visible with dark blood present.An observation and interview on 12/2/2025 at 1:23 pm with R9 reported that he had been in pain for about a month. He stated that his wife told him he did not need to go to the hospital and mentioned that she would be visiting him today and could provide more details about his condition. An interview on 12/2/2025 at 3:38 pm with R9's wife via telephone revealed that she visited R9 on 11/30/2025 and observed blood in his catheter tubing. She informed the nurse, who stated that a UA would be ordered. She was aware that R9 was in pain and believed he had a UTI, noting his history of UTIs since the Foley catheter insertion in May 2024. She expressed frustration with the lack of urgency and poor communication at the facility, noting that she was unaware that R9 had seen the NP/physician on 11/12/2025 and that a UA had been ordered at that time as well. An observation and interview on 12/3/2025 at 3:55 pm with R9 revealed he was lying in bed and continued to experience discomfort. He recalled seeing the urologist the previous month. An interview on 12/4/2025 at 3:55 pm with R9's wife via telephone to inform her of the scheduled follow-up appointment with the urologist for R9 on 12/17/2025. She expressed continued frustration regarding poor communication at the facility and noted that the facility was responsible for arranging transportation for R9 to medical appointments. She stated she planned to visit the facility that evening to speak with the Director of Nursing (DON) to address communication concerns and ensure that follow-up appointments were managed appropriately. Interview on 12/1/2025 at 12:26 pm with Licensed Practical Nurse (LPN) UU revealed that he could not find any orders in the system related to a UA and stated that he would be contacting the NP and obtain an order for a UA.An interview on 12/2/2025 at 2:58 pm with Licensed Practical Nurse (LPN) II revealed she was unsure how to check laboratory results in the system. She attempted to look for R9 results but was unable to locate any laboratory information.An interview on 12/2/2025 at 4:02 pm with the DON, who had been standing at the nurse's station during the interview with LPN II, explained the lab process, including notification of the family, collection, and processing by the [NAME] Health laboratory. He stated that it is the responsibility of both the Unit Manager and ADON to review results and track abnormal labs using the Lab Book. Further stated that for Critical results, the lab will contact the DON or Regional Consultant. Follow-up for abnormal results involved notifying the NP and resident families.An interview on 12/2/2025 at 4:32 pm with NP HH via telephone revealed that he and the physician evaluated R9 on 11/12/2025 and ordered a urinalysis for complaints of dysuria (pain/discomfort with urination). He stated he was not notified of the abnormal urinalysis and culture results from 11/13/2025, which he identified as the facility's responsibility to report. He noted that, looking at the results now, they appeared contaminated and stated that had he been notified of the abnormal findings, he would have ordered a repeat urinalysis as the appropriate next course of action; however, no follow-up testing was ordered or communicated to him.An interview on 12/4/2025 at 4:33 pm with the Assistant Director of Nursing (ADON) revealed that she and the Unit Manager were both responsible for reviewing abnormal laboratory results and ensuring that the NP was notified. She stated she had not been aware of the abnormal UA results dated 11/13/2025 until surveyors brought them to her attention, and could not explain why the NP had not been notified. She added that she held ultimate responsibility for ensuring abnormal laboratory results were reviewed and acted upon.An interview on 12/4/2025 at 5:15 pm with the Administrator revealed her expectation was that staff notify providers of abnormal laboratory findings. She stated that failure to do so could result in delays in treatment.

Based on observations, record review and staff interviews, the facility failed to ensure required privacy curtains were in place for one of 47 samples residents (R) (R118). This had the potential to put residents at risk for exposure during care due to the absence of privacy curtains.Findings included:The facility did not have a privacy policy.A review of the electronic medical record (EMR) for R118 revealed an admission date of 12/31/2023 with diagnoses including vascular dementia, moderate Alzheimer's disease, chronic kidney disease, hypertension, lack of coordination, anemia, and generalized weakness.A review of R118's quarterly Minimum Data Set (MDS) assessment documented a Brief Interview for Mental Status (BIMS) score of eight, indicating moderately impaired cognition.A review of the physician's orders for R118, dated 7/2/2024, revealed orders for incontinent care, as needed.A review of R118's care plan, revised on 10/24/2025, revealed the resident was care-planned for Activities of Daily Living (ADL) care decline related to COVID-19, Alzheimer's, dementia, hypertension, peripheral vascular disease (PVD), and anemia due to cognitive impairment and functional decline. Additionally, R118 is care planned to be at risk for skin breakdown/pressure ulcer development related to weakness, bowel and bladder incontinence, and dementia. Interventions include providing incontinence care.An observation and interview conducted on 12/1/2025 at 12:10 pm in R118's room revealed the resident was seated in a wheelchair in his room. The resident stated he was confused about what he was supposed to be doing that day and did not recall what he had eaten. Observation of the room revealed the resident's private curtain was missing; no curtain was present.An observation conducted on 12/3/2025 at 1:00 pm and 12/4/2025 at 9:31 am in R118's room revealed that the privacy curtain was missing.An interview and observation conducted on 12/4/2025 at 10:22 am with Certified Nursing Assistant (CNA) AA revealed that she had worked at the facility for four years. She described her usual process when responding to a call light as knocking on the door, introducing herself, asking what the resident needs, gathering supplies, closing the door, pulling the privacy curtain, explaining the care she will provide, performing hand hygiene, donning gloves, and beginning care. When asked whether she observed a privacy curtain in the resident's room, she stated she did not. CNA AA reported that the previous day was the first time she noticed the resident did not have a privacy curtain. She acknowledged she did not notify anyone about the missing curtain, stating she assumed the curtain had been removed for cleaning. She further stated she did not report it on the day of the interview because she was unsure how long laundry takes to return the curtains. She explained this was not her usual hall, and she rotates between halls. CNA AA stated a potential negative outcome of not having a privacy curtain was that someone could enter the room without knocking, leaving the resident exposed. She stated she typically performed the resident's brief changes in the bathroom.An interview conducted on 12/4/2025 at 10:36 am with Registered Nurse (RN) BB revealed that the process for providing personal care includes knocking, introducing oneself, explaining the care to be provided regardless of the resident's cognitive status, and honoring the resident's right to refuse. If the resident agrees, staff then close the door and pull the privacy curtain. The nurse stated that privacy is very important. Observation of the resident's room was completed with the nurse, who confirmed the resident did not have a privacy curtain. He reported that no CNA had notified him of the missing curtain. He identified a possible negative outcome as a violation of resident privacy if someone were to enter the room while care was being provided. RN BB stated his expectation is that staff notify him when privacy curtains are missing.An interview conducted on 12/5/2025 at 10:14 am with the Director of Health Services (DHS) revealed that all resident rooms were required to have privacy curtains. The DHS stated staff were expected to notify appropriate personnel when curtains are missing so they can be replaced. The DHS identified the potential negative outcome as a loss of resident privacy.An interview conducted on 12/5/2025 at 10:17 am with the Regional Consultant confirmed that all rooms are required to have privacy curtains. The Regional Consultant stated that the potential negative outcome for a missing privacy curtain is a lack of privacy for the resident.An interview conducted on 12/5/2025 at 10:21 am with the Administrator revealed that every resident is expected to have a privacy curtain in place. The Administrator stated the expectation is that staff notify management when privacy curtains are missing. The Administrator identified the potential negative outcome as a resident not receiving visual privacy.

Based on record review, staff interviews, and facility policy review, the facility failed to ensure the timely administration of a medication for one of three residents reviewed for medications (Resident (R) 4) out of a total sample of 24 residents. Specifically, R4 had multiple medications, and insulin administered late over six months. This had the potential for a reduction in the effectiveness of the medications. In addition, the late administration of fast acting and long-acting insulin had the potential to control levels of blood sugar.Findings include:Review of the facility's policy titled Medication Administration: General Guidelines dated 7/22/2024 indicated .Medications are to be administered as prescribed.Review of R4's electronic medical records (EMR) titled Resident Face Sheet indicated the resident was admitted to the facility on [DATE].a. Review of R4's Order History dated 8/16/2023 and provided by the facility indicated the physician ordered gabapentin (anticonvulsant medication used to treat nerve pain) 300 milligrams (mg) to be administered twice a date at 9:00 AM and 5:00 PM.b. Review of R4's Order History dated 2/9/2024 and provided by the facility indicated the physician ordered Hiprex (medication used to prevent UTIs) 1 gram to be administered twice a day at 9:00 AM and 5:00 PM.c. Review of R4's Order History dated 12/26/2024 and provided by the facility indicated the physician ordered Humalog five units to be administered with meals at 9:00 AM, 1:00 PM, and 5:00 PM.d. Review of R4's Order History dated 12/26/2024 and provided by the facility indicated the physician ordered Humalog solution to be administered subcutaneous as follows: If the resident's blood sugar was less than 65, to call the physician; if the resident's blood sugar was between 201 and 250 to administered three units; if the resident's blood sugar was 251 to 300 to administered six units; if the resident's blood sugar was 301 to 350 to administer eight units; and if the resident's blood sugar was 351 to 400 to administer 10 units. The order specifically indicated before meals and at bedtime scheduled at 6:30 AM, 11:30 AM, 4:30 PM, and 9:00 PM.e. Review of R4's Order History dated 5/2/2025 and provided by the facility indicated the physician ordered carvedilol tablet 25 mg to be administered twice a day at 9:00 AM and 5:00PM.f. Review of R4's Order History dated 5/20/2025 and provided by the facility indicated the physician ordered Tresiba insulin pen (three units) was to be administered once a day at 9:00 AM.Review of R4's Medication Administration History (MAH) provided by the facility from January 2025 to May 2025 revealed:Review of the documents provided by the facility for the month of January 2025 the MAH indicated Hiprex was administered late to R4 on the following dates: on 1/1/2025 the 9:00 AM dose was not administered until 11:00 AM and the 5:00 PM dose was not administered until 1/2/2025 at 12:23 AM; on 1/2/2025 the 9:00 AM dose was not administered until 3:49 PM and the 5:00 PM dose was not administered until 7:46 PM; on 1/4/2025 the 9:00 AM dose was not administered until 11:06 AM and the 5:00 PM dose was not administered until 7:40 PM; on 1/5/2025 the 9:00 AM dose was not administered until 11:38 AM; on 1/7/2025 the 9:00 AM dose was not administered until 11:12 AM; on 1/8/2025 the 5:00 PM dose was not administered until 10:49 PM; on 1/11/2025 the 9:00 AM dose was not administered until 11:02 AM and the 5:00 PM dose was not administered until 9:17 PM; on 1/12/2025 the 9:00 AM dose was not administered until 11:33 AM and the 5:00 PM dose was not administered until 6:44 PM; on 1/18/2025 the 9:00 AM dose was not administered until 12:07 PM; and on 1/21/2025 the 9:00 AM dose was not administered until 11:30 AM and the 5:00 dose was not administered until 7:16 PM.Review of documents provided by the facility titled MAH for the month of February 2025 indicated the Hiprex was administered late to R4 on the following dates: on 2/1/2025 the 5:00 PM dose was not administered until 7:51 PM; on 2/2/2025 the 9:00 AM dose was not administered until 1:39 PM; on 2/4/2025 the 9:00 AM dose was not administered until 10:25 AM and the 5:00 PM dose was not administered until 7:13 PM; on 2/5/2025 the 9:00 AM dose was not administered until 12:06 PM; on 2/7/2025 the 9:00 AM dose was not administered until 12:06 PM; on 2/6/2025 the 9:00 AM dose was not administered until 10:39 AM; on 2/7/2025 the 5:00 PM dose was not administered until 10:12 PM; on 2/9/2025 the 9:00 AM dose was not administered 10:43 AM and the 9:00 PM dose was not administered until 7:38 AM; 02/10/25 the 9:00 AM dose was not administered until 12:41 PM; on 2/10/2025 the 9:00 AM dose was not administered until 12:41 PM; on 2/11/2025 the 9:00 AM dose was not administered until 10:22 AM; on 2/12/2025 the 9:00 AM dose was not administered until 12:06 PM; and on 2/13/2025 the 5:00 PM dose was not administered until 9:58 PM.Review of documents provided by the facility titled MAH for the month of February 2025 indicated the Humalog five units was administered late to R4 on the following dates: 2/1/2025 indicated the 9:00 AM dose was not administered until 10:50 AM and 5:00 PM dose was not administered until 7:51 PM; on 2/2/2025 the 9:00 AM dose was not administered until 1:39 PM; on 2/4/2025 the 9:00 AM dose was not administered until 10:25 AM and 5:00 PM dose was not administered until 7:13 PM; 2/5/2025 the 9:00 AM dose was not administered until 12:06 PM; on 2/5/2025 the 9:00 AM dose was not administered until 12:06 PM; 2/9/2025 the 5:00 PM dose was not administered until 7:38 PM; on 2/10/2025 the 9:00 AM dose was not administered until 12:41 PM.Review of documents provided by the facility titled MAH for the month of March 2025 indicated the gabapentin was administered late to R4 on the following dates: on 3/1/2025 the 9:00 AM dose was not administered until 11:00 AM and the 5:00 PM dose was not administered until 6:59 PM; on 3/2/2025 the 5:00 PM dose was not administered until 6:32 PM; on 3/3/2025 the 5:00 PM dose was not administered until 7:25 PM; 3/5/2025 the 9:00 AM dose was not administered until 12:13 PM; on 3/6/2025 the 5:00 PM dose was not administered until 7:36 PM; on 3/6/2025 the 5:00 PM dose was not administered until 3/7/2025 at 12:32 AM; on 3/7/2025 the 9:00 AM dose was not administered until 11:00 AM; on 3/8/2025 the 9:00 AM was not administered until 2:09 PM and the 5:00 PM dose was not administered until 7:02 PM; on 3/11/2025 the 5:00 PM dose was not administered until 9:27 PM; on 3/9/2025 the 9:00 AM dose was not administered until 12:11 PM.Review of documents provided by the facility titled MAH for the month of March 2025 indicated the Hiprex was administered late to R4 on the following dates: on 3/3/2025 the 5:00 PM dose was not administered until 7:25 PM; on 3/4/2025 the 9:00 AM dose was not administered until 12:13 PM; on 3/5/2025 the 5:00 PM dose was not administered until 7:36 PM; on 3/6/2025 the 5:00 PM dose was not administered until 7:36 PM; on 3/6/2025 the 5:00 PM dose was not administered until 3/7/2025 at 12:32 AM; on 3/7/2502 the 9:00 AM dose was not administered until 11:00 AM; on 3/8/2025 the 9:00 AM was not administered until 2:09 PM and the 5:00 PM dose was not administered until 7:02 PM; on 3/11/2025 the 5:00 PM dose was not administered until 9:27 PM; on 3/9/2025 the 9:00 AM dose was not administered until 12:11 PM.Review of documents provided by the facility titled MAH for the month of April 2025 indicated the gabapentin was administered late to R4 on the following dates: on 4/1/2025 the 9:00 AM dose was not administered until 10:36 AM and the 5:00 PM dose was not administered until 7:37 PM; on 4/3/2025 the 9:00 AM dose was not administered until 11:37 PM and the 5:00 PM dose was not administered until 6:37 PM; on 4/6/2025 the 9:00 AM dose was not administered until 11:16 PM; on 4/9/2025 the 5:00 PM dose was not administered until 8:11 PM; on 4/11/2025 the 9:00 AM dose was not administered until 1:11 PM; and on 4/29/2025 the 5:00 PM dose was not administered until 8:54 PM.Review of documents provided by the facility titled MAH for the month of April 2025 indicated the Hiprex was administered late to R4 on the following dates: on 4/2/2025 the 5:00 PM dose was not administered to R4 until 7:37 PM; on 4/3/2025 the 9:00 AM dose was not administered to R4 until 11:37 AM; on 4/6/2025 the 9:00 AM dose was not administered to R4 until 11:16 PM; on 4/9/2025 the 5:00 PM was not administered to R4 until 8:11 PM; on 4/10/2025 the 5:00 PM dose was not administered to R4 until 8:32 PM; on 4/11/2025 the 9:00 AM dose was not administered to R4 until 1:11 PM; and on 4/20/2025 the 9:00 AM dose was not administered to R4 until 10:32 AM.Review of documents provided by the facility titled MAH for the month of May 2025 indicated the gabapentin was administered late to R4 on the following dates: on 5/12/2025 the 5:00 PM dose was not administered to R4 until 7:31 PM; on 5/14/2025 the 5:00 PM dose was not administered to R4 until 10:04 PM; on 5/15/2025 the 5:00 PM was not administered to R4 until 9:15 PM; on 5/17/2025 the 9:00 AM dose was not administered to R4 until 12:44 PM; on 5/17/2025 the 5:00 PM dose was not administered to R4 until 9:57 PM; on 5/18/2025 the 5:00 PM dose was not administered to R4 until 9:31 PM; on 5/20/2025 the 5:00 PM dose was not administered to R4 until 7:20 PM; and on 5/22/2025 the 5:00 PM was not administered to R4 until 8:37 PM.Review of documents provided by the facility titled MAH for the month of May 2025 indicated the Hiprex was administered late to R4 on the following dates: on 5/12/2025 the 5:00 PM dose was not administered to R4 until 7:31 PM; on 5/14/2025 the 5:00 PM dose was not administered to R4 until 10:04 PM; on 5/15/2025 the 5:00 PM was not administered to R4 until 9:15 PM; on 5/17/2025 the 9:00 AM dose was not administered to R4 until 12:44 PM; on 5/17/2025 the 5:00 PM dose was not administered to R4 until 9:57 PM; on 5/18/2025 the 5:00 PM dose was not administered to R4 until 9:31 PM; on 5/20/2025 the 5:00 PM dose was not administered to R4 until 7:20 PM; and on 5/22/2025 the 5:00 PM was not administered to R4 until 8:37 PM.Review of documents provided by the facility titled MAH for the month of May 2025 indicated the Tresiba was administered late to R4 on the following dates: on 5/21/2025 the 9:00 AM dose was not administered until 4:38 PM; on 5/22/2025 the 9:00 AM dose was not administered to R4 until 10:49 AM; and on 5/27/2025 the 9:00 AM dose was not administered to R4 until 3:14 PM.A review was conducted of R4's EMR Progress Notes located under the Resident tab failed to indicate the late administration of the medication and failed to show that the medical provider was notified as a result.During an interview on 7/1/2025 at 1:44 PM, the Director of Nursing (DON) confirmed the entry made by a nurse was the time the medication was to be administered. The DON stated the medical records system locks the time that the medications were administered.During an interview on 7/1/2025 at 2:16 PM, the DON confirmed the medications for R4 were administered late and the nurse should have notified him and the physician.(Cross Reference F842)

Based on observations, family member and staff interviews, record review, and facility policy review, the facility failed to ensure residents received timely and necessary treatments for their conditions for two of 24 sampled residents (Resident (R) 1 and R4). These failures placed the residents at risk for their conditions to worsen by receiving delayed treatment. Findings include: Review of the facility's policy titled Medication Administration: General Guidelines, dated 04/10/29 indicated . Medications are administered in accordance with written orders of the attending physician. 1. Review of R1's Face Sheet located in the resident's electronic medical record (EMR) under the Face Sheet tab revealed the resident was admitted to the facility with diagnoses including but not limited to senile degeneration of /the brain, not elsewhere classified, wedge compression fracture of second lumbar vertebra, scabies, and other nonspecific skin eruptions.Review of R1's EMR under the Resident Census tab indicated R1 was enrolled on Hospice services as of 12/11/2024. Review of R1's Progress Note dated 3/13/2025 and located in the resident's EMR under the Progress Note tab, indicated a staff member noticed spotted redness on R1's hands. The staff asked R1 what had happened and R1 stated she was itchy all over. The Progress note indicated the Nurse Practitioner (NP) was notified and ordered hydrocortisone 1% cream apply topically twice daily for 14 days. The Progress Note indicated R1's responsible party was notified of the change of condition. Review of R1's Progress Note, dated 3/6/2025 in the resident's EMR under the Progress Note tab indicated the nursing staff was notified by the Certified Nurse Aide (CNA) staff that R1's rash was distributed on R1's bilateral upper extremities and chest area, the Physician Assistant (PA) was present in the facility doing rounds and was able to assess the rash. The Progress Note indicated the PA ordered triamcinolone ointment treatment; two times a day for R1's rash.Review of R1's Progress Note, dated 4/2/2025 and located in R1's EMR under the Progress Note tab indicated R1's rash on the bilateral upper extremities and chest area had not improved. Skin treatment applied as ordered. Review of R1's Progress Note, dated 4/4/2025 and located in R1's EMR under the Progress Note tab indicated that triamcinolone acetonide cream was applied to the rashes.Review of R1's Progress Note, dated 4/8/2025 and located in R1's EMR under the Progress Note tab indicated R1's rash appeared to be spreading on different parts of her body, and the Nurse Practitioner (NP) and Responsible Person (RP) were made aware. The Progress note indicated that R1 denied itching or discomfort. A further note dated 4/8/2025 indicated the NP ordered hydrocortisone 1% (percent) cream, and a dermatology consult, and the RP was notified.Review of R1's Medication Administration Record (MAR) located in R1's EMR indicated R1 had a dermatology visit on 5/6/2025, and the Physician ordered mometasone ointment (topical ointment used to treat skin inflamed skin conditions) 0.1 %, .Amount to Administer: small amount; topically twice a day. The recommendation was for R1 to return to the Dermatologist in two weeks if the rash was not better.Review of R1's Patient Handout, dated 6/26/2025 and located in R1's EMR under the Orders tab, indicated R1 was seen by the Dermatologist on 6/25/2025, more than five weeks after the initial consultation instead of two weeks as the Dermatologist had recommended that she return if the rash was not improved. The Patient Handout contained the following information: Step one (every day)-permethrin 5% topical cream-apply neck to entire body overnight, wash off in am and repeat in one week, step one as directed-Ivermectin three milligram (mg) tablet take three tablets by mouth as a single dose and repeat in one week, and step two (as directed) triamcinolone acetonide 0.1% topical cream apply to affected areas on body twice a day as needed for itching.Review of R1's MAR, dated June 2025 and located in in R1's EMR under the Orders tab, indicated an order for Permethrin cream [a medication used to treat scabies and lice]; 5%, amount to administer: as appropriate, daily, and topically, the ivermectin [used to treat parasitic worm infections in humans] three mg tabs.three tablets by mouth as a single dose to be repeated in a week and triamcinolone acetonide 0.1% topical cream as needed for itching were being administered. According to the MAR the orders for this treatment were dated 6/26/2025, the same day R1 saw the Dermatologist.During an interview with Family Member (FM) 2 on 7/1/2025 at 3:00 PM, FM2 stated she attended a care plan meeting last Friday and she was told that it was the hospice staff's fault that R1's medicine did not arrive at the facility until 6/28/2025. She said R1 has had the rash for a while. FM2 said R1 finally saw the Dermatologist on 6/26/2025 and the medicine did not start until 6/28/2025. During an interview with Licensed Practical Nurse (LPN) 5 on 7/1/2025 at 3:30 PM, LPN5 called the facility pharmacy and was told that the Physician did not send the e-script (electronic prescription) to the Pharmacy until 6/27/2025, so the medicine was sent to the facility either Friday night (6/27/2025) or Saturday morning (6/28/2025), and the treatment plan was initiated. 2. Review of R4's electronic medical records (EMR) titled Resident Face Sheet indicated the resident was admitted to the facility with a diagnosis of but not limited to hyperglycemia (diabetes).Review of R4's EMR titled Orders located under the Resident tab dated 6/25/2025 indicated the medical provider ordered Humalog solution five units to be administered three times per day at 9:00 AM, 1:00 PM, and 5:00 PM. The administration of Humalog was to give the insulin 10 to 15 minutes before meals. There was no evidence of standing orders for the administration of glucagon. Review of R4's EMR titled Situation, Background, Assessment, Recommendations (SBAR) located under the Resident tab dated 2/8/2025 indicated the resident's blood sugar dropped to 42 and indicated the resident was administered glucagon and orange juice which raised the resident's blood sugar to 311. The SBAR revealed the medical provider and the resident's responsible party were notified. Review of an undated document provided by the facility titled, Mealtimes indicated the lunch meals were to be started at 1:10 PM.During an interview on 7/1/2025 at 11:58 AM, Licensed Practical Nurse (LPN) 3 stated she follows whatever the physician directed for the treatment of R4. An interview was conducted on 7/1/2025 at 12:57 PM with LPN3 and LPN2 (Unit Manager for [NAME] A/B halls). LPN3 confirmed she had administered R4's insulin at noon. The noon meal trays had not been delivered to the resident's hallway. LPN2 asked LPN3 if R4 was provided with a snack around the time of administration and LPN3 confirmed she did not provide the resident with a snack. During an interview on 7/1/2025 at 1:10 PM, Nurse Practitioner (NP) 1 stated R4's order came from her endocrinologist since there were concerns with hypoglycemia (low blood sugar). NP1 stated that the meal not being delivered for over an hour was a bit too long since given the resident's blood sugar, the staff were looking at potential hypoglycemia. During an interview on 7/1/2025 at 1:27 PM, Registered Nurse (RN) 2 stated if there was a delay in a resident's meal after being administered with a short acting insulin, a snack should be provided so the resident does not become hypoglycemic. R4's meal was delivered during this interview. During an interview on 7/2/2025 at 12:48 PM, the Director of Nursing (DON) stated staff should have intervened for R4 with the glucagon and then obtain a physician order. The DON stated there were no standing orders for the administration of glucagon for R4.

Based on resident and staff interviews and record review, the facility failed to ensure one of three residents (Resident (R) 12) reviewed for transportation out of a total sample size of 24 residents, was picked up from a medical appointment by the facility's transportation. This failure placed residents at risk for unsafe transportation to a medical appointment from the facility.Findings include:Review of R12's electronic medical record (EMR) titled Resident Face Sheet located under the Resident tab indicated the resident was admitted to the facility on [DATE].Review of R12's EMR titled quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) dated 1/30/2025 located under the survey shell indicated the resident had a Brief Interview for Mental Status (BIMS) score of 14 out of 15, which revealed the resident was cognitively intact.During an interview on 6/30/2025 at 10:26 AM, Certified Nurse Aide (CNA) 2 confirmed she left R12 at her medical appointment on 2/6/2025. CNA2 stated CNA1 was to pick the resident up.During an interview on 6/30/2025 at 10:29 AM, CNA1 stated there was a delay at R12's medical appointment and she was scheduled to clock out at 5:00 PM. CNA1 stated she informed the resident's son that she could not wait to take the resident back to the facility, so the son brought the resident back to the facility.During an interview on 6/30/2025 at 12:02 PM, R12 stated she was left at a medical appointment, and her son had to place her in the back of his car and this hurt her leg.During an interview on 6/30/2025 at 2:58 PM, the Administrator stated the facility did not have a policy on transportation for residents but stated her expectation was if the facility provided the transportation to the medical appointment for the resident, then the resident needed to be picked up by the facility.

Based on record review, staff interviews, and facility policy review, the facility failed to ensure that clinical records were complete and contained accurate documentation for one of 24 residents sampled residents (Resident (R) 4). This failure had the potential for R4 not to receive accurate care.Findings include:Review of a facility's policy titled Medication Administration: General Guidelines dated 4/10/2019 indicated . Medications are administered as prescribed, in accordance with good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have familiarized themselves with the medication.Review of R4's electronic medical records (EMR) titled Resident Face Sheet indicated the resident was admitted to the facility on [DATE].Review of documents provided by the facility titled Medication Administration History (MAH) for the month of January 2025 indicated R4's Hiprex was not documented as administered on the following dates: 1/3/2025 at 9:00 AM; 1/19/2025 at 9:00 AN; and on 2/13/2025 there was no documented evidence the resident received her Hiprex.Review of R4's Order History dated 8/16/2023 and provided by the facility indicated the physician ordered gabapentin (anticonvulsant medication used to treat nerve pain) 300 milligrams (mg) to be administered twice a date at 9:00 AM and 5:00 PM and Hiprex (methenamine Hippurate) tablet; 1 gram; amt: 1; oral Special Instructions: Take with meals.Review of a document provided by the facility titled MAH for the month of February 2025 indicated R4's gabapentin was not documented as administered to R4 on the following date: there was no documented evidence the medication was administered on 2/1/2025 at 5:00.Review of documents provided by the facility titled MAH for the month of May 2025 indicated R4's gabapentin was not documented as administered on the following dates: on 5/4/25 and on 05/05/2025 the 5:00 PM dose had no documented evidence that the gabapentin was administered to R4; and on 5/25/2025 the 5:00 PM dose had no documented evidence that the gabapentin was administered to R4.Review of documents provided by the facility titled MAH for the month of May 2025 indicated R4's Hibrex was not documented as administered on the following dates: on 5/4/2025 and on 5/5/2025 5:00 PM dose had no documented evidence that the gabapentin was administered to R4; and on 5/25/2025 the 5:00 PM dose had no documented evidence that the gabapentin was administered to R4.Review of R4's Order History dated 5/2/2025 and provided by the facility indicated the physician ordered carvedilol tablet 25 mg to be administered twice a day at 9:00 AM and 5:00PM.Review of documents provided by the facility titled MAH for the month of June 2025 indicated R4's carvedilol 5:00 PM dose was not documented as administered on 6/28/2025.During an interview on 7/2/2025 at 12:48 PM, the Director of Nursing (DON) stated that his expectation was for the nurses to document that medications were administered and this was part of the standard of care.

Based on record review, and family member and staff interviews, the facility failed to ensure one of one resident reviewed for billing (Resident (R) 3's) Family Member (F1) was provided with a timely refund for paying for a private room and failed to review the resident's billing for accuracy. As a result of this deficient practice, the resident was billed for excessive charges, and the bill was sent to collections for an unjustified charge.Findings include:Review of R3's Face Sheet located in the electronic medical record (EMR) under the Face Sheet tab, revealed an admission date of 1/5/2024 and discharge date of 2/1/2024.During an interview on 7/1/2025 at 10:07 AM, Family Member (F) 1 explained the desire to have R3 in a private room and on 1/10/2024 they paid $3720, as requested by the facility for the private room, being reassured that everything else was covered by Medicare and the supplemental insurance. F1 had a concern about being billed for over $5600 and called the facility several times concerning the bill. During an interview on 6/30/2025 at 10:45 AM, the Business Office Manager (BOM) provided documentation from the business office files for R3 and confirmed there was a billing entry error for R3 resulting in being billed for 484 days of private room care when the actual days were 22 days. F1 had paid $3720 on 1/10/2024 for R3 to have care in a private room. When the error was revealed, a refund of $992 was sent to R3.Review of R3's Resident Statement, dated 2/19/2024 and provided by the facility revealed an outstanding balance of $56,296 for 484 days for a private room.Review of the debt collection letter, provided by the facility to R3 dated 4/26/2024 revealed a past due amount of $56,296, requesting immediate payment to the facility.Review of R3's Resident Statement, dated 11/22/2024 and provided by the facility revealed a refunded amount of $992.During an interview on 7/2/2025 at 2:47 PM, the Administrator confirmed refunds should be sent in a timely manner when a refund was due to a resident/resident family member.Review of the admission agreement, signed by R3 dated 1/5/2024 and provided by the facility revealed, Refunds. Any overpayments made by the Resident and held by the Facility will be refunded as soon as possible after any outstanding insurance claims have been verified and paid.

Based on record review, resident and staff interviews, and facility policy review, the facility failed to ensure one of three residents reviewed for falls (Resident (R) 12) out 24 sampled residents, had adequate supervision and the resident and/or family had been trained to transfer the resident from her wheelchair to a personal vehicle. The deficient practice had the potential for R12 to sustain a fall and cause harm.Findings include:Review of a facility policy titled Occurrences dated 1/11/2024 indicated .The healthcare center recognizes that due to the fragility of the patient/residents served, there is an increased risk of occurrences that may result in injury to the patient/resident and/or others. To prevent occurrences, each patient/resident will be observed and assessed for risks. Appropriate, realistic interventions will be implemented in accordance with their plan of care.Review of R12's electronic medical record (EMR) titled Resident Face Sheet located under the Resident tab indicated the resident was admitted to the facility on [DATE].Review of R12's EMR titled quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) dated 01/30/25 located Aspen MDS Viewer indicated the resident had a Brief Interview for Mental Status (BIMS) score of 14 out of 15, which revealed the resident was cognitively intact. The assessment indicated the resident had impairments of her upper and lower extremities. The assessment indicated the resident was dependent on staff for transfers from bed to a chair and from a chair to the bed.Review of R12's Physical Therapy Treatment Encounter Note(s), dated 2/6/2025 and provided by the facility indicated the resident was a fall risk due to a right-side hemiplegia (stroke) and was dependent on staff for chair to bed and from bed to chair transfers.Review of R12's EMR titled Care Plan located under the RAI (Resident Assessment Instrument) tab dated 11/20/2024 revealed the resident was identified as being at risk for falls related to weakness, pain, and lack of coordination.During an interview on 6/30/2025 at 12:02 PM, R12 confirmed she was taken to a medical appointment (on 2/6/2025) and was not picked up by the facility. R12 stated her son needed to place her in the back of his car and transport her back to the facility.During an interview on 6/30/2025 at 2:58 PM, the Administrator stated the facility had no policy on transportation of a resident. The Administrator stated that depending on a resident's mobility, a family member could transport a resident back to the facility.During an interview on 7/1/2025 at 2:23 PM, the Director of Rehabilitation (DOR) stated that R12 was dependent on staff for transfers and stated rehabilitation did not provide the family with education on performing safe transfers with the resident. The DOR stated she would not have provided family education for transferring a resident to and from a car due to safety and her right sided paralysis.(Cross Reference F774)

Based on observations, interviews, record review, and the facility's policy titled, Dish Machine- High Temperature, the facility failed to ensure that the dishwashing machine consistently reached the required operating temperature. The deficient practice had the potential to affect 114 out of 117 residents receiving an oral diet from the kitchen. Findings include: Review of the facility policy titled Dish Machine-High Temperature reviewed 1/8/2021 revealed under Scope: This policy applies to each facility that uses a high temperature dish machine and to those dietary partners that operate the high temperature dish machine. Under Procedure: An 'name of company' T-Stick, 'name of company' Temperature Indicator Stick, or Water Proof Thermometer will be used to test and verify the internal temperature of a High Temperature Dish Machine is being achieved. Review of the manufacturer signage in the kitchen for the dish machine dated 2004 revealed that the temperature of the water should be 120 degrees Fahrenheit (F). Fill the dish machine with hot water (120 F- 140 F). Observation on 6/11/2024 at 9:28 am, Kitchen Staff TT was observed operating the dishwashing machine. When questioned on the procedure to ensure the machine was prepared for use, Kitchen Staff TT was unsure of the required temperatures and chemical levels, as her primary responsibility had been food scrap removal, not machine operation. Interview on 6/11/2024 at 9:30 am with the Dietary Manager (DM), the DM described the dish machine as a temperature-critical device that should operate at 118 degrees Fahrenheit (F) for both washing and rinsing, though observations did not consistently support this claim. The washing and rinsing temperatures during three consecutive cycles were recorded as follows: Cycle 1: Wash at 100 degrees F, Rinse at 102 degrees F. Cycle 2: Wash at 100 degrees F, Rinse at 112 degrees F, Cycle 3: Wash at 110 degrees F, Rinse at 118 degrees F. Interview on 6/11/2024 at 9:45 am, the Regional corporate representative acknowledged the temperature discrepancies and committed to contacting the dish machine chemical company for technical support. Meanwhile, the facility would switch to disposable dining ware and in-service training would be scheduled for the kitchen staff. A review of the Dish Machine Temperature Log dated June 2024: On 6/1/2024, the temperature at breakfast was recorded at 118 degrees F for washing. On 6/2/2024, the temperature at breakfast was recorded at 118 degrees F for washing and rinsing. On 6/3/2024, the temperature at lunch was recorded at 118 degrees F for washing and rinsing, and supper was recorded at 118 degrees F for rinsing. On 6/4/2024, the temperature at breakfast was recorded at 118 degrees F for rinsing; lunch was recorded at 118 degrees F for washing and rinsing; and supper was recorded at 118 degrees F for rinsing. On 6/5/2024, the temperature at breakfast, lunch, and supper was recorded as 118 degrees F for washing. On 6/6/2024, the temperature at breakfast was recorded at 118 degrees F for rinsing; lunch was recorded at 118 degrees F for washing; and supper was recorded at 118 degrees F for rinsing. On 6/7/2024, the temperature at breakfast, lunch, and supper were recorded at 118 F for the wash. On 6/8/2024, the temperature for rinsing at lunch and washing at supper was recorded at 118 degrees F. On 6/9/2024, the temperature at breakfast was recorded at 118 degrees F for washing; lunch was recorded at 118 degrees F for washing, and supper was recorded at 118 degrees F for washing. On 6/10/2024, the temperature at breakfast, lunch, and supper were recorded at 118 degrees F for washing. On 6/11/2024, the temperature was not recorded as being checked. Interview on 6/12/2024 at 10:00 am with the Dietitian revealed the ongoing efforts to rectify the temperature issue, mentioning a temporary increase in boiler settings that inadvertently raised water temperatures at other points of use within the kitchen. A booster was ordered to stabilize temperatures specifically for the dish machine. On 6/13/2024 at 4:06 pm the DM provided evidence of recent staff training on the importance of achieving and verifying correct temperatures in the dishwashing process. This training followed a visit from a dish machine chemical representative who emphasized the need for temperatures to reach at least 120 F during operation cycles.

Based on observations, resident and staff interviews, record review, and review of the facility policy titled, Grievances: Healthcare Centers, the facility failed to file a grievance on behalf of one of 38 sampled residents (R) (R47) who had concerns with a roommate. Findings include: Review of the facility policy titled Grievances: Healthcare Centers revised 11/21/2022 revealed under Scope: This policy applies to all partners employed by the healthcare center, patients, and/or other customers. It revealed under Definitions: A grievance includes, but is not limited to, complaints with respect to care and treatment that has been furnished to a patient, as well as that which has not been furnished, the behavior of staff and of other patients, and other concerns regarding the patient's facility stay. Under Procedures it revealed: 1. In the event a patient expresses a grievance or complaint to a staff member, one or more of the following actions will be taken: If the patient or family member requires assistance with writing the grievance, the staff person receiving the information will assist with completing the appropriate section of the Grievance/Complaint Form: Healthcare Centers. Observations and interview during walking rounds on 6/11/2024 at 11:38 am, R47 was seated in his room doorway. R47 expressed concerns about persistent odors coming from his roommate's area, particularly during activities of daily living (ADL) care and wound treatment. Observation on 6/12/2024 at 10:15 am, R47 was seated in a wheelchair, still distressed by the odors. R47 confirmed that the smell was affecting his ability to enjoy meals and impacting his quality of life within the facility. Interview on 6/12/2024 at 1:10 pm with Certified Medication Aide (CMA) QQ, she stated that R47 had told her a few times about the situation with smells from his roommate's area of the room, and he would not eat his food. She didn't file a grievance, but when she was working on this hall, she tried to honor his wishes. Interview on 6/12/2024 at 1:18 pm with Certified Nursing Assistant (CNA) RR, she said that R47 had expressed concerns regarding the smell in the room. She said she tried to be mindful and provide treatment after he had eaten his breakfast, but she didn't think to report it or file a grievance on his behalf. She offered for him to eat in the dining room, but he refused. Interview on 6/12/2024 at 1:35 pm with Unit Manager JJ, she stated she was aware of R47's complaint about the smell in his room. They tried to accommodate him by offering him the option of going into the dining room and moving, but he declined. She was asked why she had not filed a grievance, and she stated, I don't think it's that in depth to file a grievance. It's not that serious. Interview on 6/12/2024 at 2:50 pm with Wound Care Nurse EE, when asked about R47 complaining about the smell in the room and not being able to eat his food, she stated that he hadn't said that to her and would try to be more mindful of the situation, but she had just gotten back from vacation and maybe mentioned it to another wound care nurse. Review of the Grievance Log revealed no documentation that a grievance was filed on behalf of R47. Interview on 6/13/2024 at 8:12 am with the Director of Health Services (DHS) and the Administrator, when asked what the proper protocol was for a resident who was not happy with their roommate and didn't feel comfortable eating in their room due to bad smells, she said the protocol was to write a grievance and try to accommodate the resident by changing rooms or offering another alternative. When asked if R47 had ever complained to her or if the staff had ever reported R47's concerns, the DHS and the Administrator said it was the first time they had heard of it, or they would have addressed it. When asked what the protocol was for facility staff that R47 had informed of his concern, she stated they were supposed to tell their supervisor so they could follow up with a grievance.

Based on observations and staff interviews, the facility failed to provide a safe, clean, comfortable, homelike environment for six of 64 rooms on two of four halls. These rooms and hallway contained dirty damaged bathroom ceiling exhaust fan vent covers, dirty damaged Packaged Terminal Air Conditioner (PTAC) units, a bathroom sink with low water pressure, damaged hallway handrails, and pungent odor in the west wing hallways. Initial screening observations on 6/11/2024 at 9:00 am in/near room [ROOM NUMBER] revealed a strong, pungent odor near the doorway. Initial screening observations on 6/11/2024 at 9:15 am in rooms [ROOM NUMBER] revealed PTAC unit filters were dirty with thick, gray, fluffy substances. Further observations revealed the vent in room [ROOM NUMBER] also had black substances scattered on the upper vents. Initial screening observations on 6/11/2024 at 9:40 am in room [ROOM NUMBER] revealed the bathroom sink with low water pressure. Initial screening observations on 6/11/2024 at 11:30 am in rooms [ROOM NUMBERS] revealed dirty ceiling exhaust fan vent covers, not secured to the ceiling and hanging above the toilet area. Observations on 6/12/2024 at 10:26 am and 6/13/2024 at 10:45 am in rooms [ROOM NUMBER] revealed PTAC unit filters dirty with thick, gray, fluffy substances. Further observations revealed the vent in room [ROOM NUMBER] also had black substances scattered on the upper vents. Observations on 6/12/2024 at 10:26 am and 6/13/2024 at 10:45 am in room [ROOM NUMBER] revealed the bathroom sink with low water pressure. Observations on 6/12/2024 at 10:26 am and 6/13/2024 at 10:45 am in rooms [ROOM NUMBERS] revealed dirty ceiling exhaust fan vent covers, not secured to the ceiling and hanging above the toilet area. Observations on 6/12/2024 at 10:26 am and 6/13/2024 at 10:45 am revealed the handrails between rooms [ROOM NUMBERS] had exposed wood, and the veneer covering was loose on the handrail between rooms [ROOM NUMBERS], and rooms [ROOM NUMBERS]. Interview and walking rounds on 6/12/2024 at 10:45 am with the Administrator, Environmental Services Director (ESD) and Maintenance Director (MD) confirmed dirty damaged bathroom ceiling exhaust fan vent covers, dirty damaged (PTAC) units, bathroom sink with low water pressure, and damaged hallway handrails. The ESD revealed the maintenance staff clean the filters monthly and they keep a log of this. He did not want to say if he thought the filters were cleaned in the last month. The Administrator stated they were cleaned, and they just collected a lot of dust because they had been doing a lot of construction work and running electrical cords through the windows. The ESD stated his expectation was for environmental issues to be taken care of as soon as possible. He stated the staff reported issues to maintenance via the maintenance logbook located at each nursing desk and they now have the TELS (maintenance work order system) system that the staff have been acclimating to. He revealed he also oversaw Housekeeping and he stated there were several rooms which they consider to be hot rooms. He stated this means the housekeepers clean those rooms more often. He stated the housekeepers will clean those rooms twice a day on each morning and evening shift. He stated they have been trying a number of cleaning agents to address the strong pungent odors on the west wing halls. The ESD further stated that the bathroom ceiling exhaust fans and hallway handrails needing repair must have just happened because staff are good at reporting issues to him. Review of the [NAME] Wing maintenance logbook revealed no issues identified were logged in the last month. The ESD and MD stated they were not aware of any Maintenance policy. The Administrator confirmed the facility do not have a Maintenance or Environmental policy. The Administrator asked the ESD and MD to immediately correct and address the areas of concern in each room.

Based on observations, staff and resident interviews, and record review, the facility failed to ensure a resident's right to dignity for one of 38 sampled residents (R) (R41). Specifically, R41 was left unclothed and uncovered in the middle of care. Findings include: Review of the electronic medical record (EMR) for R41 revealed that she was admitted to the facility with diagnoses that included but were not limited to generalized anxiety disorder, depression, and quadruple amputee. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed that R41 had a Basic Interview of Mental Status (BIMS) score of 15, indicating intact cognition. Review of Section E (Behavior) revealed that she had no behavior which includes refusal of care. Review of section GG (Functional Abilities and Goals) revealed that she had impairment on both sides of both upper and lower extremities and was total dependence of staff with all activities of daily living (ADLs). Observation and interview on 6/12/2024 at 4:55 pm, R41 was observed sitting in her wheelchair, dressed, wearing sunglasses. The resident stated that she felt like she had a target on her back, and it had been ever since she filed a complaint about a Certified Nurses Aid (CNA) neglecting her. She stated that on 2/14/2024 the CNA on duty had come in to render care. She continued by stating that during care, she had asked the CNA if she could come back at around 2:00 pm that afternoon so that she could help her get ready for the Valentines Day party. She then stated that the CNA got angry with her and told R41 that she would try, but that she had other residents to attend to and would not guarantee that she could come back at 2:00 pm. R41 then stated that the CNA got upset with her and threw one of her prosthetic legs at the wall, then left the room with her naked and uncovered. Interview on 6/13/2024 at 1:45 pm, R41 stated that the care plan meeting went like she thought it would go. She stated that Social Services offered help if she wanted to transfer to another facility. I still feel like I have a target on my back. It didn't use to be this way, but now since 2/14/2024, it has progressively worsened. She stated that they will come in at 11:00 am to get me up. She stated that there would be several hours between visits. Second Shift usually only came in when I called. She stated that third shift, it depended on who was here. They would come in at the beginning of the shift and then maybe at 6:00 am. She stated that the Nurse Supervisor would come in around 3:30 am or 4:30 am. A lot of times, it took them a long time to get someone in my room to answer the call bell. She then continued by stating at times she had turned on her call light and it took so long that she had gone down to the nurse's station and found nurses just sitting there, with the call light still going off. Review of the facility reported incident report that was filed on 2/27/2024 revealed that R41 alleged that a CNA neglected her on 2/14/2024. It was reported to staff on this date that a CNA that was providing care left her in the bed with no clothes on and did not come back to finish the care. There were interviews that were obtained during the investigation that revealed that the resident was left naked and uncovered. Interview on 6/13/2024 at 2:43 pm with the Unit Manager, she stated that it was the responsibility of everyone to answer the call lights. Interview on 6/13/2024 at 3:05 pm with CNA PP, she stated that R41 had never had any difficult behaviors that she had seen. If she was doing care, R41 would always ask for details so that all her needs were being meet. If she wanted to go to an activity, she would ask her about all the details and would come back and help her to get ready for that activity. She then stated that she had noticed that R41 had isolated herself. She had been upset about an incident that occurred when she turned on her call light and no one answered the light. She stated that she did not turn on the call light very often and if she turned it on, then she really did need something. She continued by stating that R41 was not needy, just particular about what she wanted and when she needed to get her up for the day, she needed to dedicate a full hour to her, because of her condition. And she also knew that she needed two bathroom breaks during the shift after she had been gotten up. Interview on 6/13/2024 at 6:30 pm with the Director of Healthcare Services (DHS), she stated that she expected that staff were providing privacy, and at the time of the incident with R41, that she expected that the resident be covered and to go and get another CNA and nurse to finish providing care, and that the CNA did close the curtain. She then stated that it was the responsibility of everyone to answer call lights. She would expect any non-clinical staff to do what they could do after answering the call light and then letting the appropriate person know if it was something that they could not do. If all CNAs were busy, if the nurse was not in the middle of a med pass of something else, I would expect the nurses to answer the call lights and do what was needed, if not, go and get the CNA. Interview on 6/13/2024 at 6:32 am with the Administrator, she stated that she expected call lights to be answered and everyone was responsible for doing it.