Every finding on record at Resorts at Chester River Manor Corp

Based on interview and document review, the facility failed to ensure a licensed practical nurse (LPN) maintained her current credentials for 1 (LPN #1) of 8 licensed nursing staff reviewed for current credentials. This deficient practice had the potential to affect all residents who currently resided in the facility.Findings included: According to the Maryland Department of Health, LPN #1 nursing licensed expired on [DATE] and had not been renewed. LPN #1's Time Card Report for the timeframe [DATE] - [DATE], revealed LPN #1 worked 69 days in the facility. LPN #1's Employee Punch Report for the timeframe [DATE] - [DATE], revealed LPN #1 worked 67 days in the facility from [DATE] to [DATE]. LPN #1's Payroll Change Notice dated [DATE], revealed LPN #1 was removed from the facility's payroll effective [DATE]. Per the Payroll Change Form, LPN #1 informed the facility she was retiring. During an interview on [DATE] at 10:40 AM, LPN #1 stated she did not know her license lapsed. LPN #1 stated she worked multiple shifts without knowing there had been a lapse in her nursing license. During an interview on [DATE] at 3:02 PM, the Human Resources (HR) Director stated she was not aware that LPN #1's license had expired. The HR Director acknowledged LPN #1 worked 136 shifts between [DATE] and [DATE] without a nursing license. During an interview on [DATE] at 3:43 PM, the Director of Nursing (DON) stated she relied on the HR Director to ensure all nurses' licenses were current and not expired. The DON stated she was not aware LPN #1 did not have a current license after [DATE]. During an interview on [DATE] at 3:30 PM, the Administrator stated the HR Director kept a spreadsheet used to track when nurses' licenses expired. The Administrator stated he was not aware LPN #1 worked in the facility without a current nursing license.

Based on medical record review and interviews, the facility staff failed to 1) ensure a resident was seen timely by the Urologist as ordered and 2) reassess and intervene for a resident with urinary catheter problems. This was evident for 1 (Resident #3) of 4 residents reviewed for urinary catheters during a complaint survey. This failure led to the hospitalization of Resident #3 with diagnosis to include urinary tract infection and acute kidney injury. The findings include:Review of Resident #3's medical record on 4/20/26 revealed the Resident was admitted to the facility on [DATE] from the hospital with a urinary catheter (Foley) and a diagnosis of retention of urine. 1) The facility staff failed to ensure the Resident was seen by the Urologist as ordered.Review of the hospital discharge instructions on 4/21/26 at 11:40 AM dated 3/25/26 revealed the Resident was to follow up with urology within 2 weeks.Further review of Resident #3's medical record revealed no evidence that the Resident went to a urology follow up appointment. Review of a nurse's note written on 4/3/26 at 12:22 PM stated: Resident returned from urologist appointment in Chestertown. Urology office made scheduling error and booked Resident appointment in [NAME]. Appointment will be rescheduled. MD (doctor)/ RP (resident representative) made aware.During an interview with LPN #3 on 4/20/26 at 12:22 PM, LPN #3 was asked about the Resident's urology follow up appointment. LPN #3 stated, I know it got messed up but the Resident told me it had been rescheduled. During an interview with UM #6 on 4/21/26 at 9:33 AM, UM #6 stated she was the one that called the Urology office and no one told her it was for [NAME], it was a Chestertown number. UM #6 stated the facility's transporter took the Resident to the appointment thinking it was in Chestertown, but when we found out it was scheduled in [NAME], the transporter returned with the Resident. UM #6 was asked when the Urology appointment was rescheduled for. UM #6 stated she would let me know.UM #6 followed up with the Surveyor on 4/21/26 at 10:59 AM and stated Resident #3's Urology appointment was rescheduled for 5/6/26. The Surveyor asked UM #6 if they could get an earlier appointment and UM #6 stated, No, that was the earliest appointment they had. During an interview with the Medical Director on 4/22/26 at 10:49 AM, the Surveyor asked the Medical Director if she was aware the Resident did not go to his/her Urology follow up appointment on 4/3/26 and it was rescheduled for 5/6/26. The Medical Director stated she was aware and believed the facility had the Resident on a wait list to get an earlier appointment.During interview with the Urology office scheduler on 4/22/26 at 12:45 PM, the Scheduler stated UM #3 called their office on 3/27/26 at 12:08 PM and cancelled the Resident's appointment on 4/1/26. The Scheduler stated the 4/1/26 appointment had been previously made on 3/23/26 (when the Resident was in the hospital). The Scheduler stated at that time, Our system notes says the 4/1/26 appointment was cancelled due to facility staff transportation. The Scheduler stated the Resident's appointment was rescheduled during that call on 3/27/26 for Friday 4/3/26. The Scheduler stated at that time the 4/3/26 appointment was confirmed with the [NAME] location, appointment time of 1 PM, and the Resident was seeing provider NP #35. The Scheduler stated she received a phone call from the facility on 4/3/26 at 2:09 PM to reschedule the 4/3/26 because the facility staff went to the wrong location. The Scheduler added that the Chestertown location is closed on Fridays, and they only see patients at the [NAME] office on Fridays. The Scheduler stated she offered the facility dates and they chose 5/6/26 for the next appointment. The Scheduler stated she documented in her notes they were offered earlier appointments but declined those dates. 2) The facility staff failed to reassess and intervene for Resident #3's urinary catheter problems.During an interview with GNA (geriatric nursing assistant) #4 on 4/20/26 at 12:16 PM, the Surveyor asked the GNA if she remembered Resident #3 and any issues with his/her urinary catheter. GNA #4 stated he/she only took care of the Resident one time but remembered his/her catheter was leaking.During an interview with LPN (Licensed Practical Nurse) #3 on 4/20/26 at 12:22 PM, the Surveyor asked if LPN #3 remembered Resident #3 and if there were any issues with his/her urinary catheter. LPN #3 stated: We were not to touch the catheter since it had to be changed by a Urologist. LPN #3 stated: He/she was always playing with the catheter, he/she would push it into him/her up to the Y. LPN #3 demonstrated with an unused catheter where the Resident would push on the catheter up to. LPN #3 stated she would educate the Resident that he/she couldn't do that and would adjust the catheter back to where it was supposed to be. LPN #3 was asked if the urinary catheter was leaking, she stated not when he/she first came in but then it started leaking. LPN #3 added sometimes it was and sometimes it wasn't. During an interview with Unit Manager (UM) #6 on 4/21/26 at 9:33 AM, UM #6 stated she remembered it was leaking and he/she would play with it a lot. We were instructed we could not take it out because it had to be replaced by Urology. The UM stated the catheter was draining. The UM was asked if the urinary output was recorded and she replied, yes on the MAR (Medication Administration Record).Review of Resident #3's April 2026 Mediation and Treatment Administration Records on 4/21/26 revealed no documentation of urinary output. On 4/21/26 at 11:00 AM, UM #6 confirmed the urinary outputs were not recorded on the MARs (Medication Administration Record) and provided the Surveyor with 2 nurses notes from LPN #22 on 3/28/26 at 11:28 PM and 3/29/26 at 7:30 AM that documented an amount of urinary output, no further documentation was provided to Surveyor.During an interview with RN #5 on 4/21/26 at 12:35 PM, RN #5 was asked about what she remembers about the Resident's urinary catheter. RN #5 stated that it was draining. RN#5 also stated she remembered one time a GNA told her that the Resident kept touching the catheter, she told the Resident not to touch it and as long as it's draining to keep it like that.During an interview with LPN #17 on 4/21/26 at 2:48 PM, LPN #17 stated the Resident's catheter was supposed to be changed by Urology and it was leaking. LPN #17 was asked what the staff used for the leaking, LPN #17 stated he/she wore a diaper.During an interview with GNA #21 on 4/22/26 at 7:48 AM, GNA #21 confirmed the Resident's catheter was leaking and when he would come in 3-11 shift the Resident would be wet and he would change him/her.During an interview with LPN #3 on 4/22/26 at 8:05 AM, the Surveyor asked if she ever notified a provider that the Resident's catheter was leaking, his/her discomfort with the catheter and the Resident pushing on the catheter. LPN #3 stated no, she told UM #6.During an interview with GNA #30 on 4/22/26 at 11:30 AM, GNA #30 stated she doesn't remember the day but she got report that the Resident's catheter was leaking. GNA #30 stated the catheter drained well for me. GNA #30 was asked if she had any concerns with the catheter. GNA #30 stated the Resident complained it was burning and she notified the nurse and they looked at it and said it was fine.Review of a nursing note on 3/29/26 at 7:30 AM, LPN #22 documented: Resident observed during rounds with wet incontinent pad. Adjusted catheter and emptied foley bag with 300 cc of clear yellow urine. Made Nurse Practitioner (NP) #28 aware, waiting for response.During an interview with LPN #22 on 4/22/26 at 8:20 AM, LPN #22 stated it was her first time taking care of the Resident on 3/29/26 and she noticed the catheter was leaking. She stated she notified NP #28 that morning and also reported to day shift nurse RN (Registered Nurse) #5. The Surveyor asked LPN #22 what else she remembered, LPN #22 stated she knew the Resident had a urologist appointment scheduled, the Resident's scrotum was red, and the Resident was annoyed he/she was wet. LPN #22 did state she believes she only took care of the Resident one more time the following night and doesn't remember the catheter leaking that night.Review on 4/21/26 of a nursing note written on 3/29/26 at 7:46 AM revealed RN #5 documented: NP consulted with the Resident. According to the Resident his/her last visit to the ER (Emergency Room) after multiple attempts to insert a Foley by the ER nurses and the ER doctor, Urologist had to insert it. Order not to touch the Foley (leaking but draining yellow urine in the bag) Schedule follow up with Urologist. Review of NP #28's note dated 3/29/26 revealed no assessment or plan related to the Resident's urinary catheter.During an interview with NP #28 on 4/22/26 at 10:20 AM, NP #28 was asked why there is no documentation that Resident #3 had a urinary catheter, assessment of the catheter or plan related to the catheter. NP #28 stated he was in the facility early and had seen the Resident prior to staff telling him about the leakage from the urinary catheter. NP #28 stated: I knew the Urologist put in the urinary catheter, so I told the staff not to touch it. I told them to reinforce with gauze because I figured the leakage would be irritating to him/her. I knew he/she was supposed to be seen by the Urologist. The Surveyor told NP #28 the Resident did not see the Urologist on 4/3/26 as scheduled and asked if he knew that. NP #28 stated he was not aware of that. The Surveyor asked if he saw the Resident after that, NP #28 stated: I think I checked in on him/her, but I don't have any notes saying that. Review of the Medical Director's note dated 4/2/26 that was provided to the Surveyor on 4/22/26 revealed no assessment or plan related to Resident #3's urinary catheter.During an interview with the Medical Director on 4/22/26 at 10:49 AM, the Surveyor asked if she was aware of the Resident's urinary catheter. The Medical Director stated she was aware and knew it was inserted by the Urologist at the hospital and the Resident was to be seen by the Urologist. The Medical Director was asked if she was aware the Resident's catheter was leaking. She stated she believed the leakage to be mild and not a major thing and it was not a daily thing. The Medical Director was asked if she was aware the Resident had been pushing or manipulating his/her urinary catheter, she stated: No. The Medical Director was asked if she was aware the Resident had complaints of penile pain to the Pain Management physician on 4/7/26, she stated, No, that would be a concern. Review on 4/21/26 of a Pain Management physician note written on 4/7/26 revealed it stated: He is complaining of penile pain at the insertion site of his Foley catheter. Asking for consideration of removal of his catheter today. I referred him to the primary treatment team and his unit nurse for discussion.During an interview with the Pain Management physician on 4/22/26 at 9:14 AM, the Surveyor reviewed the note he wrote on 4/7/26 and asked if he advised the nursing staff of the Resident's complaint of penile pain and wanting his catheter out. The Pain Management physician stated, I do not recall if I told the nurse and would have to rely on my notes, but if a Resident is alert and oriented and discusses other concerns that I can't handle I will tell them to tell their nurse so it can be addressed.Review of NP #29's note dated 4/12/26 revealed no mention of the Resident's urinary catheter. The NP does document the Resident's genitourinary symptoms: no hematuria. Hematuria is blood in the urine.During an interview with NP #29 on 4/22/26 at 9:53 AM, NP #29 stated she saw the Resident on 4/12/26 for a requested visit regarding his/her blood sugars. NP #29 stated she had reviewed the medical record and knew his/her Foley shouldn't be touched. NP #29 stated he/she should have gone to his/her Urology follow up appointment but was not aware if he/she went or not. NP #29 stated she was unaware of any issues with the urinary catheter.Review of RN #5's nurse's note dated 4/12/26 at 11:44 PM (late entry for 4:00 PM), RN #5 documented: During the day the Resident is alert and oriented times 4. The resident had meds and meals. Therapy got him/her up in chair. While with the resident giving meds or during the rounds he/she did not verbalize any concerns. The Resident's family member was in to visit and stated the Resident was in a lot of pain and not feeling well and she is calling 911 to take him/her to the ER. Resident left the facility via stretcher.During an interview with RN #5 on 4/21/26 at 12:35 PM, RN #5 was asked what she remembered the day the Resident went to the hospital. RN #5 stated: that morning the Resident was sleeping during her first rounds, then got his/her blood sugar, then therapy got the Resident up in a chair for breakfast and then the Resident complained he/she was tired and wanted to go back to bed. RN #5 stated the family member approached her saying they need to send the Resident to ER, wasn't doing well, and in a lot of pain. RN #5 stated I told her I gave the Resident pain medication already. I went to call the provider, but the family member already called 911.Review of Resident #3's hospital medical records on 4/21/26 for admission dated 4/12/26 revealed the Resident was admitted to the hospital with diagnosis to include urinary tract infection and acute kidney injury. The hospital ER nurse's note dated 4/12/26 at 4:32 PM states: Nurse called and spoke with facility staff (RN #36). She advised the Foley has been a problem since the first day of admission. The hospital ER nurse's note dated 4/12/26 at 4:38 PM states Foley upon arrival draining around catheter. No urine noted in Foley bag. 23 milliliters saline removed from balloon (is a 10-milliliter balloon). Patient immediately began to urinate. Was able to obtain 200 milliliters in urinal. New Foley catheter inserted. Patient immediately has 2000 milliliters output of milky yellow urine. Urine sample obtained and bag emptied. Patient now has approximately 400 milliliters red tinged urine in Foley bag.On 4/22/26 at 1:50 PM the Surveyor reviewed the concerns with the Director of Nursing, Administrator, Regional Nurse and Regional Director of Operations the facility staff failure to reassess and intervene for Resident #3's urinary catheter problems and ensure the Resident was followed with the Urologist within 2 weeks as ordered caused Resident #3 harm.

Based on medical record review and interview, it was determined the facility failed to maintain complete and accurate medical records in accordance with accepted professional standards. This was evident for 2 (Residents #4, #3) of 9 residents reviewed during a complaint survey.The findings include: A medical record is the official documentation of a healthcare organization. As such, it must follow applicable regulations, accreditation standards, professional practice standards, and legal standards. All entries to the record must be legible and accurate. 1) On 4/20/26 at 10:10 AM a review of Resident #4's medical record revealed that Resident #4 was admitted to the facility on [DATE] with diagnoses including cutaneous abscess of the left lower limb, orthopedic aftercare, pathological fracture of the left femur, and disruption of external operation (surgical) wound. A review of Resident #4's March 2026 Treatment Administration Record (TAR) revealed a physician's order to cleanse the left knee area with a prescribed solution and cover the area with a dry dressing daily, beginning 3/14/26. The TAR had a blank space for 3/14/26. There were no nurse's initials indicating the treatment was completed, and there were no corresponding nursing notes. On 4/22/26 at 11:50 AM an interview was conducted with Registered Nurse (RN) #31. RN #31 was asked if she performed the dressing change on 3/14/26 as there was no documentation that the dressing was done. RN #31 stated that she remembered Resident #4 and knew she performed the resident's dressing on 3/14/26 because the resident was talking to her during the dressing change. RN #31 was able to describe the wound and the dressing. RN #31 stated she did not realize she failed to sign off that the treatment was completed. On 4/22/26 at 2:00 PM the Director of Nursing and the Nursing Home Administrator were informed of the concern. 2) The facility staff failed to ensure provider notes were included in Resident #3's medical record in a timely manner. Review of Resident #3's medical record on 4/20/26 revealed the Resident was admitted to the facility in March 2026 and discharged from the facility on 4/12/26. Review of Resident's paper medical record on 4/21/26 revealed no provider notes. Review of Resident's electronic medical record on 4/21/26 revealed the following provider notes: -History and Physical by the Medical Director dated 3/26/26 not uploaded in the Resident's medical record until 4/10/26.-Progress note from Nurse Practitioner #28 dated 3/29/26 not uploaded in the Resident's medical record until 4/20/26, after the Resident's discharge.-Progress note from Nurse Practitioner #29 dated 4/12/26 not uploaded in the Resident's medical record until 4/20/26, after the Resident's discharge. On 4/22/26 the Surveyor asked the Director of Nursing (DON) if there were any other provider notes for Resident #3 that were not in the medical record. The DON provided a paper progress note from the Medical Director dated 4/2/26 that the DON stated had not yet been included in the Resident's medical record. The Surveyor reviewed the facility's staff failure to include provider notes in Resident #3's medical record in a timely matter with the DON on 4/23/26 at 1:50 PM.

Based on facility staff interviews and surveyor record reviews, it was determined that the facility failed to ensure that Minimum Data Set (MDS) assessments were coded accurately. This finding was found to be evident in 4 (Resident #1, #9, #33 and #103) out of 16 Residents reviewed for accuracy of assessments during the recertification/complaint survey.The findings include: A Minimum Data Set (MDS) assessment is a comprehensive, federally mandated clinical evaluation for Residents in Medicare/Medicaid-certified nursing homes in the United States. The purpose is to provide a standardized, uniform assessment of Resident health status, identify problems, strengths, and preferences, and inform care planning and payment. MDS assessments are completed by trained nursing home staff upon admission, quarterly, annually, and whenever a Resident's condition significantly changes. Functional capabilities, cognitive status, health conditions, treatment, therapies, psychosocial well-being and discharge planning are assessed in the MDS process. 1) The surveyor conducted a record review of Resident #103's closed medical record on 12/9/2025 at 2:38 PM. Record review revealed that Resident #103 was discharged home with home health services, Amedisys. Further review of the medical record revealed that the Discharge MDS – return not anticipated dated 9/22/2025 was coded that Resident #103 was discharged to home/community and the type of discharge was unplanned. The Discharge MDS – return not anticipated should have been coded as home under care of organized home health service organization and type of discharge coded as planned. The surveyor interviewed the RN (Registered Nurse) MDS Coordinator on 12/10/2025 at 11:10 AM and conveyed that the Discharge MDS assessment dated [DATE] for Resident #103 was coded that Resident was discharged to home/community and that the type of discharge was unplanned. The surveyor further reviewed that according to the documentation in the progress notes by social services, Resident #103 received discharge planning and was discharged home with home health services. The RN MDS Coordinator stated that she coded the discharge MDS assessment this way when Residents discharged home. 2) On 12/11/2025 at 7:15 AM the surveyor conducted a record review of Resident #33's medical record. Review of the medical record revealed that Resident #33 had physician orders for Aspirin 81 mg daily and Clopidogrel 75 mg daily (antiplatelet medications). Continued review of the medical record revealed that the MDS assessments for 8/28/2025 and 11/6/2025 did not indicate that Resident #33 was taking antiplatelet medications (prevent blood clots). Additionally, Resident #33 had a physician order for Lovenox 40 mg two times a day (anticoagulant medication – blood thinner) with a start date of 10/31/2025 and an end date of 11/14/2025, and the 11/6/2025 MDS assessment was not coded that Resident was taking an anticoagulant medication. At 8:35 AM on 12/11/2025 the surveyor conveyed to the Director of Nursing (DON) the inaccurate coding on the MDS assessments. DON acknowledged the surveyor and stated that she would notify the MDS Coordinator. In an interview with the RN MDS Coordinator at 8:50 AM on 12/11/2025 the surveyor reviewed with the RN MDS Coordinator that Resident #33 had physician orders for Aspirin and Clopidogrel and the 8/28/2025 and 11/6/2025 MDS assessments were not coded that Resident takes antiplatelet medications. RN MDS Coordinator stated that she does not usually code Clopidogrel as an antiplatelet, but she does code Aspirin as an antiplatelet medication on the MDS assessments. RN MDS Coordinator stated that she would correct and modify Resident #33's MDS assessments. During the survey exit conference, the Licensed Nursing Home Administrator (LNHA) was notified of the concern with inaccurate MDS assessments. 3) During an interview on 12/10/2025 at 12:38 PM Unit Manager #4 stated that Resident #1 did not have pneumonia, indicating a potential MDS discrepancy. During a record review on 12/10/2025 at 1:08 PM, the surveyor noted that the MDS Quarterly, dated 9/1/2025, coded Section I200 Pneumonia as yes. On 12/10/2025 at 1:40 PM, the MDS Coordinator acknowledged the error stating she hit pneumonia by accident when I coded. When asked what she does if an error if found she stated, Normally when I find out I made an error I file a modification so I will do that now. 4) On 12/11/2025 at 7:14 AM, the surveyor did not identify a significant weight loss during record review however Resident #9 was coded for weight loss on MDS Quarterly, dated 11/19/2025, section K300, Yes, not on prescribed weight-loss regimen. The MDS Coordinator stated Section K is coded by the dietician. On 12/11/2025 at 8:11 AM the Registered Dietician stated, I think I coded weight loss inaccurately. I look at weights in the electronic record. My note and care plan do not reflect weight loss. It is an entry error. The Director of Nursing stated, We will correct this right now.

Based on observations and interviews it was determined that the facility failed to provide treatment/services to maintain hearing. This was found evident in 1 of 3 consults reviewed for Resident #59 on the recertification/complaint survey. The findings include:On 12/8/25 at 9:44 AM, the surveyor conducted an interview with Resident #59. During the interview Resident #59 expressed concerns about the facility's coordination regarding his/her appointments.On 12/15/25 at 10:33 AM the surveyor reviewed Resident #59's medical record. The review revealed that Licensed Practical Nurse (LPN) #23 wrote a progress note stating that Resident #59 was complaining about left ear wax build up and difficulty hearing. The note stated that the Nurse Practitioner (NP) was contacted and ordered Debrox ear drops for 5 days (11/15/25-11/19/25) and an Ear Nose Throat (ENT) consult. The LPN wrote, as this is a recurring problem.Next the surveyor reviewed a consult note from Resident #59's consult provider Staff #24. A note was written on 11/17/25 recommended that the left ear be irrigated to remove wax.On 11/26/25 LPN #23 wrote a note stated that the NP saw Resident #59 and again ordered Debrox for 5 days (11/26/26-12/1/25) and then to flush.On 12/3/25 LNP #23 wrote an additional note that stated Resident #59 continued to complain of left ear fullness and wax build up. It further stated that the Resident had been receiving the Debrox drops and after an ear flush there was minimal to no results.Following the progress notes the surveyor reviewed orders. The review revealed that Debrox drops were first ordered on 8/12/25 (for 5 days), and then again as follows; 8/26/25 (for 5 days), 9/1/25 (for 3 days), 9/5/25 (for 10 days), 11/14/25 (for 5 days) and on 11/26/25 (for 5 days). No ENT consult was noted in the orders.The surveyor reviewed a Psychiatry Nurse Practitioner NP #25's note written on 12/3/25. In the note NP #25 documents that Resident #59's behavior is calm, however mildly tense when Resident #25 expresses his/her recent frustration with communications. The note further states that nursing staff reports Resident #59 had been encouraged to participate in facility activities despite occasional frustration with scheduling and communication regarding appointments.On 12/15/25 at 11:57 AM, the surveyor conducted an interview with the Unit Manager # 4. During the interview the surveyor asked if Resident #59 had an ENT consultation. UM #4 stated she would check and follow-up. On 12/15/25 at 12:16 PM, the surveyor conducted a follow-up interview with UM #4 and the Director of Nursing (DON). During the interview the surveyor relayed the concern that Resident #59's ENT consult was never ordered despite having a reoccurring problem. The UM #4 stated she was unaware that Resident #59 needed an ENT consult.On 12/15/25 at 12:45 PM, an order was placed for Resident #59 to have an ENT consult due to left ear pain/wax build up.

Based on observations, record review, review of facility policy, and interviews it was determined that the facility failed to utilize professional standards during medication administration. This was found evident in 2 (Resident #59 and #6) of 3 medications administrations on the recertification/complaint survey.The findings include:1) On 12/8/25 at 9:30 AM, the surveyor conducted an interview with Resident #59. During the interview, the surveyor observed 4 medications cups on Resident #59's over-the-bed table. Two contained liquid (one orange, one yellow) and the other two contained what appeared to be medications (one with a crushed substance and the other with 12 pills in the cup). Resident #59 stated that the medications were left for him/her to take. Resident #59 stated he/she was not sure what they were but knew the orange substance was Potassium.On 12/9/25 at 11:31 AM, the surveyor reviewed the observations with the Director of Nursing (DON). During the interview the DON confirmed that medications should not be left out at the bedside, and it is the nurses' responsibility to make sure the medications are taken.On 12/10/25 at 1:18 PM, the surveyor reviewed the policy titled, Administering Medications. In the Interpretation/Implementation it stated in step number 24; Never leave a medication unattended in a resident's room.2) On 12/9/25 at 8:35 AM, the surveyor observed Licensed Practical Nurse (LPN) #12 prepare and administer medications to Resident #6. LPN #12 reviewed the electronic Medications Administration Record (eMAR) and then gathered the medications. During the preparation the surveyor noted that LPN #12 gathered some of Resident #6's medications from a prepackaged pouch that came from the pharmacy and others from bubble packs or floor stock bottles located in the medication cart. 15 different medications (one being an inhaler) were prepared to be given to Resident #6.On 12/9/25 at 10:35 AM, the surveyor reconciled the medications. The review compared the medications that were observed given to the ordered medications for Resident #6 in the MAR. During the reconciliation the surveyor noted that Resident #6 was given sulfa/trim ds 800/160mg (a combination antibiotic containing 800 mg of sulfamethoxazole and 160 mg of trimethoprim, used to treat a variety of bacterial infections) however, Resident #6 did not have an order for that medication to be given.On 12/09/25 at 1:30 PM, the surveyor conducted an interview with LPN #12. During the interview the surveyor asked LPN #12 why the sulfa/trim ds 800/160mg medication was administered to Resident #6. LPN #12 stated that he did not realize it was not on Resident #'s MAR. He further stated he knew Resident #6 had cellulitis and thought maybe the antibiotic was ordered but recently discontinued.On 12/09/25 at 1:43 PM, the surveyor interviewed the Director of Nursing (DON). During the interview the DON stated she would follow-up to find out why the medication was given without an order.The surveyor reviewed the policy titled, Administering Medications. In Interpretation/Implementation #3 states; Medications must be administered in accordance with the orders, including any required time frame. In #7 it states; The individual administering the medication must check the label to verify the right resident, the right medication, right dosage, right time and right method (route) of administration before giving the medication.At the time of exit no additional documents were provided to the surveyor.

Based on observation, record review and interviews, it was determined that the facility failed to administer oxygen and maintain continuous positive airway pressure (CPAP) therapy in accordance with professional standards of practice. This was found to be evident for 2 (Residents #1, #58) out of 2 residents receiving oxygen and 1 (#1) out of 1 resident receiving CPAP therapy reviewed during the recertification/complaint survey.The findings include:CPAP, or Continuous Positive Airway Pressure, is a common treatment for sleep apnea, using a machine to deliver pressurized air through a mask to keep airways open during sleep, preventing breathing pauses, improving sleep quality, and reducing risks of heart disease and stroke.On 12/8/2025 at 10:28 AM, the surveyor observed Resident #1 was receiving oxygen and had a CPAP machine, which he/she stated was used at night. No oxygen in use signage was found outside the room. On 12/9/2025 at 11:50 AM, the surveyor observed Resident #58 using oxygen and no oxygen in use signage outside the room. During a record review on 12/9/2025 at 1:22 PM, no order was found for cleaning and maintenance of the CPAP device. The facility policy for CPAP administration required an order to clean and maintain the CPAP device.During an interview on 12/10/2025 at 8:29 AM, the Director of Nursing (DON) and Administrator stated they were told by the Fire Marshall that we need to post oxygen in use outside the building and not at each door. They acknowledged the concern and stated they would put the signs back up. At 9:13 AM, the Maintenance Director was observed placing oxygen signage outside of rooms.During an interview on 12/10/2025 at 12:38 PM, Unit Manager #4 stated there was no order to clean and maintain the CPAP and she would review the policy and obtain the orders from the physician. The Director of Nursing acknowledged the concern and stated the facility would obtain an order to clean and maintain the CPAP on Resident #1. During a follow up interview on 12/11/2025 8:20 AM, the DON stated the facility had implemented orders for CPAP cleaning and maintenance.

Based on observations and facility staff interviews it was determined that the facility failed to have a safe/clean/comfortable/homelike environment for Residents. This finding was found to be evident in the following Resident rooms (room [ROOM NUMBER], 109, 111, 112 and 113) and the facility conference room during the recertification/complaint survey.The findings include:On the initial tour of the facility on 12/8/2025 at 8:45 AM the surveyor observed the facility environment not in good repair as there were doors chipped and marred, doors not shutting properly and a missing call light string for bathroom call light device. The following rooms were observed: room [ROOM NUMBER] - marred/chipped bathroom door; room [ROOM NUMBER] - marred/chipped Resident room door; room [ROOM NUMBER] and room [ROOM NUMBER] shared bathroom - missing call light string for call light device; room [ROOM NUMBER] - marred/chipped Resident room door. Additionally, the Resident room door for room [ROOM NUMBER] and the facility conference room door did not shut properly as there was a door stopper attached to both doors.In an interview with the Regional Administrator and the Director of Nursing (DON) at 3:05 PM on 12/8/2025 the surveyor conveyed that the Resident room door to room [ROOM NUMBER] did not shut properly as there was a door stopper attached to the door, and there was not a call light string attached to the call light device in the shared bathroom for Resident rooms [ROOM NUMBERS]. The Regional Administrator and the DON observed with the surveyor the Resident door not shutting properly and the door stopper, and the missing string to the call light device in Resident shared bathroom. They acknowledged the surveyor and stated that they would follow up with maintenance.Additionally, on 12/9/2025, the DON stated that the call light device in the Resident bathroom now had a string attached as it was found on the counter in the Resident room, the stopper to the Resident room door was removed by maintenance, and maintenance was going to remove the stopper from the conference room door.

Based on medical record review and staff interview it was determined that the facility failed to provide pain management as prescribed. This was evident for 1 (Resident #109) of 1 resident reviewed for pain management during the recertification/complaint survey.The findings include:Resident #109's Representative (RP) filed complaint #2580649 regarding the resident's pain management. The RP stated that the resident had been prescribed by the medical personnel pain medication for the large pressure ulcers (PU) and the pain incurred when the resident received treatment for these PU. On 12/15/2025 at 1:00pm, after reviewing the medical record and an interview with the Director of Nursing it was discovered that Resident #109 was not receiving the Tramadol medication every 8 hours as prescribed and the 2 pm dose was signed off on the Medication Administration Record (MAR) as being given but when the Medication Administration Record was compared with the Narcotics Record it was evident that the Tramadol had not been given. The missing Tramadol dates were 8/4-8/8/2025.When the Director of Nursing was informed of the surveyor's concern in an interview on 12/15/2025 at 2pm, she stated that she had spoken with Employee #28 who thought that he/she had signed the MAR in error and that he/she thought the resident had refused the 2:00 AM medication. When the progress notes were reviewed there was no note that supported that the resident had refused the 2:00 AM medication. During the interview, the DON was asked what the facility's expectations were for narcotic medication administration and they stated that the expectation was that medication was to be administered at the time ordered and if the resident refused, the refusal was to be documented in the progress notes.

Based on observation, facility staff interview and surveyor record review it was determined that the facility failed to ensure that the posted nurse staffing information document displayed the required information. This finding was found to be evident in the review of sufficient and competent nurse staffing during the recertification/complaint survey. The findings include:The facility's staffing data document may be a form or spreadsheet, and all the required information displayed clearly and in a visible place. The information should be displayed in a prominent place that was readily accessible to Residents, staff and visitors and presented in a clear and readable format. This information posted must be up to date and current. The facility must post the nurse staffing data on a daily basis at the beginning of each shift. The facility must ensure staffing information was accurate and current. The data requirements for the daily posted nurse staffing information document must include facility name, current date, the total number and actual hours worked per shift for licensed and unlicensed nursing staff (Registered Nurses, Licensed Practical Nurses, Nurse Aides) directly responsible for Resident care, and Resident census. The facility must maintain the daily posted nurse staffing data documents for a minimum of 18 months. On 12/9/2025 at 10:40 AM the surveyor conducted a record review of the posted nurse staffing information documents for the time period of 11/17/2025 - 11/30/2025 that were provided by the Licensed Nursing Home Administrator (LNHA). Review of the posted nurse staffing information documents revealed that the facility name and Resident census were not indicated on the nurse staffing documents for this time period. The surveyor observed the posted nurse staffing information document that was posted at the time clock in the facility on 12/9/2025 at 11:45 AM. The current posted nurse staffing information document did not include the facility name and the Resident census. In an interview with the Human Resources Director/Staffing Coordinator (HRD/SC) on 12/16/2025 at 8:50 AM the surveyor conveyed to the HRD/SC that the review of the posted nurse staffing information documents for the time period of 11/17/2025 - 11/30/2025 did not include the facility name and the Resident census, and that the current posted nurse staffing information document at the time clock did not include the facility name and the Resident census . The HRD/SC reviewed the posted nurse staffing information documents, acknowledged the surveyor and stated that going forward the posted nurse staffing information documents would be corrected to include the facility name and the census.

Based on surveyor record review, review of consultation notes and Resident and staff interviews, it was determined that the facility failed to maintain medical records in accordance with acceptable professional standards and practices by keeping complete and accurate documentation. This finding was found to be evident in 4 (Resident # 6, #33, #59, and #112) out of 41 Residents reviewed for identifiable information in the Resident medical records during the recertification/complaint survey. The findings include: A Medication Administration Record (MAR) is a legal document used by healthcare professionals to track all medications administered to a Resident. It is a crucial component of a Resident's medical chart, serving to ensure patient safety, accountability, and communication among care teams. The purpose of the MAR is to ensure safe and accurate medication management by providing a clear, trackable history of every medication dose given or missed. A Care Plan is a written document that outlines a person's care needs and how they will be met. It's a key tool for health and social care professionals to ensure a Resident receives the right level of care. Care plans are usually created after care needs assessment and risk assessment, involving the person receiving care and their family. Care plans are used to guide health and social care professionals in delivering care and standardize evidence-based care. A Minimum Data Set (MDS) assessment is a comprehensive, federally mandated clinical evaluation for Residents in Medicare/Medicaid-certified nursing homes in the United States. The purpose is to provide a standardized, uniform assessment of Resident health status, identify problems, strengths, and preferences, and inform care planning and payment. MDS assessments are completed by trained nursing home staff upon admission, quarterly, annually, and whenever a Resident's condition significantly changes. Functional capabilities, cognitive status, health conditions, treatment, therapies, psychosocial well-being and discharge planning are assessed in the MDS process. 1) On 12/08/25 at 9:02 AM, the surveyor interviewed Resident #6. During the interview Resident #6 stated that he/she had not had any teeth in years. On 12/10/25 at 10:20 AM, the surveyor reviewed Resident #6's nursing admission assessment dated [DATE]. The assessment documented Resident #6 had an oral exam completed for this assessment. In a section titled, Describe Natural Teeth (if applicable) Resident #6 was coded, no decay. The Missing some or all Teeth option was left blank. Next the surveyor reviewed Resident #6's most recent Minimum Data Set (MDS) assessment dated [DATE]. In the oral dental assessment, there was a list that gave options to capture an abnormal evaluation. One option was, no natural teeth or tooth fragment(s) (edentulous) but this option was left blank. Resident #6 was coded as none of the above were present. On 12/10/25 at 10:47 AM, the surveyor interviewed the Director of Nursing (DON). During the interview the surveyor reviewed the concern that Resident #6's assessments were inaccurate. The DON stated she would look into the concern. On 12/10/25 at 11:02 AM, Director of Admissions Staff #7 confirmed that Resident #6 did not have teeth, and confirmed the assessments were inaccurate. On 12/10/25 at 11:11 AM, the surveyor interviewed the MDS coordinator Staff #17. During the interview Staff #17 stated that the oral/dental assessment is completed by looking at nursing, dietary and speech documentation and that it is not common practice for the MDS coordinator to do an oral examination. She further stated that she would code the oral/dental status based off the other disciplines assessments. She further stated that Resident #6 should have been coded edentulous. 2) On 12/15/25 at 10:33 AM the surveyor reviewed Resident #59's medical record. The review revealed that Licensed Practical Nurse (LPN) #23 wrote a progress note on 11/26/25 that stated the Nurse Practitioner (NP) saw Resident #59 and ordered Debrox for 5 days (11/26/26-12/1/25) and then instructed to flush the ear. Next the surveyor looked to find the corresponding NP note but was unable to find the note in Resident #59's electronic medical record. The last primary provider note in the electronic Medical Record was dated 10/26/25. The surveyor reviewed an additional note written by LNP #23 on 12/3/25. The note stated that Resident #59 continued to complain of left ear fullness and wax build up. It further stated that Resident #59 had been receiving the Debrox drops and after an ear flush there was minimal to no results. (last dose of Debox was given on 12/1/25) On 12/16/25 at 8:30 AM, the surveyor conducted an interview with Unit Manager #4. When asked about the note written on 12/3/25 that stated Resident #59's left ear was flushed, the surveyor asked if this was done by the LPN. UM #4 stated that she would look into it but believed a Nurse Practitioner (NP) saw Resident #59 that day. The surveyor reviewed the concern that the last note from the primary provider in Resident #59's medical record was from October 2025 even though it was documented in the progress notes that a provider saw Resident #59 after October 2025 date. The surveyor requested all primary provider notes from November and December of 2025 for Resident #59. On 12/16/25 at 10:37 AM, the surveyor conducted a follow up interview with UM #4. During the interview UM #4 stated that she had reached out to the providers and that they were uploading the notes into the electronic medical system. She further stated that the Medical Director saw Resident #59 yesterday and would provide the notes. The surveyor reviewed the provider's notes written by Nurse Practitioner (NP) #26. The notes were all created 12/16/25 and are as follows: Created on 12/16/25 at 10:34 AM for an effective date of 11/26/25 at 10:34 AM. Created on 12/16/25 at 10:35 AM for an effective date of 12/3/25 at 10:35 AM. Created on 12/16/25 at 10:56 AM for an effective date of 11/30/25 at 10:57 AM. On 12/16/25 at 11:54 AM, the surveyor reviewed the concern that Resident #59's medical record was not completed and that multiple provider's notes were not timely written and not part of Resident #59's medical record. UM #4 agreed that the provider's notes should have been in Resident #59's medical record. 3) On 12/15/25 at 10:28 AM, the surveyor reviewed Resident #112's orders. The review revealed that Resident #112 had orders written on 3/12/25 for Physical Therapy (PT) to be provided 3-5 times per week. The surveyor requested PT notes for Resident #112's therapy treatment. Next the surveyor reviewed the PT sessions. Resident #112 worked with PT as follows: Week 1. 3/13/25 (TH), 3/17/25 (M), and 3/19/25 (W). Week 2. 3/24/25 (M), and 3/26/25 (W). Week 3. 3/27/25 (TH), 3/29/25 (Sat), and 4/2/25 (W). Week 5 4/6/25 (Sat), and 4/7/25 (M). On 12/16/25 at 8:51 AM, the surveyor conducted an interview with the Director of Rehabilitation Staff #5. During the interview the surveyor asked why Resident #112 was only seen twice in the 2nd week of therapy when the order was for 3-5 times. Staff #5 stated she would look into the issue and follow-up. On 12/16/25 at 10:07 AM, the surveyor conducted a follow-up telephone interview with Staff #5. During the interview Staff #5 stated that on 3/25/25 PT documented that Resident #112 was unavailable. The surveyor asked Staff #5 if it was protocol to make a second attempt if a resident was not available. The surveyor also reviewed with Staff #5 that Resident #112 had been available and worked with Occupational Therapy that same day. Staff #5 stated that it is the expectation for therapy to attempt to see the Resident a second time if they are unavailable at the first attempt. There was no documentation available to demonstrate why Resident #112 was not seen three times in his/her second week of rehab. 4) In an interview with Resident #33 on 12/8/2025 at 2:25 PM the surveyor asked Resident if he/she was taking a blood thinner medication and Resident stated, yes, I have had 2 heart attacks in the past. The surveyor conducted a record review of Resident #33's medical record on 12/11/2025 at 7:15 AM. The review of the medical record revealed that Resident #33 had an active, current physician order that stated, anticoagulant medication – monitor for discolored urine, black tarry stools, sudden severe headache, N&V (nausea and vomiting), diarrhea, muscle joint pain, lethargy, bruising, sudden changes in mental status and/or V/S (vital signs), nose bleeds every shift. Further review of the medical record revealed that Resident #33 did not have an active, current physician order for an anticoagulant medication (blood thinner). Additionally, review of Resident #33's medication administration records (MAR), care plans and Minimum Data Set (MDS) assessments did not indicate that Resident was currently taking an anticoagulant medication. In an interview with the Director of Nursing (DON) at 8:35 AM on 12/11/2025 the surveyor conveyed that Resident #33 had an active, current physician order for monitoring of an anticoagulant medication, but the Resident was not currently taking an anticoagulant medication according to the documentation in the medical record. Resident #33 did not have an active, current physician order for the anticoagulant medication, the MARs did not have an anticoagulant medication listed, the plan of care did not have a care plan for anticoagulant medication, and the MDS assessments were not coded for Resident taking an anticoagulant medication. The Director of Nursing (DON) reviewed the physician orders, acknowledged the surveyor, and stated that Resident #33 was not currently prescribed an anticoagulant medication, and that the physician order for monitoring of the anticoagulant medication would be discontinued. No additional information was provided by the facility at the time of exit.

Based on record review, review of facility's policy, and interviews it was determined that the facility failed to identify and provide appropriate interventions for a resident's condition. This was found evident of 1 (Resident #112) out of 1 resident reviewed constipation/diarrhea during the recertification/complaint survey.The findings include:On 12/15/25 at 8:08 AM, the surveyor reviewed intake #361829. The intake alleged that the facility did not monitor or administer bowel regimen medications appropriately.On 12/16/25 at 12:30 PM, the surveyor reviewed Resident #112's Medication Administration Record (MAR) for March of 2025. Both Miralax (an over-the-counter osmotic laxative used to help with constipation) and Senna (over-the-counter stimulating laxative used to prevent constipation) were ordered to be given. The order for Miralax was daily and Senna was for two pills twice a daily. On 3/19/25 the Miralax was discontinued and Senna was written to be given every other day and decreased to one pill. Additionally, Imodium (a medication given to help with diarrhea) was ordered on 3/19/25, written to use as needed (for 3 days), with the indication for loose bowel movements. One dose was given on 3/19/25. The surveyor also noted that a Bisacodyl suppository was also ordered on admission and written to be given rectally every 48 as needed. No administration of the suppository was noted in March of 2025.Next the surveyor review of bowel movement log provided by the facility for Resident #112. The review revealed that Resident #112 had no bowel movement documented from 3/25/25- 3/29/25 (5 days). The surveyor noted that during this time frame the Resident's bowel regimen medications had recently been decreased and an antidiarrheal was given.On 12/16/25 at 12:32 PM, the surveyor interviewed Unit Manager #4. During the interview the surveyor asked what the protocol would be if a Resident went 5 days without having a bowel movement. UM #4 stated that she would expect the provider would be notified and a bowel protocol to be ordered. The surveyor reviewed the time frame that Resident #112 was documented as not having a bowel movement. UM #4 stated that she would review the notes because sometimes the bowel movements can be captured there.Next, the surveyor reviewed the progress notes. The review revealed nursing notes on 3/25/25 at 1:22 PM, 3/27/25 at 12:03 PM, and 3/29/25 at 7:03 AM that all documented Resident #112 had active bowel sounds in all four quadrants along with the comment constipation noted.On review of the facility's Bowel Management Protocol the policy states; Residents will be monitored daily for bowel movements (BM) and have the bowel protocol PRN (as needed) initiated after it's identified that an intervention is required. In the procedure it states; The Geriatric Nursing Assistant (GNA) will document in Point of Care (POC) all resident bowel activity. Alert listing will be checked for no bowel activity in 72 hours. Bowel protocol will be initiated if ordered by a Medical Doctor (MD). Results of the protocol will be documented in electronic health record.At the time of exit no additional information was provided.

Based on observation, and interviews, it was determined that the facility failed to maintain practices to help prevent the transmission of infections. This was found evident on 2 (Resident #6 & #70) out of 2 observations of medication administration during the recertification/complaint survey.The findings include:1) On 12/9/25 at 8:34 AM, the surveyor observed Licensed Practical Nurse (LPN) #12 prepare medications to be administered to Resident #6. The medications were gathered from a shared medication cart. LPN #12 gathered medications from multiple drawers and bottles. After preparing the medications the surveyor observed LPN #12 walk into Resident #6's room, move a wheelchair and table, and then administer medications. No hand hygiene was utilized before administering the medications.On exiting Resident #6's room the surveyor asked LPN #12 if it is the expectation to perform hand hygiene prior to providing medications to the Resident. He confirmed hand hygiene should be performed before medications are given.2) On 12/9/25 at 9:20 AM, the surveyor observed Licensed Practical Nurse (LPN) #13 prepare medications to be administered to Resident #70. The medications were gathered from a shared medication cart. LPN #13 gathered medications from multiple drawers and bottles. After preparing the medications the surveyor observed LPN #13 walk into Resident #70's room and then administer the medications. No hand hygiene was utilized before administering the medications.On exiting Resident #70's room the surveyor asked LPN #13 if it is the expectation to perform hand hygiene prior to providing medications to the Resident. She confirmed hand hygiene should be performed before medications are given.

Based on record review and interview, it was determined that the facility failed to provide necessary services to maintain good personal hygiene for dependent Residents. This was found evident in 1 (Resident #112) out of 1 residents reviewed for Activity of Daily Living (ADL) care during the recertification/complaint survey.The findings include:On 12/15/25 at 8:08 AM, the surveyor reviewed intake #361829. The intake alleged that Resident #112 only received one shower while a resident at the facility.On 12/15/25 at 1:28 PM, the surveyor requested all shower documentation for Resident #112 stay from mid-March of 2025 to mid-April of 2025.On 12/16/25 at 7:36 AM, the surveyor conducted an interview with Unit Manger #4. During the interview UM #6 presented skin check sheets for Resident #112 however, there was no notation or documentation on the skin sheets that indicated that a shower was provided. The UM stated that the skin sheets are done on the 2 assigned shower days each week. The UM stated she would look to see if there was additional documentation.On 12/16/25 at 7:55 AM, the surveyor conducted a follow-up interview UM #6. During the interview the surveyor reviewed the documentation provided by UM #6. On review of the March 2025 Point to Care (POC) (a place where Geriatric Nursing Assistance (GNA)s document the care they provided) it was marked that Resident #112 was dependent or needed substantial to maximal assistance with shower/bathing. The section that documented the assistance needed to transfer to the Resident to the shower had one date marked, 3/24/25. On this day it was documented that Resident #112 was dependent on staff to help transfer to the shower. No other days documented that Resident #112 was assisted to and then showered. UM #6 agreed there was limited documentation that demonstrated that multiple showers were completed. She explained that in the past transfers and showers were prompted on an as needed basis and not on the scheduled shower days. She further stated that currently the shower days are scheduled on the POC and documentation is prompted on scheduled shower days. She confirmed that there was no additional documentation to demonstrate Resident #112 received more than one shower.

Based on observations and interviews it was determined that the facility failed to provide a safe, functional, sanitary environment for a resident. This was found in 1 (Resident #59) of 26 Resident rooms reviewed in the initial sample during the recertification/complaint survey.The findings include:On 12/08/2025 at 9:26 AM, the surveyor observed Resident #59's bathroom. The toilet had what appeared to be urine in the toilet bowl. The surveyor noted that around the bowl, on the bathroom floor, it was wet. Resident #59 stated that the toilet had been leaking for some time and that the facility was aware it was leaking. Resident #59 asked the surveyor to flush the toilet and see that it continued to leak. When the surveyor flushed the toilet, the toilet leaked additional water onto the bathroom floor.On 12/08/25 at 11:42 AM, the surveyor interviewed the Maintenance Director Staff #10. During the interview Staff #10 stated he was aware the toilet was leaking and that he had ordered the parts to repair it. He further stated that he was going to repair the toilet today now that the parts came in. The surveyor asked why Staff #10 why the toilet continued to be used when it was known to leak. He stated that he was informed it only leaked every once in a while.On 12/9/25 at 11:33 AM, the surveyor conducted an interview with the Director of Nursing (DON). During the interview the DON confirmed she was unaware of the toilet concern and that the bathroom should not have been utilized while it was not functioning correctly.

Based on facility staff interviews and surveyor record reviews it was determined that the facility failed to develop and implement comprehensive care plans and follow care plan interventions for Residents. This finding was found to be evident for 3 (Resident #1, #29 and #41) out of 16 Residents reviewed for comprehensive care plans during the recertification/complaint survey. The findings include:A Care Plan is a written document that outlines a person's care needs and how they will be met. It's a key tool for health and social care professionals to ensure a Resident receives the right level of care. Care plans are usually created after care needs assessment and risk assessment, involving the person receiving care and their family. Care plans are used to guide health and social care professionals in delivering care and standardize evidence-based care. A Minimum Data Set (MDS) assessment is a comprehensive, federally mandated clinical evaluation for Residents in Medicare/Medicaid-certified nursing homes in the United States. The purpose is to provide a standardized, uniform assessment of Resident health status, identify problems, strengths, and preferences, and inform care planning and payment. MDS assessments are completed by trained nursing home staff upon admission, quarterly, annually, and whenever a Resident's condition significantly changes. Functional capabilities, cognitive status, health conditions, treatment, therapies, psychosocial well-being and discharge planning are assessed in the MDS process. 1) The surveyor conducted a record review of Resident #41's medical record on 12/10/2025 at 12:50 PM. Review of the physician orders for Resident #41 revealed a physician order for an anticoagulant medication (blood thinner) Eliquis 5 mg twice daily and a medical diagnosis of pulmonary embolism (blockage, blood clot in the lung's arteries). Further review of Resident #41's comprehensive care plan revealed that there was not a care plan for an anticoagulant medication or a diagnosis of pulmonary embolism. Continued review of Resident #41's medical record revealed that the MDS assessments indicated that Resident was receiving an anticoagulant medication and had a diagnosis of pulmonary embolism. The surveyor interviewed the Director of Nursing (DON) and the Unit Manager at 1:45 PM on 12/10/2025 and conveyed that Resident #41 was receiving Eliquis for a diagnosis of pulmonary embolism and that the anticoagulant medication and the pulmonary embolism diagnosis was not on the comprehensive care plan. Both acknowledged the surveyor and stated that the anticoagulant medication and the pulmonary embolism diagnosis were not on Resident #41's care plan, and the DON would follow-up with the MDS Coordinator. 2) The surveyor conducted a record review of Resident #29's medical record on 12/11/2025 at 10:49 AM. Review of Resident #29's medical record revealed that Resident had a comprehensive care plan for an anticoagulant medication as of 9/17/2024, however, review of the active, current physician orders revealed that Resident was not receiving an anticoagulant medication. Further review of the MDS assessments for Resident #29 revealed that Resident had not received an anticoagulant medication. The surveyor interviewed the RN (Registered Nurse) MDS Coordinator on 12/11/2025 at 11:30 AM and conveyed to the RN MDS Coordinator that Resident #29 did not have an active, current order for an anticoagulant, but had a care plan for anticoagulant medication. The RN MDS Coordinator reviewed the care plan, MDS assessments and physician orders for Resident #29, acknowledged the surveyor and stated that she would resolve the anticoagulant medication care plan for Resident #29 as the Resident was not receiving an anticoagulant medication. 3) The surveyor reviewed Resident #1's Treatment Administration Record (TAR) on 12/11/2025 at 7:50 AM and no documentation was found for evaluating the effectiveness or side effects of pain medicine, which were indicated as interventions in the Care Plan dated 12/1/2025. The Director of Nursing (DON) stated on 12/11/2025 at 9:26 AM, that the facility would only monitor pain levels for as needed pain medications if it was given, but staff should have documented the care plan interventions on the TAR. The DON added that the facility would correct the issue.

Based on facility staff interviews and surveyor record reviews, it was determined that the facility failed to update and revise a Resident's care plan. This finding was found to be evident for 1 (Resident #29) out of 6 Residents reviewed for revision of Resident's care plans during the recertification/complaint survey.The findings include:A Care Plan is a written document that outlines a person's care needs and how they will be met. It's a key tool for health and social care professionals to ensure a Resident receives the right level of care. Care plans are usually created after care needs assessment and risk assessment, involving the person receiving care and their family. Care plans are used to guide health and social care professionals in delivering care and standardize evidence-based care. Care plans should be regularly reviewed to monitor their effectiveness. Care plans are updated and revised periodically and as care needs and conditions change with Residents.A Minimum Data Set (MDS) assessment is a comprehensive, federally mandated clinical evaluation for Residents in Medicare/Medicaid-certified nursing homes in the United States. The purpose is to provide a standardized, uniform assessment of Resident health status, identify problems, strengths, and preferences, and inform care planning and payment. MDS assessments are completed by trained nursing home staff upon admission, quarterly, annually, and whenever a Resident's condition significantly changes. Functional capabilities, cognitive status, health conditions, treatment, therapies, psychosocial well-being and discharge planning are assessed in the MDS process.The surveyor conducted a record review of Resident #29's medical record on 12/11/2025 at 10:49 AM. Review of the medical record revealed that Resident #29 had a care plan for an anticoagulant (blood thinner) medication that was initiated on 9/17/2024 and a revision on 8/26/2025 with a target date of 2/12/2026. Further review of Resident #29's medical record revealed that there was no current physician order for an anticoagulant medication.Continued record review of Resident #29's medical record on 12/11/2025, specifically the MDS assessments dated 5/19/2024, 9/23/2024, 8/14/2025 and 11/12/2025 revealed that these assessments did not indicate that Resident was receiving an anticoagulant medication. In an interview with the Registered Nurse (RN) MDS Coordinator on 12/11/2025 at 11:30 AM the surveyor conveyed that Resident #29 had a current care plan for an anticoagulant medication since September 2024, but Resident was not on an anticoagulant medication. The RN MDS Coordinator reviewed the care plan, physician orders and MDS assessments, acknowledged the surveyor and stated that she would resolve the anticoagulant medication care plan for Resident #29 as Resident was not receiving an anticoagulant medication.

Based on the medical record review and staff interview it was determined the facility failed to keep complete and accurate medical records. This deficient practice was evident in 7 of 20 (#37, #42, #58, #5, #10, #77, #24) resident during the survey. The findings include: 1. During observation rounds on 03/05/24 at 11:21 am Resident #37 made the surveyor aware his/her wheelchair was too large and the wheelchair cushion was too small. On 03/06/24 at 9:51 am during an interview with Director of Rehabilitation #18, he/she verbalized the rehab staff measures the wheelchair to make sure it's a proper fit. When asked if the facility provided the resident with a wheelchair, he/she verbalized needing to check and follow-up. On 03/06/24 at 1:06 pm the surveyor received documentation from Rehab Director #18 which was an occupational therapy evaluation for Resident #37. Rehab Director #18 verbalized the resident's wheelchair and cushion were appropriate for Resident #37 when discharged from rehab services. Upon review of the documentation the surveyor noticed the form did not indicate the resident's wheelchair or cushion were evaluated. Rehab Director #18 verbalized giving the surveyor the wrong form. On 03/07/24 at 11:44 am during an interview with Director of Rehab #18, he/she verbalized after doing an investigation, the therapist did not feel seating and positioning was warranted at that time. Resident #37's wheelchair came from a fleet of wheelchairs. The resident will be evaluated to see if the wheelchair is appropriate. The process is the therapist assesses the resident and makes sure the wheelchair fits and they work on mobility. Director of Rehab #18 was unable to provide documentation the resident's wheelchair was assessed to be appropriate for Resident #37. 2. On 03/05/24 at 10:42 am while reviewing Resident #42's medical record the surveyor noticed Section A of the resident's PASSAR was completed but there was not a signature indicating who completed Section A. On 03/05/24 at 3:52 pm during an interview with Social Worker #7 he/she verbalized Section A of Resident #42's assessment should have been signed. Social Worker #7 revealed they started going through the resident's files to update them but did not have the opportunity to review every file thus far and the files of the residents who were admitted since Social Worker #7 started working at the facility were up to date. 3. On 03/05/24 at 12:15 pm the surveyor received a copy of Resident #58's transportation request form which was stamped with the date 12/13/23. Review of the transportation request revealed the form was not signed or dated by the staff. On 03/05.24 at 1:27 pm Director of Nursing #2 was made aware the transportation request form was not signed or dated by the staff who completed the form. Director of Nursing #2 made the surveyor aware the person who completed the form must have forgotten to sign and date the form. 30440 4. During a review of a medication cart on the Osprey Unit with nurse (#27), a Licensed Practical Nurse (LPN) on 3/7/24 at 2:30 PM, the following concerns were identified while reviewing the narcotic drawer: The nurse counted the medication blister pack of Tramadol Tablet 50 mg for Resident # 5. There were 7 pills observed inside of the blister pack. At that time the surveyor and the nurse reviewed the controlled drug receipt record/disposition form. There was an entry on 3/7/24 at 0900 indicating that 1 tablet was given and 6 tablets were left with a signature entry by the nurse. 5. The nurse counted the medication blister pack of Pregabalin Capsule 100 mg for Resident # 10. There were 29 pills observed inside the blister pack. At that time the surveyor and the nurse reviewed the controlled drug receipt record/disposition form. There was an entry on 3/7/24 at 0800 indicating that 1 tablet was given and 30 tablets were left with a signature entry by the nurse. An interview was conducted with the nurse (# 27) on 3/7/24 at 4:00 PM with the Director of Nursing (DON) present. The nurse stated to the survey team that she worked at the facility for approximately six years. The surveyor asked the nurse to explain the discrepancy of the tramadol 50 mg blister pack with 7 pills in the pack, the controlled drug receipt record for tramadol that was signed at 0900 as 1 tablet given with a remainder of 6 pills, and the audit report for 3/7/24 for Resident # 5 with tramadol as administered by her at 8:39 AM. The nurse explained she thought she gave the medication and that medications are to be signed off after administration to the resident. She confirmed the Tramadol 50 mg was signed off on the controlled drug receipt form as being administered for Resident #5 but was not given. The nurse went on to say that she failed to sign the controlled drug receipt form after administering Pregabalin 100 mg capsule to Resident # 10 at 13:39. The DON stated that re-education will be provided to staff. All concerns were discussed with the Administration team on 3/8/24 at 1:30 PM at the time of exit. 48167 6. A Subjective, Objective, Assessment and Plan (SOAP) note is a method of structured documentation that healthcare providers use to document that resident/patient visits were completed. Review of resident #77's medical record on 03/06/2024 at 12:05 PM revealed that on 01/31/2024 a visit was completed with resident (#77) by nurse practitioner (#15) and an electronic SOAP note was used to document this resident encounter. The electronic SOAP note stated that resident (#77) was on no known medications and resident (#77) but was on medications at the time of the visit. During an interview on 03/06/24 at 02:58 PM nurse practitioner (#21) was made aware that the electronic SOAP note stated that resident (#77) was on no known medications and resident (#77) but was on medications at the time of the visit. The nurse practitioner (#21) stated that the electronic system does not allow for resident's medications to be listed and needs to be corrected. The Director of Nursing was present during the interview with nurse practitioner (#21). 21859 7. Seroquel is an Antipsychotic medication. It can treat schizophrenia, bipolar disorder, and depression. Review of the Resident #24's medical record on 3/6/24 at 10am revealed the resident was admitted to the facility in February of 2024 with diagnosis that included dementia with moderate agitation. A care plan was initiated on 2/24/24 for cognitive impairment. According to the care plan the resident was receiving Seroquel for mood/behavioral. Continued review of the medical record revealed a MAR (Medication Administration Record) for February and March of 2024, that indicated the diagnosis for Seroquel was depression. During an interview with the DON (Director of Nursing) on 3/6/24 at 1pm, she stated the diagnosis for the Seroquel was entered incorrectly on the MAR. The medication is being administered for psychosis with behavioral disturbances.

Based on observation and interviews it was determined the facility staff failed to ensure that residents' call bells were in reach to request assistance. This deficient practice was evident in 2 of 8 (Resident #32 and Resident #58) residents assessed for call bell accommodations during the survey. The findings include: On 03/04/24, at 9:14 am during observation rounds the surveyor entered room [ROOM NUMBER]. Resident #32 was sitting on the side of the bed. The surveyor noticed that the call bell was draped over the bedside table and was not in the resident's reach. The surveyor greeted Resident #58 and noticed that the call bell was on the floor near the left side of the bed. On 03/04/24 at 9:19 am Social Worker#7 confirmed the surveyor's findings. On 03/06/24 at 12:49 pm during an interview with Director of Nursing #2 who verbalized the managers make rounds twice in the morning and twice in the evening before leaving. It was expected for the call bell to be always assessable to the residents. The Geriatric Nursing Assistants are expected to check on the residents periodically throughout the day.

Based on observation and interview with facility staff, it was determined that the facility failed to maintain the dignity and privacy of a resident as evidenced by the resident's nephrostomy bags left uncovered while outside of their room. This was evident for 1 (Resident # 193) of 86 residents that were observed during the survey. The findings include: A nephrostomy is a small tube inserted through the skin directly into the kidney to allow urine to drain from the kidney into a collecting bag outside the body. It is surgically placed by a healthcare provider if a person's urine cannot leave their body due to kidney stones, kidney infection, trauma, or other reasons. During an observation that took place on 3/5/24 at 10:40 AM, Resident #193 was in the Terrace Lounge during a social coffee time with both nephrostomy bags uncovered, leaving the resident's urine visible to view through the clear bags. On 3/5/24 at 10:41 AM, in an interview conducted with Licensed Practical Nurse (LPN #29), she stated that when a resident comes out of their room, their nephrostomy bags should be covered. The nurse took the resident back to their room to cover the bags. On 3/6/24 at 9:56 AM, in an interview with the Administrator, he was made aware that Resident #193 was in the Terrace Lounge with both of their nephrostomy bags uncovered. He confirmed the nephrostomy bags should have been covered. The Director of Nursing (DON), Regional DON, and Administrator were made aware of the above finding on 3/8/24 at 1:30 PM.

Based on medical record review and interview it was determined that the facility failed to identify a significant weight loss and implement interventions to address that weight loss as evidenced by failure to obtain a weight for three consecutive months, and failure of staff to provide required assistance with feeding resulting in a 50 lbs weight loss over a 4 month period of time and the development of two pressure ulcers; and failed to ensure the registered dietitian's recommendations for interventions related to weight loss were communicated to the primary care physician resulting in the failure to implement nutritional interventions. This was found to be evident for 3 out of 3 residents (Resident #13, #6 and #14) reviewed for weight loss during the survey. This failure resulted in actual harm to Resident #13. The findings include: Current professional standards of practice recommend weighing the resident on admission or readmission (to establish a baseline weight), weekly for the first 4 weeks after admission and at least monthly thereafter to help identify and document trends such as slow and progressive weight loss. Weighing may also be pertinent if there is a significant change in condition, food intake has declined and persisted (e.g., for more than a week), or there is other evidence of altered nutritional status or fluid and electrolyte imbalance. 1. On 10/28/2020 review of Resident #13's medical record revealed the resident was admitted to the facility in May of 2020 with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) with an assessment reference date of 6/4/2020 revealed that the facility documented that for eating the resident was totally dependent (indicating full staff performance every time) and required extensive assistance of two persons for bed mobility, personal hygiene and dressing. This assessment also revealed issues with swallowing. The resident's height was documented as 70 (5 ft 10 inches) and weight was 180 lbs. Further review of the medical record revealed the following weights which were obtained by use of a mechanical lift : 5/30/2020: 186.8 lbs 5/31/2020: 183 lbs 6/1/2020: 184.9 lbs Review of the resident's care plan revealed a care plan, initiated on 6/8/2020 to address: State of nourishment; less than body requirement characterized by weight loss, inadequate intake, decreased appetite related to: anorexia , decreased appetite. The goal of the care plan was to maintain or increase weight. The interventions with initiation date of 6/8/2020 include: assess for/provide food preferences; If meals refused, provide extra nourishments; and Provide therapeutic/non therapeutic supplements (Ensure Plus). Frequency for weights was not addressed in the care plan. Although planned, further review of the medical record failed to reveal documentation of an order for [REDACTED]. On 10/28/2020 review of the Profile of Resident Nutrition and the meal tickets for that day revealed a notation of Supervision. On 10/28/2020 at 2:50 PM the Food Service Director confirmed that ordered supplements (i.e. Ensure) would be provided by nursing. Review of the care plan addressing activities of daily living revealed the resident required staff participation to eat. Review of the Quarterly Minimum Data Set(MDS) with an assessment reference date of 8/18/2020 revealed the resident had declined and was coded as total dependence on staff for bed mobility, dressing, and personal hygiene and required extensive assistance for eating with one person physical assist. In addition to declines in ADLs, review of the progress notes revealed that on 8/15/2020 the registered dietitian (RD #8) wrote a quarterly review note which revealed that the resident's overall intake was poor and Please obtain recent weight to monitor weight loss. Further review of the 8/18/2020 MDS assessment revealed the resident had no swallowing issues and no known recent weight gain or loss. The weight on this MDS was documented as 185 lbs. which indicates a 5 lb weight gain over a two month period of time. This weight corresponds to the 6/1/2020 weight, no documentation of a weight was found for the 30 days prior to the 8/18 assessment. (Cross reference to F 641 for MDS inaccuracy.) No documented follow up to the dietitian's note on 8/15/20 to obtain a recent weight to monitor weight loss was found. Review of the manual for the completion of the MDS assessment revealed that the weights should be based on the most recent measure in the last 30 days and if the last recorded weight was taken more than 30 days prior to the ARD the resident should be weighed again. Further review of the medical record failed to reveal any recorded weights between 6/2/2020 and 10/5/2020. The reference date for the Quarterly MDS assessment was set for 8/18/20. The MDS coding for ADLs documented declines in three different areas (bed mobility, dressing, and personal hygiene). During the assessment window, on 8/15/20 the dietitian documented concerns with weight loss and the need to obtain weights. With more than two areas of change, the facility was required to convert the Quarterly MDS assessment to a more comprehensive Significant Change in Status Assessment (SCSA). Instead, the entered weight reflected gain that was unsupported in the record and contradicted by the dietitian and no deeper level of review identified the weight loss, the missing order for planned supplement, or the resident's increasing level of dependence. On 10/28/2020 at 3:20 PM interview with the RD #8, who acknowledged the 8/15/20 note to please obtain recent weight to monitor weight loss, she stated that it was just a request and in addition to documenting in the note she would have told one of the nurses. In regard to weight monitoring the RD reported that the expectation is a monthly weight unless there is an order for [REDACTED]. Nonetheless, MDS assessment staff was required to review the record during the assessment period when the dietitian note was entered and include the information in the MDS assessment process. Further review of the medical record failed to review an order for [REDACTED].>Review of the primary care physician visit notes revealed the resident was seen on 8/10, 8/13, 8/17, 8/20, 8/24, 8/27, 8/31, 9/3, 9/7, 9/10, 9/14, 9/17 and 9/21/2020. Each of these notes includes the following notation: No weight change. No change in appetite. No documentation was found in these notes to indicate the physician was aware that no weights had been obtained since June 2020. The 9/10, 9/17 and 9/21/20 notes include: Pt is eating ok. Review of the geriatric nursing assistant (GNA) documentation for eating revealed sections to document at 8:00 AM (breakfast); 1:00 PM (lunch) and 1800 (dinner). The GNAs document the percentage of the meal that was eaten; the resident's self performance and the amount of assistance provided by staff. Review of the September 2020 GNA documentation revealed staff failed to document regarding eating on 37 out of 90 meals to be provided. Staff documented the resident refused on 5 occasions. Contradicting the MDS coding that Resident #13 was dependent for eating, on September 9, 14, 15, 21, 22 and 23, 2020 staff documented 0, 0, 1 for the dinner indicating that the resident ate 0-25%, was Independent with no help or staff oversight at any time and that they provided set up help only. This was the only documentation for eating for September 9, 14, 21, 22 and 23, 2020. Further review of the GNA documentation revealed an area to document if the bedtime snack was offered. GNAs can document Y for yes; 99 for resident not available; 98 for resident refused or 97 for not applicable. Review of the September 2020 documentation for offering bedtime snack revealed staff documented that a bedtime snack was offered on 15 out of 30 days in September. On 5 occasions the staff documented resident refusal. On 10 occasions the staff either failed to document or documented '97' for not applicable. There was also an area for GNAs to document snack provided prn (as needed). Staff documented prn snack on 6 days in September 2020, however on 5 of these 6 days the bedtime snack was also documented as having been provided. Further review of the GNA documentation for eating revealed the resident refused breakfast, lunch, dinner and the bedtime snack on 9/4/2020. No documentation was found that a PRN snack was offered or extra nourishments as indicated in the care plan. No documentation was found to indicate nursing or the physician were made aware of the resident's refusal to eat for an entire day. On 9/5/20 the resident ate between 75-100% of breakfast but refused lunch and only ate 0-25% of dinner. Staff failed to document regarding breakfast and lunch on 9/6 but dinner was documented as having eaten 0-25%. On 9/7/2020 the primary care physician document: Eating better. Based on review of the GNA documentation there was no documentation to indicate that anyone assisted the resident to eat on September 21, 22 or 23, 2020. Review of the GNA documentation for eating and snacks for 9/7, 9/21, 9/22 and 9/23/20 failed to reveal documentation regarding breakfast or lunch; dinner was documented as eating between 0-25%; no documentation was found regarding the provision of as needed snack, and staff documented 97-not applicable for the evening snack. No documentation was found for assistance with eating or snack provision on 9/24/20 as evidenced by blanks in the area for GNAs to document Review of the 9/25/2020 primary care physician (#13) note revealed the resident's appetite is less than ideal. Weight has gone down since admission. Cachexia pt (patient) is losing weight, dietary and speech following, no reversible cuase (cause) found . There was a notation that this note was electronically signed on 10/21/2020 at 11:21 AM. Cachexia is a state in which a person who is malnourished has marked wasting of body mass. (Pathophysiology: Concepts of Altered Health States Third Edition). Review of the 9/28/2020 primary care physician note revealed the following: Cachexia follow up with dietary and speech. There was a notation that this note was electronically signed on 10/21/2020 at 11:38 AM. Further review of the GNA documentation for eating and snacks revealed that on 10/14/20 the resident refused breakfast, lunch and dinner; there was no documentation of attempts to provide a snack as evidenced by blanks for as needed snacks and documentation of 97- not applicable for the bedtime snack. On 10/18/20 the staff failed to document regarding eating for breakfast, lunch or dinner; additionally no documentation was found to indicate a PRN or bedtime snack was offered. On 10/19/20 staff failed to document regarding eating for breakfast or lunch; dinner was documented as 25-50% but no documentation was found for PRN snack and 97 was documented for the bedtime snack. Review of the 10/2/2020 primary care physician note revealed the following: Pt is eating but less then [MEDICAL CONDITION](stroke) so weight down. This note failed to include the cachexia assessment or mention of dietary or speech to follow the resident. There was a notation that this note was electronically signed on 10/20/2020 at 3:16 PM, which is prior to the signing the notes dated 9/25 and 9/28/20. Review of the 10/5/2020 primary care physician note revealed the following: .Eating some .Cachexia pt lost a lot of weight will discuss with dietary. This note was electronically signed on 10/21/2020 at 12:37 PM. Review of the progress notes revealed a nursing note dated 10/6/2020 : SBAR sent to (name of physician #13) regarding weight loss. Dietitian,(name) also made aware of weight loss. On 10/6/2020 the resident's weight was documented as 132.6 lbs. With an admission weight of 186.8, this was a loss of 54.2 pounds in a little over four months. Further review of the medical record failed to reveal additional weight documentation between 6/2/2020 and 10/5/2020 during which time the resident lost more than 50 lbs. This 50 lbs represents a more than 25% weight loss in less than 6 months. A severe weight loss is considered more than 10% loss in 6 months. Further review of the medical record failed to reveal documentation that the resident was re-assessed by the dietician between 8/16 and 10/5/2020, despite the primary care physician notes on 9/25 and 9/28/20 which indicated dietary was addressing the issue of the weight. Further review of the medical record revealed that on 10/6/2020 the RD wrote a progress note that addressed a 26.3% weight loss and included the following recommendation: Weekly weights to monitor weight, Provide Ensure Plus 3x per day. Review food preferences. Review of a 10/8/2020 nurse progress note revealed the following: Dietician recommends resident to begin Ensure Plus three times per day and weekly weights. (name of physician) agreed. Review of the Medication Administration Record [REDACTED]. This was more than 4 months after the care plan for nutrition originally indicated that Ensure Plus should be provided and 10 days after the physician first diagnosed the resident with cachexia. Review of the 10/8/2020 primary care physician note revealed: .Pt is eating but only 10-25% Cachexia/Weight loss will look into a feeding tube . This note was electronically signed on 10/20/2020 at 3:19 PM. On 10/28/2020 review of the GNA documentation for eating failed to reveal documentation of percentage eaten or assistance provided for 17 out 83 meals due to be provided to the resident in October 2020. Documentation was found of resident refusal on at least 9 occasions. For the October 4, 2020 dinner meal staff documented 001 indicating that the resident ate 0-25%, was Independent with no help or staff oversight at any time and that they provided set up help only. Further review of the medical record revealed the following weights: 10/13/2020: 131.4 lbs. 10/14/2020: 122 lbs. 10/20/2020: 128 lbs. On 10/28/2020 at 1:50 PM the Assistant Director of Nursing #3 reported that they had identified the failure to obtain weights consistently over the past 6 months and provided documentation of a quality assurance meeting that occurred on 10/13/2020 to address this issue, a plan of correction and documentation that staff had been educated to weigh all newly admitted residents on admission then weekly for 3 weeks, after which residents are to be weighed monthly unless ordered differently. The ADON reported that staff had not been weighing residents during the time of COVID due to the residents not coming out of their rooms. On 10/28/2020 at 2:00 PM Nurse #7 confirmed that the mechanical lift used when weighing the residents is part of a lift that is brought into the resident's room. Six out of the nine weights found in the medical record for Resident #13 indicated a mechanical lift was used to obtain the weight. No documentation was found regarding the scale used for the other three weights. Poor nutritional status is a known risk factor for pressure ulcers. Prior to the severe weight loss, on admission the facility documented the need for a skin care plan but none was developed. The failure to meet the nutritional needs of Resident #13 contributed to development of pressure ulcers. Further review of the medical record revealed that on 10/23/2020 a wound physician assessed the resident with pressure ulcers on the sacrum and left elbow. (Cross reference to F 686). 2) On 10/28/2020 review of Resident #6 's medical record revealed the resident had resided at the facility for more than one year and whose [DIAGNOSES REDACTED]. In September 2020 the resident was hospitalized for [REDACTED]. The resident's weight prior to the hospitalization was 207 lbs on 9/14/2020. No weights were found for the two weeks after the re-admission. On 10/13/2020 the resident's weight was documented as 176 lbs. This weight indicates a significant weight loss of more than 14% in one month. On 10/18/2020 the RD #8 wrote a note addressing the significant weight loss. This note stated: Intake has varied, ranging between 25-75% of most meals. Intake is not sufficient to maintain weight and subsequent weight loss has occurred. Current plan of care includes Therapeutic diet. Recommend liberalizing diet regular and proving (providing) Ensure Plus TID (three times a day) when intake falls below 50%. Review of the care plans revealed that on 10/21/2020 the RD initiated a care plan to address the state of nourishment; less than body requirement characterized by weight loss, inadequate intake, decreased appetite. The only intervention was: If meals refused, provide extra nourishment. The resident also had a previous care plan , initiated in August 2019, for the potential for weight loss. The only intervention for that care plan was: Provide therapeutic diet as ordered. Review of the physician orders [REDACTED]. Review of the meal ticket provided by the Food Service Director on 10/28/2020 revealed the resident was receiving a Consistent Carbohydrate, No Added Salt, Renal diet. No documentation was found to indicate the RD's recommendation to liberalize the resident's diet to Regular had been conveyed to the primary care physician. On 10/28/2020 review of the GNA documentation for eating for 10/18 thru 10/28/20 failed to reveal documentation of amount consumed for lunch or dinner on 10/18, lunch on 10/20, dinner on 10/21, 10/22 or 10/26/20; on 10/24/20 the GNA documented the resident ate between 25-50% at breakfast and between 0-25% at lunch. No documentation was found to indicate Ensure Plus had been ordered or was being offered to the resident when/if s/he ate less than 50%. Further review of the care plans also failed to reveal the addition of this intervention the dietitian had documented on 10/18/20. On 10/28/2020 at 3:20 PM interview with the RD #8 revealed that the process for conveying recommendations to the primary care physician involves writing the recommendation on a Dietitian Recommendations to the Physician form. The RD reported she keeps one copy and gives the other to the nurse assigned to the resident. She went on to report that this process had been in place for about a year due to the last annual survey having identified an issue with recommendations being in the electronic health record but not being implemented. Surveyor then reviewed the concern with the RD #8 and the Administrator that the October 2020 RD notes indicated staff was to offer Ensure if the resident ate less than 50% but this was not found in the orders or the care plan. The RD reported that after she writes the note she tells the nurse who would contact the physician. The RD was unable to find a copy of Dietitian Recommendations to the Physician for the October 2020 recommendation for Resident #6. At 3:30 PM, the Administrator presented with the resident's hard chart, review of this chart also failed to reveal a Dietitian Recommendations to the Physician form for October 2020. The RD went on to report that her notes in the electronic health record go on the 24 hour report. She also reported that she would be following up with the resident today. 3) On 10/28/2020 Review of Resident #14's medical record revealed the resident had resided at the facility for more than a year and whose [DIAGNOSES REDACTED]. The following weights were found in the medical record: 5/1/2020: 173.2 lbs 6/8/2020: 168.8 lbs Review of the RD #8 notes revealed a note on 5/10/2020 which addressed a recent 5 lb weight loss and stated: .mild weight loss not concerning at this time. Will review on Tuesday. No additional RD notes found for May, June, July or August 2020. The resident's weight was documented as 163.8 lbs on 8/8/2020. This represents a 5 lb weight loss since June 2020. Review of the resident's care plans revealed a plan, initiated in February 2019, for unplanned/unexpected weight gain r/t overeating. There was a notation of Revision on 8/26/2020 by the RD with a target date of 10/25/2020, however no changes were found to the goal or the interventions. One of the interventions was to: monitor and record food intake at each meal. On 10/28/2020 review of the GNA documentation for October 2020 failed to reveal documentation for 28 out of 83 meals in October. Further review of the care plans also revealed a care plan, initiated in March of 2019, for Significant weight loss. There was a notation of Revision on 8/26/2020 by the RD with a target date of 10/25/2020, however no changes were found to the goal or the interventions. The only intervention found for the weight loss care plan was Provide diet as ordered and had been initiated in March 2019. Further review of the medical record failed to reveal any weights obtained for the month of September 2020. Review of the 9/12/2020 RD note revealed the following: Annual Review- Residents weight has been declining over the past year, despite intake being 75-100% go (for) most meals; .resident on cardiac diet, mechanical soft texture. New Recommendations: Between meal snacks and double protein with meals. No documentation was found to indicate the recommendation of between meal snacks and double protein was conveyed to the primary care physician. On 10/28/2020 at approximately 3:30 PM the RD #8 reported she did not have copies of any Dietitian Recommendations to the Physician forms for September 2020 in the book that she keeps the copies in. The resident's weight was documented as 156.8 on 10/6/2020. With a weight obtained on 5/1/20 of 173.2 this was a 16.4 pound loss. Review of the 10/6/2020 RD #8 note revealed: Resident noted with significant weight loss. Per observations, resident eats most meals but occasionally leave 50% or more. Resident can be easily distracted during meals and requires redirection and encouragement to finish. Recommend: Liberalize diet to regular to maximize intake. Boost Breeze 3x per day to prevent continued weight loss. The RD #8 did provide a copy of the Dietitian Recommendations to the Physician form, dated 10/7/2020, which revealed the recommendations for Boost Breeze 3x/day; weekly weights x 4 and liberalize diet. The section of the form for Physician response was noted to be blank. Further review of the medical record failed to reveal orders to liberalize the resident's diet to regular or for the supplement to be provided 3x per day. Further review of the medical record revealed a progress note written by the Assistant Director of Nursing on 10/13/2020 : Resident discussed in Risk meeting for wt. lose (weight loss). Resident is palliative care with no internal feedings. Staff will encourage resident at meals and wts per protocol. Further review of the care plans failed to reveal any updates or changes in interventions after the 10/6/20 RD assessment or the 10/13/20 at risk meeting. Review of the notes regarding the assessment and the meeting revealed that the resident required encouragement during meals. Review of the geriatric nursing assistant (GNA) documentation for eating revealed sections to document at 8:00 AM (breakfast); 1:00 PM (lunch) and 1800 (dinner). The GNAs document the percentage of the meal that was eaten; the resident's self performance and the amount of assistance provided by staff. The resident's self performance is coded as follows: 0 - independent - no help or staff oversight at any time; 1- Supervision - Oversight, encouragement or cueing; 2 - limited assistance - Resident highly involved in activity; staff provide guided maneuvering of limbs or other non-weight bearing assistance; 3- Extensive Assistance- Resident involved in activity, staff provide weight bearing support; 4- Total dependence - Full staff performance. The support provided by staff is coded as follows: 0 - No setup or physical help from staff; 1- Setup help only; 2- One person physical assist; or 3- Two + persons physical assist. Further review of the October 2020 GNA documentation regarding eating assistance provided from 10/14 thru 10/28/20, after the At Risk meeting in which nursing documented that staff will encourage resident at meals, failed to reveal any documentation for 15 out of 44 meals. On 18 occasions staff coded the self performance as 0 and the staff support provided as 1; indicating staff provided set up help only, after which the resident was independent with no oversight or encouragement provided. On 4 occasions the staff coded the self performance as 0 and staff assistance also as 0 indicating the resident was entirely independent without set up help or encouragement from staff. On only 7 out of 44 meals did staff document providing oversight, encouragement, cueing or additional assistance with resident eating. Further review of the medical record failed to reveal a documented weight between 10/7 and 10/19/20. On 10/20/2020, two weeks after the recommendation by the RD for weekly weights, evidencing additional weight loss the resident's weight was documented as 154.6 lbs., indicating a 18.6 lbs weight loss since May 2020. This 18.6 lb weight loss represented a significant weight loss of more than 10% in less than 6 months. The resident's weight was documented as 155.1 lbs on 10/21/2020. 10/28/2020 at 2:50 PM review of the Profile of Resident Nutrition and the meal tickets for 10/28/2020, which were provided by the Food Service Director (FSD), revealed the resident was currently being provided a Cardiac Diet with small portions for breakfast, lunch and dinner. The FSD denied any knowledge that the resident was to receive double protein as was indicated in the 9/12/2020 RD note. On 10/28/2020 at approximately 4:00 PM surveyor reviewed the concern with the DON that a recommendation was made in September 2020 for double protein; no documentation was found that this recommendation was reviewed with the physician. Also reviewed that weight on 8/8/20 was 163.8; no weight obtained in September 2020 and the next weight was 156.8 which is a 7 lb. weight loss. On 10/28/2020 surveyor reviewed the concern regarding significant weight loss with the DON and the Administrator at time of survey exit.

Based on medical record review, interview and observation it was determined that the facility failed to prevent the resident from falling from their bed to the floor while a bath was being provided resulting in actual harm to Resident #7. The resident suffered from an [MEDICAL CONDITION] (bleeding in the brain), right humerus (arm) fracture, and laceration to the forehead requiring ten staples. This was found to be evident for 1 of 4 residents reviewed for falls during the survey. The findings include: Review of complaints MD 687 and MD 618 revealed concerns regarding Resident #7's fall with injuries. Review of complaints MD 166 and MD 085 revealed concerns regarding staff training and competencies. On 10/26/2020 review of Resident #7's medical record revealed the resident had resided at the facility for more than a year and whose [DIAGNOSES REDACTED]. The resident had contractures (tightening of the muscles that makes it hard to move a joint) of both knees. Review of the resident's care plans addressing activities of daily living, with a revision date of 8/14/2020, revealed the resident was totally dependent on staff to provide a bath as necessary and totally dependent on staff for repositioning and turning in bed. Further review of the medical record revealed a care plan for potential to demonstrate physical behaviors agitation r/t (related to) Dementia, initiated several years ago and revised on 8/14/2020 that included the following intervention: When (name of resident) becomes agitated: Intervene before agitation escalates; Guide away from source of distress; Engage calmly in conversation; If response is aggressive, staff to walk calmly away, and approach later. There was also a care plan in place for several years for high risk for falls r/t (related to) Unaware of safety needs, that included the following interventions: floor mats at bedside while in bed. Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/4/2020 revealed the resident was totally dependent requiring two person physical assist for bed mobility and transfer; and total dependence with one person physical assist for dressing and bathing. On 10/26/2020 review of the investigation documentation provided by the facility regarding the resident's fall on 9/26/2020 revealed statements from the GNA #11, CMA (Certified Medicine Aide #21), and Nurse #20. It also included a summary: Fall Investigation for (Name of Resident #7) 09/28/20 Resident was admitted to the facility on (**/**/2018) with DX of [MEDICAL CONDITIONS] as result of [MEDICAL CONDITION], DM,[MEDICAL CONDITION] contracture of bilateral knees. On 09/26/2020 resident rolled out of bed during care sustained laceration to left forehead. Was sent to the ER for treatment. Statements obtain for staff involved: After review of statements and reenactment of the fall, resident was receiving care by the GNA, the resident became combative as the GNA rolled (him/her) to the left toward her, the resident starting sliding off the bed head first, the GNA tried to prevent the fall by grabbing the residents waist and legs but was unable to prevent the resident from hit (his/her) head. The GNA was holding the resident and lowered (his/her) body on the bed but the resident's head already hit the floor. The GNA then lowered the resident lower body to the floor. the GNA raised the bed higher and pushed the bed to the right of the room so she could place the resident's lower body on the floor. Review of the nursing notes revealed the following written by Nurse #20 on 9/26/2020 at 3:24 PM: At 1405 (2:05 PM) summonsed to room to find resident lying prone on bedside floor. Large amount of blood coming from head. Obtained a towel and light pressure was applied to head. Didn't move resident due to distortion of right arm. Demonstrated the ability to squeeze this writer's left hand. Nonverbal, however alert. Resident sent out 911 due to fall from the bed in high position. Witnessed per gna (geriatric nursing assistant). (name of physician) and (spouse) made aware of emergency transfer. Incident report completed. Report called to (name), ER triage nurse at (name of local hospital). Further review of the 9/28/2020 Fall Investigation for (Resident #7) revealed: In conclusion the resident was sent to the hospital ER and returned within 24 hrs of leaving the building. After review of resident hospital records it revealed that the resident had ICH (intercranial hemorrhage), R humerus dislocation as result of the fall and age indeterminate T/L spine fx (fracture) resident has osteopenia. Inservice provided for the GNA on safe rolling of the resident when providing care. If residents become combative stop care and go, get help or wait until resident is calm. Further review of the investigation documentation failed to reveal documentation as to whom completed the investigation. It was printed on a plain sheet of paper with text only. No documentation was found regarding the floor mats, either the presence or lack of at the time of the incident. Further review of the medical record, including the Medication Administration Records (MAR)s, Treatment Administration Record (TAR)s and Geriatric Nursing Assistant (GNA) documentation, failed to reveal an area to document that the floor mats were being utilized as indicated in the care plan. On 10/21/2020 at 10:03 AM surveyor observed the resident in bed and a fall mat was next to the bed on the side by the window. On 10/21/2020 at 11:53 AM interview with the GNA (#16) who was assigned to care for the resident that day, revealed fall precautions included a floor mat on the opposite side of the bed from where the GNA was standing while providing care. During an interview with the GNA #11 on 10/26/2020 the GNA clarified that she lowered the bed prior to lowering the bottom half of the resident to the floor and then later raised the bed so it could be moved out of the way so emergency personnel could have access. Review of the statement written by GNA #11 revealed that while providing a bed bath, with the bed at her waist level, the .resident started to fight me I explained to the resident that I was here to take care resident then resident started to move (his/her) legs back and forth as I was washing (him/her) I turn (him/her) to the left side to wash (his/her) back and bottom (s/he) started to sliding out of the bed head first I tried to prevent the fall by grabbing (his/her) waist area and legs but was unable to prevent (her/his) head from hitting the floor Review of the statement signed by Nurse #20 revealed the nurse was summoned by the CMA who was unable to find the nurse assigned to the unit. The statement included: .I found (name of resident) prone on the floor next to (his/her) bed. (His/Her) right arm was distorted to (his/her ) side. There was a large amount of blood coming from (his/her) head on the floor. The GNA was present when I got to the room. The bed was in the highest position. The patient was naked on the floor. I obtained a blanket off the bed and placed it on top of the resident, due to (his/her) shivering On 10/26/2020 at 3:30 PM during an interview with GNA #11 she was unsure if the floor mat was in place or not while she was providing care on 9/26/2020. The GNA did report this was her second time working with the resident, the first time the resident was resistive to care so I left (him/her) alone. The GNA reported that the resident had been hitting her while she was giving the bath and that if the same thing occurred today she would lower the bed and ask for assistance. The GNA denied that she called for assistance prior to the resident being on the floor. On 10/26/2020 at 4:45 PM surveyor reviewed the concern with the ADON (#3) that the care plan for physical behaviors indicated that if the resident was aggressive staff should walk calmly away and approach later but that based on the GNA's interview the resident had been hitting her while she was providing the bath and GNA continued to provide care. Cross reference to F 726

Based on review of administrative and medical records, and interviews with facility staff, it was determined the facility night shift nurse failed to administer pain medication to a hospice resident. As a result of the resident not receiving pain medication, the resident was observed to be in pain by the GNA who worked with the resident throughout the night, and by the oncoming day shift nurse who assessed the resident at the beginning of the shift. This resulted in harm to the resident. This was evident for 1 of 3 (Resident #84) facility reports reviewed during the facility's annual Medicare/Medicaid survey. The findings include: Review of facility reported incident #MD 151 on [DATE] and [DATE] and the facility's investigation revealed that on [DATE], the nurse (Staff #9) reported off on shift report that s/he did not medicate a hospice patient during his/her shift. When the day shift nurse (Staff #7) asked Staff #9 why, s/he said, they didn't want to deal with paperwork. Review of the progress note for [DATE] at 6:01 AM, from Staff #9 revealed Resident # 84 was in bed with eyes closed, out of bed in wheel-chair, breathing with minimal effort. 2 L (liters) 02 (oxygen) via NC (nasal cannula), no c/o pain or discomfort, no facial grimacing, no episodes of anxiety, resident non- verbal this shift. Further review of a progress note for [DATE] at 7:29 AM from Staff #7 revealed, Resident # 84 was in bed, restless and moaning. Makes eye contact briefly but is non-verbal. Medicated with [MEDICATION NAME] 0.5 ml per order, repositioned for comfort. 02 maintained. An interview was conducted with Staff #7 on [DATE] at 5:35 PM and s/he stated that on the morning of [DATE], the night shift nurse (Staff #9) reported that Resident #84 was not medicated. Staff #7 went on to say that s/he went into the resident room to assess the resident and observed that the resident was in pain. Staff #7 further stated that Resident #84 was visibly uncomfortable, restless and was moaning in pain. Staff #7 stated s/he immediately approached Staff #9 and questioned why s/he did not give the resident pain medication and s/he said, I don't want him/her to die on my shift. Review of the medical record for Resident #84 revealed a physician order [REDACTED]. An interview was conducted with the Geriatric Nurse assistant (GNA), Staff #8 on [DATE] at 12:45 PM and s/he was asked if Resident #84 was in pain throughout the night on the 11 PM-7:30 AM shift on [DATE]. Staff #8 stated that when s/he went to check on the resident, s/he was noted to be restless and moaning. Staff #8 went on to say that Staff #9 was made aware of the resident being in pain, as s/he immediately told him/her. Staff #8 further stated that when s/he checked on the resident several hours later with-in a couple of hours, Resident #84 was moaning, restless and his/her legs were towards the edge of the bed. Staff #8 reported that s/he went to Staff #9 and made him/her aware of the resident pain and his/her response was, I took care of the resident already. Staff #8 was asked did s/he speak with a supervisor concerning the resident's pain status, and they he/she responded, no. In a brief meeting with the Director of Nursing (DON) on [DATE] at 10:20 AM s/he submitted a copy of the facility's investigation involving Resident #84 to the survey team. The DON stated to the surveyors that Staff #9 was terminated after s/he failed to medicate a hospice resident who was in pain. The DON further stated that human resources department offered Staff #9 the option to resign in lieu of termination. Another interview was conducted with the DON on [DATE] at 3:00 PM. The DON was asked the reason for termination of Staff #9 and s/he stated that the staff was in violation of patient safety rights. The DON was asked if Staff #9 was reported to the (NAME)land Board of Nursing and s/he stated, no. The DON went on to say Staff #9 has a Delaware nursing license and was unsure of where to report a Delaware license. The DON confirmed that the (NAME)land Board of Nursing was not notified. The DON was asked if education was done of the staff and s/he stated yes. The DON submitted a 1 page signature sheet of training of GNA's on reporting, but was unable to provide education/training of nurses and all other staff. Although Resident #84 was medicated by the AM nurse (Staff #7), he/she expired later that afternoon.

Based on medical record review, interview and observation, it was determined that the nursing assistant responsible for Resident #1 during the evening meal on 01/20/2013, neglected to provide the resident the assistance needed to eat; this was evident in one of two sampled resident records. Neglect means failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. The findings included: Resident #1 was admitted to the facility with multiple [DIAGNOSES REDACTED]. According to the physician ' s admission history and physical (not dated) the resident was admitted for nursing home placement due to failure to thrive. Failure to thrive describes a state of decline that is multi-factorial and may be caused by chronic diseases and functional impairment. Manifestations of this condition include weight loss, decreased appetite, poor nutrition, and physical inactivity. Review of the resident's medical record, on 3/7/2013, revealed that this resident was dependent upon staff for eating, bathing, dressing, toileting and mobility. Secondary to this resident ' s dependency and his medical diagnoses, the nursing staff must be vigilant in supervising and assisting this resident to meet his nutritional needs. Review of the facility's investigation, which included facility video surveillance, revealed that on 01/20/2013, nursing assistant #1 delivered this resident ' s evening meal shortly before 5:30 p.m. on 01/20/2013. This resident was seated at a table by himself facing a window. Nursing assistant #1 remained in the dining room. However, she sat at a table with her back to the resident reading a magazine/book. During this meal, nursing assistant #1 provided this resident with only one sip of fluid from his tray. The resident made no purposeful attempt to consume any of the food or fluid on the tray. Thirty minutes later, at 6:01 p.m., nursing assistant #1 removed this resident's tray as the resident attempted to grab for his meal tray. Despite this nonverbal attempt to communicate on the part of the resident, the tray was not returned to him, nor was an attempt made to assist him to eat. Interview with the Director of Nursing on 03/07/2013 at 2:15 p.m., confirmed this chronology of events. The nursing assistant was neglectful in not providing the resident direct supervision, cueing or the assistance needed to eat the food and fluid presented to the resident. It is worth noting that nursing assistant#1 falsified the medical record on 1/20/2013, as she documented that she provided this resident with supervision - oversight, encouragement and cueing during the dinner meal.

Based on review of the medical record and interview, it was determined that the nursing staff failed to assess a resident for pain, identify signs or symptoms of pain, intervene when signs or symptoms of pain were present and intervene when interventions were attempted and determined not effective in pain relief in one of 25 sampled residents in the Stage 2 review. The findings included: Resident #113 was admitted to the facility with multiple [DIAGNOSES REDACTED]. [MEDICAL CONDITION] is partial or total loss of the ability to articulate ideas or comprehend spoken or written language resulting from damage to the brain caused by injury or disease. By way of history, this resident was hospitalized for [REDACTED]. While at the hospital the resident was assessed to have left shoulder and upper arm pain, swelling and bruising. These injuries were felt to have occurred when the resident had his [MEDICAL CONDITION]. The resident returned to this facility on 02/24/2012, and was assessed to have continued left shoulder and upper pain, swelling and bruising. As a part of this resident's treatment plan he was ordered to wear a left arm sling for support and comfort. Also ordered, the nursing staff was to perform a pain assessment and document their finding every shift. Tylenol and [MEDICATION NAME] ([MEDICATION NAME] for moderate pain) was, also ordered if needed to assist the resident in pain relief. Review of this resident's pain assessment form revealed that the nursing staff signed their initials but failed to document any pain assessment. Pain can be assessed either by verbal responses or nonverbal observations and should include location. Nonverbal signs or symptoms of pain can be moaning, groaning, humming, labored breathing, facial grimacing, tense and/or rigid body language. These nonverbal signs and symptoms are the most useful ways to assess for pain when a resident has dementia and/or [MEDICAL CONDITION]. Review of the medical record revealed the following nursing notes: 02/26/2012 at 10:28 p.m.: " Some periods of moaning, ... " . The medical record revealed no interventions to address this resident's moaning. 02/27/2012 at 10:35 a.m.: " Medicated (Tylenol) at 0800 for right (left) shoulder pain,and moaning. Somewhat better, less moaning. " The nursing staff identified this resident moaning in pain and medicated him with Tylenol, but the medical record revealed no further interventions were applied despite the resident's continued moaning. 02/27/2012 at 12:16 p.m.: " Resident alert with confusion, resident with sling intact to left arm for support and comfort. Resident still moaning. " Again, the medical record revealed no interventions to relieve this resident's moaning. 02/27/2012 at 9:21 p.m.: " res(ident) alert frequently moans/hums ... " . The nursing staff identified moaning and humming as a sign of pain and medicated the resident with [MEDICATION NAME]. However, the nursing staff failed to intervene when the [MEDICATION NAME] was not effective. On 02/27/2012 the resident's physician examined this resident and documented the following: " ... has c/o worsening l (left) shoulder pain since hospitalization . Tylenol/[MEDICATION NAME] not really helping per nursing report. Had shoulder X-rays in hospital - (negative) for acute fracture per Transfer Summary. L shoulder pain remains but difficult to interpret 2 (secondary) to [MEDICAL CONDITION]. Alert to examiner, intermittently coherent with responses---wordy but determine ' word salad ' (meaningless mixture of words or phrases) at times. Ortho: L shoulder w (with) (arrow pointing down - decrease) ROM (range of motion), pain over humeral head, large ecchymosis on L arm above elbow. A/P (assessment & plan) L shoulder pain: repeat X-ray to r/o subluxation, may have torn muscle during [MEDICAL CONDITION]. PCT ([MEDICATION NAME]) 5/325 mg 1 (tablet) po (by mouth) Q (every) 6 hrs (hours) prn (as needed for) severe pain. May need MRI. " Nursing notes continue: 02/28 /2012 at 3:12 a.m.: " Slept at short intervals through the night denies pain or discomfort. Moaning out in his sleep frequently. " The nursing staff failed to address this resident's moaning, a sign of pain. On 02/28/2012 X-rays were performed at the facility of this resident's left clavicle and shoulder and later that day at 2:18 p.m., results were obtained. The X-rays revealed the resident had a [MEDICAL CONDITION] humeral neck and a possible acromioclavicular joint separation. Continued nursing notes: 02/29/2012 at 6:52 a.m.: " Resident with groaning throughout the night. PRN [MEDICATION NAME] given with some effects. " Again, the nursing staff identified groaning as a sign of pain and medicated the resident with [MEDICATION NAME]. However, the nursing staff failed to intervene when the [MEDICATION NAME] was only slightly effective. 02/29/2012 at 7:28 p.m.: " conts (continues) to moan occasionally... " . Once again, the medical record revealed no evidence that the nursing staff fail addressed this resident's moaning. In conclusion, the nursing staff failed to assess a resident for pain, identify signs or symptoms of pain, intervene when signs or symptoms of pain were present or intervene when interventions were attempted and determined not effective in pain relief. 2. The nursing staff failed to ensure medical information was communicated between one health care provider to another. The findings included: Resident #7 was admitted to the facility with multiple [DIAGNOSES REDACTED]. This resident received her [MEDICAL TREATMENT] three times per week outside of the facility. Review of the medical record revealed on 02/24/2012 this resident was sent to [MEDICAL TREATMENT] for her routine treatment and returned back to the facility. Further review of the medical record revealed this resident's physician visited the resident on 02/24/12. According to the physician progress notes [REDACTED]. The progress note went on to state per the resident that her catheter needed to be replaced before any further treatments could be performed. In response to these resident statements the physician wrote the following order: 02/24/2012: "On Monday 2/27/12, please call [MEDICAL TREATMENT] and find out when she is to see the surgeon in (town) to check her [MEDICAL TREATMENT] catheter. Please call me at the office and let me know the answer." Interview with the A Wing charge nurse #6 on 03/14/12 at 10:00 a.m., revealed this resident returned back to the facility with no communication from the [MEDICAL TREATMENT] unit regarding this resident not being able to complete her [MEDICAL TREATMENT] and that her catheter needed replacement. On 02/27/2012, this resident's [MEDICAL TREATMENT] catheter was replaced and her [MEDICAL TREATMENT] schedule resumed. Continued interview on 03/14/2012 at 10:00 a.m., with the A Wing charge nurse #6 revealed that when this resident is sent to [MEDICAL TREATMENT] a communication notebook. Review of this communication book revealed no entries from the [MEDICAL TREATMENT] unit or this facility between 11/25/2011 and 02/27/2012. It is also worth noting that no communication between the [MEDICAL TREATMENT] unit and this facility occurred from 02/27/2012 to 03/14/2012, the day of this interview. The nursing staff failed to ensure interchange of medical information between this facility and the [MEDICAL TREATMENT] unit that is useful and necessary for the care of this resident. Medical information that is useful and necessary for the care and treatment of [REDACTED].