Every finding on record at Ravenswood Village

Based on review of medical record, facility reported incident, policy review and staff interview the facility failed to ensure residents were free of significant medication errors. This happened when a nurse pre-poured medications for Resident #8 and mistakenly administered the medications to Resident #52. This affected one (1) of 44 residents. Resident Identifier: #52. Facility Census: 60.This state agency determined this deficient practice constituted immediate jeopardy at past noncompliance beginning 06/09/26. The facility implemented its removal plan and the Immediate Jeopardy was removed on 07/06/26. Findings included: a) Resident #52 Review of facility reportable incident (FRI) dated 06/10/26 at 5:00 pm revealed Registered Nurse #36 on 06/09/26 at 9:30 PM administered medications to Resident #52 belonging to Resident #8. Further review of the FRI for Resident #52 revealed the resident was observed to be more lethargic than baseline. A review of the Five-Day Follow-up dated 06/16/26 revealed Nurse #36 gave medications intended for Resident #8 with similar last name as Resident #52. Nurse #36 reported that the patient was inadvertently administered Clonazepam 0.5 milligram (mg), Depakote 250 mg, Gabapentin 100 mg, Seroquel 300 mg, Trazodone 50 mg and Lupron 8 microgram (mcg). Nurse #36 immediately notified Resident #52 of the situation and contacted the medical provider. Medical provider instructed Nurse #36 to monitor vital signs which were listed as Blood Pressure (BP) 141/79, Pulse (P) 72, Respirations (R) 16, Oxygen O2 saturation (sat) 97% on room air at the time of provider notification. MD visited Resident #52 on 6/10/26 at 1:00 pm and reported Resident #52 is sleepy but arousable. MD stated all medications given to Resident #52 have a half-life of less than 14 hours except Clonazepam which is 30-40 hours. New order to continue to monitor vitals and neuro-checks every 2 hours for the next 24 hours. Daughter of Resident #52 requested Resident #52 be sent to the hospital for evaluation. Resident #52 was sent to the hospital and admitted . Nurse #36 was suspended pending investigation of the incident. Nurse #36 will receive re-education regarding medication administration policy including medication administration competency and resident rights prior to return to work with random monitoring by DON/designee of medication pass. Nurse #36 gave medications belonging to Resident #8 to Resident #52 on 06/09/26 at 9:30 pm. Resident #52 had diagnoses of Atrial Fibrillation, Tricuspid Valve Insufficiency, Hypertension, Chronic Kidney Disease, Hyponatremia, Iron deficiency anemia, Hemiplegia and Hemiparesis following Cerebral Infarction, Repeated Falls, Thrombocytopenia, Abnormalities of Gait, and Cardiac Arrhythmia's. Resident #52 received:Clonazepam 0.5mgDepakote (delayed release) 250mgGabapentin 100mg Quetiapine Fumarate 1mgTrazadone 50mgLubiprostone 8 mcg Nurse #36 discovered error and administered the correct ordered medications to Resident #8 and Resident #52. Nurse #36 contacted the on-call provider (Lumina) regarding medication error and left a voice mail. Ten minutes later the Lumina provider returned all and gave orders to monitor Resident #52 and obtain bloodwork in the AM (CMP) complete metabolic panel. Progress note of Lumina provider states: These medications carry a risk of Central Nervous System (CNS) depression, sedation, hypotension, and respiratory compromise, particularly in combination. Close monitoring is required given risk of delayed sedation and cumulative CNS effects. Nurse #36 on 06/09/26 at 9:45 pm called the DON and informed her of the medication error. DON instructed Nurse #36 to contact the MD. Nurse #36 remained on duty until 06/10/26 until 7:02 am. Nurse #36 on 06/09/26 at 9:50 pm informed the MD of the medication error. MD stated to monitor Resident #52. On 06/10/26 Resident #52 was visited by daughter. Daughter stated she wanted Resident #52 transferred to the hospital as her mother was not acting right. Resident #52 was transferred to [NAME] General hospital on 6/10/26 at 1556. Admitting ED primary notes Resident #52 found to have a diagnosis of prolonged QT interval as identified by EKG likely multifocal due to recent ingestion of QT-prolonging medications and chronic amiodarone use with the risk for arrhythmia and potential de pointes, requiring IV Magnesium administration. On 06/10/26 at 5:30pm, the hospital administered IV Magnesium 2 Gm. Resident #52 was admitted and remained at the hospital until 06/11/26 until her cardiac arrhythmias stabilized. A review of the facility policies revealed the following: Medication Administration General Guidelines Section 7.1 Policy 01/26 Page 3: Medications are to be administered are to be administered at the time they are prepared. Medication Error Policy (NG306) effective 01/01/24 revision 07/01/24The Center will consider factors indicating errors in medication administration including but not limited to: 2.3 Medications administered not in accordance with professional standards and principles. 5) To prevent medication errors and ensure safe medication administration, nurses should verify the following information: 5.1 Right medication, dose, route, and time of administration5.2 Right patient and right documentation. On 07/07/26 at 7:17 pm surveyors interviewed Nurse #36. Nurse #36 verbally confirmed being the author of the handwritten statement describing the incident of the medication error. Nurse #36 confirmed during the interview that she administered the wrong medications to Resident #52 which belonged to Resident #8. Nurse #36 confirmed she picked up the medication cup with the wrong resident's name written on the medication cup. During an interview on 07/09/26 at 9:30 am with the Director of Nursing (DON) and Administrator they confirmed Nurse #36 was contacted by the Administrator on 06/10/26 to come to the facility to discuss the medication error. Nurse #36 arrived at the center on 06/11/26 and was suspended pending investigation. Nurse #36 returned to work 06/23/26 at 6:40pm. DON reported that Nurse #36 received a written (PIP) performance improvement plan as a final Counseling, and a medication administration quiz. On 06/15/26 facility initiated Critical Element Pathways for Medication Administration. 06/16/26 facility-initiated Medication Administration Quizzes for all licensed nurses and completed testing on 07/06/26.

Based on record review and staff interview, the facility failed to ensure complete and accurate medical records for Resident #25, Resident #30, Resident #34, Resident #64, and Resident #66. This was true for one (1) of three (3) sampled for hospitalization and four (4) of five (5) sampled for Activities of Daily Living during the Long-Term Care Survey process. Resident identifiers: #64, #25, #30, #34, and #66. Facility census: 60. Findings included: a) Resident #64 Review of the eInteract Hospital Transfer form, for the hospital transfer on 06/22/26, showed the date of transfer as 09/17/25 in multiple places on the form. In an interview with Director of Nursing (DON), on 07/09/26 at 9:05AM, she confirmed the dates were inaccurate on the hospital transfer form. b) Resident #34 Resident #34 stated in her initial interview, on 07/06/26 at approximately 12:00 PM, that she preferred showers and was not getting them regularly. Review of the 30 day bathing task revealed Resident #34 received a shower two (2) times in the last month - on 06/19/26 and 06/24/26. The facility provided documentation from the Medication Administration Record (MAR) for 06/26 and 07/26 that showed resident received her showers as scheduled. In an interview with the DON, at 12:25 PM on 07/09/26, she confirmed the documentation for Resident #34 was conflicting regarding whether Resident #34 had received her showers. c) Resident #25 During the initial interview on 07/06/26 at approximately 12:30 PM, Resident #25 stated she was not getting regular showers and she preferred showers. Review of the 30 day bathing task revealed Resident #25 received a shower on 06/11/26, 06/12/26, and 06/30/26 in the last 30 days The facility provided documentation from the Medication Administration Record (MAR) for 06/26 and 07/26 that showed resident received her showers as scheduled. In an interview with the DON, at 12:25 PM on 07/09/26, she confirmed the documentation for Resident #25 was conflicting regarding whether Resident #25 has received her showers. d) Resident #30 On 07/09/2026 at 11:53 AM, a record review was completed for Resident #30. The review found inaccurate documentation for the resident's showers. A review of bathing under the tasks tab and the documentation on the medication administration record (MAR) did not reflect the same information. The following was documented under the tasks tab: --06/08/26 shower --06/21/26 bed bath --06/22/26 shower --06/23/26 bed bath --07/06/26 bed bath On 07/09/26 at 12:30 PM, the Administrator was notified of the lack of activities of daily living (ADLs) being completed for Resident #30. The Administrator stated, Let me review the record. On 07/09/26 at approximately 1:30 PM, the Administrator provided copies of the 06/2026 and 07/2026 MARs. The review found the following documentation: --06/08/26 shower --06/11/26 shower --06/15/26 shower --06/18/26 shower --06/25/26 shower --06/29/26 shower --07/02/26 shower --07/05/26 shower On 07/09/26 at 2:12 PM, the Administrator was notified of the inaccurate documentation throughout the record. The Administrator stated, The person I have checking those has been unable to do so due to working the medication cart. We will review with the staff. On 07/09/2026 at 11:53 AM, a record review was completed for Resident #30. The review found all meal percentages were not documented. A review of the meal percentages under the tasks tab found the following: --06/09/26 dinner-75% --06/10/26 dinner-25% --06/11/26 breakfast-100% --06/11/26 lunch-100% --06/12/26 dinner-25% --06/13/26 dinner-25% --06/14/26 breakfast-75% --06/14/26 dinner-50% --06/15/26 no documentation --06/17/26 breakfast-75% --06/17/26 lunch-25% --06/18/26 no documentation --06/19/26 no documentation --06/20/26 breakfast-50% --06/25/26 dinner-50% --06/26/26 no documentation --06/27/26 dinner-75% --06/28/26 dinner-75% --06/29/26 no documentation --07/01/26 no documentation --07/02/26 no documentation --07/03/26 dinner-25% --07/04/26 dinner-100% --07/05/26 breakfast-25% --07/05/26 lunch-25% --07/06/26 dinner-50% On 07/09/26 at 12:50 PM, the Administrator was notified of the lack of meal percentages documented for the resident. The Administrator stated, Let me review the record. On 07/09/26 at 1:30 PM, the Administrator provided a hand-written copy of a form entitled, Meal Sheet. The Administrator and the State Agency Surveyor reviewed the hand-written documentation. The review found some of the missing documentation under the tasks tab; however, some meals were documented with different percentages as well as blanks for other meals. On 07/09/26 at approximately 3:00 PM, the Administrator confirmed the documentation was not accurate and complete. e) Resident #66 On 07/06/26 at 12:30 PM, a record review was completed for Resident #66. A review of the physician's orders found an incomplete order. The order states, Enteral Feed: Type: G/T (gastronomy tube) Size_____ tube as needed. On 07/06/26 at 1:40 PM, the DON was notified and confirmed the physician's order was incomplete.

Based on observation, tray testing, menu and recipie review and staff interview the facility failed to ensure menus were followed for the preperation of fish and that food was palatable. This had the potential to affect more than an isolated number of residents. Facility census: 60.Findings included: a) On 07/08/26, a test tray was provided to the State Agency Surveyors for taste testing. The following items were served on the test tray: -Herb Roasted Fish-Dinner Roll-Gelatin Cubes with Whipped Cream-Garlic Seasoned Potatoes-Spring Vegetable Blend -Chicken Noodle Casserole Aside from the Chicken Noodle Casserole, which was a soup consistency, the food had very little taste. The recipe for the fish included several spices that were not apparent on the serving. Ingredients for Herb Basted Fish- Corporate Recipe #2167: -Fish, Tilapia, Fillet, Skinless, Raw, Frozen, 3-5 ounces-Onions, Green, Fresh-Oil, Pan Coating/Food Release, Spray-Margarine, Solid-Wine, White, Dry, Cooking-Juice, Lemon, Bulk-Spice, Basil, Sweet, Leaf-Spice, Parsley, Flakes, Dehydrated-Spice, Pepper, Black, Ground-Spice, Thyme, Leaf On 07/08/26 at 2:53 PM, the Regional Kitchen Manager was when interviewed about ingredients of the fish served. He reported they did not have dry, white wine. He denied that any other ingredient was left out of the recipe. Stating that all of the green onions were fresh and had been used and the remainder of the herbs were dried and in containers.

Based on staff interview and resident interview the facility failed to ensure three (3) of 60 residents were served their dinner meal at a time that was comparable with the normal dinner service in the facility. Resident identifiers: #35, #9, and #48. Facility census: 60. Findings included: a) During an interview with Resident #35, at 7:15 PM on 07/07/26, she stated she was hungry.On 07/07/26 at 7:15 PM, Surveyors recognized that Resident#4, Resident #9, Resident #35, and Resident #48 had not yet been served their dinner meals.In an interview with Dietary Staff #71, at 7:35 PM, she stated the residents left the dining room and their meal tickets were put to the side where no one saw them until after 7:00 PM. At the time meals were delivered at 7:30 PM, the residents were served hamburgers instead of the beef chili con carne that was on the menu. An interview with Certified Nursing Assistant #22 at 7:40 PM confirmed the above residents did not receive their dinner tray until 7:30 PM. A further interview with Dietary Staff #71 at 8:30 AM on 07/08/26 confirmed the other residents in the facility had dinner trays sent out at 5:15 PM on 07/07/26.

Based on observation, record review, and staff interview, the facility failed to ensure Resident #10 and Resident #22 had call lights within reach. This was a random opportunity for discovery during the Long-Term Care Survey Process. Resident identifiers: #10, #22. Facility Census: 60. Findings included: a) Resident #10 On 07/06/26 at approximately 12:00 PM during initial interviews, Resident #10 was observed with her call light on the floor under her bed, On 07/07/26 at 9:00 AM. Resident #10 had her call light hooked over the top of the headboard out of reach. Nursing was made aware at that time. b) Resident #22 On 07/07/26 at 9:00 AM Resident #22 did not have a call light cord. In an interview with Licensed Practical Nurse #9, on 07/07/26 at 9:10AM, she confirmed that there was no call light for Resident #22 and the call light was not in reach for Resident #10. The facility's policy titled, Call Lights, with a revision date of 07/15/25, read as follows: Staff will ensure the call light is within reach of the patient and secured as needed.

Based on record review and staff interview, the facility failed to develop and implement a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care of the resident. This was a random opportunity discovered during the completion of the initial pool process throughout the Long-Term Care Survey Process. Resident Identifiers: #65, #67, and #66. Facility census: 60.Findings included: a) Resident #65 A brief record review, completed on 07/06/26 at 12:40 PM, revealed Resident #65 had been admitted to the facility on [DATE]. Resident #65's medical history included, but was not limited to, the following medical diagnoses: -Presence of coronary angioplasty implant and graft-Atherosclerotic heart disease of native coronary artery with other forms of angina pectoris-Chronic obstructive pulmonary disease-Infarction, unspecified-Personal history of colon polyps-Vitamin D deficiency-Long term (current) use of insulin-Diverticulosis -Post-traumatic stress disorder, chronic-Diaphragmatic hernia -Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits-Presence of right artificial shoulder joint-Scoliosis-Primary osteoarthritis, right shoulder-Long term (current) use of anticoagulants-Gastroesophageal reflux disease without esophagitis-Allergic rhinitis-Pulmonary fibrosis-Type 2 Diabetes mellitus with diabetic chronic kidney disease-Presence of aortocoronary bypass graft-Cardiac murmur-Effusion, right knee-Other intervertebral disc degeneration, lumbar region -Hyperlipidemia-Low back pain-Unspecified asthma-Idiopathic sleep related nonobstructive alveolar hypoventilation-Presence of left artificial knee joint-Chondrocostal junction syndrome [[NAME]] -Interstitial pulmonary disease-Essential (primary) hypertension-Pure hypercholesterolemia, unspecified-Age-related physical debility -Long term (current) use of anti-thrombotic/antiplatelets-Pressure ulcer of unspecified site, unspecified stage-Pain in right lower leg-Unilateral primary osteoarthritis, right knee -Chronic kidney disease, stage 3 -Angina pectoris, unspecified-Benign prostatic hyperplasia without lower urinary tract symptoms-Constipation -Encounter for other orthopedic aftercare The Baseline Care Plan read: Resident/Patient requires assistance/is dependent for ADL care in ________________(specify: bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion, toileting) related to:Date Initiated: 07/06/2026Created on: 07/06/2026 Resident/Patient will improve current level of function in: ________(specify: bathing, grooming/personal hygiene, dressing, eating, bed mobility, transfer, locomotion, toileting) by next review as evidenced by improved ADL scores.Date Initiated: 07/06/2026Created on: 07/06/2026 Resident exhibits or is at risk for oral health or dental care problems as evidenced by Date Initiated: 07/06/2026Created on: 07/06/2026 The resident will maintain intact oral mucous membranes as evidence by the absence of discomfort, gum inflammation/infection, oral lesions x___ days.Date Initiated: 07/06/2026Created on: 07/06/2026 Resident will have no falls with injury x ___ days.Date Initiated: 07/06/2026Created on: 07/06/2026 Therapy/Rehab -PT Evaluation/Treat :_(indicate plan)_________________________________________Date Initiated: 07/06/2026Created on: 07/06/2026 When resident is in bed or bed-side chair place the following personal items withinreach: ________________Date Initiated: 07/06/2026Created on: 07/06/2026 Resident will achieve acceptable level of pain control, as defined by the patient, of _________(indicate level) x___ days.Date Initiated: 07/06/2026Created on: 07/06/2026 Offer the following non-pharmacologic interventions prior to PRN pain medication administration:__________________Date Initiated: 07/06/2026Created on: 07/06/2026 Resident at risk for skin breakdown related to________ and or has actual skin breakdown Type:___________Location_______Date Initiated: 07/06/2026Created on: 07/06/2026 At Risk Goal: The resident will not show signs of skin breakdown x ____ daysDate Initiated: 07/06/2026Created on: 07/06/2026 Healing Goal: The resident's wound /skin impairment will heal as evidenced by decrease in size, absence of erythema anddrainage and/or presence of granulation X____________daysDate Initiated: 07/06/2026Created on: 07/06/2026 Assist resident in turning and reposition every ___________hrsDate Initiated: 07/06/2026Created on: 07/06/2026 Encourage resident to consume all fluids of choice _________ during mealsDate Initiated: 07/06/2026Created on: 07/06/2026 During an interview on 07/08/26 at approximately 2:40 PM, the MDS Coordinator reported she had been on vacation when Resident #65 had been admitted to the facility. The MDS Coordinator reported she worked on and finalized the resident's care plan by the close of business on her first day back to work which was 07/06/26. b) Resident #67 A brief record review, completed on 07/06/26 at 12:50 PM, revealed Resident #67 had been admitted to the facility on [DATE]. -Schizophrenia-Unspecified severe protein-calorie malnutrition-Difficulty in walking, not elsewhere classified-Anxiety disorder-Allergic rhinitis-Adult failure to thrive-Thrombocytopenia-Essential (primary) hypertension-Dementia in other diseases classified elsewhere, severe, with other behavioral disturbance-Major depressive disorder, recurrent severe without psychotic features-Starvation, subsequent encounter-Delirium due to known physiological condition-Pain, unspecified-Age-related physical debility-Vitamin deficiency, unspecified-Cardiac arrhythmia-Gastro-esophageal reflux disease The Baseline Care Plan read: Resident/Patient requires assistance/is dependent for mobility related to:Date Initiated: 07/03/2026Created on: 07/03/2026 Resident will utilize bed rail(s) (Y/N) indicate type___________ (indicate one: independently; with assistance) for ________ (indicate: turning and repositioning while in bed; transferring to/from bed) .Date Initiated: 07/03/2026Created on: 07/03/2026 During an interview on 07/08/26 at approximately 2:44 PM, the MDS Coordinator reported she had been on vacation when Resident #67 had been admitted to the facility. The MDS Coordinator reported she worked on and finalized the resident's care plan by the close of business on her first day back to work which was 07/06/26. c) Resident #66 On 07/07/26 at 11:30 AM, a record review was completed for Resident #66. The review found the resident was admitted to the facility on [DATE]. However, the baseline care plan was not developed until 07/06/26. On 07/07/26 at 1:06 PM, the Director of Nursing (DON) confirmed the baseline care plan had not been developed within the allotted timeframe. The DON stated, The MDS nurse was on vacation. She completed it when she returned to work.

Based on record review and staff interview, the facility failed to ensure all mental illness diagnoses were on the Pre-admission Screening and Resident Review (PASARR) for Resident #55. This was true for two (1) of five (5) residents reviewed under the care area of unnecessary medications. Resident Identifier: #55. Facility Census: 60. Findings included: a) Resident #55 A review of medical record's for Resident #55 revealed the resident was admitted to facility on 11/06/23. Resident had a diagnosis of Bipolar Disorder, Unspecified on 08/22/25. Resident's most recent [NAME] Virginia Department of Health and Human Resources Pre-admission Screening, completed 10/17/25,revealed Question 30 Current Diagnosis was marked as Major Depression and Other: Dementia. Bipolar was not marked or listed. During an interview on 07/09/26 at 11:15 AM, Admissions Staff #8 reported the hospital had completed the last PASSAR, the diagnosis was not included in any other PASSAR, and she would complete a new one.

Based on record review and staff interview, the facility failed to correctly code the Minimum Data Set (MDS) for swallowing. This was true for one (1) of six (6) residents sampled for nutrition during the Long-Term Care Survey process. Resident identifier: #34. Facility Census: 60. Findings included:a) Resident #34 An electronic health record review revealed the following details; -The diet orders, dated 01/27/26, read, Chopped meats, extra gravy/sauces.-Section K of the Quarterly MDS, dated [DATE], did not have Resident #34 coded as having a mechanically altered diet. In an interview with the Clinical Reimbursement Coordinator #51, on 07/08/26 at approximately 4:00 PM, she confirmed the Quarterly MDS was inaccurate regarding Resident #34's swallowing.

Based on record review and staff interview, the facility failed to protect residents from resident-to-resident physical abuse. This was true for one (1) of seven (7) residents sampled for abuse during the Long-Term Care Survey Process. Resident identifier: #68. Facility census: 60. Findings included: Findings included: a) Resident #68 An eInteract Change in Condition form for Resident #55, dated 12/27/25 and signed at 5:30 PM, read as follows:-RES/RES [resident-to-resident] altercation with alleged abuse; [Resident #55] in co-resident room and punched co-resident in face.-The recommendations read, To maintain supervision and minimize risk [Resident #55] is placed on one-on-one (1:1) observation.' An eInteract Change in Condition form for Resident #68, dated 12/27/25 and signed at 6:30 PM, showed a resident-to-resident altercation between Resident #55 and Resident #68 where Resident #55 was the perpetrator of physical abuse. A Facility Reported Incident (FRI), dated 12/27/25, showed the altercation that occurred at 6:30 PM between Resident #55 and Resident #68. The 1:1 documentation provided by the facility for Resident #55 showed 1:1s did not begin until 7:15 PM. In an interview with Director of Nursing at 11:15AM on 07/09/26, she confirmed Resident #55 was supposed to be placed on 1:1 supervision at 5:30 PM according to documentation. Resident #68 was the victim of a physical altercation at 6:30 PM with Resident #55 and the 1:1 supervision did not actually begin until 7:15 PM. The facility policy titled, Abuse Prohibition with a revision date of 11/14/25, Section 6.3.1 read, the Center will provide adequate supervision when the risk of patient-to-patient altercation is suspected.

Based on record review and staff interview, the facility failed to obtain informed consent for psychotropic medications for two (2) of five (5) residents reviewed under the care area of unnecessary medications throughout the Long-Term Care Survey Process. Resident Identifiers: #34 and #4. Facility Census: 60. Findings included:a) Resident #34 On 07/09/26 at 9:00 AM, a record review was completed for Resident #34. The review found the resident was taking two (2) antidepressants, Wellbutrin and Doxepin. The review found informed consent was not obtained for the medications. On 07/09/26 at 1:15 PM, the Director of Nursing (DON) confirmed the informed consent was not obtained for either medication. The DON stated, We will call and get consent today. b) Resident #4 Record review revealed no signed informed consent for Bupropion HCl ER (XL) 150 mg. During an interview on 07/08/26 at 4:50 PM, the DON confirmed the facility had failed to obtain a signed psychotropic medication informed consent for the medication. The DON further confirmed the informed consent document was completed only after surveyor intervention.

Based on observation and staff interview, the facility failed to ensure a dignified experience during toileting for Resident #27 and Resident #56. These were random opportunities for discovery. Resident Identifiers: #56 and #27. Facility Census: 60. Findings included:a) Resident #27 On 07/07/26 at 7:55 PM, a tour was completed throughout the facility. An observation was made of Licensed Practical Nurse (LPN) #34 assisting the resident, who was in a wheelchair, to the bathroom. Upon leaving the resident's room, the door to the bathroom, as well as the door to the hallway, was left open. Resident #45 was pacing up and down the hallway by the Resident #56's door. At this time, LPN #34 was notified Resident #27 could be observed from the hallway. LPN #34 stated, You cannot shut the bathroom door because of the wheelchair. I'm sorry I should've shut the other door. On 07/07/26 at 8:05 PM, the Administrator was notified. The Administrator confirmed the door to the hallway should have been closed and the call light should be within reach of the resident. b) Resident #56 On 07/06/26 at 3:15 PM, Resident #56 was observed sitting at the end of the 100 hall. Nurse Aide #27 was walking up the hallway and yelled out, [Resident's First Name], do you wanna go get your brief changed? Resident #27 did not answer. She approached him and pushed his wheelchair into his room. When interviewed about the incident at 3:25 PM, Nurse Aide #27 reported, I don't usually do that. Review of the resident's Physician Determination of Capacity form, dated 11/30/23, revealed resident lacked capacity to make his own health care decisions with expected duration long-term due to Alzheimer's Disease. Review of the resident's Brief Interview for Mental Status (BIMS) score, dated 05/12/26, indicated a score of 07. A BIMS score of 07 is indicative of an individual with severe cognitive impairment. The Director of Nursing acknowledged the interaction was inappropriate on 07/07/26 at 10:00 AM.

Based on medical record review and staff interview the facility failed to ensure a resident's medication was no administered outside of parameters in the physicain order. Resident identifier: #66. Facility Census: 60. Findings included: a) Resident #66 On 07/07/26 at 1:00 PM, a review of the physician's orders was completed for Resident #66. The review found two (2) antihypertensive medications, Norvasc and Lisinopril, had specific perimeters to hold the medications if the heart rate is less than 65 or the systolic blood pressure is less than 110. The review found both medications were not held on 07/05/26 when the resident's blood pressure was 105/58. On 07/07/26 at 1:06 PM , the Director of Nursing (DON) confirmed the medications should have been held due to the resident's blood pressure being below the perimeter of 110.

The facility failed to ensure transportation arrangements were made to a follow-up ortho appointment for a newly admitted resident. This was a random opportunity for discovery throughout the Long-Term Care Survey Process. Resident Identifier: #65. Facility census: 60.Findings included:a) Resident #65During an interview on 07/06/26 at 1:40 PM, Resident #65 stated that he had been admitted to the facility on [DATE] following a brief hospitalization for knee surgery. Resident #65 went on to state his follow-up appointment orthopedic had been cancelled for today at 11:00 AM. The resident was unable to provide any further information regarding the cancellation and stated that his wife would speak to someone at the facility about what had happened. During a record review, completed on 07/06/26 at 2:24 PM the following physician order was found: Follow-up with [Name of certified physician assistant] Monday July 6, 2026 at 11:00 am. [Name of Orthopedic office as well as the address and telephone number.]During a telephone interview on 07/06/26 at 1:59 PM, the receptionist at the orthopedic office stated that the 11:00 AM appointment was considered a No call. No show. The receptionist went on to say she had just hung up with Resident #65's wife who was very upset about the missed appointment.During an interview, on 07/08/26 at 11:20 AM, the Scheduler reported she had made note of all of Resident #65's upcoming specialist appointments on Friday, 07/03/26, but did not realize the orthopedic appointment was on Monday, 07/06/26. The scheduler reported she was off on vacation on 07/06/26 and the orthopedic appointment went overlooked.

Based on resident interview, record review, and staff interviews, the facility failed to ensure Resident #34 received dentures within a reasonable timeframe of having her teeth pulled. This was true for one (1) of one (1) residents sampled for dentures during the Long-Term Care Survey Process. Resident identifier: #34. Facility Census: 60. Findings included:a) Resident #34 In an initial interview with Resident #34 on 07/06/26 at 12:25 PM, she stated she had her teeth pulled several months ago, but had not yet received her dentures or had an appointment for dentures. Review of the electronic medical record revealed Resident #34 had her upper teeth pulled on 12/01/25. During an an interview with Administrator, on 07/07/26 at 3:45 PM, it was reported that Resident #34 had a hospital stay after her teeth were pulled which prevented her from seeing the dentist for a denture consult. Per record review, Resident #34 was in the hospital from [DATE] through 01/26/26. In an interview with Van Driver #61 at 11:20 AM on 07/08/26, she stated when someone needs dental services such as a loose or broken tooth. or a denture consult, they email 360 Care to add that resident to the list for their next visit. In an interview with Medical Records Staff #38, at approximately 12:00 PM on 07/08/26, she stated Resident #34 was not on the previous lists for visits from the 360 Care Dental services. She also provided the schedule for the days 360 Care Dental services were in the building after Resident #34 was discharged from the hospital. Those dates were: -02/11/26-04/12/26-04/17/26 The facility policy titled Dental Services stated: When necessary, or if requested, Center staff will assist the patient in making dental appointments and arranging transportation to and from the dental service location.

Based on observation, record review and staff interview, the facility failed to ensure an infection control program for enhanced barrier precautions for Resident #66 and the disposal of soiled linen for Resident #15. These were random opportunities for discovery. Resident Identifiers: #66 and #15. Facility Census: 60. Findings Included:a) Resident #66 On 07/06/26 at 11:30 AM, an observation was made of Nurse Aide (NA) #39 and Licensed Practical Nurse (LPN) #17 entering a room to assist the resident with positioning, who should have been on enhanced-barrier precautions. The resident was noted with a tracheostomy (trach) and a gastrosomy (g-tube) tube. There was no signage on the door to indicate the resident should be in enhanced-barrier precautions. An interview was held with LPN #17 and NA #39. NA #39 stated, I think she is on contact precautions but I'm not sure. LPN #17 stated, I don't know why there isn't a caddy on the door. Yes, she is on enhanced-barrier precautions. On 07/06/26 at 11:35 AM, LPN #17 and NA #39 confirmed no signage was on the resident's door and no personal protective equipment (PPE) was donned. On 07/06/26 at 11:50 AM, the Administrator was notified. The Administrator provided a copy of the door signage. The copy indicated staff must wear gown and gloves when providing high-contact direct care for residents. Change PPE before caring for another patient. Examples of high-contact direct-care changing linens, dressing, bathing/showering, providing hygiene, transferring/repositioning, changes briefs or assisting with toileting, device care or use: urinary catheter, feeding tube, tracheostomy, etc., and wound care: any chronic skin opening requiring a dressing. The Administrator confirmed the resident should have been in enhanced-barrier precautions. b) Resident #15 On 07/07/2026 at 3:20 PM, an observation of soiled linen laying in the floor by Resident #15's bed was made. NA #60 entered the resident's room at this time and removed the soiled linen. NA #60 stated, I don't know who put it there, but I will get it.

Based on record review and staff interview, the facility failed to complete the in-room refrigerator temperature logs and to monitor food for proper labeling of the date the food was placed in the refrigerator as stated in the Policy and Procedure #OPS192 Refrigerators: Patient In-Room. This was true for three (3) of four (4) in room refrigerators observed. Resident identifiers: #28, #17 and #1. Facility Census: #58. Findings Included: a) Resident #28 On 03/24/25 at 1:27 PM observation of the Refrigerator/Freezer Temperature Log form, which was located on the front of Resident #28's in-room refrigerator, found nine (9) out of twenty three (23) days had not had a temperature check. In addition, there was food items in the refrigerator that were opened and not dated. On 03/24/25 at 1:30 PM it was confirmed with Licensed Practical Nurse (LPN) #44 there was a sandwich, two containers of unknown food and various other items in the refrigerator that were not dated. According to Policy OPS192 Refrigerators: Patient In-Room POLICY: Foods may be stored in refrigerators within patient rooms (in-room), at locations where in-room refrigerators are permitted. Food supplied by the patient/responsible party that requires refrigeration must be labeled with the date the food was placed in the refrigerator . Perishable food will be held in the refrigerator for three (3) days following the date on the label and will be discarded by staff upon notification to patient and/or patient representative. PROCESS: .nursing will observe and record temperatures of the refrigerator on a daily basis using the Refrigerator/Freezer Temperature Log. Nursing will monitor food for proper labeling, date food was placed in the refrigerator, Staff will discard food beyond expiration or perishable food held in the refrigerator for three (3) days following date on label upon notification of patient and/or representative. On 03/25/25 at 2:33 PM this was confirmed with the Administrator who agreed the temperatures are to be monitored daily and the food should be labeled with the date it is placed in the refrigerator and discarded after three (3) days. b) Resident #17 On 03/24/25 at 1:27 PM observation of the Refrigerator/Freezer Temperature Log form, which was located on the front of Resident #17's in-room refrigerator, found nine (9) out of twenty three (23) days had not had a temperature check. In addition, there was food items in the refrigerator that were opened and not dated. On 03/24/25 at 1:30 PM it was confirmed with Licensed Practical Nurse #44 there were two (2) opened containers of tarter sauce, a sandwich and various other items in the refrigerator that were not dated. On 03/25/25 at 2:33 PM this was confirmed with the Administrator who agreed the temperatures are to be monitored daily and the food should be labeled with the date it is placed in the refrigerator and discarded after three (3) days. c) Resident #1 On 03/24/25 at 1:27 PM observation of the Refrigerator/Freezer Temperature Log form, which was located on the front of Resident #1's in-room refrigerator, found four (4) out of twenty three (23) days had not had a temperature check. According to Policy OPS192 Refrigerators: Patient In-Room PROCESS: .nursing will observe and record temperatures of the refrigerator on a daily basis using the Refrigerator/Freezer Temperature Log. Resident #1's refrigerator contained nothing but bottles of unopened water. On 03/25/25 at 2:33 PM the Administrator confirmed the temperatures are to be monitored daily.

Based on record review and staff interview, the facility failed to revise the Preadmission Screening and Resident Review (PASARR) when residents were diagnosed with a new diagnosis after being admitted to the facility. This was true for three (3) of six (6) PASARRs' reviewed during the Long Term Care Process Survey. Resident Identifiers: #28, #1 and #42. Facility Census: 58. Findings Included: a) Resident #28 On 03/24/25 at 1:48 PM record review shows Resident #28 has a current medical diagnosis of dementia, anxiety, major depressive mood disorder and psychotic disorder with hallucinations. The Psychotic disorder with hallucinations was a new diagnoses after Resident #28 was admitted to the facility. There is an active order for Aripiprazole for targeted behavior(s) as evidenced by (AEB): auditory hallucinations and hears voices. According to the PASARR dated 09/24/24 which was provided by the facility, there is no indication of psychotic disorder with hallucinations on the PASARR. On 03/26/25 at 10:18 AM during an interview with the Social Services Director #34, it was confirmed that the psychotic disorder with hallucinations should be on the PASARR. b) Resident #1 On 03/26/25 at 9:51 AM record review shows Resident #1 had a current medical diagnosis of anxiety, vascular dementia, delusional disorder, major depressive disorder and bipolar. The major depressive disorder and delusional disorder were new diagnoses after Resident #1 was admitted to the facility. According to the PASARR dated 10/18/10 which was provided by the facility, there are no indications of major depressive disorder or delusional disorder on the PASARR. On 03/26/25 at 10:18 AM during an interview with the Social Services Director #34, it was confirmed that the major depressive disorder and delusional disorder should both be on the PASARR. c) Resident #42 Resident's PASARR was completed on 04/08/24, and did not state any diagnoses of depression, Post Traumatic Stress Disorder (PTSD), and anxiety. Resident had a new diagnosis of major depressive order on 12/09/24, Delusional Disorders on 12/09/24, and Anxiety Disorder was present upon admission. The PASARR was not updated with the new diagnoses from 12/09/24. The Social Services Assessment was completed on 01/08/25 by the Director of Social Services. The Assessment stated, A Social Services Assessment and Documentation UDA was completed today resulting in a PCL-C score that indicated a PCL-C negative screening for symptoms related to possible PTSD. The Minimun Data Set (MDS) assessment dated [DATE] Section I Diagnoses had Depression, Psychotic Disorder and Post Traumatic Stress Disorder marked. During an Interview with the Director of Social Services on 03/26/25 at 9:32 AM, when asked about the social services assessment completed on 01/08/25 where note stated negative screening for symptoms related to possible PTSD', and compared to MDS completed on same date with PTSD marked, Social Worker stated I must have missed changing that. During an interview with the Director of Nursing on 03/26/25 at 11:21 AM, the Director of Nursing (DON) acknowledged they missed updating the PASARR. 51554

Based on record review and staff interview, the facility failed to ensure the Preadmission Screening and Resident Review (PASARR) contained all admitting diagnoses. This was true for three (3) of six (6) PASARRs' reviewed during the Long Term Care Process Survey. Resident Identifiers: #28, #14 and #1. Facility Census: 58. Findings Included: a) Resident #28 On 03/24/25 at 1:48 PM record review shows Resident #28 has a current medical diagnoses of dementia, anxiety, major depressive mood disorder and psychotic disorder with hallucinations. According to a list of medical diagnoses present on admission/readmission Resident #28 has a diagnosis of anxiety. According to the PASARR dated 09/24/24 which was provided by the facility, there is no indication of a diagnosis of Anxiety Disorder on the PASARR. On 03/26/25 at 10:18 AM during an interview with the Social Services Director #34, it was confirmed that the anxiety diagnosis should be on the PASARR. b) Resident #14 On 03/26/25 at 9:10 AM a record review shows Resident #14 has a current medical diagnosis of anxiety, bipolar, dementia/Alzheimer's disease. Resident #14 has an active physicians order for Lithium Carbonate Oral Capsule (Lithium Carbonate) for bipolar; Buspirone HCl for generalized anxiety disorder. According to a list of medical diagnoses present on admission/readmission Resident #14 was admitted with a diagnosis of bipolar and anxiety. According to the PASARR dated 03/15/23 which was provided by the facility, there is no indication of a diagnosis of bipolar or anxiety on the PASARR. On 03/26/25 at 9:45 AM during an interview with the Social Services Director #34, confirmed that both bipolar and anxiety should be on the PASARR. c) Resident #1 On 03/26/25 at 9:51 AM record review shows Resident #1 has a current medical diagnosis of anxiety, vascular dementia, delusional disorder, major depressive mood disorder and bipolar. According to a list of medical diagnoses present on admission/readmission both the anxiety disorder and bipolar diagnoses were present upon admission. According to the PASARR dated 10/18/10 which was provided by the facility, there were no indications of anxiety disorder, bipolar or major depressive disorder on the PASARR. On 03/26/25 at 10:18 AM during an interview with the Social Services Director #34 confirmed that anxiety disorder, bipolar or major depressive disorder should be on the PASARR.

49751 Based on observations, record review and staff interviews, the facility failed to ensure residents were free from accident hazards by not having the janitor's closet locked, and completing smoking evaluations for Resident #17. This failed practice was a random opportunity for discovery and had the potential to affect a minimal number of residents residing in the Long Term Care Facility. Resident Identifier: #17 Facility Census: 58. Findings included: a) Facility janitor closet unlocked On 03/25/25 at 10:20 AM this surveyor observed the janitor's closet door unlocked, this is located at the beginning of Hall 200 across from the nurses station. The following chemicals were on the MSDS Sheet and were stored in the janitor's closet. The sheet listed the following: virex 2-256 disinfectant Stride industrial floor cleaner GP forward industrial cleaner Glance Window cleaner triad 3 Disinfectant cleaner rapid disinfectant Disinfectant cleaner Bio Matic Cleaner [NAME] Dual Action FLoor cleaner Good sense Air Freshener During an interview on 03/25/25 at 10:30 AM with Housekeeper #30 who stated yes the door (janitor's closet) should be locked I must have forgotten and she immediately locked the door. On 03/25/25 at approximately 11:00 AM the Corporate Registered Nurse (CRN) provided the following policy: Manual title Environmental services policies and procedures Policy title EVN103 Environmental Services Safety Procedure under process number 3 states staff will ensure equipment (e.g., cords, ladders, or chemicals) is properly stored and not left unattended in areas that are accessible to patients/residents. When not in use, equipment must be stored in a locking closet, cabinet, or storage area for safety. b) Resident #17 On 03/24/25 at 2:55 PM according to a list provided by the facility, Resident #17 is an active nicotine user by means of smoking cigarettes. On 03/25/25 at 10:00 AM record review shows Resident #17 had a smoking assessment on 03/13/24 and 06/07/24. According to the facility Policy and Procedure OPS137 Smoking: it reads Residents will be assessed on admission, quarterly and with change in conditions for the ability to smoke safely and, if necessary, will be supervised. During an interview on 03/25/25 at 3:03 PM it was confirmed with the Administrator that there should have been an additional smoking assessment in September and December of 2024 and one due in March 2025 at a minimum, depending on any change of condition that may have occurred.

Based upon record review, staff interviews and policy review, the facility failed to ensure antipsychotic, antidepressant, antianxiety medications ordered by the physician had an appropriate diagnosis. This was found to be true in three (3) of five (5) records reviewed during the recertification survey. Resident identifiers: #42, #35, #45. Facility census: 58. Findings included: a) Resident #42 Physician orders were as follows: Trazadone HCl for insomnia as evidenced by (AEB): Depression Sleeplessness, not Socializing. Active 8/23/2024; Risperidone AEB: Depression, Grabbing, Yelling, Restlessness 12/13/2024 ; and Buspirone for anxiety AEB pacing and nervousness nerves 11/13/2024 . Related diagnoses pacing and nervousness nerves. During an interview with Registered Nurse (RN) #26 on 03/25/25 at 2:53 PM, when asked about informed consents for these medication, she stated we dropped the ball and did not get this done. I have completed one just now and sent it out for physician's signature. b) Resident #35 Physician orders: Sertraline AEB: Unhappiness, Loss of Appetite, Poor Grooming, Withdrawn, Crying. Active 2/7/2025 Related diagnoses Unhappiness, Loss of Appetite, Poor Grooming. During an interview on 03/26/25 at 10:26 AM with the Director of Nursing (DON), she stated, We got some new guidelines and I know she has had a lot of physical behaviors so we may have mislabeled that. We just had some training on this, so we must have missed the mark on that. c) Resident #45 A record review on 03/26/25 at 9:18 AM, revealed that Resident #45 was ordered Trazodone oral tablet 100 milligrams (mg) by mouth one time a day, with an order date of 11/22/24. The indication for the usage is listed as agitation as evidenced by yelling and arguing. Under related diagnosis the medication is listed for: Restlessness and agitation. During an interview on 03/26/25 at 10:26 AM, the DON stated, We got some new guidelines and I know she has had a lot of physical behaviors so we may have mislabeled that. We just had some training on this so we must have missed the mark on that one. d) Policy A review of the policy on 03/26/24 at 11:45 AM, titled Medication Regimen Review and Reporting, under Procedures # two (2) reads as follows: The consultant pharmacist reviews the medication regimen and medical chart of each resident at least monthly to appropriately monitor the medication regimen and ensure that the medications each resident receives are clinically indicated .

Based on medical record review and staff interview, and policy review the facility failed to provide Cardiopulmonary Resuscitation (CPR) for Resident #62, according to Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #62's medical record found a progress note written on [DATE] at 3:18 am by Employee #59, (typed as written) that read CNA (certified nursing assistant) in room at 1:30 am resident resting comfortably. CNA went back in at 2:00 am resident appeared to not be breathing CNA got nurse. Nurse assessed resident no apical pulse on auscultation 911 called Resident was pronounced at 2:03 am. 911 arrived and straight line on EKG . Nineteen (19) of fifty-six (56) residents who resided in the facility on [DATE] had an advance directive to receive cardiopulmonary resuscitation (CPR) in the event of a [CONDITION(S)]. Based on these findings, it was determined nineteen (19) residents who had an advance directive for CPR in the event of [CONDITION(S)] were in an immediate jeopardy situation. The resident identifier numbers for the residents are: #28, #37, #31, #4, #16, #44, #262, #35, #10, #42, #57, #46, #40, #34, #13, #19, #32, #3, and #27. After consultation with the Office of Health Facility Licensure and Certification (OHFLAC) at 10:08 AM on [DATE], and preparation of a written statement, the Administrator and Director of Nursing were notified of the Immediate Jeopardy (IJ) on site. The facility submitted an acceptable Plan of Correction (POC) at 11:37 am on [DATE] as follows: Resident # 62 no longer resides in the facility. All residents of the facility have the potential to be affected. The Social Services/designee will complete an audit of all residents to ensure a code status is documented to include physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] @ 11:00 AM with any corrective action immediately upon discovery. Director of Nursing /designee conducted an audit on [DATE] @ 3:30 PM to ensure all licensed nurses including agency licensed nurses had current Cardiopulmonary Resuscitation (CPR) cards with no corrective action required. All center licensed staff, including agency licensed staff to be reeducated by the Nurse Practice Educator(NPE)/designee starting on [DATE] @ 12:00 PM to ensure Cardiopulmonary Resuscitation (CPR) is initiated according to Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . All licensed staff, including agency licensed staff, who are not available during this timeframe will be provided reeducation including posttest by the NPE/designee upon the day of return to work before providing care. New licensed staff including agency licensed staff will be provided education and posttest during orientation by the NPE/designee. Director of Nursing (DON)/Designee will conduct mock CPR drills to ensure for residents is initiated according to the POST form including an interview with licensed nurses including agency licensed nurse on the Obvious Clinical Signs of irreversible death across all shifts daily starting on [DATE] @ 2:00 PM for 2 weeks, including weekends and holidays, then 3 times a week for 2 weeks then randomly thereafter. Results of the monitor will be reported by the Director of Nursing DON/designee monthly to the Quality Assurance Performance Improvement (QAPI) Committee for any additional follow-up and/or in servicing until the issue is resolved and as determined by the QAPI Committee. The facility's Plan of Correction (POC) was accepted at 12:09 p.m. on [DATE]. After verifying implementation of the plan of correction, the immediate jeopardy was abated at 3:30 p.m. on [DATE]. After the abatement of the IJ a deficient practice remained. Findings included: a) Resident #62 Review of Resident #62's medical records on [DATE] at 8:00 am, found the resident was admitted to the facility on [DATE] for rehabilitation for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . During the admission process the POST form was unable to be completed due to the resident's Power of Attorney (POA) was unable to accompany the resident, but voiced he wanted everything including CPR and life support until the doctors say there is no hope. On [DATE], Resident #62's POA completed the POST form requesting CPR to be administered in the event the resident has no pulse and is not breathing. The attending physician signed the POST form on [DATE], making the POST form to be active and in place. Additional review of Resident #62's medical record found a progress note written on [DATE] at 3:18 am by Employee #59, a Registered Nurse (RN),(typed as written) that read CNA in room at 1:30 am resident resting comfortably. CNA went back in at 2:00 am resident appeared to not be breathing CNA got nurse. Nurse assessed resident no apical pulse on auscultation 911 called Resident was pronounced at 2:03 am. 911 arrived and straight line on EKG . Nineteen (19) of fifty-six (56) residents who resided in the facility on [DATE] had an advance directive to receive cardiopulmonary resuscitation (CPR) in the event of a [CONDITION(S)]. Review of the facility's policy for, Cardiac and/or Respiratory Arrest read: If the resident does not have a DNR or/and a Full code status the certified staff will initiate CPR, call 911 and the primary physician, continue CPR until one of the following occurs: It is discovered that the patient has a DNR order; restoration of effective, spontaneous circulation; care is transferred to a team providing advance life support (emergency medical service (EMS); the rescuer is unable to continue because of exhaustion, the presence of dangerous environmental hazards, or because continuation of the resuscitate efforts places others in jeopardy; if licensed nurse notes indicating irreversible death met . When EMS personnel arrive, they assume responsibility Interview with the Director of Nursing (DON) and Nursing Home Administrator (NHA) on [DATE] at 9:30 am, found the RN #59 failed to initiate CPR on Resident #62 on [DATE] when the resident was found with no pulse or respirations as directed by the POST form.

Based on medical record review, facility documentation review and staff interview, the facility failed to ensure that one (1) of six (6) residents reviewed received care and treatment in a manner that was free from neglect. Resident #3 sustained serious bodily injury during resident care. This failed practice resulted in actual physical harm of Resident #3. Resident identifier : #3. Facility census: 50. Findings included: A review of the medical record, on 08/17/20, showed Resident #3 had sustained a fall with serious bodily injury on 09/15/19. Resident #3 sustained the injury while receiving care. On 09/15/19, NA #1 was providing incontinence care to Resident #3 at 6:30 PM. Further review noted NA #1 was administering the care alone. The resident's bed was in the high position. The documentation noted NA #1 had the resident on her side and proceeded to reach for supplies and the resident rolled out of the bed onto the floor. Resident #3 was transferred to the hospital for additional evaluation and medical intervention. The facility was notified on 09/16/19 at 1:26 PM, Resident #3 had sustained a Right Intertrochanteric Fracture with modest angulation and displacement. A review of the care for Resident #3 showed the resident had been assessed to require assistance from two staff members at the time the accident occurred as follows: --A review of the Minimum Data Set ((MDS) dated [DATE] showed under section G, Resident #3 required 2 person physical assist for bed mobility, transfer, dressing, toileting and personal hygiene. This MDS was the most current completed assessment prior to the injury, demonstrating Resident #3 required assistance of two staff members for the care she would have received on 09/15/19 when the fall took place. --A review of the comprehensive resident centered care plan for Resident #3 , noted Resident #3's focus areas required assistance for Activities of Daily living (ADL) care in bathing, grooming , personal hygiene, dressing, eating, bed mobility, transfer, locomotion and toileting related to debility initiated on 05/17/18 with a revision made, dated 10/01/18 , to require assistance of two for bed mobility and toilet use. --A review of facility documentation showed on 09/15/19 at 6:30 PM, NA#1 had Resident #3 turned on side, changing the resident. NA#1 had one hand on Resident #3 and reached to get cleaning wipes then started to turn back around to hold Resident #3 when she fell out of the bed. It was confirmed NA #1 was not not using the assistance of two as assessed and care planned. It was documented no one else was present and assisting NA #1 with Resident #3's care during this incident. Review of the personnel file revealed NA #1 received an individual performance improvement plan on 09/17/19 for counseling only as a result of the incident. An interview with the administrator on 08/19/20 at 12:48 PM, verified Resident #3 experienced pain from the incident on 09/15/19 and was sent to the hospital for evaluation. The administrator further verified Resident #3 continued to complain of pain when returned to the facility and an X-ray was ordered for further evaluation. An interview, with the Director of Nursing on 08/19/20 at 3:05 PM, verified the results of the mobile X-ray showing a right introchanteric fracture with modest angulation and displacement was reported to the facility at 1:26 PM on 09/16/19.

Based on medical record review, facility documentation review, and staff interview, the facility failed to ensure that two (2) of six (6) residents reviewed, received supervision and assistive devices to prevent accidents. Resident #3 sustained serious bodily injury during resident care. This failed practice resulted in physical harm of Resident #3. Resident identifiers: #3 and #6. Facility census: 50. Findings included: a.) Resident #3 A review of the medical record , on 8/17/20, for Resident #3 noted this resident had sustained a fall with serious bodily injury on 09/15/19. On 9/15/19, NA #1 was providing incontinence care to Resident #3 at 6:30 PM. Further review noted NA #1 was administering the care alone. The documentation noted NA #1 had the resident on her side and proceeded to reach for supplies and the resident rolled out of the bed onto the floor. Resident #3 was transferred to the hospital for additional evaluation and medical intervention. The facility was notified on 9/16/19 at 1:26 PM, Resident #3 had sustained a Right Intertrochanteric Fracture with modest angulation and displacement. A review of the care for Resident #3 showed the resident had been assessed to require assistance from two staff members at the time the accident occurred as follows: A review of the Minimum Data Set ((MDS) dated [DATE] showed under section G, Resident #3 required 2 person physical assist for bed mobility, transfer, dressing, toileting and personal hygiene. This MDS was the most current completed assessment prior to the injury, demonstrating Resident #3 required assistance of two staff members for the care she would have received on 9/15/19 when the fall took place. A review of the comprehensive resident centered care plan for Resident #3 , noted Resident #3's focus areas required assistance for Activities of Daily living (ADL) care in bathing, grooming , personal hygiene, dressing, eating, bed mobility, transfer, locomotion and toileting related to debility initiated on 5/17/18 with a revision made, dated 10/1/18 , to require assistance of two for bed mobility and toilet use. A review of facility documentation showed' on 9/15/19 at 6;30 PM, NA#1 had Resident #3 turned on side, changing the resident. NA#1 had one hand on Resident #3 and reached to get cleaning wipes then started to turn back around to hold Resident #3 when she fell out of the bed. It was confirmed NA #1 was not not using the assistance of two as assessed and care planned. It was documented no one else was present and assisting NA #1 with Resident #3's care during this incident. An interview with the administrator on 8/19/20 at 12:48 PM, verified Resident #3 experienced pain from the incident on 9/15/19 and was sent to the hospital for evaluation. The administrator further verified Resident #3 continued to complain of pain when returned to the facility and an X-ray was ordered for further evaluation. An interview, with the Director of Nursing on 8/19/20 at 3:05 PM, verified the results of the mobile X-ray showing a right introchanteric fracture with modest angulation and displacement was reported to the facility at 1:26 PM on 9/16/19. b) Resident #6 A facility documentation review, on 08/17/20 at 5:30 PM, revealed an Event Tracking Log that stated a reportable was available for a fall on Resident #6 for the date of 06/01/20. An interview with Social Worker (SW), on 08/17/20 at 5:45 PM, stated that when a person falls with injury they are to report the fall to Office of Health Faciilty Licensure and Certification (OHFLAC) the Ombudsman and Adult Protctive Services (APS). SW was asked for the reportable information for Resident #6 's fall on 06/01/20. SW stated, there was no reportable available for the incident/fall for Resident #6 on 06/01/20. SW stated the incident was not reported. Interview with the Administrator, on 08/17/20 at 6:40 PM, stated they did not have to report the the incident as there was a blanketed email by Office of Health Faciilty Licensure and Certification (OHFLAC) on 12/18/19 that stated, they did not have to report such incident. The Adminstrator stated, if you have a person who always falls you do not have to report it. A medical review, on 08/18/20 at 8:00 AM, revealed Resident # 6 sustained a fall with serious bodily injury on 6/01/20. A progress note dated for 06/01/20 at 10:30 PM revealed, Resident found on floor. Resident moving around in floor. Resident complaining of left hip and leg pain. Resident covered with blanket and made comfortable on floor to await EMS arrival. EMS Called. Resident # 6 was admitted to the hospital with [REDACTED]. Resident # 6 was approved for hip repair surgery and was readmitted back to the facility after surgery on 06/04/2020. Further medical records review on 08/18/20 at 10:00 AM, revealed a Minimum Data Set ((MDS) dated [DATE]. The MDS revealed Resident needing one (1) person assist for bed mobility, transfers, toileting and personal hygiene. A care plan with a focus risk for falls with a previous history of fall with [MEDICAL CONDITION] with an initiated date of 12/26/2018. Care plan with an additional focus of Assistance with ADL Care was initiated on 12/17/18. Interventions included limited assist of one (1) for transfer using a pivot transfer. He will transfer independently most of the time regardless of re-education attempts with initiation date 12/17/18. Care plan revealed lack of evidence of any additional supervision or assistive device measures put in place to prevent further accidents. A second review of the Event Tracking Log was reviewed, Resident # 6 had an additional fall 19 days later on 06/20/20 after the unwitnessed fall on 06/01/20 where Resident #6 sustained serious bodily injury resulting in hospialization and surgery. An interview with Director of Nursing (DON) on 08/18/20 at 3:45 PM, revealed, If there is a a major injury or we do not know what happened with an unwitnessed fall we do a reportable. If we know how a fall happened then we don't have to report it. An interview with Registered Nurse (RN) #7 on 08/18/20 at 5:00PM. RN #7 stated Resident #6's fall was unwitnessed. She stated that she was at the medication cart and the NA stated that Resident #6 was laying on his floor. RN # 7 stated she went into the room where Resident #6 laid on his bedroom floor rubbing his leg and stated that it was hurting. RN # 7 stated no one knew how he fell as it was an unwitnessed fall. RN #7 stated that DON was notified first thing in the morning when she arrived at work. An interview with Administrator, on 08/19/20 at 4:25 PM, revealed an incident report for Resident #6's fall on 06/01/20. Administrator emailed Incident Report (IR) immediately for review. A review of facility documentation in the form of an Incident Report (IR), on 08/19/20 at 4:30 PM. The IR revealed RN # 7 was the primary nurse on duty on 06/01/20 when the accident occured. IR revealed injury of Resident #7 was a fracture with the Physician and Family representative notified. IR confirms a No for state agency notification. IR reveals Resident #7 found on floor and moving around in floor. Resident complaining of hip and leg pain. No witnesses were listed on IR as accident was an unwitnessed fall. The IR also states, Unwitnessed fall (found on floor).