Every finding on record at River Bend Health and Rehabilitation

Based on record review and staff interviews, the facility failed to implement their abuse policy when the Administrator was not immediately notified of an allegation of staff to resident abuse resulting in delayed investigation, protection, and reporting to the State Agency, law enforcement, and Adult Protective Services for 1 of 3 residents review for abuse (Resident #1).A facility policy dated 9/1/24 titled Abuse, Neglect, and Exploitation indicated the following:-all alleged violations were to be reported to the Administrator, State Agency, Adult Protective Services (APS), and to all other required agencies (e.g., law enforcement) when applicable with in specified time frames: Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury.-An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur.-The facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation. Included but not limited to: Responding immediately to protect the alleged victim and integrity of the investigation; removal of alleged perpetrator or suspension of employee; examining the alleged victim for any sign of injury, including a physical examination or psychosocial assessment if needed. Resident #1 was admitted to the facility on [DATE]. Her diagnoses included dementia without behavioral disturbances.During an interview with Nurse Aide (NA) #1 on 2/23/26 at 3:22 PM he revealed that sometime in September 2025 he observed NA #2 push Resident #1's head to the side with her hand. He said NA #2's hand was open and positioned on the left side of Resident #1's head above her ear and temple area when she pushed Resident #1's head to the side. NA #1 stated if an employee put their hands on a resident, then he believed it would be considered abuse. NA #1 indicated he did not report the incident to anyone until sometime in January 2026 when he reported the incident to Nurse #1 (an agency nurse). He did not have a reason why he did not report the incident at the time it occurred. NA #1 revealed he observed NA #2 working on the floor after this incident in September 2025, to include care provided to Resident #1.A telephone interview was conducted with Nurse #1 on 2/24/26 at 4:50 PM. Nurse #1 indicated that during the last week of January 2026 (unable to recall the exact date) NA #1 informed her he had witnessed NA #2 hit Resident #1 upside the head in the past. The date of the incident was not known. Nurse #1 reported that NA #1 had acted out the motion of how NA #2 hit Resident #1 on the side of the head and stated what NA #1 had shown her was that NA #2 popped Resident #1's head with an open hand. She stated NA #1 told her that sometime after the incident she observed NA #2 alone with Resident #1. Nurse #1 stated from the way NA #1 described what he had observed, she thought that NA #1 should have reported the incident. Nurse #1 stated she did not tell anyone at the facility about what NA #1 told her because NA #1 told her that NA #2 was friendly with the supervisor. Nurse #1 said after her shift ended, she called APS and reported what NA #1 had told her.An initial allegation report dated 1/30/26 completed by the Administrator indicated APS came to the facility on 1/30/26 to investigate a report for Resident #1 that included an allegation that NA #2 slapped the resident. The report indicated when the facility became aware of the allegation NA #2 was removed from the schedule. The investigation report dated 2/6/26 completed by the Administrator indicated the allegation was not substantiated.During an interview with the Director of Nursing (DON) on 2/25/26 at 3:25 PM she stated if someone had concerns about abuse, they were supposed to report it immediately. The DON said abuse could be reported to her but that it had to be reported to the Administrator. The DON said NA #1 should have reported the incident with NA #2 touching Resident #1's face when it happened if he suspected abuse.An interview was conducted with the Administrator on 2/26/26 at 10:30 AM. The Administrator stated if someone had concerns about abuse, suspected abuse, or saw something concerning related to abuse, they were supposed to report it immediately to their supervisor. She indicated that the supervisor should then contact her immediately to report the abuse allegation. The Administrator stated if NA #1 had concerns about NA #2 putting her hands on Resident #1's face and pushing her head to the side then it should have been reported immediately so it could have been investigated to determine if it was or was not abuse at that time and not months later. The Administrator indicated she was not aware it was an agency nurse, Nurse #1, who NA #1 had reported the allegations involving NA #2 to in January 2026. She revealed that Nurse #1 should have reported the abuse allegation to her supervisor, the DON, or her (Administrator) immediately so it could have been investigated by the facility. She further revealed that Nurse #1 did not follow the facility's policy on reporting abuse.

Based on observations, record review, and staff and Medical Director interviews, the facility failed to assess a resident (Resident #1) after a fall when a Nurse Aide (NA #2) did not report a fall to the nurse on 11/24/25. X-ray's completed on 11/25/25 showed Resident #1 had a fracture (break in the bone) of her right olecranon (bony pointed tip of the elbow) and right femoral (thigh bone) neck requiring her to be transferred to the hospital on [DATE]. Resident #1's right arm and right hip were surgically repaired on 11/25/25 and she was readmitted to the facility on [DATE]. This deficient practice occurred for 1 of 3 residents reviewed for quality of care. The findings included:Resident #1 was admitted to the facility on [DATE]. Her diagnoses included dementia.A quarterly Minimum Data Set (MDS) assessment dated [DATE] documented Resident #1 had severe cognitive impairment. The MDS documented Resident #1 had sustained two or more falls with no injury. An undated written statement by NA #2 read: On 11/24/25 I was picking up trays. [Resident #1] was at her room with two lids with a plate in-between in her hand. She was giving them to me then as she was backing up to turn around, she fell. She started yelling as she stood back up on her own and I suggested to her that she sit down on her bed. She sat down on her bed then proceeded to lie down. I met the nurse coming down the hall as she asked me, was that [Resident #1] yelling. I told her yes and that she had fallen. The nurse went into [Resident #1's] room to check on her. I finished picking up the trays when the nurse was coming back up the hall and she said [Resident #1] said she was fine and staying in the bed.An interview was conducted with NA #2 on 2/24/26 at 4:53 PM. NA #2 stated Resident #1 fell in November; she did not remember the date but said that she did not report it right. NA #2 explained she should have reported the fall, but she didn't. NA #2 reported the fall happened around 6:30 PM. She said Resident #1 had been walking in the hallway near her room and she saw her fall. She said Resident #1 lost her balance and fell. NA #2 stated she helped Resident #1 up after she fell and assisted her back to her bed. She said Resident #1 had not complained of any pain after the fall and was able to walk fine after the fall. Toward the end of the interview NA #2 changed her recount of events and stated that she had told the nurse that Resident #1 had fallen but had not told her how she had helped her up.An interview was conducted on 2/25/26 at 10:00 AM with Nurse #2. She reported she was the day shift (7:00 am to 7:00 pm) nurse assigned to Resident #1 on 11/24/25. Nurse #2 said around 6:30 pm, she heard a resident scream and went to see what had happened. Nurse #2 said NA #2 was in the hallway outside of Resident #1's room at the meal tray cart. Nurse #2 said she went into Resident #1's room to check on her and she was lying in bed. She stated Resident #1 had a frightened expression on her face, was tense, and stiff. Nurse #2 said Resident #1 was unable to say what had happened. She reported Resident #1 did not seem like she was in pain and did not have any indicators of pain. She explained Resident #1 was not grimacing, holding, or guarding any parts of her body. She did not recall observing any bruising or swelling on her arms. Nurse #2 reported she went back to NA #2 who was still in the hallway at the tray cart and asked her what had happened. Nurse #2 reported NA #2 seemed agitated and was doing hand motions showing how Resident #1 had been taking the dirty tray lids off the cart. She stated she tried to ask NA #2 again what had happened, but NA #2 did not elaborate or talk to her further and went back to collecting trays. Nurse #2 stated NA #2 never reported that Resident #1 had fallen. An interview was conducted with NA #1 on 2/23/26 at 3:22 PM. He reported he was Resident #1's assigned NA on 11/24/25. He stated he was providing feeding assistance to another resident 1 or 2 rooms down from Resident #1's room. He said around 6:30 PM he heard Resident #1 scream. He stated he looked out into the hallway and saw NA #2 coming out of Resident #1's room and at that time Nurse #2 was coming down the hallway. He stated Nurse #2 stopped and asked him if he heard a scream and after he told her yes, she then proceeded to go to Resident #1's room. NA #1 stated he heard Nurse #2 asking NA #2 what happened. He reported hearing NA #2 tell Nurse #2 Resident #1 was taking the tray lids off the cart. NA #1 stated he did not hear NA #2 tell Nurse #2 Resident #1 had fallen.An interview was conducted with NA #3 on 2/25/26 at 9:53 am. NA #3 was Resident #1's assigned night shift (7:00 pm to 7:00 am) NA on 11/24/25. NA #3 reported Resident #1 was in bed at the start of her shift. She said between 7:00 pm and 8:00 pm she tried to get Resident #1 up for her scheduled shower and she could not get Resident #1 to stand up. She explained Resident #1 was struggling to stand and seemed weak. NA #3 reported she went and told Nurse #3 and Nurse #3 went to check on Resident #1.An interview was conducted with Nurse #3 on 2/25/26 at 8:46 AM. Nurse #3 reported she worked night shift (7:00 pm to 7:00 am) on 11/24/25 and was Resident #1's assigned nurse. She did not remember the exact time but said it was sometime between 8:00 pm and 9:00 pm when NA #3 came and reported to her she could not get Resident #1 up to take a shower. She stated NA #3 thought it was behavioral. Nurse #3 stated when she went to Resident #1's room she was lying on the bed. Nurse #3 said she was able to get Resident #1 to stand up but she was only able to take one or two steps. She stated Resident #1 yelled out and grabbed her right leg. She reported she sat Resident #1 back down on her bed and asked her where she hurt and Resident #1 pointed to her right elbow. Nurse #3 reported she looked at Resident #1's right arm and hip. She recalled Resident #1's right elbow was swollen; she did not recall seeing anything that looked abnormal to her right leg or hip. Nurse #3 said nothing had been mentioned in shift report about Resident #1 having a new fall on 11/24/25 but said she knew Resident #1 had fallen a couple of days prior on 11/22/25. Nurse #3 reported she contacted the on-call provider, and the provider ordered an x-ray of Resident #1's right elbow, right hip, and right leg. Nurse #3 stated she called the mobile x-ray company to schedule the x-rays that night, she did not recall the time. Nurse #3 reported she checked on Resident #1 several times throughout the night. She said mobile x-ray did not come on her shift to complete Resident #1's x-rays. She reported if x-rays were ordered at night, it was sometimes the next day when the mobile x-ray company came to the facility to complete the x-rays. She stated Resident #1 remained in her bed all night and did not have any indicators of pain.An order dated 11/24/25 at 9:15 PM read: x-ray 2 view of right elbow, femur, and hip related to pain/ edema (swelling).An interview was conducted on 2/25/26 at 10:00 AM with Nurse #2. Nurse #2 reported she was Resident #1's assigned nurse on 11/25/25 day shift (7:00 am to 7:00 pm). She said when she returned to work on 11/25/25 she received in report from the night shift Nurse (Nurse #3) that Resident #1 was unable to walk, her right arm was swollen, and x-rays had been ordered but they had not been done yet. Nurse #2 reported after report she went to check on Resident #1. She said her right arm around her elbow was swollen and bruised. She reported she looked at Resident #1's right leg and hip. Nurse #2 recalled there was also bruising to her right hip but did not recall swelling. She stated the Supervisor came to Resident #1's to check on her that morning. She stated while the Supervisor was in Resident #1's room she was trying to get out of bed. She said Resident #1 stood up but was only able to take a couple of steps before she sat down in a bedside chair in her room. She reported that the Supervisor went to get a wheelchair for Resident #1 because she was having difficulty walking. She said sometime that morning, she was not sure of the time an NA, told her Resident #1 was up walking in the hallway but was having trouble walking and they had sat her in the wheelchair. She could not remember the NAs name. Nurse #1 explained after that she kept Resident #1 with her at her medication cart to keep a close eye on her. She recalled around 9 :00 AM Resident #1 had an episode where she became unresponsive. She recalled the Supervisor, DON, and NP came to assess Resident #1 during the episode and she was assisted back to bed. She reported that Resident #1 remained in her bed after that until the mobile x-ray technician came to complete the x-rays of her right arm and right leg around lunch time. She said when the x-ray results returned, they showed Resident #1 had fractured her right elbow and right hip. Nurse #2 reported the provider was contacted, she thought by the Director of Nursing (DON) about the x-ray results and gave orders for Resident #1 to be transferred to the hospital.An interview was conducted with the Supervisor on 2/25/26 at 11:26 AM. She recalled Resident #1 had a fall on 11/22/25. She stated she was not present for the fall that occurred on Saturday 11/22/25, but recalled she had an abrasion she thought to her right elbow from the fall but no other injuries. The Supervisor explained she worked Monday through Friday 7:00 am to 7:00 pm. She stated she worked again on 11/24/25 and Resident #1 was her normal self and did not have any difficulty walking during the day. She recalled seeing her up walking around in the hallway during the day as she normally did. The Supervisor said Nurse #3 called her on the night of 11/24/25 on her drive home from work between 7:40 PM and 8:00 PM. She stated Nurse #3 asked her if something had happened with Resident #1 because she was unable to stand up or walk and her right elbow was swollen and bruised. The Supervisor said nothing had been reported to her about Resident #1. She told Nurse #3 she should call the on-call provider to let them know what was going on and that Resident #1 had a recent fall on 11/22/25, to see if they wanted to do x-rays. The Supervisor stated when she returned to work on the morning of 11/25/25 she went to Resident #1's room to check on her. She reported Resident #1 was in her bed and when she looked at her right elbow it was swollen around the elbow and a few inches above/ below her elbow. She stated there was a circular bruise over her elbow about the size of a nickel that was purple/ maroon colored, like a fresh bruise. She stated when she palpated her elbow it hurt because Resident #1 said ouch. She stated she checked Resident #1's legs and did not see any bruise, swelling, or abnormalities. She reported Resident #1 tried to get out of bed and stood up on her own. The Supervisor said she tried to redirect Resident #1 not to get up, but she got up anyways. The Supervisor said Resident #1 tried to walk and could not do so. She stated when Resident #1 tried to take a step she was off balance because she was limping, she thinks the limp was on her right side. She said Resident #1 sat down in a stationary chair that was next to her room door. The Supervisor stated Nurse #2 had come into the room and stayed with Resident #1 while she went to get a wheelchair. The Supervisor said she told Nurse #2 she could keep Resident #1 with her to keep an eye on her or Resident #1 could go to the dining room for breakfast, but she needed to have a close eye kept on her. The Supervisor reported Resident #1 went to breakfast and she had gone to the morning meeting. She stated the morning meeting was at 9:00 AM. She said sometime during the morning meeting Nurse #2 called and said Resident #1 was having what appeared to be an unresponsive episode, she reported the DON went to check on Resident #1 with her. She stated Resident #1 had previously had similar unresponsive episodes. The Supervisor stated the NP was in the building and came to assess Resident #1. She reported Resident #1's unresponsive episode resolved and she was assisted back to bed. She reported sometime after the episode that the mobile x-ray technician came to do the x-rays, she thought it was sometime around lunch. She did not know what time the x-ray results returned but knew they showed Resident #1 had a fracture of her right hip and right elbow. She could not remember who called, but said someone called the provider and they wanted her sent to the hospital. She said Resident #1 remained in bed after the unresponsive episode until she left the facility. An interview was conducted with the NP on 2/26/26 at 9:57 AM. She stated she had seen Resident #1 on the morning of 11/25/25 for follow up because the on-call provider had been called the night prior (11/24/25) about her not being able to walk and had ordered x-rays. She stated an NA reported to her they had seen Resident #1 walking earlier that morning on 11/25/25 but when she saw Resident #1, she was sitting in a wheelchair. She stated Resident #1 had x-rays ordered but they had not been done yet. She said it was unclear how much pain Resident #1 was having because she had dementia, she said the pain was not keeping her from getting up and trying to walk so it was hard to tell how much pain she was having. She reported she did not know at the time that Resident #1 had fallen on 11/24/25. She stated she looked at Resident #1's right arm and said there was bruising, it was tender to touch, swelling and she had decreased range of motion. She stated Resident #1's hip did not seem to bother her. She explained Resident #1 had not seemed to have a lot of pain and had been up walking. She reported she had seen Resident #1 again that same morning because she had an unresponsive episode. The NP stated Resident #1 had similar prior episodes. The NP reported when she arrived to the floor Resident #1 was already responsive, and the episode resolved after she was put back in bed.X-ray reports for Resident #1 dated 11/25/25 revealed the following:-The right elbow x-ray under impression read: Acute fracture of the olecranon (arm bone that forms the pointy tip of the elbow)-The right hip x-ray under impression read: acute right hip fracture-The right femur x-ray under impression read: acute right hip fractureDuring an interview with NP on 2/26/26 at 9:57 AM the NP said the x-ray results for Resident #1 were reported to the facility at 12:52 PM and she was notified of the results at 12:59 PM and gave orders to send Resident #1 to the hospital. She stated Resident #1 left the facility at 1:16 PM. NP #1 stated in her professional opinion if a resident had a fall an NA should not get them up until they were assessed by a Nurse, because a Nurse had schooling and could better assess them for an injury than an NA.A progress note by Nurse #1 dated 11/25/25 at 1:16 PM documented Resident #1 was transferred by Emergency Medical Services (EMS) to the hospital for evaluation and treatment following the x-ray results.A hospital Discharge summary dated [DATE] indicated Resident #1 was admitted to the hospital on [DATE] after presenting to the emergency room following a fall and sustaining a fracture of her right olecranon and a fracture of her right femoral neck. The discharge summary indicated she had procedures to surgically repair the right femoral neck fracture and right olecranon fracture on 11/25/25. A face sheet indicated Resident #1 was re-admitted to the facility on [DATE] after hospitalization. Her diagnoses included displaced mid cervical (middle portion of femoral neck) fracture of the right femur, displaced placed fracture of olecranon process. An interview was conducted with the Director of Nursing (DON) on 2/25/26 at 3:25 PM. The DON stated after Resident #1's x-rays returned on 11/25/25 showing she had fractured her right arm and right hip the provider was notified, and she was transferred to the hospital. The DON did not recall what time the facility received the x-ray results or who called the provider about the x-ray results. The DON reported that the facility started investigating how Resident #1's fractures occurred on 11/25/25. The DON said when NA #2 was interviewed she reported Resident #1 had a fall on 11/24/25 around 6:30 PM. The DON reported NA #2 said Resident #1 fell in her room on 11/24/25 and that Resident #1 had gotten herself up. She stated NA #2 said after Resident #1 got herself up she went and laid on her bed. The DON recalled NA #2 said when Resident #1 fell she screamed and Nurse #2 came down the hallway a couple minutes later and asked what happened. The DON explained NA #2 reported she had told Nurse #2 that Resident #1 fell and Nurse #2 went into Resident #1's room and assessed her. The DON said Nurse #2 was also interviewed and said NA #2 did not tell her that Resident #1 had fallen. She did not know why Nurse #2 would say NA #2 did not tell her that Resident #1 had fallen. The DON said Residents were not supposed to be moved after a fall until they were assessed by a nurse for injury.An interview was conducted with the Medical Director on 2/26/26 at 3:03 PM. The Medical Director stated what was done for Resident #1 was appropriate. He stated the on-call provider was notified and x-rays were ordered. The Medical Director said it was not unusual if x-rays orders were placed at night that they were not done until the next day. He stated when the x-ray results returned showing the fractures on 11/25/25 Resident #1 was transferred to the hospital. He stated Resident #1's x-rays not being completed until 11/25/25 and her not being transferred to the hospital until 11/25/25 was not impactful to her care. The MD did not think Resident #1 being moved or attempting to get up would make her fractures worse. He stated the facility should follow their fall protocol. He said it made sense that an NA should not move a resident after a fall until they were assessed by a nurse for injury because Nurses had more training to assess for injuries.An interview was conducted with the Administrator on 2/26/26 at 10:30 AM. She stated NAs should not get a resident up after a fall. The Administrator explained after a fall the NA should get a nurse so the nurse could assess the resident for injuries and decide if the resident was okay to be moved. The Administrator stated NA #2 was interviewed and had said Resident #1 was playing with the tray lid covers, lost her balance and fell on [DATE]. She said NA #2 reported Resident #1 had gotten herself up after falling, she had told Nurse #2 that Resident #1 fell, and that Nurse #2 had then gone into the room and checked on Resident #1.

Based on record review, and staff and pharmacist interviews, the facility failed to protect the resident's right to be free from misappropriation of controlled narcotic medications for 6 of 6 residents reviewed for misappropriation of residents' property (Residents #6, #7, #8, #9, #10, and #11).Findings included: The facility's Abuse, Neglect and Exploitation policy revised on 9/01/24 read in part that it is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. a. Resident #6 was admitted to the facility on [DATE]. The physician's order dated 10/27/25 revealed Resident #6 had an order to receive Oxycodone (narcotic pain medication) 10 milligrams (mg) tablet three times daily for pain. Review of Resident #6's narcotic record revealed Nurse #1 had signed out one (1) Oxycodone 10 mg tablet on 11/14/25 at 7:30 PM and 11:30 PM. Nurse #1 also signed out one (1) Oxycodone 10 mg tablet on 11/14/25 at an illegible time as wasted with Nurse #2 signing as a witness. The November 2025 Medication Administration Record (MAR) revealed Resident #6's Oxycodone scheduled administration times were 9:00 AM, 1:00 PM and 9:00 PM. Nurse #1 documented on the MAR that the scheduled Oxycodone 10 mg had been administered to Resident #6 on 11/14/25 at 9:00 PM. The physician's order dated 10/27/25 also included an order for Oxycodone 5 mg tablet every 4 hours as needed for pain. Review of Resident #6's narcotic record revealed a second narcotic record sheet of Oxycodone 5 mg. On this narcotic sheet Nurse #1 had signed out one (1) Oxycodone 5 mg tablet on 11/14/25 at 9:00 PM and one (1) Oxycodone 5 mg tablet on 11/15/25 at 1:00 AM and 5:00 AM. Review of Resident #6's narcotic record revealed a third narcotic record sheet of Oxycodone 5 mg. On this narcotic sheet the tablet count had been changed from 28 to 26, but the record lacked dates and signatures. The November 2025 MAR revealed Resident #6's Oxycodone 5 mg as needed had not been signed as administered on 11/14/25 or 11/15/25 by Nurse #1 or any other nurse. b. Resident #7 was admitted to the facility on [DATE]. The physician's order dated 11/07/25 revealed Resident #7 had an order to receive Hydromorphone (narcotic pain medication) 2 mg tablet every 6 hours as needed for pain. Review of Resident #7's narcotic record revealed Nurse #1 had signed out one (1) Hydromorphone 2 mg tablet on 11/14/25 at 8:00 PM and one (1) Hydromorphone 2 mg tablet on 11/15/25 at 2:00 AM. The November 2025 MAR revealed Resident #7's Hydromorphone had not been signed as administered on 11/14/25 or 11/15/25 by Nurse #1 or any other nurse. c. Resident #8 was admitted to the facility on [DATE]. The physician's order dated 11/14/25 revealed Resident #8 had an order to receive Oxycodone (narcotic pain medication) 5 mg tablet every 3 hours as needed for pain. Review of Resident #8's narcotic record revealed Nurse #1 had signed out one (1) Oxycodone 5 mg tablet on 11/14/25 at 7:30 PM and 10:00 PM. Nurse #1 also signed out one (1) Oxycodone 5 mg tablet on 11/15/25 at 12:30 AM, 3:00 AM, and 6:00 AM. The November 2025 MAR revealed Resident #8 Oxycodone had not been signed as administered on 11/14/25 or 11/15/25 by Nurse #1 or any other nurse. d. Resident #9 was admitted to the facility on [DATE]. The physician's order dated 11/06/25 revealed Resident #9 had an order to receive Oxycodone (narcotic pain medication) 10 mg tablet every 3 hours as needed for pain. Review of Resident #9's narcotic record revealed Nurse #1 had signed out one (1) Oxycodone 10 mg tablet on 11/14/25 at 7:30 PM and 10:30 PM. Nurse #1 also signed out one (1) Oxycodone 10 mg tablet on 11/14/25 at an illegible time wasted with Nurse #2 signing as a witness. In addition, Nurse #1 had signed out one (1) Oxycodone 10 mg on 11/15/25 at 1:20 AM, 3:30 AM, and 6:30 AM. The November 2025 MAR revealed Resident #9's Oxycodone had not been signed as administered on 11/14/25 or 11/15/25 by Nurse #1 or any other nurse. e. Resident #10 was admitted to the facility on [DATE]. The physician's order dated 9/06/25 revealed Resident #10 had an order to receive Tramadol (narcotic pain medication) 25 mg tablet every 6 hours as needed for pain. Review of Resident #10's narcotic record revealed Nurse #1 had signed out one (1) Tramadol 25 mg tablet on 11/14/25 at 8:00 PM and one (1) Tramadol 25 mg tablet on 11/15/25 at 2:00 AM. The November 2025 MAR revealed Resident #10's Tramadol had not been signed as administered on 11/14/25 or 11/15/25 by Nurse #1 or any other nurse. f. Resident #11 was admitted to the facility on [DATE]. The physician's order dated 11/13/25 revealed Resident #11 had an order to receive Hydrocodone-Acetaminophen (narcotic pain medication with acetaminophen) 5-325 mg tablet every 6 hours as needed for pain. Review of Resident #11's narcotic record revealed Nurse #1 had signed out one (1) Hydrocodone-Acetaminophen 5-325 mg tablet on 11/14/25 at 7:19 PM and one (1) Hydrocodone-Acetaminophen 5-325 mg tablet on 11/15/25 at 12:20 AM and 6:20 AM. The November 2025 MAR revealed Resident #11's Hydrocodone-Acetaminophen had not been signed as administered on 11/14/25 or 11/15/25 by Nurse #1 or any other nurse. Review of the initial allegation report dated 11/17/25 revealed the facility became aware of the misappropriation of residents' property on 11/17/25 at 9:00 AM when Nurse #3 reported a concern to the Director of Nursing (DON) about as needed narcotics being signed out for a resident who usually did not ask for pain medication. The facility reported the incident to the North Carolina Division of Health Service Regulation (DHSR) on 11/17/25 at 2:02 PM and the local law enforcement on 11/17/25 at 2:30 PM. The investigation report dated 11/21/25 revealed on 11/17/25 the Director of Nursing (DON) was notified by Nurse #3 that as needed pain medication was signed out for a resident who did not usually ask for as need pain medication. A review of the narcotic sign out sheets revealed Nurse #1 had signed out narcotics but had not signed them as administered on the MAR. A review of the narcotics sheets revealed discrepancies which were attributed to Nurse #1. A completed audit revealed 6 residents had multiple entries on their narcotic sheets not documented on their MAR. An unsuccessful attempt was made on 1/29/26 at 2:02PM to conduct a phone interview with Nurse #1. An unsuccessful attempt was made on 1/29/26 at 2:03 PM to conduct a phone interview with Nurse #2. Review of an email dated 11/17/25 at 10:30 pm between the DON and Nurse #2 showed that Nurse #2 signed the narcotic sheets as witness to waste medications for Residents #6 and #9 at Nurse #1's request without observing the medication disposal. An interview on 1/29/26 at 1:46 PM with the DON revealed Nurse #1 was an agency nurse who worked one 12-hour shift at the facility on 11/14/25 at 7:00 PM until 11/15/25 at 7:00 AM. Nurse #2 was an agency nurse who had worked 12 shifts prior to that night between 6/12/25 and 11/15/25. She stated when Nurse #3 had signed the narcotic sheet, she noticed the number of narcotics signed out, became concerned and reported it to her. The DON contacted Nurse #1 who told her that narcotics did not have to be signed on the MAR since they were on the narcotic sheet. The DON contacted Nurse #2 who stated she signed as the narcotic waste witness without visualization of the waste. Nurse #1 and Nurse #2 were blocked from working future shifts at the facility or any of their sister facilities. The DON completed an audit of narcotics and a pain assessment audit for all residents. The DON stated that local law enforcement, the North Carolina Board of Nursing, the Tennessee Board of Nursing, the pharmacy, and the Medical Director had been notified of the misappropriation of narcotics. An interview on 1/30/26 at 8:38 AM with Nurse #3 revealed she had reported her concerns to the DON after she noticed that Resident #6 had some as needed Oxycodone medication missing. She stated he denied taking the pain medication and they were not signed as administered on the MAR. An interview on 1/30/26 at 9:51 AM with the Pharmacist revealed she remembered the misappropriation of resident narcotics in November. She stated the pharmacy did not participate in the investigation and the facility replaced all unaccounted-for narcotic medications at facility expense. An interview on 1/30/26 at 10:04 AM with the Administrator revealed she felt this was not the first time Nurse #1 had taken narcotics from a facility. She stated he had been reported to local law enforcement, the North Carolina Board of Nursing and to the Tennessee Board of Nursing where he was originally licensed.

Based on record review and staff interviews, the facility failed to have effective systems in place for accurate reconciliation of narcotics medications when Nurse #2 signed narcotic records as witness to wasting without visually observing narcotic medications being wasted for 2 of 6 residents reviewed for misappropriation of residents' property (Residents #6 and #9).Findings included: a. Resident #6 was admitted to the facility on [DATE]. The physician's order dated 10/27/25 revealed Resident #6 had an order to receive one oxycodone (narcotic pain medication) 10 milligram (mg) tablet three times daily for pain. Review of Resident #6's narcotic record revealed Nurse #1 (an agency nurse) had signed out one (1) oxycodone 10 mg tablet on 11/14/25 at 7:30 PM and 11:30 PM. Review of Resident #6's narcotic record revealed Nurse #2 (an agency nurse) signed as a witness to Nurse #1's disposal of one (1) oxycodone 10 mg tablet on 11/14/25 at an illegible time. b. Resident #9 was admitted to the facility on [DATE]. The physician's order dated 11/06/25 revealed Resident #9 had an order to receive oxycodone 10 mg tablet every 3 hours as needed for pain. Review of Resident #9's narcotic record revealed Nurse #1 had signed out one (1) oxycodone 10 mg tablet on 11/14/25 at 7:30 PM and 10:30 PM. Review of Resident #9's narcotic record revealed Nurse #2 signed as a witness to Nurse #1's disposal of one (1) oxycodone 10 mg tablet on 11/14/25 at an illegible time. Review of the initial report of alleged misappropriation dated 11/17/25 revealed the facility became aware of the allegation of misapproprriation of residents' property on 11/17/25 at 9:00 AM when Nurse #3 reported a concern to the Director of Nursing (DON) about as needed narcotics being signed out for a resident who usually did not ask for pain medication. The facility reported the allegation to the North Carolina Division of Health Service Regulation (DHSR) on 11/17/25 at 2:02 PM and the local law enforcement on 11/17/25 at 2:30 PM. The investigation report dated 11/21/25 revealed on 11/17/25 that the DON was notified by Nurse #3 that as needed pain medication was signed out for a resident who did not usually request it. A review of the narcotic sign out sheet revealed Nurse #2 had signed as a witness to Nurse #1's disposal of narcotic medications for Residents #6 and #9. An interview on 1/30/26 at 8:38 AM with Nurse #3 revealed she had reported her concerns about excessive pain medication being signed out for residents by Nurse #1 to the DON after she noticed that Resident #6 had some as needed oxycodone medication missing. Nurse #2 stated Resident #6 denied taking the pain medication and they were not signed as administered on the MAR. Review of an email dated 11/17/25 at 10:30 PM from Nurse #2 to DON showed Nurse #2 communicated she had signed the narcotic sheets as a witness to the disposal of medications for Residents #6 and #9 at Nurse #1's request without observing the medication disposal. Attempts to interview Nurse #1 and Nurse #2, who were both no longer employed at the facility, were unsuccessful. An interview on 1/29/26 at 1:46 PM with the DON revealed Nurse #2 was an agency nurse who had worked multiple shifts at the facility since 6/12/25 but had not worked at the facility since 11/15/25. The DON explained Nurse #1, who was also an agency nurse that worked only one 12-hour shift at the facility from 7:00 PM on 11/14/25 until 7:00 AM on 11/15/25M. The DON stated when Nurse #3 signed the narcotic sheet, she noticed the number of narcotics signed out, became concerned and reported it to the DON. The DON further stated she contacted Nurse #2 who told her she signed as the narcotic waste witness without visualizing the waste. An interview on 1/30/26 at 10:04 AM with the Administrator revealed Nurse #1 and Nurse #2 were blocked from working at the facility as of 11/17/25. She stated it was the standard practice for nurses to visually witness narcotic medication being wasted prior to signing as a witness on the narcotic sheet and she did not know why Nurse #2 had not.

Based on record review, and staff, resident, family, Physician, Medical Director, and Nurse Practitioner interviews, the facility failed to notify the Physician when a resident (Resident #69) reported she had fallen and was experiencing acute pain after the reported fall. Due to ineffective communication between staff a medical provider was not notified of the fall until the following day which delayed x-rays, medical interventions and an evaluation in the emergency department. Resident #69 sustained an acute proximal tibia and fibula fracture (breaks in the upper part of the shinbone (tibia) and the smaller bone of the lower leg (fibula) from the reported fall and required a two day hospitalization. Orthopedics recommended hinged knee brace with non-weight bearing status to the right lower extremity. This deficient practice occurred for 1 of 3 residents reviewed for notification of changes. Findings included: Resident # 69 was admitted to the facility on [DATE]. Her diagnoses included cerebral infarction (stroke) and hemiplegia (paralysis) affecting the dominant right side. An observation and interview were conducted with Resident #69 on 6/9/25 at 10:52 AM. Resident #69 was observed in her room in her bed covered with a sheet. She was noted to be grimacing. When spoken to by the surveyor Resident #69 replied in Spanish. The surveyor asked Resident #69 Habla Ingles (speak English?), Resident #69 replied no. Resident #69 was asked by the surveyor dolor (pain)? Resident #69 replied see (yes) mucho (a lot) and grabbed her right leg at the knee. Resident #69 proceeded to uncover her right leg. When she uncovered her right leg Resident #69 began grimacing, crying, and moaning. A pillow was observed under her lower right leg. There was light blue/ purple colored bruising along her right shin and to the top of her right knee. Her right lower leg and knee had visible swelling present. Resident #69 said pain was mucho, diez (a lot, 10). The bathroom was in front of Resident #69's bed. She pointed at her right leg and the bathroom and said bano (bathroom). Resident #69's roommate was in the room who was also Spanish speaking. The roommate approached Resident #69's bed while the surveyor was in the room. The roommate translated that Resident #69 stated she had fallen on Saturday in bathroom and had a lot of pain in her leg. An additional interview was conducted with Resident #69 on 6/12/25 at 2:13 PM with Physical Therapy Assistant (PTA) #1 providing translation. Resident #69 stated she had gone to the bathroom with two staff members. She reported when she was getting off the toilet, she was holding on to the assist rail, and all a sudden she started falling. Resident #69 said she fell onto her right knee and had pain in her right knee immediately but did not cry or scream out. She said the staff member in the bathroom could not reach her fast enough to keep her from falling. She explained that the staff member who was in the bathroom with her helped her up and sat her in her wheelchair. She reported two female staff members put her back into bed after. Resident #69 stated no one asked her if she was hurt or anything afterwards, that they just put her back into bed. A telephone interview was conducted with NA #6 on 6/10/25 at 3:35 PM. NA #6 reported that she worked the night shift (7:00 pm to 7:00 am) on Saturday 6/7/25. She said at the start of her shift around 7:00 PM she was doing rounds and Resident #69's roommate was in the doorway of their room and asked her to come into the room. The roommate told her Resident #69 was having bad pain in her right knee. NA #6 recalled Resident #69 was in bed. She stated she looked at Resident #69's right knee and the top of her kneecap was bruised. NA #6 explained that the roommate assisted with translating for Resident #69 and she asked what had happened. NA #6 stated Resident #69 said she had fallen earlier that day in the bathroom and that she had fallen on her knee. NA #6 reported she asked Resident #69 if she was by herself when she fell or if staff were helping her. Resident #69 told her two girls had been helping her in the bathroom, but she did know who they were. NA #6 said she went and reported what Resident #69 was saying to the day shift (7:00 am to 7:00 pm) Nursing Supervisor. She recalled the Nursing Supervisor said she did not know anything about Resident #69 falling and the Nursing Supervisor went to check on Resident #69. A telephone interview was conducted with the day shift weekend Nursing Supervisor on 6/10/25 at 11:50 AM. The Nursing Supervisor stated a Nurse Aide (NA) came and got her around shift change on Saturday (6/7/25) around 7:30 PM and asked her to check on Resident #69. She reported the NA told her Resident #69 was saying she had fallen and was having pain in her right knee. She said she could not remember the name of the NA who came and got her. The Nursing Supervisor explained she went to Resident #69's room to assess her. She said Resident #69 was in pain and said her knee was hurting when she saw her. She reported Resident #69's roommate was present in the room and provided translation for what Resident #69 said happened. The Nursing Supervisor said Resident #69 reported she had fallen about an hour prior while she was being assisted in the bathroom by staff. The Nursing Supervisor reported she asked the day shift nurse (Nurse #8) if Resident #69 had fallen during the shift. She said Nurse #8 reported she did not know anything about Resident #69 having a fall. The Nursing Supervisor stated she updated Nurse #8 on what Resident #69 was reporting and told her what she needed to do. The Nursing Supervisor said she explained to Nurse #8 what she needed to do for the fall and told her she needed to call the physician and the Director of Nursing (DON). The Nursing Supervisor stated she had also made the oncoming night shift nurse (Nurse #9) aware of what was going on and what Resident #69 had reported. The Nursing Supervisor said she did not call the physician on Saturday. The Nursing Supervisor stated she did not think Nurse #8 had called anyone or done anything for the fall because when she returned on Sunday there was no documentation to indicate the physician had been notified or about the fall. The Nursing Supervisor said she went to assess Resident #69 on Sunday around 11:00 AM and that she was still hurting. She said she knew she was in pain because she was grimacing and holding her right leg. She stated when she looked at Resident #69's knee on Sunday there was swelling and bruising to the top of her knee. The Nursing Supervisor said she talked to Nurse #10, who was Resident #69's assigned nurse on Sunday day shift to ask him if he got anything in report about Resident #69 falling. She stated she could not remember if Nurse #10 had said yes or no. The Nursing Supervisor said she spoke to Resident #69's Family Member on the phone on Sunday. She stated that the Family Member reported Resident #69 told him she had fallen last night and was having pain. The Nursing Supervisor explained that she contacted the on-call provider on Sunday about Resident #69's pain and the fall she reported. She stated the on-call provider ordered an x-ray of Resident #69's right leg and as needed ibuprofen for pain. The Nursing Supervisor said she called the mobile x-ray company and placed an order for them to come to the facility to complete the x-ray. The Nursing Supervisor stated she called Resident #69's Family Member back and updated him on the new orders for Resident #69. A telephone interview was conducted with Nurse #8 on 6/10/25 at 1:49 PM. Nurse #8 stated she was the assigned nurse for Resident #69 on day shift on Saturday 6/7/25. She reported she had given shift report to the oncoming night shift nurse (Nurse #9) around 7:00 PM. Nurse #8 explained the day shift Nursing Supervisor came to her around 7:35 PM and told her Resident #69 was reporting she had fallen one hour ago. She stated no one had reported to her that Resident #69 had fallen during her shift. Nurse #8 said she went to Resident #69's room to check on her and that Resident #69 indicated she was in pain. She reported when she touched Resident #69's right leg she showed an expression of pain that was indicated by facial grimacing. Nurse #8 said it was not a fall that was reported to her during her shift and that it was not reported until 7:35 PM. She explained she had already given report to the night shift nurse (Nurse #9). She reported after she assessed Resident #69 and noticed she was in pain, she communicated to the night nurse, Nurse # 9, what she had seen. Nurse #8 said she asked Nurse #9 to continue the assessment and to complete the post fall things. She stated she did not specifically tell Nurse #9 what she needed to do but said Nurse #9 should have known what to do. She reported Nurse #9 had said yes. Nurse #8 said she assumed Nurse #9 would contact the physician and complete the rest of the post fall documentation. Nurse #8 stated the day shift the Nursing Supervisor had not told her anything specific she needed to do related to the fall. A telephone interview was conducted with Nurse #9 on 6/10/25 at 2:15 PM. She reported she had been the assigned night shift for Resident #69 on 6/7/25. Nurse #9 recalled she had been in the middle of taking report from the off going day shift nurse (Nurse #8). She stated she was outside of Resident #69's room with Nurse #8 and could hear another nurse in the room talking to Resident #69 and her roommate. Nurse #8 stated she did not know who the nurse in the room was, but that she overheard the nurse asking how and when Resident #69 fell. She explained an NA, whose name she did not know, was also in the room and they were trying to figure out how Resident #69 had fallen. She stated she did not see Nurse #8 again after she received report from her. Nurse #9 said the fall had occurred on day shift and she assumed Nurse #8 notified the physician and completed the fall documentation. She stated the Nursing Supervisor had not told her anything she needed to do for the fall. A nursing note dated 6/8/25 at 1:30 PM by Nursing Supervisor read: [family member] called about getting an x-ray and getting something for pain at the right knee for his [Resident #69]. Resident stated she is having pain in her right knee. Nurse evaluated right knee. There was inflammation at site. This nurse spoke with the on call doctor to get an order for an x-ray, that order has been called in to mobile x-ray. Nurse on cart gave as needed (PRN) for pain. Will continue to follow up. A telephone interview was conducted on 6/9/25 at 3:19 PM with Resident #69's Family Member. The Family Member stated they received a phone call from Resident #69 on Sunday (6/8/25). He said resident #69 was crying and said she was hurting. He reported Resident #69 said she had fallen the night before. The Family Member explained he called and spoke with the Nursing Supervisor on Sunday afternoon to ask about the fall, pain medication, and if an x-ray was going to be done. The Family Member said the Nursing Supervisor indicated she was just aware and that she was going to call the physician. The Family Member said Resident #69 could not speak English but that she was alert and oriented. An x-ray report dated 6/8/25 read: There are nondisplaced fractures of the proximal tibia and fibular neck. There are no bony lesions. Degenerative changes are noted. Diffuse osteopenia is noted. The soft tissues are unremarkable. Impression: Acute proximal lower leg fractures. A telephone interview was conducted with the Nurse Practitioner (NP) #1 on 6/10/25 at 4:16 PM. NP #1 stated she was alerted by Nurse #4 on Monday morning (6/9/25) that she had received in report from night shift that Resident #69 had an acute fracture of her knee. NP #1 explained her company's on-call service had not been notified about Resident #69's fall or her having pain over the weekend. She explained that the Medical Director was part of a different physician service group and that sometimes the staff get confused and call the Medical Directors on call service. She said it was okay for staff to call the other physician service group because he was the Medical Director. NP #1 explained she had reviewed documentation for Resident #69 and could not see where a physician was notified about Resident #69's fall or her pain until around 1:00 PM on Sunday. NP #1 said the nursing staff should have called the on-call service Saturday night when Resident #69 reported she had fallen and was having acute pain. NP #1 explained she had spoken with Resident #69 this morning using an interpreter to provide translation because Resident #69 did not speak English. NP #1 said Resident #69 reported on Saturday night she was assisted by a NA to the bathroom and had fallen onto her right knee and that she was in pain all Saturday night and Sunday morning. NP #1's company was contacted on 06/13/25 at 9:58 AM. They stated all calls were logged and there were no calls from the facility on Saturday or Sunday regarding Resident #69. A hospital Discharge summary dated [DATE] indicated Resident #69 had a mechanical fall and was admitted to the hospital on [DATE] with a right nondisplaced proximal tibia and fibula fractures. The discharge summary stated orthopedics was consulted and felt her fractures were amenable to nonoperative management. Orthopedics recommended hinged knee brace with non-weight bearing status to the right lower extremity and close outpatient follow-up with orthopedic services in two weeks. An interview was conducted with the Medical Director on 6/12/25 at 12:00 PM. He stated he did not remember the facility contacting him over the weekend but that he has had a lot of calls since then. He reviewed his calls and stated he did not have a call from the facility. He stated he had been on vacation on Sunday. He said their service tracked all the calls physicians received and he would check to see if there was a log of the facility calling his services over the weekend and call the Surveyor back. A return call was not received from the Medical Director. An interview was conducted with Physician #1 on 6/12/25 at 1:59 PM. He stated he was the on-call provider for the Medical Director physician service group over the weekend. He explained there was a system that tracked all the calls and that he had not been called on Saturday or Sunday about Resident #69. An interview was conducted with the Director of Nursing (DON), Regional Clinical Director, and Administrator on 6/12/25 at 4:00 PM. The Regional Clinical Director said she would have expected the staff to reach out to the DON and Administrator about what Resident #69 was reporting and the pain she was having because the staff did not know what had happened and should have asked for guidance on what they should have done. The Administrator agreed the staff should call the DON to ask for guidance about what the Resident was reporting. They said if someone had that much pain, they would expect the nurse to call the physician. They stated the Medical Director had called back and said one of the on-call providers, part of his service group, had received a phone call on Sunday from the facility where the nurse called and reported the issues with Resident #69, and that was where the orders for the x-ray and ibuprofen had come from.

Based on record review, and staff, resident, family, Physician, Medical Director, and Nurse Practitioner (NP) interviews, the facility failed to protect a resident's right to be free from neglect after Resident #69 had a fall during a staff assisted transfer on 6/27/25 (Saturday). The Nursing Supervisor went to assess Resident #69 after a nurse aide told her the resident reported she had fallen and was having pain in her right knee. Resident #69 told the Nursing Supervisor she was in pain and said her knee was hurting. The Nursing Supervisor did not report the fall or pain to a medical provider. Resident #69 spoke Spanish and there was no evidence that staff utilized an interpreter to determine what had occurred or her level of pain. Due to ineffective communication between staff a medical provider was not notified of fall or pain until 6/8/25 at which time orders were received for an x-ray and ibuprofen (a nonsteroidal anti-inflammatory drug) for pain. The x-ray results received on 6/8/25 noted an acute proximal tibia and fibula fracture (breaks in the upper part of the shinbone (tibia) and the smaller bone of the lower leg (fibula) and were not communicated to a medical provider until 6/9/25 when NP #1 assessed the Resident, which further delayed medical interventions and treatment for the fracture. Through an interpreter Resident #69 told NP #1 she had fallen on Saturday and had been in pain all Saturday night and Sunday morning. NP #1 noted Resident #69 was in a lot of pain and crying and ordered an opioid pain medication to treat the pain for the acute fracture of her tibia and fibula. Resident #69 was sent to the hospital emergency room on 6/9/25 and required a two day hospitalization. Orthopedics recommended hinged knee brace with non-weight bearing status to the right lower extremity. Resident #69 stated through an interpreter several days after the fall that no one asked her if she was hurt or anything afterwards, that they just put her back into bed. This deficient practice occurred for 1 of 1 resident reviewed for neglect. Findings included: This tag is cross referred to: F 580- Based on record review, and staff, resident, family, Physician, Medical Director, and Nurse Practitioner interviews, the facility failed to notify the Physician when a resident (Resident #69) reported she had fallen and was experiencing acute pain after the reported fall. Due to ineffective communication between staff a medical provider was not notified of the fall until the following day which delayed x-rays, medical interventions and an evaluation in the emergency room. Resident #69 sustained an acute proximal tibia and fibula fracture (breaks in the upper part of the shinbone (tibia) and the smaller bone of the lower leg (fibula) from the reported fall and required a two day hospitalization. Orthopedics recommended hinged knee brace with non-weight bearing status to the right lower extremity. This deficient practice occurred for 1 of 3 residents reviewed for notification of changes. F684- Based on record review, and staff, resident, family, and Nurse Practitioner interviews, the facility failed to recognize a resident experienced a fall during a staff transfer that resulted in acute pain to her right knee/ leg on 6/7/25. The nurse aides did not report Resident #69 falling to a nurse and Resident #69 was not assessed by a nurse or medical provider before she was moved and transferred back to her bed. In addition, nursing staff did not complete or document comprehensive assessments of the resident and did not recognize Resident #69 needed medical evaluation and treatment. Due to ineffective communication between staff a medical provider was not notified of fall until the following day and x-ray results reported on 6/8/25 were not communicated to a medical provider until 6/9/25, which delayed medical interventions and an evaluation in the emergency department. Resident #69 sustained an acute proximal tibia and fibula fracture (breaks in the upper part of the shinbone (tibia) and the smaller bone of the lower leg (fibula) from the reported fall and required a two day hospitalization. Orthopedics recommended hinged knee brace with non-weight bearing status to the right lower extremity. This deficient practice occurred for 1 of 1 resident reviewed for quality of care (Resident #69). F689- Based on record review, and staff, resident, family, and Nurse Practitioner interviews, the facility failed to provide a safe transfer for a resident who reported she fell during a transfer with staff. Resident #69 stated she was assisted off the toilet by two staff members, had difficulty holding on to the assist rail because her right hand did not work, fell on her right knee and had pain her in right knee immediately. Resident #69 sustained an acute proximal tibia and fibula fracture (breaks in the upper part of the shinbone (tibia) and the smaller bone of the lower leg (fibula) from the reported fall and required a two day hospitalization. Orthopedics recommended hinged knee brace with non-weight bearing status to the right lower extremity. This deficient practice occurred for 1 of 5 residents reviewed for falls (Resident #69). F 697- Based on record review, and staff, resident, family, and Nurse Practitioner (NP) interviews, the facility failed to provide effective pain management for a resident who had acute pain after a reported fall on 6/27/25 (Saturday). Resident #69 spoke Spanish and reported through an interpreter two days after the fall she fell on her right knee during an assisted transfer and had pain immediately which she rated at a pain scale of 9 (Pain scale of 0 is no pain and pain scale of 10 is the worst pain). Due to ineffective communication between staff a medical provider was not notified of fall or pain until 6/8/25 at which time ibuprofen (a nonsteroidal anti-inflammatory drug) was ordered for pain. There was no evidence staff utilized an interpreter to determine an accurate level of pain or the effectiveness of pain medication. The first documented administration of pain medication was on 6/8/25 at 3:52 PM when Resident #69 received ibuprofen for a pain level of 10 which was ineffective. There was no evidence a medical provider was contacted for additional pain medication. NP #1 was notified of the x-ray results on 6/9/25 and assessed Resident #69 and documented the Resident was in a lot of pain and crying. Through an interpreter Resident #69 told NP #1 she had fallen on Saturday and had been in pain all Saturday night and Sunday morning. NP #1 ordered an opioid pain medication to treat the pain for the acute fracture of her tibia and fibula. Resident #69 received the first dose of opioid pain medication on 6/9/25 at 9:34 AM for a pain level of 7 which was documented as effective. This deficient practice occurred for 1 of 1 resident reviewed for pain (Resident #69). F 777- Based on record review, and staff, resident, family, Physician, Medical Director, and Nurse Practitioner interviews, the facility failed to notify the Physician of radiology results for a resident who was experiencing acute pain after a reported fall on 6/7/25. Due to ineffective communication between staff x-ray results reported on 6/8/25 were not communicated to a medical provider until 6/9/25 which delayed medical interventions and an evaluation in the emergency room. Resident #69 sustained an acute proximal tibia and fibula fracture (breaks in the upper part of the shinbone (tibia) and the smaller bone of the lower leg (fibula) from the reported fall and required a two day hospitalization. Orthopedics recommended hinged knee brace with non-weight bearing status to the right lower extremity. This deficient practice occurred for 1 of 3 residents reviewed for notification of radiology results (Resident #69). An interview was conducted with the Director of Nursing (DON), Regional Clinical Director, and Administrator on 6/12/25 at 4:00 PM. They declined to comment on whether they felt like what happened with Resident #69 was neglect.

Based on record review, and staff, resident, family, and Nurse Practitioner interviews, the facility failed to recognize a resident experienced a fall during a staff transfer that resulted in acute pain to her right knee/ leg on 6/7/25. The nurse aides did not report Resident #69 falling to a nurse and Resident #69 was not assessed by a nurse or medical provider before she was moved and transferred back to her bed. In addition, nursing staff did not complete or document comprehensive assessments of the resident and did not recognize Resident #69 needed medical evaluation and treatment. Due to ineffective communication between staff a medical provider was not notified of fall until the following day and x-ray results reported on 6/8/25 were not communicated to a medical provider until 6/9/25, which delayed medical interventions and an evaluation in the emergency department. Resident #69 sustained an acute proximal tibia and fibula fracture (breaks in the upper part of the shinbone (tibia) and the smaller bone of the lower leg (fibula) from the reported fall and required a two day hospitalization. Orthopedics recommended hinged knee brace with non-weight bearing status to the right lower extremity. This deficient practice occurred for 1 of 1 resident reviewed for quality of care (Resident #69). Findings included: Resident # 69 was admitted to the facility on [DATE]. Her diagnoses included cerebral infarction (stroke) and hemiplegia (paralysis) affecting the dominant right side. The quarterly Minimum Data Set Assessment (MDS) dated [DATE] revealed Resident #69 was cognitively intact. The MDS documented that she was dependent on dressing, personal hygiene, toileting, and toilet transfers. The MDS indicated she required substantial/maximal assistance with sit to stand and chair to bed transfers. It was documented on the MDS Resident #69's preferred language was Spanish, and she needed an interpreter. An interview was conducted with Resident #69 on 6/12/25 at 2:13 PM with Physical Therapy Assistant (PTA) #1 providing translation. Resident #69 stated while staff members were assisting her in the bathroom to get off the toilet, she fell onto her right knee. Resident #69 reported she had pain in her right knee immediately but did not cry or scream out. She explained that the staff member who was in the bathroom with her helped her up and sat her in her wheelchair. Resident #69 said she could not see if it was one or two people who helped her off the toilet and back to her wheelchair because she could not see around the larger staff member to see who was in the bathroom with her. She reported two female staff members put her back into bed after. Resident #69 stated no one asked her if she was hurt or anything afterwards, that they just put her back into bed. An interview was conducted on 6/10/25 at 10:46 AM with Nurse Aide (NA) #7. She recalled assisting Resident #69 with toileting on Saturday afternoon (6/7/25); she could not recall the exact time. She stated NA #9 had assisted her with transferring Resident #69 off the toilet. NA #7 reported Resident #69 did not fall during the transfer. She did not recall Resident #69 twisting her leg or her leg getting caught on anything during the transfer. NA #7 was not aware of Resident #69 having pain after the transfer. NA #7 said after Resident #69 was finished in the bathroom, she assisted her back to her bed. An interview was conducted with NA #9 on 6/10/25 at 12:41 PM. NA #9 reported NA #7 had asked her to assist with transferring Resident #69 off the toilet Saturday (6/7/25). She explained Resident #69 was not really able to sit on the toilet because she would lean and was unstable when she was sitting on the toilet. She stated she did not think it was a good idea for Resident #69 to sit on the toilet because she might fall off the toilet. She explained she had been called to assist with transferring Resident #69 off the toilet so Resident #69 would not fall off of the toilet because she was leaning. NA #9 reported she and NA #7 armed and armed her and put her in the wheelchair. She said they each took a side to help her stand up and put her back in the wheelchair. She said during the transfer Resident #69's leg did not give out, get twisted, or catch on anything. NA #9 reported Resident #69 did not have any signs of pain during or after the transfer. A telephone interview was conducted with NA #6 on 6/10/25 at 3:35 PM. NA #6 reported that she worked the night shift (7:00 pm to 7:00 am) on Saturday 6/7/25. She said at the start of her shift around 7:00 PM Resident #69's roommate was in the doorway of their room and asked her to come into the room. The roommate told her Resident #69 was having bad pain in her right knee. NA #6 recalled Resident #69 was in bed. She stated she looked at Resident #69's right knee and the top of her kneecap was bruised. NA #6 explained that the roommate assisted with translating for Resident #69 and she asked what had happened. NA #6 stated Resident #69 said she had fallen earlier that day in the bathroom and that she had fallen on her knee. NA #6 reported she asked Resident #69 if she was by herself when she fell or if staff were helping her. Resident #69 told her two girls had been helping her in the bathroom, but she did know who they were. NA #6 stated the night shift nurse (Nurse #9) was outside of the door when she was talking to Resident #69 and had heard the conversation. NA #6 stated Nurse #9 told her she did not get anything in report about Resident #69 falling. NA #6 said she went and reported what Resident #69 was saying to the day shift (7:00 am to 7:00 pm) Nursing Supervisor. She recalled the Nursing Supervisor said she did not know anything about Resident #69 falling and the Nursing Supervisor went to check on Resident #69. A telephone interview was conducted with the day shift weekend Nursing Supervisor on 6/10/25 at 11:50 AM. The Nursing Supervisor stated a Nurse Aide (NA) came and got her around shift change on Saturday (6/7/25) around 7:30 PM and asked her to check on Resident #69. She reported the NA told her Resident #69 was saying she had fallen and was having pain in her right knee. She said she could not remember the name of the NA who came and got her. The Nursing Supervisor explained she went to Resident #69's room to assess her. She said she did not see anything abnormal when she looked at Resident #69's knee. She did not recall her having bruising or swelling to her knee. She said Resident #69 was in pain and said her knee was hurting when she saw her. She reported Resident #69's roommate was present in the room and provided translation for what Resident #69 said happened. The Nursing Supervisor said Resident #69 reported she had fallen about an hour prior while she was being assisted in the bathroom by staff. The Nursing Supervisor said she updated the night shift Nurse (Nurse #9) about what was going on and then went to find the day shift nurse (Nurse #8). The Nursing Supervisor reported she asked Nurse #8 if Resident #69 had fallen during the shift and Nurse #8 reported she did not know anything about Resident #69 having a fall. The Nursing Supervisor further reported she asked Resident #69's assigned NA, NA #7 if Resident #69 had fallen. The Nursing Supervisor stated NA #7 told her Resident #69 had not fallen. She stated she went back to Nurse #8 and updated her on what Resident #69 was reporting and told her what she needed to do. The Nursing Supervisor said she explained to Nurse #8 what she needed to do for the fall and told her she needed to call the physician. She told Nurse #8 she needed to go talk to Resident #69 and her roommate because Resident #69 was reporting she had fallen. She said she told Nurse #8 she needed to call the physician because Resident #69 was in pain, and she only had as needed Tylenol ordered. The Nursing Supervisor stated she also told Nurse #8 she needed to call the Director of Nursing (DON) about what Resident #69 was reporting and the fall. The Nursing Supervisor stated Nurse #8 had said okay. The Nursing Supervisor stated she had also made the oncoming night shift nurse (Nurse #9) aware of what was going on and what Resident #69 had reported. The Nursing Supervisor stated she did not think Nurse #8 had called anyone or done anything for the fall because when she returned on Sunday there was no documentation to indicate anything had been done for Resident #69 or her reported fall and Resident #69 was still having pain. The Nursing Supervisor explained she went to assess Resident #69 on Sunday around 11:00 AM and that she was still hurting. The Nursing Supervisor stated she knew Resident #69 was in pain because she was grimacing and holding her right leg. She stated when she looked at Resident #69's knee on Sunday there was swelling and bruising to the top of her knee. The Nursing Supervisor said she talked to Nurse #10, who was Resident #69's assigned nurse on Sunday day shift to ask him if he got anything in report about Resident #69 falling. She stated she could not remember if Nurse #10 had said yes or no. The Nursing Supervisor explained that she contacted the on-call provider on Sunday about Resident #69's pain and the fall she reported had happened on Saturday. The Nursing Supervisor reported an x-ray was ordered for Resident #69 by the on-call physician on Sunday. She recalled the x-ray was completed and the results returned before the end of her shift on Sunday. She said she had spoken to the DON about the results and that she had told Nurse #10 and Nurse #3 about the x-ray results. She reported she wrote the on-call physician's phone number down for Nurse #10 but had not told him or Nurse #3 to call the physician and report the x-ray results. The Nursing Supervisor said she did not call the x-ray results to the physician. She stated she could not remember what she told Nurse #3 and Nurse #10 to do after that. Nurse #10 was unavailable for interview. A telephone interview was conducted with Nurse #8 (agency nurse) on 6/10/25 at 1:49 PM. Nurse #8 stated she was the assigned nurse for Resident #69 on day shift on Saturday 6/7/25. She reported she had given shift report to the oncoming night shift nurse (Nurse #9) around 7:00 PM. Nurse #8 explained the day shift Nursing Supervisor came to her around 7:35 PM and told her Resident #69 was reporting she had fallen one hour ago. She stated no one had reported to her that Resident #69 had fallen during her shift. Nurse #8 said she went to Resident #69's room to check on her and that Resident #69 indicated she was in pain. Nurse #8 said she assessed Resident #69 by touching areas of her body like her arms and legs. She reported when she touched Resident #69's right leg she showed an expression of pain that was indicated by facial grimacing. She said Resident #69 did not cry or yell out and that the resident did not have any bruising or swelling to her right leg that she recalled. Nurse #8 said it was not a fall that was reported to her during her shift and that it was not reported until 7:35 PM. She explained she had already given report to the night shift nurse (Nurse #9). She reported after she assessed Resident #69 and noticed she was in pain, she communicated to Nurse # 9, what she had seen. Nurse #8 said she asked Nurse #9 to continue the assessment and to complete the post fall things. She stated she did not specifically tell Nurse #9 what she needed to do but said Nurse #9 should have known what to do. She reported Nurse #9 had said yes. Nurse #8 said she assumed Nurse #9 would contact the physician and complete the rest of the post fall documentation. Nurse #8 said she had not done any vital signs, documentation, or incident report related to Resident #69's reported fall. Nurse #8 said if she had done all those things she would have been at the facility another hour and that her agency would not pay her if she was there longer than her scheduled shift. She stated the Nursing Supervisor had not told her anything specific she needed to do related to the fall. A telephone interview was conducted with Nurse #9 on 6/10/25 at 2:15 PM. She reported she had been the assigned night shift nurse for Resident #69 on Saturday night 6/27/25. Nurse #9 recalled she had been in the middle of taking report from the off going day shift nurse (Nurse #8). She stated she was outside of Resident #69's room with Nurse #8 and could hear another nurse in the room talking to Resident #69 and her roommate. Nurse #8 stated she did not know who the nurse in the room was, but that she overheard the nurse asking how and when Resident #69 fell. She explained an NA, whose name she did not know, was also in the room and they were trying to figure out how Resident #69 had fallen. Nurse #9 reported she had thought since it had happened on the day shift that the day shift nurse (Nurse #8) was going to do the fall stuff because it was her shift. Nurse #9 said the nurse who had been in the room talking with Resident #69 about the fall had not told her to do anything. She recalled after Nurse #8 gave her report Nurse #8 had said she was going to step away to do charting. She stated Nurse #8 never came back to talk to her after giving report. Nurse #9 indicated Nurse #8 did not come back and to tell her she had assessed Resident #69 or asked her to do anything related to the fall, she said she never saw Nurse #8 again after report. An interview was conducted with Nurse #3 on 6/12/25 at 6:25 AM. She was the assigned night shift nurse on Sunday 6/8/25 for Resident #69. Nurse #3 reported she received in report from Nurse #10 that Resident #69 had a fractured knee. She also spoke with the day shift Nursing Supervisor who told her they had gotten the x-ray back and knew Resident #69 had a fracture. Nurse #3 stated she knew the day shift nurses had spoken with the Physician at some point, but she did not know if it was before or after they had received the x-ray results. She reported she had not seen the x-ray report. Nurse #3 explained she came in after they had done everything and they were just telling her what had happened. Nurse #3 stated they did not ask her to do anything or tell her she needed to do anything else. Nurse #3 recalled Resident #69's roommate came and got her during the night and let her know Resident #69 was having pain. She did not remember the time. Nurse #3 said she checked on Resident #69 and observed her having pain. She said Resident #69 was pointing at her right leg and she could tell she was having pain by her facial expression and that she was grimacing. Nurse #3 said she gave Resident #69 the PRN ibuprofen. Nurse #3 reported she went back and checked on Resident #69 again about an hour later and she was asleep. Review of Resident #69's medical record on 6/9/25 at 11:00 AM revealed there was no documentation or assessment information from Saturday 6/7/25 related to a fall. Resident #69's last progress note was documented on 6/6/25. There was no additional documentation for Resident #69 until 6/8/25 at 1:30 PM. A nursing note dated 6/8/25 at 1:30 PM by the Nursing Supervisor read: [family member] called about getting an x-ray and getting something for pain at the right knee for his [Resident #69]. Resident stated she is having pain in her right knee. Nurse evaluated right knee. There was inflammation at site. This nurse spoke with the on call doctor to get an order for an x-ray, that order has been called in to mobile x-ray. Nurse on cart gave as needed (PRN) for pain. Will continue to follow up. A telephone interview was conducted on 6/9/25 at 3:19 PM with Resident #69's Family Member. The Family Member stated they received a phone call from Resident #69 on Sunday (6/8/25). He said resident #69 was crying and said she was hurting. He reported Resident #69 said she had fallen the night before. Resident #69 had told him the staff members brought her back and put her into bed and that no one followed up to check on her. The Family Member said Resident #69 could not speak English but that she was alert and oriented. He stated he thought there would be a process for when someone fell and was injured, not just staff putting them back in bed, not contacting the doctor, or not doing any radiology screening. He reported it was around noon the next day when he spoke to the facility and nothing had been done. The Family Member indicated he thought someone would have made a report and called the Doctor. An x-ray report dated 6/8/25 read: There are nondisplaced fractures of the proximal tibia and fibular neck. There are no bony lesions. Degenerative changes are noted. Diffuse osteopenia is noted. The soft tissues are unremarkable. Impression: Acute proximal lower leg fractures. A progress note dated 6/9/25 by Nurse Practitioner (NP) #1 reported Resident #69 was being seen for right leg pain. The progress note indicated an interpreter had been used during the exam. The progress note said Resident #69 reported she had fallen onto her right knee while in the restroom with a NA Saturday night. The note further stated Resident #69 said she immediately had pain and the NA at the time got her up and helped her back to bed. NP #1's note indicated there was no documentation of the fall in the electronic computer system on 6/7/25. The progress note stated on 6/8/25 a nurse contacted the on-call physician who ordered an x-ray. The NP note stated the x-ray was reviewed this morning (6/9/25) by herself and showed a right nondisplaced fracture of the proximal tibia and fibular neck. The progress note indicated Resident #69 reported 8/10 pain to her right leg when attempting to move the leg. The NP progress note additionally said an ortho consult was ordered and non-weight bearing to the right leg was ordered. The progress note reported that NP#1 made the DON aware of what Resident #69 reported occurred Saturday and that there was no documentation. A telephone interview was conducted with the Nurse Practitioner (NP) #1 on 6/10/25 at 4:16 PM. NP #1 stated she was alerted by Nurse #4 on Monday morning (6/9/25) that she had received in report from night shift that Resident #69 had an acute fracture of her knee. She explained if Nurse #4 had not mentioned it to her she would never have known about it. NP #1 explained she reviewed the x-ray of Resident #69's right leg and it showed she had an acute fracture of her tibia and fibula. NP #1 explained she had spoken with Resident #69 this morning using an interpreter to provide translation because Resident #69 did not speak English. NP #1 said Resident #69 reported on Saturday night she was assisted by a NA to the bathroom, and she was attempting to hold onto the assist rail to get onto the toilet and felt weak. Resident #69 told her she missed the assist rail and had fallen onto her right knee and that she was in pain all Saturday night and Sunday morning. NP #1 said she had also spoken with Resident #69's Family Member who reported Resident #69 had called him Sunday and said she was in a lot of pain and had fallen. NP #1 said no one from the facility had contacted her or the company's on-call service over the weekend about Resident #69's fall, her pain, or the x-ray results. She said this morning was the first time she had learned about it. NP #1 explained if Resident #69's leg was not splinted or immobilized there was a risk that the fractures could become more displaced. A hospital Discharge summary dated [DATE] indicated Resident #69 had a mechanical fall and was admitted to the hospital on [DATE] with a right nondisplaced proximal tibia and fibula fractures. The discharge summary stated orthopedics was consulted and felt her fractures were amenable to nonoperative management. Orthopedics recommended hinged knee brace with non-weight bearing status to the right lower extremity and close outpatient follow-up with orthopedic services in two weeks. An interview was conducted with the Director of Nursing (DON), Regional Clinical Director, and Administrator on 6/12/25 at 4:00 PM. They reported when a fall was reported staff were supposed to contact the DON, responsible party, provider, and follow the fall protocol. They explained the fall protocol was to assess for injury/ pain, document the assessment, and complete an incident report. The Regional Clinical Director said she would have expected the staff to reach out to the DON and Administrator about what Resident #69 was reporting and the pain she was having because the staff did not know what had happened and should have asked for guidance on what they should have done. The DON stated if the staff had reached out and called her, she would have told them to call the on-call provider to report that Resident #69 said she had a fall and had pain. The Administrator agreed the staff should call the DON to ask for guidance about what the Resident was reporting. The DON explained she was aware of Resident #69's x-ray results Sunday night. She reported the x-ray report pinged on her computer around shift change on Sunday night at 6:56 PM and she reviewed the report. The DON said she called the facility and spoke to the day shift Nursing Supervisor around 7:00 PM. The DON stated she had called the Nursing Supervisor to notify her and make sure she had the results as well. She reported that the Nursing Supervisor confirmed she had the x-ray results. The DON said she did not tell the Nursing Supervisor what she needed to do. The DON explained that the Nursing Supervisor was not a new nurse and had assumed she knew what to do and knew she needed to call the Physician. The DON said she felt it was common sense that the nurse would call the Physician about critical x-ray results. The DON explained she was hyper focused on trying to figure out the cause of the fractures because she did not know anything about the x-ray or why it had been ordered.

Based on record review, and staff, resident, family, and Nurse Practitioner interviews, the facility failed to provide a safe transfer for a resident who reported she fell during a transfer with staff. Resident #69 stated she was assisted off the toilet by two staff members, had difficulty holding on to the assist rail because her right hand did not work, fell on her right knee and had pain her in right knee immediately. Resident #69 sustained an acute proximal tibia and fibula fracture (breaks in the upper part of the shinbone (tibia) and the smaller bone of the lower leg (fibula) from the reported fall and required a two day hospitalization. Orthopedics recommended hinged knee brace with non-weight bearing status to the right lower extremity. This deficient practice occurred for 1 of 5 residents reviewed for falls (Resident #69). Findings included: Resident # 69 was admitted to the facility on [DATE]. Her diagnoses included cerebral infarction (stroke) and hemiplegia (paralysis) affecting the dominant right side. The quarterly Minimum Data Set Assessment (MDS) dated [DATE] revealed Resident #69 was cognitively intact. The MDS documented that she was dependent on dressing, personal hygiene, toileting, and toilet transfers. The MDS indicated she required substantial/maximal assistance with sit to stand and chair to bed transfers. It was documented on the MDS Resident #69's preferred language was Spanish, and she needed an interpreter. A care plan dated 1/12/25 read Resident #69 requires staff assistance for activity of daily living (ADL) care needs related to generalized weakness and history of stroke with right side weakness. The care plan interventions included to assist with ADL care needs as needed. The ADL care plan did not specify how Resident #69 transferred. A care Kardex (quick reference tool that summarizes important care information) for Resident #69 included she was dependent for transfers and required a total mechanical lift and two persons assist for transfers. The Kardex stated as of 6/9/25. An observation and interview were conducted with Resident #69 on 6/9/25 at 10:52 AM. Resident #69 was observed in her room in her bed covered with a sheet. She was noted to be grimacing. When spoken to by the surveyor Resident #69 replied in Spanish. The surveyor asked Resident #69 Habla Ingles (speak English?), Resident #69 replied no. Resident #69 was asked by the surveyor dolor (pain)? Resident #69 replied see (yes) mucho (a lot) and grabbed her right leg at the knee. Resident #69 proceeded to uncover her right leg. When she uncovered her right leg Resident #69 began grimacing, crying, and moaning. A pillow was observed under her lower right leg. There was light blue/ purple colored bruising along her right shin and to the top of her right knee. Her right lower leg and knee had visible swelling present. Resident #69 said pain was mucho, diez (a lot, 10). The bathroom was in front of Resident #69's bed. She pointed at her right leg and the bathroom and said bano (bathroom). Resident #69's roommate was in the room who was also Spanish speaking. The roommate approached Resident #69's bed while the surveyor was in the room. The roommate translated that Resident #69 stated she had fallen on Saturday in bathroom and had a lot of pain in her leg. An additional interview was conducted with Resident #69 on 6/12/25 at 2:13 PM with Physical Therapy Assistant (PTA) #1 providing translation. Resident #69 stated she had gone to the bathroom with two staff members. She reported when she was getting off the toilet, she was holding on to the assist rail, and all a sudden she started falling. She explained that one of the staff members helping her had left to go get her wheelchair. She said she was standing at the assist rail, and the other staff member was in the bathroom next to her but was not paying attention to her. She said the staff member was not looking at her and that she was looking out the bathroom door. She recalled the staff members had her hold onto the assist rail in the bathroom. She said she could not hold onto the rail with both her hands because her right hand does not work. Resident #69 reported she had said me estoy cayendo (I'm falling) but the staff members did not understand what she was saying. Resident #69 said she fell onto her right knee and had pain in her right knee immediately but did not cry or scream out. She said the staff member in the bathroom could not reach her fast enough to keep her from falling. She explained that the staff member who was in the bathroom with her helped her up and sat her in her wheelchair. Resident #69 said she could not see if it was one or two people who helped her off the toilet and back to her wheelchair because she could not see around the larger staff member to see who was in the bathroom with her. She reported two female staff members put her back into bed after. Resident #69 stated no one asked her if she was hurt or anything afterwards, that they just put her back into bed. An interview was conducted on 6/10/25 at 10:46 AM with NA #7. She reported she had been Resident #69's assigned NA on Saturday 6/7/25. She said she and NA #8 assisted Resident #69 to the toilet on Saturday. She could not recall the time they had taken her to the toilet but said it had been sometime after lunch and thought it was before dinner but could not remember exactly. She reported she held the back of the wheelchair while NA #8 assisted Resident #69 to transfer from the bed to her wheelchair doing a stand and pivot transfer. She recalled they took Resident #69 into the bathroom that was in her room. She said she stood behind the wheelchair while NA #8 had Resident #69 hold the assist rail in the bathroom with her hand and then assisted her to open her right hand and placed her right hand on the railing. She reported NA #8 assisted Resident #69 to pull up to a standing position using the bathroom railing and then assisted her with a pivot transfer to the toilet. NA #7 reported after the transfer was completed NA #8 left the room. NA #7 reported nothing unusual occurred during the transfer and Resident #69 did not have any indicators of pain during or after the transfer onto the toilet. NA #7 recalled she closed the bathroom door slightly but left it ajar to provide privacy to Resident #69 while she was on the toilet. She stated while Resident #69 was using the toilet she remained in the room and straightened her bed and chatted with the roommate. NA #7 reported when Resident #69 indicated she was finished using the toilet, she asked NA #9 from the doorway to help her transfer Resident #69. NA #7 said she and NA #9 transferred Resident #69 back to her wheelchair using a 2-person transfer. NA #7 again, said nothing unusual occurred during the transfer and that Resident #69 did not cry out or have any indicators of pain during or after the transfer. NA #7 said Resident #69's right leg did not give way, twist, get caught, or hit anything during the transfer. NA #8 reported they then transferred Resident #69 back to her bed. NA #7 said she was not aware of Resident #69 having any pain in her right knee/ leg during her shift on Saturday. An interview was conducted with NA #8 on 6/10/25 at 10:21 AM. She reported she had assisted NA #7 with transferring Resident #69 to the toilet on Saturday. NA #8 was not sure what time they assisted her to the toilet but said it was some time after lunch. She thought it had been before dinner but was not exactly sure. NA #8 stated she had only assisted with transferring Resident #69 onto the toilet and had then left the room. She said nothing unusual happened during the transfer onto the toilet and that Resident #69 did not cry out or have any indicator of pain during or after the transfer to the toilet. An interview was conducted with NA #9 on 6/10/25 at 12:41 PM. NA #9 reported NA #7 had asked her to assist with transferring Resident #69 off the toilet. She explained Resident #69 was not really able to sit on the toilet because she would lean and was unstable when she was sitting on the toilet. She stated she did not think it was a good idea for Resident #69 to sit on the toilet because she might fall off the toilet. She explained she had been called to assist with transferring Resident #69 off the toilet so Resident #69 would not fall off of the toilet because she was leaning. NA #9 reported she and NA #7 armed and armed her and put her in the wheelchair. NA #9 stated Resident #4 was not able to hold onto the assist rail to pull herself up off the toilet. She reported Resident #69 was able to stand and pivot enough to get back into the wheelchair. NA #9 recalled the wheelchair was outside of the bathroom door. She said they each took a side to help her stand up and put her back in the wheelchair. NA #9 stated when they had Resident #69 up and turned/ pivoted her they moved the wheelchair under her and sat her down in the wheelchair. She said during the transfer Resident #69's leg did not give out, get twisted, or catch on anything. NA #9 reported Resident #69 did not have any signs of pain during or after the transfer. A telephone interview was conducted with NA #6 on 6/10/25 at 3:35 PM. NA #6 reported that she worked the night shift (7:00 pm to 7:00 am) on Saturday 6/7/25. She said at the start of her shift around 7:00 PM she was doing rounds and Resident #69's roommate was in the doorway of their room and asked her to come into the room. The roommate told her Resident #69 was having bad pain in her right knee. NA #6 recalled Resident #69 was in bed. She stated she looked at Resident #69's right knee and the top of her kneecap was bruised. NA #6 explained that the roommate assisted with translating for Resident #69 and she asked what had happened. NA #6 stated Resident #69 said she had fallen earlier that day in the bathroom and that she had fallen on her knee. NA #6 reported she asked Resident #69 if she was by herself when she fell or if staff were helping her. Resident #69 told her two girls had been helping her in the bathroom, but she did know who they were. NA #6 said she went and reported what Resident #69 was saying to the day shift (7:00 am to 7:00 pm) Nursing Supervisor. She recalled the Nursing Supervisor said she did not know anything about Resident #69 falling and the Nursing Supervisor went to check on Resident #69. A telephone interview was conducted with the day shift weekend Nursing Supervisor on 6/10/25 at 11:50 AM. The Nursing Supervisor stated a Nurse Aide (NA) came and got her around shift change on Saturday (6/7/25) around 7:30 PM and asked her to check on Resident #69. She reported the NA told her Resident #69 was saying she had fallen and was having pain in her right knee. She said she could not remember the name of the NA who came and got her. The Nursing Supervisor explained she went to Resident #69's room to assess her. She said she did not see anything abnormal when she looked at Resident #69's knee. She did not recall her having bruising or swelling to her knee. She said Resident #69 was in pain and said her knee was hurting when she saw her. She reported Resident #69's roommate was present in the room and provided translation for what Resident #69 said happened. The Nursing Supervisor said Resident #69 reported she had fallen about an hour prior while she was being assisted in the bathroom by staff. The Nursing Supervisor said she updated the night shift Nurse (Nurse #9) about what was going on and then went to find the day shift (Nurse #8). The Nursing Supervisor reported she asked Nurse #8 if Resident #69 had fallen during the shift and Nurse #8 reported she did not know anything about Resident #69 having a fall. The Nursing Supervisor further reported she asked Resident #69's assigned NA, NA #7 if Resident #69 had fallen. The Nursing Supervisor stated NA #7 told her Resident #69 had not fallen. She stated she went back to Nurse #8 and updated her on what Resident #69 was reporting and told her what she needed to do. The Nursing Supervisor said she explained to Nurse #8 what she needed to do for the fall and told her she needed to call the physician and the Director of Nursing (DON). The Nursing Supervisor stated she had also made the oncoming night shift nurse (Nurse #9) aware of what was going on and what Resident #69 had reported. The Nursing Supervisor stated she did not think Nurse #8 had called anyone or done anything for the fall because when she returned on Sunday there was no documentation to indicate anything had been done for Resident #69 or her reported fall. The Nursing Supervisor said she went to assess Resident #69 on Sunday (6/8/25) around 11:00 AM and that she was still hurting. She said she knew she was in pain because she was grimacing and holding her right leg. She stated when she looked at Resident #69's knee on Sunday there was swelling and bruising to the top of her knee. The Nursing Supervisor said she talked to Nurse #10, who was Resident #69's assigned nurse on Sunday day shift to ask him if he got anything in report about Resident #69 falling. She stated she could not remember if Nurse #10 had said yes or no. The Nursing Supervisor said she spoke to Resident #69's Family Member on the phone on Sunday. She said the Family Member reported Resident #69 told him she had fallen and was having pain. The Nursing Supervisor explained that she contacted the on-call provider on Sunday about Resident #69's pain and the fall she reported. She stated the on-call provider ordered an x-ray of Resident #69's right leg and as needed ibuprofen for pain. The Nursing Supervisor said she called the mobile x-ray company and placed an order for them to come to the facility to complete the x-ray. The Nursing Supervisor stated she called Resident #69's Family Member back and updated him on the new orders for Resident #69. A telephone interview was conducted with Nurse #8 (agency nurse) on 6/10/25 at 1:49 PM. Nurse #8 stated she was the assigned nurse for Resident #69 on day shift on Saturday 6/7/25. She reported she had given shift report to the oncoming night shift nurse (Nurse #9) around 7:00 PM. Nurse #8 explained the day shift Nursing Supervisor came to her around 7:35 PM and told her Resident #69 was reporting she had fallen one hour ago. She stated no one had reported to her that Resident #69 had fallen during her shift. Nurse #8 said she went to Resident #69's room to check on her and that Resident #69 indicated she was in pain. Nurse #8 said she assessed Resident #69 by touching areas of her body like her arms and legs. She reported when she touched Resident #69's right leg she showed an expression of pain that was indicated by facial grimacing. She said Resident #69 did not cry or yell out and that the resident did not have any bruising or swelling to her right leg that she recalled. Nurse #8 said it was not a fall that was reported to her during her shift and that it was not reported until 7:35 PM. She explained she had already given report to the night shift nurse (Nurse #9). She reported after she assessed Resident #69 and noticed she was in pain, she communicated to Nurse # 9, what she had seen. Nurse #8 said she asked Nurse #9 to continue the assessment and to complete the post fall things. She stated she did not specifically tell Nurse #9 what she needed to do but said Nurse #9 should have known what to do. She reported Nurse #9 had said yes. Nurse #8 said she assumed Nurse #9 would contact the physician and complete the rest of the post fall documentation. Nurse #8 said she had not done any vital signs, documentation, or incident report related to Resident #69's reported fall. Nurse #8 said if she had done all those things she would have been at the facility another hour and that her agency would not pay her if she was there longer than her scheduled shift. She stated the Nursing Supervisor had not told her anything specific she needed to do related to the fall. A telephone interview was conducted with Nurse #9 on 6/10/25 at 2:15 PM. She reported she had been the assigned night shift nurse for Resident #69 on Saturday night 6/27/25. Nurse #9 recalled she had been in the middle of taking report from the off going day shift nurse (Nurse #8). She stated she was outside of Resident #69's room with Nurse #8 and could hear another nurse in the room talking to Resident #69 and her roommate. Nurse #8 stated she did not know who the nurse in the room was, but that she overheard the nurse asking how and when Resident #69 fell. She explained an NA, whose name she did not know, was also in the room and they were trying to figure out how Resident #69 had fallen. Nurse #9 reported she had thought since it had happened on the day shift that the day shift nurse (Nurse #8) was going to do the fall stuff because it was her shift. Nurse #9 said the nurse who had been in the room talking with Resident #69 about the fall had not told her to do anything. She recalled after Nurse #8 gave her report Nurse #8 had said she was going to step away to do charting. She stated Nurse #8 never came back to talk to her after giving report. Nurse #9 indicated Nurse #8 did not come back and to tell her she had assessed Resident #69 or asked her to do anything related to the fall, she said she never saw Nurse #8 again after report. A nursing note dated 6/8/25 at 1:30 PM by the Nursing Supervisor read: [family member] called about getting an x-ray and getting something for pain at the right knee for his mom. Resident stated she is having pain in her right knee. Nurse evaluated right knee. There was inflammation at site. This nurse spoke with the on call doctor to get an order for an x-ray, that order has been called in to mobile x-ray. Nurse on cart gave as needed (PRN) for pain. Will continue to follow up. An x-ray report dated 6/8/25 read: There are nondisplaced fractures of the proximal tibia and fibular neck. There are no bony lesions. Degenerative changes are noted. Diffuse osteopenia is noted. The soft tissues are unremarkable. Impression: Acute proximal lower leg fractures. A telephone interview was conducted on 6/9/25 at 3:19 PM with Resident #69's Family Member. The Family Member stated they received a phone call from Resident #69 on Sunday (6/8/25). He said resident #69 was crying and said she was hurting. He reported Resident #69 said she had fallen the night before. The Family Member explained he called and spoke with the Nursing Supervisor on Sunday afternoon to ask about the fall, pain medication, and if an x-ray was going to be done. The Family Member said the Nursing Supervisor indicated she was just aware and that she was going to call the physician. He reported Resident #69 had told him a staff member had taken her to the bathroom on Saturday evening. She told him when they were transferring her off the toilet back to her wheelchair, the staff members had told her to hold onto the railing, and she lost her balance and fell onto the floor. The Family Member said Resident #69 could not speak English but that she was alert and oriented. The Family Member reported he had spoken with a provider at the facility earlier today (6/9/25) who let him know about the x-ray results. A telephone interview was conducted with the Nurse Practitioner (NP) #1 on 6/10/25 at 4:16 PM. NP #1 stated she was alerted by Nurse #4 on Monday morning (6/9/25) that she had received in report from night shift (7pm-7am) that Resident #69 had an acute fracture of her knee. NP #1 explained she had asked for the radiology report because it was not in Resident #69 chart, and nothing was documented in her chart about a fall or the injury. She said when she reviewed the x-ray of Resident #69's right leg it showed she had an acute fracture of her tibia and fibula. NP #1 explained she had spoken with Resident #69 this morning using an interpreter to provide translation because Resident #69 did not speak English. NP #1 said Resident #69 reported on Saturday night she was assisted by a NA to the bathroom, and she was attempting to hold onto the assist rail to get onto the toilet and felt weak. Resident #69 told her she missed the assist rail and had fallen onto her right knee and that she was in pain all Saturday night and Sunday morning. NP #1 said she had also spoken with Resident #69's Family Member who reported Resident #69 had called him Sunday and said she was in a lot of pain and had fallen. NP #1 explained this morning she had given orders for pain medication, non-weight bearing status and to try to immobilize her right leg. She stated she had also given an order to refer Resident #69 to the orthopedic walk-in clinic. NP #1 reported she had spoken to the orthopedic office this morning, and they had said they could cast Resident #69 in the office, so she did not have to go the emergency room (ER). NP #1 explained she had been notified around 2:30 PM by the facility that they did not feel they could immobilize Resident #69's leg for transport to the orthopedic office. She said the facility had asked for Resident #69 to go to the ER and she had agreed. NP #1 stated the therapy department at the facility had not felt comfortable splinting or touching Resident #69's leg due to the fractures and that was when she had made the decision to send her out. She explained she had spoken to the facility at 2:55 PM to confirm the ER transfer orders. NP #1 explained if Resident #69's leg was not splinted or immobilized there was a risk that the fractures could become more displaced. NP #1 further explained, a displaced fracture created more issues and was harder to treat. She reported that a non-displaced fracture is treated by keeping the leg immobilized to heal and that a displaced fracture would need surgical interventions to fix it. A hospital Discharge summary dated [DATE] indicated Resident #69 had a mechanical fall and was admitted to the hospital on [DATE] with a right nondisplaced proximal tibia and fibula fractures. The discharge summary stated orthopedics was consulted and felt her fractures were amenable to nonoperative management. Orthopedics recommended hinged knee brace with non-weight bearing status to the right lower extremity and close outpatient follow-up with orthopedic services in two weeks. An interview was conducted with the Director of Nursing (DON), Regional Clinical Director, and Administrator on 6/12/25 at 4:00 PM. The Regional Clinical Director said she would have expected the staff to reach out to the DON and Administrator about what Resident #69 was reporting and the pain she was having because the staff did not know what had happened and should have asked for guidance on what they should have done. The Administrator agreed the staff should call the DON to ask for guidance about what the Resident was reporting. The Regional Clinical Director stated Resident #69 was officially interviewed on Monday 6/9/25 by NP #1 using an interpreter for a more formal interview. She stated Resident #69 had also been interviewed by staff on Saturday and Sunday about what had happened, and all her statements, including the reports from the hospital, had been that she had fallen in the bathroom. The Regional Clinical Director said because Resident #69 had been constant in her statements that she had fallen they had determined her injury was from a fall.

Based on record review, and staff, resident, family, and Nurse Practitioner (NP) interviews, the facility failed to provide effective pain management for a resident who had acute pain after a reported fall on 6/27/25 (Saturday). Resident #69 spoke Spanish and reported through an interpreter two days after the fall that she fell on her right knee during an assisted transfer and had pain immediately which she rated at a pain scale of 9 (Pain scale of 0 is no pain and pain scale of 10 is the worst pain). Due to ineffective communication between staff a medical provider was not notified of fall or pain until 6/8/25 at which time ibuprofen (a nonsteroidal anti-inflammatory drug) was ordered for pain. There was no evidence staff utilized an interpreter to determine an accurate level of pain or the effectiveness of pain medication. The first documented administration of pain medication was on 6/8/25 at 3:52 PM when Resident #69 received ibuprofen for a pain level of 10 which was ineffective. There was no evidence a medical provider was contacted for additional pain medication. NP #1 was notified of the x-ray results on 6/9/25 and assessed Resident #69 and documented the Resident was in a lot of pain and crying. Through an interpreter Resident #69 told NP #1 she had fallen on Saturday and had been in pain all Saturday night and Sunday morning. NP #1 ordered an opioid pain medication to treat the pain for the acute fracture of her tibia and fibula. Resident #69 received the first dose of opioid pain medication on 6/9/25 at 9:34 AM for a pain level of 7 which was documented as effective. This deficient practice occurred for 1 of 1 resident reviewed for pain (Resident #69). Findings included: Resident # 69 was admitted to the facility on [DATE]. Her diagnoses included cerebral infarction (stroke) and hemiplegia (paralysis) affecting the dominant right side. The quarterly Minimum Data Set Assessment (MDS) dated [DATE] revealed Resident #69 was cognitively intact. The MDS documented that she was dependent on dressing, personal hygiene, toileting, and toilet transfers. The MDS indicated she required substantial/maximal assistance with sit to stand and chair to bed transfers. It was documented on the MDS Resident #69's preferred language was Spanish, and she needed an interpreter. The MDS documented Resident #69 did not have pain. Resident #69 did not have a care plan in place for pain. An observation and interview were conducted with Resident #69 on 6/9/24 at 10:52 AM. Resident #69 was observed in her room in her bed covered with a sheet. She was noted to be grimacing. Resident #69 was asked by the surveyor dolor (pain)? Resident #69 replied see (yes) mucho (a lot) and grabbed her right leg at the knee. Resident #69 proceeded to uncover her right leg. When she uncovered her right leg Resident #69 began grimacing, crying, and moaning. A pillow was observed under her lower right leg. There was light blue/ purple colored bruising along her right shin and to the top of her right knee. Her right lower leg and knee had visible swelling present. Resident #69 said pain was mucho, diez (a lot, 10). Resident #69's roommate was in the room who was also Spanish speaking. The roommate approached Resident #69's bed while the surveyor was in the room. The roommate translated that Resident #69 stated she had fallen on Saturday in bathroom and had a lot of pain in her leg. An additional interview was conducted with Resident #69 on 6/12/25 at 2:13 PM with Physical Therapy Assistant (PTA) #1 providing translation. Resident #69 reported she fell in the bathroom when staff were assisting her off the toilet. She said she fell onto her right knee and had pain immediately, she rated the pain as 9/10. Resident #69 reported after she fell her knee had hurt with any movement and when it was at rest. She said it had felt like her knee was constantly being torn apart. A telephone interview was conducted with NA #6 on 6/10/25 at 3:35 PM. NA #6 reported that she worked the night shift (7:00 pm to 7:00 am) on Saturday 6/7/25. She said at the start of her shift around 7:00 PM she was doing rounds and Resident #69's roommate was in the doorway of their room and asked her to come into the room. The roommate told her Resident #69 was having bad pain in her right knee. NA #6 recalled Resident #69 was in bed and she looked at Resident #69's right knee and the top of her kneecap was bruised. NA #6 explained that the roommate assisted with translating for Resident #69 and she asked what had happened. NA #6 stated Resident #69 said she had fallen earlier that day in the bathroom on her knee. She stated Resident #69 was asking for something for pain. NA #6 stated the night shift nurse (Nurse #9) was outside of the door when she was talking to Resident #69 and had heard the conversation. NA #6 stated Nurse #9 told her she did not get anything in report about Resident #69 falling. NA #6 said she went and reported what Resident #69 was saying to the day shift Nursing Supervisor. She recalled the Nursing Supervisor said she did not know anything about Resident #69 falling. She said the Nursing Supervisor went to check on Resident #69. She recalled Resident #69 had pain during the night and that she reported it to Nurse #9. NA #6 said she went to Resident #69's room around 6:15 AM Sunday (6/8/25) to provide incontinent care. She reported when she changed the position of the bed and laid it flat to provide care, Resident #69 started shaking and indicated her knee was hurting. NA #6 stated Resident #69 indicated her knee was hurting by grabbing her knee, grimacing, and crying out. NA #6 stated it was shift change and she reported Resident #69 having pain to Nurse #9 and told the nurse she needed something for pain. An interview was conducted on 6/10/25 at 2:15 PM with Nurse #9. Nurse #9 recalled she went to Resident #69's room to give her nighttime medications Saturday night (6/7/25). She did not recall the time. Nurse #9 explained she asked Resident #69 if she was hurting and she did not get a response from her. She explained Resident #69 spoke Spanish and Nurse #9 stated she was not sure if Resident #69 understood or not when she had asked her about pain. Nurse #9 stated Resident #69 was not grimacing or crying and did not have any indicators of pain. Nurse #9 reported she checked on Resident #69 several times during the night and every time she checked on her Resident #69 was asleep. Nurse #9 stated Resident #69 slept the entire shift up until shift change and no one reported her having pain during the shift. A telephone interview was conducted with the day shift (7:00 am to 7:00 pm) weekend Nursing Supervisor on 6/10/25 at 11:50 AM. The Nursing Supervisor stated a Nurse Aide (NA) came and got her around shift change on Saturday (6/7/25) around 7:30 PM and asked her to check on Resident #69. She reported the NA told her Resident #69 was saying she had fallen and was having pain in her right knee. She said she could not remember the name of the NA who came and got her. The Nursing Supervisor explained she went to Resident #69's room to assess her. She said Resident #69 was in pain and said her knee was hurting when she saw her. The Nursing Supervisor said she updated the night shift nurse (Nurse #9) what was going on and then went to find the day shift nurse (Nurse #8). The Nursing Supervisor reported she asked Nurse #8 if Resident #69 had fallen during the shift and Nurse #8 reported she did not know anything about Resident #69 having a fall. She stated she updated Nurse #8 on what Resident #69 was reporting and told her what she needed to do. The Nursing Supervisor said she told Nurse #8 she needed to call the physician and the Director of Nursing (DON). The Nursing Supervisor stated she had also made the oncoming night shift nurse (Nurse #9) aware of what was going on and what Resident #69 was reporting. The Nursing Supervisor stated when she returned on Sunday there was no documentation to indicate anything had been done for Resident #69. The Nursing Supervisor said she went to assess Resident #69 on Sunday around 11:00 AM and that she was still hurting. The Nursing Supervisor stated she knew Resident #69 was in pain because she was grimacing and holding her right leg. She stated when she looked at Resident #69's knee on Sunday there was swelling and bruising to the top of her knee. The Nursing Supervisor said she talked to Nurse #10, who was Resident #69's assigned nurse on Sunday day shift and asked him if he got anything in report about Resident #69 falling. She stated she could not remember if Nurse #10 had said yes or no. The Nursing Supervisor indicated she spoke to Resident #69's Family Member on the phone on Sunday. She said the Family Member reported Resident #69 told him she had fallen and was having pain. The Nursing Supervisor explained that she contacted the on-call provider on Sunday about Resident #69's pain and the fall she reported. She stated the on-call provider ordered an x-ray of Resident #69's right leg and as needed ibuprofen for pain. The Nursing Supervisor stated she called Resident #69's Family Member back and updated him on the new orders for Resident #69. Multiple attempts were made to speak with Nurse #10. He was unavailable to be interviewed. An interview was conducted with NA #7 on 6/10/25 at 10:46 AM. She was assigned NA for Resident #69 on day shift Saturday and Sunday. She stated Resident #69 did not complain of any pain or have any indicators of pain during her shift on Saturday (6/7/25). NA #7 reported when she returned on Sunday Resident #69 was having pain. She recalled checking on Resident #69 between 8:30 am and 9:00 am on Sunday and that Resident #69 was complaining of pain in her right knee/ leg. She said Resident #69 was grimacing and grabbing her knee. NA #7 stated she told Nurse #10 Resident #69 was having pain in her right leg/ knee. NA #7 recalled Nurse #10 saying he had already given Resident #69 her morning medications and there had been Tylenol in her morning medication and that he would be there in a second. NA #7 reported Nurse #10 did go and check on Resident #69 about 15-20 minutes later. NA #7 stated she went to provide incontinent care to Resident #69 around 10:00 AM and that she could tell her knee was still hurting because of her facial expressions, she said Resident #69 was grimacing and closing her eyes. NA #7 stated Resident #69 did not cry or yell out but that she could tell she was hurting. NA #7 stated she went and told Nurse #10 that Resident #69 was still hurting and that Nurse #10 said okay. NA #7 stated she provided incontinent care to Resident #69 again after lunch and she was still having pain. NA #7 indicated she did not notice a change in Resident #69's level of pain from earlier in the shift and felt like it was about the same. She recalled Resident #69 was grabbing her right leg and grimacing, she reported she told Nurse #10 again and that Nurse #10 told her he would go check on Resident #69 and was going to talk to the Nursing Supervisor. Resident #69's June 2025 medication administration record (MAR) revealed an every shift pain assessment. On 6/7/25 Resident #69's pain was documented as a 0 by Nurse #9 for the evening shift and night shift. A telephone interview was conducted on 6/9/25 at 3:19 PM with Resident #69's Family Member. The Family Member stated they received a phone call from Resident #69 on Sunday (6/8/25). He said resident #69 was crying and said she was hurting. He reported Resident #69 said she had fallen the night before and could not sleep all night because she was in a lot of pain. The Family Member explained he called and spoke with the Nursing Supervisor on Sunday and asked about the fall, pain medication, and if an x-ray was going to be done. The Family Member said the Nursing Supervisor indicated she would call the physician. A nursing note dated 6/8/25 at 1:30 PM by the Nursing Supervisor read: [family member] called about getting an x-ray and getting something for pain at the right knee for [Resident #69]. Resident stated she is having pain in her right knee. Nurse evaluated right knee. There was inflammation at site. This nurse spoke with the on call doctor to get an order for an x-ray, that order has been called in to mobile x-ray. Nurse on cart gave as needed (PRN) for pain. Will continue to follow up. An every shift pain assessment on Resident #69's June 2025 MAR, completed by Nurse #10 documented a pain level of 10 for 6/8/25 day shift and a pain level of 0 for the evening shift. A pain level of 2 was documented for the night shift on 6/8/25 by Nurse #8. Review of Resident #69's June 2025 Medication Administration Record (MAR) revealed the following orders: - An order dated 6/2/25 that read: Acetaminophen 325 milligram (mg) give two tablets by mouth every eight hours as needed for pain for 14 days. There was no documentation of the medication being administered from 6/7/25 through 6/9/25. -An order dated 6/8/25 that read: Ibuprofen 600 mg give one tablet by mouth every six hours as needed for inflammation for 5 days. The MAR indicated the order had been entered at 2:25 PM. The MAR documented the medication as administered by Nurse #10 on 6/8/25 at 3:52 PM for a pain level of 10. The MAR further documented the medication was ineffective. The MAR documented the medication was administered again on 6/8/25 at 11:34 PM by Nurse #3 for a pain level of 6 and that the medication was effective. An x-ray report dated 6/8/25 read: There are nondisplaced fractures of the proximal tibia and fibular neck. There are no bony lesions. Degenerative changes are noted. Diffuse osteopenia is noted. The soft tissues are unremarkable. Impression: Acute proximal lower leg fractures. A telephone interview was conducted with Nurse #3 on 6/12/25 at 6:25 AM. She stated she was Resident #69's assigned nurse on Sunday (6/8/25) during night shift . Nurse #3 said she received in report from the day shift nurse, Nurse #10 that Resident #69 had a fractured knee, and she had a new order for PRN pain medication had been put in for her. It was reported to her by Nurse #10 that Resident #69 had pain earlier during his shift and he had given her pain medication. Nurse #3 recalled Resident #69's roommate came and got her during the night and let her know Resident #69 was having pain. She did not remember the time. Nurse #3 said she checked on Resident #69 and observed her having pain. Resident #69 was pointing at her right leg and she could tell she was having pain by her facial expression. Nurse #3 said she gave Resident #69 the PRN ibuprofen. Nurse #3 reported she went back and checked on Resident #69 again about an hour later and she was asleep. Nurse #3 reported she went back to Resident #69's room to administer early morning medications to her roommate and Resident #69 was still asleep. Nurse #3 said she reported to the oncoming dayshift nurse (Nurse #4) Monday morning, what was going on with Resident #69, that she had a fracture, and what Resident #69 had listed PRN for pain. An interview was conducted with Nurse #4 on 6/9/25 at 11:01 AM. Nurse #4 stated she spoke with NP #1 this morning about Resident #69's fracture and pain. She stated NP #1 ordered PRN hydrocodone/ acetaminophen (pain medication) 5/325 mg for Resident #69. Nurse #4 reported she administered the pain medication this morning around 9:30 AM to Resident #69. A pain level of 7 was documented by Nurse #4 on Resident #69's June 2025 MAR every shift pain assessment for 6/9/25 day shift. An active order dated 6/9/25 entered at 9:00 AM was present on Resident #69's June 2025 MAR that read: hydrocodone-acetaminophen (pain medication) oral tablet 5-325 mg, every 8 hours as needed for right leg fracture for 7 days. The MAR documented the medication was administered at 9:34 AM by Nurse #4 for a pain level of 7. The MAR documented the medication as being effective. An interview was conducted with NP #1 on 6/10/25 at 4:16 PM. NP #1 reported she had seen Resident #69 on Monday morning (6/9/25) and had used an interpreter during the visit to translate what was being said. She stated Resident #69 reported she had fallen on Saturday. NP #1 explained she had reviewed the x-ray results of Resident #69 right leg this morning and she had an acute fracture of her tibia and fibula. NP #1 said Resident #69 told her she was in pain when she saw her this morning. She further stated Resident #69 told her she had been in pain all Saturday night and Sunday morning. NP #1 reported Resident #69 was in a lot of pain and crying when she saw her this morning. She stated she ordered the hydrocodone PRN every eight hours for Resident #69 this morning and Nurse #4 had given her a dose. NP #1 stated she told the staff to call her if every eight hours was not enough and she would adjust the frequency so Resident #69 could have pain medication every 4 or 6 hours. NP #1 did not think PRN ibuprofen was enough to treat pain from a fracture. She explained Nurse #4 called her around 3:03 PM asking for more pain medication for Resident #69 but NP #1 said she had just spoken to someone at the facility a few minutes before Nurse #4 called confirming orders to send Resident #69 to the emergency room (ER) for evaluation. An interview was conducted with the Director of Nursing (DON), The Regional Clinical Director, and the Administrator on 6/12/25 at 4:00 PM. They said if someone was having that much pain, they would expect the staff to call the provider about her pain. .

Based on record review, and staff, resident, family, Physician, Medical Director, and Nurse Practitioner interviews, the facility failed to notify the Physician of radiology results for a resident who was experiencing acute pain after a reported fall on 6/7/25. Due to ineffective communication between staff x-ray results reported on 6/8/25 were not communicated to a medical provider until 6/9/25 which delayed medical interventions and an evaluation in the emergency department. Resident #69 sustained an acute proximal tibia and fibula fracture (breaks in the upper part of the shinbone (tibia) and the smaller bone of the lower leg (fibula) from the reported fall and required a two day hospitalization. Orthopedics recommended hinged knee brace with non-weight bearing status to the right lower extremity. This deficient practice occurred for 1 of 3 residents reviewed for notification of radiology results (Resident #69). Findings included: An interview was conducted on 6/12/25 at 2:13 PM with Resident #69. PTA #1 provided translation. Resident #69 stated she fell on Saturday (6/7/25) in the bathroom. She explained she fell onto her right knee and felt pain immediately. Resident #69 stated her right knee, and leg has been hurting the entire time since she fell. She said it had felt like her knee was constantly getting torn apart. Resident #69 said her knee had hurt really bad when they moved her and when she was at rest and her leg was not being moved. A telephone interview was conducted with the day shift (7:00 am to 7:00 pm) weekend Nursing Supervisor on 6/10/25 at 11:50 AM. The Nursing Supervisor stated Saturday 6/7/25 around 7:35 PM Resident #69 was in pain and said her knee was hurting. The Nursing Supervisor said Resident #69 reported she had fallen about an hour prior while she was being assisted in the bathroom by staff. The Nursing Supervisor said she went back to assess Resident #69 on Sunday around 11:00 AM and that she was still hurting. The Nursing Supervisor explained that she contacted the on-call provider on Sunday about Resident #69's pain and the fall she reported. She stated the on-call provider ordered an x-ray of Resident #69's right leg. The Nursing Supervisor said she called the mobile x-ray company and placed an order for them to come to the facility to complete the x-ray. The Nursing Supervisor could not remember what time the mobile x-ray came to the facility to complete the x-ray but stated it was sometime in the afternoon after lunch. The Nursing Supervisor reported the x-ray results came back before she left at the end of her shift. She did not remember what time the x-ray results had come back. The Nursing Supervisor stated she did not call the x-ray results to the physician. The Nursing Supervisor explained she told Nurse #10 the x-ray results and wrote the Physician's number down and gave it to him. The Nursing Supervisor stated she had also told the oncoming night shift (7:00 pm to 7:00 am) nurse (Nurse #3) the results. She said she had not told Nurse #10 or Nurse #3 to call the Physician to report the x-ray results. Nurse #10 was unavailable for interview. An x-ray report dated 6/8/25 read: There are nondisplaced fractures of the proximal tibia and fibular neck. There are no bony lesions. Degenerative changes are noted. Diffuse osteopenia is noted. The soft tissues are unremarkable. Impression: Acute proximal lower leg fractures. At the bottom of the x-ray report a statement read: the report has been successfully faxed, emailed, delivered and/or viewed by the client at [facility] at 2025-06-08 20:02:20 (8:20 PM) central time. Receipt of report was confirmed and read back was given. An interview was conducted with Nurse #3 on 6/12/25 at 6:25 AM. She was the assigned night shift nurse on Sunday 6/8/25 for Resident #69. Nurse #3 reported she received in report from Nurse #10 that Resident #69 had a fractured knee. She also spoke with the day shift Nursing Supervisor who told her they had gotten the x-ray back and knew Resident #69 had a fracture. Nurse #3 stated she knew the day shift nurses had spoken with the Physician at some point, but she did not know if it was before or after they had received the x-ray results. She reported she had not seen the x-ray report. Nurse #3 explained she came in after they had done everything and they were just telling her what had happened. Nurse #3 stated they did not ask her to do anything or tell her she needed to do anything else. An interview was conducted with Nurse #4 on 6/9/25 at 11:01 AM. She was Resident #69's assigned day shift nurse on 6/9/25. She stated she received in report from Nurse #3 that Resident #69 had a fractured knee. Nurse #4 said she notified NP #1 this morning (6/9/25). A telephone interview was conducted with the Nurse Practitioner (NP) #1 on 6/10/25 at 4:16 PM. NP #1 stated she was alerted by Nurse #4 on Monday morning (6/9/25) that she had received in report from night shift that Resident #69 had a fractured knee. She said when she reviewed the x-ray report, the report said Resident #69 had acute fractures of the tibia and fibula. NP #1 explained her company's on-call service had not been notified about Resident #69's x-ray results over the weekend. She explained that the Medical Director was part of a different physician service group and that sometimes the staff got confused and called the Medical Director's on call service. She said it was okay for staff to call the other physician service group because he was the Medical Director. NP #1 explained she had reviewed documentation for Resident #69 and could not see where a physician was notified of Resident #69's x-ray results. NP #1 said the nursing staff should have called the on-call service on Sunday when Resident #69's x-ray results returned. NP #1 reported if they had called the on-call service, with it being the weekend, they would most likely have given orders to send Resident #69 to the Emergency Department to be evaluated. NP #1 said if she had been the one who received the call over the weekend, she would have been okay waiting to see if she could get her into see an orthopedic first thing Monday morning to save her from an ER visit. She said knowing she had acute fractures she would have ordered something stronger than Ibuprofen to manage her pain. NP #1 explained this morning she had given orders for pain medication, non-weight bearing status and to try to immobilize her right leg. NP #1's company was contacted on 06/13/25 at 9:58 AM. They stated all calls were logged and there were no calls from the facility on Saturday or Sunday regarding Resident #69. A hospital Discharge summary dated [DATE] indicated Resident #69 had a mechanical fall and was admitted to the hospital on [DATE] with a right nondisplaced proximal tibia and fibula fractures. The discharge summary stated orthopedics was consulted and felt her fractures were amenable to nonoperative management. Orthopedics recommended hinged knee brace with non-weight bearing status to the right lower extremity and close outpatient follow-up with orthopedic services in two weeks. An interview was conducted with the Medical Director on 6/12/25 at 12:00 PM. He stated he did not remember the facility contacting him over the weekend but that he has had a lot of calls since then. He reviewed his calls and stated he did not have a call from the facility. The Medical Director stated he was on vacation on Sunday. He said their service tracked all the calls received. He reported he would check to see if there was a log of the facility calling over the weekend and call the Surveyor back. A return call was not received from the Medical Director. An interview was conducted with Physician #1 on 6/12/25 at 1:59 PM. He stated he was the on-call provider for the Medical Director physician service group over the weekend. He explained there was a system that tracked all the calls and that he had not been contacted about Resident #69. Physician #1 stated if he had been called about the x-ray results on Sunday, he would have sent Resident #69 to the ER. Physician #1 said he was not sure if Resident #69's fractures were displaced or non-displaced but that it did not matter, he would have sent her to the hospital for evaluation for orthopedics to see her. He explained at the ER orthopedist would be consulted and decide if Resident #60 needed surgical intervention or if the fractures could be treated with casting or immobilization. Physician #1 indicated unless the family refused there was no reason not to send Resident #69 to the hospital. An interview was conducted with the Director of Nursing (DON), Regional Clinical Director, and Administrator on 6/12/25 at 4:00 PM. The DON explained she was aware of Resident #69's x-ray results Sunday night (6/8/25). She reported the x-ray report pinged on her computer around shift change on Sunday night at 6:56 PM and she reviewed the report. The DON said she immediately forwarded the results to the Administrator and then called the facility and spoke to the day shift Nursing Supervisor at around 7:00 PM. The DON stated she had called the Nursing Supervisor to notify her and make sure she had the results as well. She reported that the Nursing Supervisor confirmed she had the x-ray results. The DON said she did not tell the Nursing Supervisor what she needed to do. The DON explained that the Nursing Supervisor was not a new nurse and she had assumed the Nursing Supervisor knew what to do and knew she needed to call the Physician. The DON said she felt it was common sense that the nurse would call the Physician about critical x-ray results. The DON explained later that night around 8:30 PM herself, the Administrator, and the Regional Clinical Director got together on a three-way call to discuss the situation. They said their conversation was more around trying to figure out what had happened. The DON explained she was hyper focused on trying to figure out the cause of the fractures because she did not know anything about the x-ray or why it had been ordered. They all agreed that the physician should have been notified of the x-ray results.

4. Resident #5 was admitted to the facility on [DATE]. His cumulative diagnoses included protein-calorie malnutrition and dysphagia (difficulty swallowing). A Speech Therapy (ST) evaluation and plan of treatment for the certification period 05/01/25 through 07/29/25 revealed at baseline, Resident #5 presented with mild oropharyngeal (middle part of the throat behind the mouth) dysphagia characterized by mildly impaired lingual (tongue)/labial (lips) range of motion/coordination, loss of bolus (soft mass of chewed food), and coughing/gagging. A nutrition evaluation dated 05/29/25 revealed Resident #5 had the following signs/symptoms of a swallowing disorder: loss of liquids/solids from mouth when eating or drinking, coughing or choking during meals or when swallowing medications, and complaints of difficulty or pain when swallowing. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #5 did not have signs and symptoms of a swallowing disorder. During an interview on 06/13/25 at 11:02 AM, the Regional MDS Consultant revealed the facility was currently without a MDS Coordinator and she had been filling in to assist with completing MDS assessments. The Regional MDS Consultant stated based on the ST evaluation, swallowing disorder should have been coded on Resident #5's MDS assessment dated [DATE] and it was an oversight. During an interview on 06/13/25 at 1:46 PM, the Administrator stated she expected MDS assessments to be coded correctly. Based on record review and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessment in the areas of pressure ulcers and dental status (Resident #4), restraints (Resident #18 and Resident #1), and swallowing disorders (Resident #5) for 4 of 30 residents reviewed for accuracy of assessments. Findings included: 1 a. Resident #4 was admitted to the facility on [DATE] with diagnoses including dementia and malnutrition. A review of the admission weekly skin evaluation dated 01/23/25 revealed Resident #4 had no skin issues. A review of the Wound Care Practitioner notes revealed on 02/26/25 Resident #4 was evaluated for two unstageable pressure ulcers located on the left hip and sacrum that were newly identified on 02/25/25. The Wound Care Practitioner continued weekly evaluations and treatments for two unstageable pressure ulcers located on the left hip and sacrum until 03/26/25. A review of the discharge MDS assessment dated [DATE] revealed Resident #4 was discharged to the hospital. The MDS assessment identified two unstageable pressure ulcers and incorrectly coded the ulcers were present on admission. A review of the Wound Care Practitioner note dated 04/02/25 revealed Resident #4 was not seen due to being hospitalized on [DATE]. During an interview on 06/13/25 at 11:48 AM, the Regional MDS Consultant revealed MDS assessments were being completed remotely. After review of Resident #4's electronic medical records, the Regional MDS Consultant confirmed the pressure ulcers were identified after admission to the facility and the discharge MDS assessment dated [DATE] was coded incorrectly to indicate the ulcers were present on admission. During an interview on 06/13/25 at 2:43 PM, the Administrator revealed MDS assessments should accurately reflect Resident #4's pressure ulcers were not present on admission, and she expected MDS assessments were correctly coded for skin conditions. b. A review of the admission MDS assessment dated [DATE] indicated Resident #4 was not edentulous (no natural teeth). A review of the significant change in status MDS assessment dated [DATE] indicated Resident #4 was not edentulous (no natural teeth). During an observation of the lunch meal on 06/11/25 at 12:11 PM, Resident #4 was served pureed textured food and was edentulous. During an interview on 06/13/25 at 11:48 AM, the Regional MDS Consultant revealed MDS assessments were being completed remotely. After review of Resident #4's electronic medical records, the MDS Regional Consultant revealed a Speech Therapist evaluation dated 01/22/25 noted Resident #4 was edentulous upon admission to the facility on [DATE]. The Regional MDS Consultant stated the admission MDS assessment dated [DATE] and significant change in status MDS assessment dated [DATE] were coded incorrectly to indicate Resident #4 was not edentulous. She revealed the MDS Coordinator completed the assessments remotely and was expected to review the resident's medical records or contact the facility when more information was needed to accurately complete the assessment. During an interview on 06/13/25 at 2:43 PM, the Administrator revealed MDS assessments should accurately reflect Resident #4 had no natural teeth (edentulous) and she expected the assessment was correctly coded for dental status. 2. Resident #18 was admitted to the facility on [DATE] with diagnoses including congestive heart failure and history of cerebral infarction (loss of blood flow to an area of the brain). A review of quarterly MDS assessment dated [DATE] revealed Resident #18's cognition was intact. The MDS indicated bed rails were used daily and coded as a physical restraint. An interview and observation of Resident #18 was conducted on 06/09/25 at 2:26 PM. Resident #18 was resting in bed with bilateral quarter bed rails located at the head of the bed in an up position. Resident #18 revealed she used the bed rails for mobility to help reposition herself. During an interview on 06/13/25 at 12:17 PM, the Regional MDS Consultant revealed MDS assessments were being completed remotely and stated the facility was restraint free. After review of Resident #18's medical records, the Regional MDS Consultant stated the quarterly MDS assessment dated [DATE] was incorrectly coded to indicate bed rails were a physical restraint. The Regional MDS Consultant stated Resident #18 was cognitively intact and the bed rails did not restrict movement and were not a restraint. During an interview on 06/13/25 at 2:55 PM, the Administrator revealed MDS assessments should accurately reflect Resident #18's bed rails were not a restraint and confirmed the facility was restraint free. The Administrator revealed she expected the quarterly MDS assessment dated [DATE] was correctly coded to show no physical restraints were used. 3. Resident #1 was admitted to the facility on [DATE] with diagnoses including dementia and cerebrovascular disease. A review of the quarterly MDS assessment dated [DATE] revealed Resident #1's cognition was moderately impaired. The MDS indicated a physical restraint was used less than daily and coded as a chair that prevented Resident #1 from rising. During an interview on 06/11/25 at 4:56 PM, the Rehabilitation Director revealed after review of Resident #1's therapy notes she did not know why a chair restraint was coded on the quarterly MDS assessment dated [DATE]. An observation and interview was conducted on 06/12/25 at 4:34 PM with Resident #1. Resident #1 stated he was able to self-transfer without assistance from staff. Resident #1 revealed he used a wheelchair for mobility and there was no type of restraint used. Resident #1's wheelchair had a cushion on the seat and no type of seat belt or device used to prevent him from rising from the chair. During an interview on 06/13/25 at 12:13 PM, the Regional MDS Consultant revealed MDS assessments were being completed remotely. After review of Resident #1's medical records, the Regional MDS Consultant confirmed the quarterly MDS assessment dated [DATE] was incorrectly coded for the use of a chair restraint. The Regional MDS Consultant revealed the assessment was coded in error and a modification of Resident #1's quarterly MDS assessment dated [DATE] was sent on 06/11/25 to reflect no chair restraint was used. During an interview on 06/13/25 at 2:55 PM, the Administrator revealed the MDS assessment should accurately reflect Resident #1 did not use a chair restraint and confirmed the facility was restraint free. The Administrator revealed she expected the quarterly MDS assessment dated [DATE] was correctly coded to show no physical restraint was used.

Based on record review, and resident and staff interviews, the facility failed to invite a resident to participate and provide input in the care planning process for 1 of 2 sampled residents (Resident #16). Findings included: Resident #16 was readmitted to the facility on [DATE]. The annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #16 had intact cognition. Review of Resident #16's electronic medical record revealed no evidence he was invited to attend care plan meetings to discuss and provide input regarding his plan of care following the completion of a quarterly Minimum Data Set (MDS) assessment dated [DATE], a quarterly MDS assessment dated [DATE], a quarterly MDS assessment dated [DATE], and an annual MDS assessment dated [DATE]. During an interview on 06/09/25 at 2:11 PM, Resident #16 stated he had been invited and attended care plan meetings in the past but could not recall the last time one was held. Resident #16 expressed that he wanted to participate in the care plan meetings so he could communicate and provide input about his care. During interviews on 06/11/25 at 3:19 PM and 06/12/25 at 8:20 AM, the Social Worker (SW) explained after the facility's last recertification survey (06/27/24) they put processes in place for him to keep track of when care plan meetings were due so that residents and/or their Responsible Party were invited to participate. The SW stated he had not been consistent with documenting care plan meetings that were held in the resident's medical record. The SW stated he seemed to recall having a care plan meeting with Resident #16 sometime in September 2024 but he was unable to locate any documentation. The SW stated care plan meetings for Resident #16 had fell through the cracks and verified there had been no care plan meetings held for Resident #16 this year (2025). During an interview on 06/13/25 at 1:46 PM, the Administrator revealed the SW was responsible for keeping track of when care plan meetings were due and inviting residents to participate in the care plan meetings. The Administrator stated she would expect for care plan meetings to be scheduled and held with the resident and/or Responsible Party per the regulatory guidance.

Based on observation, record review, and interviews with residents and staff, the facility failed to ensure a dependent resident's accessibility to the light switch located behind the bed for 1 of 1 resident reviewed for accommodation of needs (Resident #30). The findings included: Resident #30 was admitted to the facility on [DATE]. The quarterly Minimum Data Set (MDS) assessment dated [DATE] coded Resident #30 with severely impaired cognition. The MDS indicated he required partial to moderate assistance for walking between locations inside the room for more than 10 feet. During an observation conducted on 06/09/25 at 12:47 PM, the switch for the light fixture behind Resident #30's bed was attached with a broken cord 2.5 inches in length. It was 5 feet from the floor and 6 feet from the bed. Resident #30 was unable to reach the switch cord from the bed if needed. An interview was conducted with Resident #30 on 06/09/25 at 12:49 PM. He could not recall when the switch cord was broken. He stated that he did not have any control of the light fixture behind his bed as he could not stand up without assistance in reaching the broken switch cord on the wall. He had to rely on nursing staff to switch off the light fixture before sleeping. Resident #30 indicated it was inconvenient as he had to ask for assistance repeatedly. He wanted the maintenance staff to fix the switch cord immediately to accommodate his needs. During joint observation and subsequent interviews with Nurse Aide #2 (NA) and Nurse #4 on 06/09/25 at 3:05 PM, NA #2 stated she provided care for Resident #30 frequently in the past few days. However, she did not notice that the switch cord was broken as it was blocked by a tall table lamp standing next to it. Nurse #4 stated that she had provided care for Resident #30 frequently in the past few months, but she did not notice that the switch cord was broken and inaccessible for him. Both nursing staff acknowledged that the broken switch cord needed to be fixed as soon as possible to accommodate Resident #30's needs. An interview was conducted with the Maintenance Director on 06/10/25 at 3:49 PM. He stated he walked through the entire facility at least once weekly to identify repair needs. He also depended on nursing staff to report repair needs either verbally or through work order that were placed in each nurse's station. He acknowledged that Resident #30's broken switch cord needed to be fixed immediately to accommodate his needs. During an interview conducted on 06/11/25 at 11:47 AM, the Director of Nursing acknowledged that even though Resident #30 rarely used the switch cord to switch on the light fixture behind his bed, the facility should make the switch cord available and accessible. It was her expectation for all the residents to have full accessibility to their light fixture to accommodate their needs all the time. An interview was conducted with the Administrator on 06/13/25 at 1:15 PM. She expected the staff to be more attentive to residents' living environment and reported repair needs in a timely manner to ensure all the residents had full accessibility to their light fixture at all times.

Based on record review and interviews with the Resident Representative and staff, the facility failed to ensure the basis for a resident's discharge from the facility met the discharge requirement criteria for 1 of 3 residents reviewed for discharge (Resident #189). On 01/28/25, Resident #189 was issued a 30-day notice for non-payment prior to a claim being submitted to the Managed Medicaid plan (private insurance company contracted to manage the provision of care and benefits) for payment of his stay. Findings included: Resident #189 was admitted to the facility on [DATE]. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #189 had intact cognition and there was no active discharge plan in place. A Nursing Home Notice of Transfer/Discharge form dated 01/28/25 revealed Resident #128 would be discharged from the facility on 02/28/25. The reason for the transfer/discharge was marked, you have failed, after reasonable and appropriate notice, to pay for (or to have paid under Medicare or Medicaid) a stay at this facility. During a phone interview on 06/10/25 at 11:52 AM, Resident #189's Representative stated Resident #189 was issued a discharge notice by the facility on 01/28/25 due to non-payment which was unexpected because both she and Resident #189 had planned on him remaining in the facility a little longer to give her time to find other housing that would accommodate his wheelchair in order to safely bring him back home. The Representative stated since his discharge on [DATE], they had continued to receive monthly billing statements amounting to over $50,000.00 dollars. The Representative stated Resident #189 had medical insurance and they were told insurance would cover the first 90 days of his stay but she was not sure if insurance was billed or how much the insurance had paid since there was nothing listed on the billing statement. The representative stated the Administrator had told Resident #189 he could remain at the facility and not be discharged if he paid something toward the amount owed and he made a payment of $400.00 but was still issued the 30-day discharge notice. During an interview on 06/12/25/25 at 8:56 AM, the Business Office Manager (BOM) revealed she had only been employed at the facility for about 2 weeks. The BOM reviewed Resident #189's account and confirmed he had a balance due of $51,353.68. She stated he had insurance coverage through a Managed Medicaid plan but when she looked at his payer source in his medical record it was listed as private pay. She explained the facility had received approval from the Managed Medicaid Plan for Resident #189's nursing home stay for the period of 11/01/24 through 01/31/25 but because his payer source was listed as private pay, a claim was never submitted to insurance for payment. The BOM stated typically when a resident had insurance coverage through a Managed Medicaid Plan, the resident had to remain at the facility for a period of 90 days then Medicaid could be notified to start the process for the resident to be disenrolled from the Managed Medicaid plan and switched to long-term traditional Medicaid. She stated Medicaid should have been notified on 01/18/25 to start the process for Resident #189 to be switched to long-term traditional Medicaid but there was nothing documented in his account. She stated had this been done, Resident #189 would likely not have owed anything to the facility. During an interview on 06/13/25 at 1:46 PM, the Administrator confirmed Resident #189 was issued a 30-day discharge notice on 01/28/25 due to non-payment. The Administrator was unaware that a claim was never submitted to Resident #189's Managed Medicaid plan for payment of his stay and could not provide an explanation why the insurance was not billed. She explained he was issued the discharge notice strictly for non-payment of his Managed Medicaid Plan co-payment amount and not for the entire balance owed to the facility. The Administrator stated she was told by the former BOM that Resident #189 had a monthly copay amount of $1,100 but was not sure how that amount was determined. The former Business Office Manager was unable to be interviewed during this investigation. During a follow-up interview on 06/13/25 at 3:02 PM, the BOM explained they typically didn't know if there was a co-payment amount owed until the claim was submitted to the Managed Medicaid Plan and reconfirmed a claim was never submitted to Resident #189's Managed Medicaid plan for his entire stay at the facility.

Based on record review and staff interviews, the facility failed to complete a discharge summary that included a recapitulation of the resident's stay and final summary of the resident's status for 1 of 3 sampled residents reviewed for discharge (Resident #189). Findings included: Resident #189 was admitted to the facility on [DATE]. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #189 had intact cognition and there was no active discharge plan in place. The discharge MDS assessment dated [DATE] revealed Resident #189 discharged to the community. Review of Resident #189's electronic medical record on 06/11/25 revealed an assessment titled Discharge Summary (Recap [recapitulation] of Resident's Stay) dated 02/24/25 had a status of in progress. The discharge summary assessment consisted of 5 sections to complete: 1) Discharge Information such as location, date of discharge, referrals, and primary provider contact information, 2) Recap of Stay that included sub-sections for Nursing, Therapy, Dietary, Social Services, and Activity to document discharge summaries, 3) Reason for Discharge, 4) Medical Summary that included medical diagnosis, course of treatment, discharge plan, and date/time of follow-up appointment(s), and 5) Acknowledgement with a section for the resident or representative to sign and date and also included check boxes for documentation provided to the resident/representative at the time of discharge such as laboratory results, radiology results, consultation notes, medications sent with the resident, and a copy of the discharge summary. All sections except for the Therapy discharge summary were left blank. During an interview on 06/13/25 at 9:12 PM, the Social Worker (SW) explained when a resident was ready for discharge he (the SW) was the one who typically initiated the discharge summary-recapitulation of stay assessment for each department manager to complete their section. The SW confirmed Resident #189's discharge summary-recapitulation of stay assessment was opened on 02/24/25 and the Therapy discharge summary was the only section completed, all other sections of the assessment were left blank, including the Social Services section he was responsible for completing. The SW stated he was not always consistent with entering his documentation in a resident's medical record and although he did not have any documented evidence, a care plan meeting was held with Resident #189 and his representative on 02/24/25 to discuss his discharge plans and needs. The SW stated during the care plan meeting, prescriptions were provided to Resident #189's representative to have filled along with a cushion for his wheelchair and bedside commode for him to have once he discharged from the facility. The SW explained Resident #189 the completion of his discharge summary-recapitulation of stay assessment was just overlooked. During an interview on 06/13/25 at 1:46 PM, the Administrator was unaware Resident #189's discharge summary-recapitulation of stay assessment was not completed upon his discharge from the facility. The Administrator stated she would expect for discharge summary-recapitulation of stay assessments to be completed in their entirety with input from all disciplines per the regulatory guidelines.

2. Resident #5 was admitted to the facility on [DATE] with diagnoses that included cerebral palsy (group of disorders that affect movement, balance and posture). The admission Minimum Data Set (MDS) dated [DATE] revealed Resident #5 had intact cognition. He required partial/moderate to substantial/maximum staff assistance with self-care tasks and was dependent on staff for mobility and transfers. It was noted on the MDS assessment that Resident #5's activities of daily living functional/rehabilitation potential would be addressed in the care plan. The significant change MDS dated [DATE] revealed Resident #5 had intact cognition. He required supervision or touching assistance with eating and was dependent on staff for all other self-care tasks. He required substantial/maximum staff assistance with rolling left-to-right and from a sit-to-lying position and was dependent on staff with lying-to-sitting on the side of the bed and transfers. It was noted on the MDS assessment that Resident #5's activities of daily living functional/rehabilitation potential would be addressed in the care plan. Resident #5's comprehensive care plans, last revised on 04/01/25, included a plan that addressed his limited physical mobility related to weakness and cerebral palsy with the following interventions: invite him to activity programs that encourage physical activity/mobility, monitor/document/report as needed any signs/symptoms of immobility, and provide gentle range of motion as tolerated with daily care. There was no care plan that addressed his need for assistance with activities of daily living (ADL) such as transfers, bathing, personal and oral hygiene. During an interview on 06/09/25 at 11:36 AM, Resident #5 revealed he could eat independently with set-up assistance but was dependent on staff assistance for all other ADL tasks. Resident #5 stated staff used a mechanical lift when assisting him with transfers. During an interview on 06/13/25 at 11:02 AM, the Regional MDS Consultant revealed the facility was currently without a MDS Coordinator and she had been filling in to assist with completing MDS assessments and updating care plans as needed. She explained Resident #5's limited physical mobility was addressed in his comprehensive care plans; however, it did not address his care needs. She stated it was overlooked due to the facility not having a MDS Coordinator and there should have been a care plan developed with interventions that addressed his ADL care needs and transfer status which would be important information for staff to know. During an interview on 06/13/25 at 1:46 PM, the Administrator revealed she would expect care plans to be developed to accurately reflect the resident's ADL care needs and transfer status. Based on record review and staff interviews, the facility failed to develop care plans in the area of transfers, bathing, and personal and oral hygiene for 2 of 11 residents whose activities of daily living (ADL) care plans were reviewed (Resident #51 and Resident #5). Findings included: 1. Resident #51 was admitted to the facility 04/01/25 with a diagnosis including acquired absence of right leg below knee. The admission Minimum Data Set (MDS) assessment dated [DATE] reflected Resident #51 was cognitively intact and required substantial/maximum assistance for transfers. Resident #51's comprehensive care plan initiated 04/21/25 for ADL self-care performance deficit related in part to a right below the knee amputation did not reflect his need for assistance with transfers. An interview with the Regional MDS Consultant on 06/13/25 at 11:14 AM revealed Resident #51's transfer status should be reflected on his care plan. She stated it was overlooked due to MDS staff having a personal emergency when Resident #51's care plan was initiated. The Regional MDS Consultant stated the transfer status of Resident #51 would be important information for staff to know. An interview with the Administrator on 06/13/25 at 2:46 PM revealed she expected care plans to be developed to accurately address the resident's transfer status.

Based on record review and interviews with the staff, resident and the Nurse Practitioner (NP), the facility failed to request a refill from the pharmacy prior to the last dose being administered resulting in a resident missing 3 doses of the scheduled medication for 1 of 9 residents reviewed for unnecessary medications (Resident #16). Findings included: Resident #16 was admitted to the facility on [DATE] with diagnosis that included hypertensive heart disease without heart failure. The annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #16 had intact cognition. A physician order dated 04/20/24 revealed Resident #16 was to receive prazosin hydrochloride (medication used to lower blood pressure) 5 milligrams (mg) at bedtime for blood pressure related to hypertensive heart disease without heart failure. A physician order dated 04/21/24 revealed Resident #16 was to receive amlodipine (medication used to lower blood pressure) 5 mg once a day at 9:00 AM for arterial hypertension related to hypertensive heart disease without heart failure. The Medication Administration Record (MAR) for the period of 06/07/25 through 06/11/25 revealed Resident #16 received his scheduled doses of amlodipine daily as physician ordered. Further review revealed Resident #16 received his last scheduled dose of prazosin hydrochloride medication on 06/07/25 at 9:00 PM. For the 06/08/25 scheduled dose of prazosin hydrochloride, Nurse #3 noted a chart code of 9=Other/See Progress Note to indicate the medication was not administered. For the 06/09/25 and 06/10/25 scheduled doses of prazosin hydrochloride, a chart code H was documented indicating the medication was held. It was further noted on the MAR under the medication order that the medication was held starting 06/09/25 at 9:00 PM to 06/10/25 at 1:28 AM and again from 06/10/25 at 7:23 PM to 06/11/25 at 7:22 PM. Further review revealed Resident #16 received his next scheduled dose of prazosin hydrochloride on 06/11/25 at 9:00 PM. Continued review of Resident #16's MAR for the period of 06/07/25 through 06/11/25 revealed his blood pressure (BP) vital signs were documented as follows: 06/07/25 during the day shift (7:00 AM to 7:00 PM) his BP was 141/78 and during the evening shift (7:00 PM to 7:00 AM) his BP was 138/74. 06/08/25 during the day shift his BP was 142/79 and during the evening shift his BP was 137/77. 06/09/25 during the day shift his BP was 166/97 and during the evening shift his BP was 164/98. 06/10/25 during the day shift his BP was 161/87 and during the evening shift his BP was 149/96. 06/11/25 during the day shift his BP was 177/99 and during the evening shift his BP was 147/86. During a phone interview on 06/13/25, Nurse #3 recalled when she went to administer Resident #16's prazosin hydrochloride medication on 06/08/25 there was none available on the medication cart. Nurse #3 stated when she clicked on the medication order, she saw that a refill had been requested from the pharmacy, so she marked the order as held on Resident #16's MAR. Nurse #3 stated she did not contact the pharmacy on 06/08/25 to inquire on the status of the refill request nor did she notify the Director of Nursing (DON). Nurse #3 stated when she worked her next scheduled shift on 06/11/25, the medication was available on the medication cart and Resident #16 was administered his scheduled dose. During an interview on 06/11/25 at 11:25 AM, Nurse #4 revealed her scheduled hours were 7:00 AM to 7:00 PM and she did not work over the weekend (06/07/25 or 06/08/25) but Resident #16 had informed her he did not receive his prazosin hydrochloride medication. Nurse #4 confirmed there was no prazosin hydrochloride medication currently available in the medication cart for Resident #16. A review of the pharmacy refill order for Resident #16's prazosin hydrochloride medication provided by the Director of Nursing on 06/11/25 at 4:24 PM revealed on 06/09/25 it was noted a medication order from the pharmacy was on hold. On 06/10/25 it was noted the medication was on still on hold pending clarification and receipt of a prescription from the NP. On 06/11/25 at 8:27 AM the pharmacy received a faxed prescription from the NP and the medication was dispensed to the facility (no time was listed). During interviews on 06/09/25 at 2:11 PM and 06/11/25 at 3:47 PM, Resident #16 was lying in bed displaying no signs of distress. He stated the prazosin hydrochloride medication was prescribed for his blood pressure. Resident #16 stated he thought it had been about 10 days since he had received the medication and his blood pressure had increased as a result. Resident #16 stated he spoke with the NP about why he hadn't gotten his medication on Monday (06/09/25) and she had told him that he had been receiving it all along; however, Nurse #3 told him on Sunday (06/08/25) that there was none on the cart to administer and she had put a stop on the medication. During an interview on 06/11/25 at 4:03 PM, the DON explained residents should never run out of their medications as nurses should request a refill from the pharmacy 5 to 7 days before the last dose was used so there was no gap in administration. She stated the pharmacy delivered twice daily; the first delivery between 3:30 PM to 4:00 PM and the second delivery around midnight. If a medication did run out, nurses were expected to request a refill and contact the pharmacy to see when the medication would be sent to the facility and then notify the provider for additional instructions if the resident would miss any scheduled doses of the medication. The DON stated the NP was notified and sent a prescription to the pharmacy on 06/10/25 to refill Resident #16's prazosin hydrochloride medication. The DON stated if a medication was ordered and did not arrive from the pharmacy, the nurse should have checked with the pharmacy and then notified her (DON) so she could follow up with the pharmacy. She stated no one had informed her that Resident #16's had missed scheduled doses of his prazosin hydrochloride medication because the medication had not been received from the pharmacy as requested and it was her expectation residents received their medications as ordered. During interviews on 06/12/25 at 12:55 PM and 1:20 PM, the NP confirmed she was notified Resident #16 had missed 3 doses of his prazosin hydrochloride medication. The NP stated she expected nurses to have a sense of urgency to reorder medication at least 7 days before the medication ran out, especially for controlled medications which could take longer to process, to avoid any gaps in medication administration. During an interview on 06/13/25 at 1:11 PM, the Administrator stated it was her expectation for nurses to have a sense of urgency to reorder medications at least 5 days before the medication ran out to ensure the resident had a continuous supply of medication as needed and ordered.

Based on observations, record review, and staff interviews, the facility failed to assess the risks of entrapment and complete bed rail assessments and failed to obtain informed consent prior to the installation for 2 of 3 residents reviewed for bed rails (Resident #4 and Resident #76). Findings Included: 1. Resident #4 was admitted to the facility 01/21/25 with diagnoses including dementia and Parkinson's disease (a brain disorder that can cause uncontrollable movements). A review of Resident #4's electronic medical records revealed no bed rail assessments had been completed since admission to the facility on [DATE]. The significant change in status Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #4 was rarely or never understood, and her cognition was severely impaired. The MDS indicated Resident #4's range of motion was impaired on both sides of the upper and lower extremities, and she was dependent on staff assistance to roll left and right. The MDS revealed Resident #4's ability to move from lying to sitting on the side of the bed was not attempted due to medical or safety concerns and bed rails were not used as a physical restraint. An active physician's order revealed a pressure-reduced mattress was ordered on 4/23/25. During an observation on 06/12/25 at 2:28 PM, Resident #4 was resting in bed. Bilateral quarter length bed rails located at the head of bed were in an up position. Resident #4 was being repositioned by Nurse Aide (NA) #3 and was able to follow cues to grab and hold on to the bed rails with assistance to roll left and right. An air mattress was in place and inflated. There was no space between the air mattress and bed rails and the rails were secured to the bed frame. During an interview on 06/12/25 at 2:28 PM, NA #3 revealed Resident #4 required one person assistance to roll from left to right for bed mobility. NA #3 revealed Resident #4 was able to understand simple cues to grab and hold on to the bed rail, but she was unsure the resident could physically use the bed rail without assistance. An interview was conducted on 06/13/25 at 1:12 PM with Nurse #2, the assigned nurse for Resident #4. Nurse #2 revealed Resident #4 required staff assistance to move side to side in the bed. Nurse #2 revealed bed rail assessments were included as part of the nurse's packet and completed upon admission and if used completed quarterly. Nurse #2 revealed Resident #4's cognition was impaired and for a resident cognitively impaired the Responsible Party would need to give consent for the use of bed rails. Attempt to interview Resident #4's Responsible Party on 06/13/25 at 9:55 AM was unsuccessful. An interview was conducted on 06/12/25 at 11:15 AM with the Rehab Therapy Director. The Rehab Therapy Director revealed a resident with poor cognition was at risk for entrapment or injury and not a good candidate for the use of bed rails and needed to be evaluated based on individual needs and/or case by case. She further revealed if a resident's cognition was impaired and they were unable to consent for the use of bed rails the Responsible Party would need to give consent. She revealed therapy did complete bed rails assessments when nursing requested and she thought nursing completed ongoing bed rail assessments. She revealed she was new to the facility since 04/2025 and it was discussed there was a need to implement a process for bed rail assessments and therapy would complete assessments, but she had not heard anything else about the process since last discussed on 05/13/25. During an interview on 06/13/25 at 12:55 PM, the Director of Nursing (DON) revealed she was aware bed rail assessments were not completed. She revealed the completion of bed rail assessments was a collective effort that included therapy and nursing and were done as needed and when a request was made. A joint interview was conducted on 06/13/25 at 2:55 PM with the Administrator and Regional Clinical Director of Operations. The Regional Clinical Director of Operations revealed bed rail assessments should be completed prior to the bed rails being placed on the bed and then quarterly. The Regional Clinical Director of Operations revealed Resident #4's bed rail assessment would need to be completed by therapy and discussed with nursing. She further revealed that maintenance should inspect bed rails properly fit and were secured to the bed and ensure there was no space between the mattress and bed rails for a resident to become entrapped including when the air mattress was newly placed. The Administrator confirmed bed rails assessments should be completed prior to being placed on the bed, upon admission, and quarterly. 2. Resident #76 was admitted to the facility on [DATE] with diagnoses including non-displaced fracture of the right humerus and osteoporosis. A review of Resident #76's electronic medical records revealed she was her own Responsible Party. A review of Resident #76's electronic medical records revealed no bed rail assessments had been completed since admission to the facility on [DATE]. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #76 was rarely or never understood, and her cognition was moderately impaired. The MDS indicated Resident #76's range of motion was impaired on one side of her upper extremity and substantial to maximal assistance was needed to roll left to right and move from a lying to sitting on the side of the bed. The MDS revealed Resident #76 was able to walk 150 feet with supervision and bed rails were not used as a physical restraint. During an observation on 06/10/25 at 12:22 PM, Resident #76 was sitting upright in bed eating lunch with the head of the bed raised approximately 90 degrees. Quarter length bilateral bed rails located at the head of bed were in the up position. The bed rails were secured to the bed frame and there was no space between the mattress or rails. During an observation on 06/11/25 at 10:20 AM, Resident #76 walked around in her room and was able to stand from a sitting position off the side of the bed adlib (as desired) without assistance. Bilateral quarter bed rails were in the up position and Resident #76 did not use the rails when she stood up from the bed. Resident #76 did not verbally respond to questions and did not confirm she used the bed rails for mobility. The bed rails were secured to the bed frame and there was no space between the mattress or rails. During an interview on 06/13/25 at 2:29 PM, NA #3 revealed Resident #76 was able to roll left and right, stand up from the bed and walk adlib without staff assistance. An interview was conducted on 06/13/25 at 1:12 PM with Nurse #2, the assigned nurse for Resident #76. Nurse #2 revealed Resident #76 was able to roll left and right in bed and use the bed rails for mobility and walked about the facility without assistance. Nurse #2 revealed bed rail assessments were included as part of the nurse's packet and completed upon admission and if used completed quarterly. Nurse #2 revealed Resident #76's cognition was impaired and for a resident cognitively impaired the Responsible Party would need to give consent for the use of bed rails. An interview was conducted on 06/12/25 at 11:15 AM with the Rehab Therapy Director. The Rehab Therapy Director revealed a resident with poor cognition was at risk for entrapment or injury and not a good candidate for the use of bed rails and needed to be evaluated based on individual needs and/or case by case. She further revealed if a resident's cognition was impaired and they were unable to consent for the use of bed rails the Responsible Party would need to give consent. She revealed therapy did complete bed rails assessments when nursing requested and she thought nursing completed ongoing bed rail assessments. She revealed she was new to the facility since 04/2025 and it was discussed there was a need to implement a process for bed rail assessments and therapy would complete assessments, but she had not heard anything else about the process since it was discussed on 05/13/25. During an interview on 06/13/25 at 12:55 PM, the Director of Nursing (DON) revealed she was aware bed rail assessments were not completed. She revealed the completion of bed rail assessments was a collective effort that included therapy and nursing and were done as needed and when a request was made. A joint interview was conducted on 06/13/25 at 2:55 PM with the Administrator and Regional Clinical Director of Operations. The Regional Clinical Director of Operations revealed bed rail assessments should be completed prior to the bed rail being placed on the bed and then quarterly. She further revealed that maintenance should be inspecting bed rails properly fit and were secured to the bed to ensure there was no space between the mattress and bed rails for a resident to become entrapped. The Administrator confirmed bed rails assessments should be completed prior to being placed on the bed, upon admission, and quarterly.

Based on record review, and staff, resident, family, and Nurse Practitioner interviews, the facility failed to provide ongoing, consistent, effective means of communication for a resident (Resident #69) to be able to communicate. Resident #69's primary language was Spanish, and she did not speak English. This deficient practice occurred for 1 of 1 resident reviewed for medically related social services. Findings included: Resident #69 was admitted to the facility on [DATE]. Her diagnoses included cerebral infarction (stroke) and hemiplegia (paralysis) affecting the dominant right side. The quarterly Minimum Data Set Assessment (MDS) dated [DATE] revealed Resident #69 was cognitively intact. It was documented on the MDS Resident #69's preferred language was Spanish, and she needed an interpreter. A care plan dated 1/12/25 read: Resident #69 has a communication problem related to language barrier; resident speaks Spanish language. The care plan goal was for her to be able to make basic needs known. The care plan interventions included anticipating and meeting needs. To be conscious of position when in groups, activities, dining room to promote proper communication with others. Discuss with resident/ family concerns or feelings regarding communication difficulty. encourage resident to continue stating thoughts even if resident is having difficulty, focus on a word or phrase that makes sense, or respond to the feeling she is trying to express. Ensure/ provide a safe environment. Monitor/ record confounding problems. Monitor/ document physical/ nonverbal indicators of discomfort or distress, and follow-up as needed. Monitor/ document frustration level, wait 30 seconds before providing resident with word. Monitor/ document resident ability to express and comprehend language, speak on an adult level speaking clearly and slower than normal. An observation and interview were conducted with Resident #69 on 6/9/24 at 10:52 AM. Resident #69 was observed in her room in her bed covered with a sheet. She was noted to be grimacing. When the surveyor spoke to Resident #69, she started speaking in Spanish. The Surveyor asked Resident #69 habals ingles (you speak English)? and Resident #69 replied no. The roommate approached Resident #69's bed while the surveyor was in the room and translated what Resident #69 was saying. An additional interview was conducted on 6/12/25 at 2:13 PM with Physical Therapy Assistant (PTA) #1 providing translation. Resident #69 reported staff not being able to understand her and her not being able to let them know what she needs makes her feel very bad. When asked if she understood staff when they came to provide care, Resident #69 said no not really. Resident #69 reported that her roommate was the only one who helped her communicate and that sometimes her roommate got upset because she got asked too much. Resident #69 stated staff did not try to communicate with her using their phones to translate. An interview was conducted with Nurse #4 on 6/9/25 at 11:01 AM. Nurse #4 stated Resident #69's roommate could speak English and Spanish and usually could interpret what Resident #69 needed. She stated the roommate would ring the bell if Resident #69 needed something and told staff what she needed. Nurse #4 reported sometimes there were NAs (Nurse Aides) who could speak Spanish and that one of the therapists knew Spanish. Nurse #4 said if no one was around that spoke Spanish then she looked for non-verbal cues such as facial grimacing for pain. She said sometimes Resident #69 would use gestures and point at her mouth if she was hungry. Nurse #4 said there was an app on her phone for translation but that she had never used it. An interview was conducted with NA #8 on 6/10/25 at 10:21 AM. NA #8 said she had cared for Resident #69 and reported she understood a little Spanish and could understand a little bit of what Resident #69 said. She said it depended on what Resident #69 was talking about whether she could understand her or not. NA #8 explained if she did not understand Resident #69, she would ask her roommate. She said her roommate was usually in the room. NA #8 said if the roommate was not in the room she would try to use google translate. NA #8 stated the facility had not told her how or what to do to communicate with Resident #69. An interview was conducted with NA #7 on 6/10/25 at 10:46 AM. She was assigned NA for Resident #69 on day shift (7:00 am to 7:00 pm) on Saturday (6/7/25) and Sunday (6/8/25). NA #7 stated she spoke very little Spanish. She explained Resident #69's roommate also spoke Spanish and could speak English as well. She said Resident #69's roommate rang the bell if Resident #69 needed something and lets the staff know what Resident #69 needs. NA #7 reported she communicated with Resident #69 by using gestures to indicate the type of care she was going to provide. NA #7 said she has a translation app on her phone that she used to communicate with Resident #69 sometimes. She explained that if Resident #69's roommate was in the room she used her to communicate, but if she was not in the room, she would use the app. The Surveyor asked if Resident #69's roommate was reliable to provide translation, NA #7 replied that she had dementia and said she gets confused sometimes. A telephone interview was conducted with the day shift weekend Nursing Supervisor on 6/10/25 at 11:50 AM. The Nursing Supervisor stated she used Resident #69's roommate to communicate with Resident #69. She reported the facility had not provided her with information or told her of any translation services that she should be used to communicate with individuals who did not speak English. An interview was conducted on 6/10/25 at 1:49 PM with Nurse #8. Nurse #8 said she had worked day shift on 6/7/25 and had been the assigned nurse for Resident #69. She explained Resident #69 spoke Spanish and did not speak English. Nurse #8 reported she had not been told how to communicate with Resident #69 and she stated she had used gestures to communicate with Resident #69. An interview was conducted on 6/10/25 at 2:15 PM with Nurse #9. She explained she worked night shift (7:00 pm to 7:00 pm) Saturday 6/7/25 and had been Resident #69's assigned nurse. She explained Resident #69 spoke Spanish and did not understand English. Nurse #9 reported no one had told her how to communicate with Resident #69. A telephone interview was conducted with NA #6 on 6/10/25 at 3:35 PM. NA #6 reported Resident #69 spoke very few English words and that her roommate translated for her a lot. An interview was conducted with Nurse #3 on 6/12/25 at 6:25 AM. She stated she was Resident #69's assigned nurse on Sunday during night shift. Nurse #3 said she tried to use the app on her phone to communicate with Resident #69, but it was hard to use it for communication. Nurse #3 reported the facility had not told her how to communicate with Resident #69. Nurse #3 reported she used what she had so she could communicate as much as possible with Resident #69 but that she had not gotten anything specific from the facility on what to use to communicate with her. An interview was conducted with NP #1 on 6/10/25 at 4:16 PM. NP #1 reported she used an interpreter service to translate when she saw Resident #69. She reported she was familiar with Resident #69's roommate. NP #1 reported the roommate was not a reliable interpreter for staff to be using and the roommate was not medical. NP #1 stated staff should be using a translator service to communicate with Resident #69. NP #1 explained when she saw Resident #69 this morning, she had said no one had spoken to her in Spanish and she had asked the Administrator about it. She reported Resident #69 had been asking for pain medication and for staff to elevate her leg and that staff did not understand. NP #1 stated the Administrator had told her the facility had a translator service, but NP #1 stated she had never seen anyone use it. An interview was conducted with the Social Worker (SW) on 6/11/25 at 10:25 AM. The SW reported he was not sure who would set up translation services or what services staff were supposed to use to communicate with non-English speaking residents. He said he was not sure but would find out. The SW indicated he personally did not know how staff communicated with Resident #69 or what was supposed to be in place for communication for her but that he would find out. The SW stated Resident #69's roommate was Spanish speaking but was stronger with Spanish than English communicating. The SW reporter said Resident #69 roommate did have a diagnosis of dementia and that he did not know if she would be reliable for translation. The SW stated when he had done Resident #69's assessments he had used her family member to translate. The SW explained he had not been told by the facility about any translation services that should be used. He said there should be a defined way for staff to communicate with Resident #69 and was not really sure why there was not. An interview was conducted with the Director of Nursing (DON), The Regional Clinical Director, and the Administrator on 6/12/25 at 4:00 PM. They acknowledged there should be translation services in place to communicate with Resident #69. The Regional Clinical Director stated there was nothing in place but that it was in the process of getting set up now. The Regional Clinical Director stated they had started working on that this week.

Based on record review and interviews with the staff and the Nurse Practitioner (NP), the facility failed to have effective systems in place for acquiring a scheduled opioid pain medication when nursing staff failed to request a prescription from the medical provider to avoid a gap in medication administration when refilling a controlled medication, and failed to utilize pharmaceutical resources in Pyxis (an automated dispensing machine that provided secure medication storage) which resulted in Resident #139 missing 3 days of a scheduled pain medication. This deficient practice occurred for 1 of 8 residents reviewed for pharmacy services (Resident #139). The findings included: Resident #139 was admitted to the facility on [DATE] with diagnoses including osteoporosis. She expired in the facility on [DATE]. The physician's order dated [DATE] revealed Resident #139 had an order to receive 1 tablet of tramadol (an opioid pain medication used to treat moderate to severe pain) 50 milligrams (mg) by mouth once daily in the evening for generalized pain. The [DATE] Medication Administration Record (MAR) revealed the last tablet of Resident #139's tramadol was administered by Nurse #5 on [DATE] around 5:00 PM. Resident #139 did not receive her scheduled daily tramadol from [DATE] to [DATE] as it was initialed by Nurse #6 with a 9 on the MAR which coded as see progress notes on [DATE]; and initialed by Nurse #2 with a 9 again on [DATE] and [DATE]. A review of Resident #139's medical records revealed no progress notes were documented on [DATE]. A review of nurse's progress note documented by Nurse #2 on [DATE] revealed Nurse #2 had initiated the refilling process and was waiting for the NP to sign the prescription for Resident #139's tramadol. On [DATE] at 6:25 PM, Nurse #2 documented she called the pharmacy to follow up with the status of Resident #139's tramadol. She was told by the pharmacy staff that Resident #139's tramadol would be delivered on the next run, and it would arrive around midnight. A review of Pyxis records and inventory list for [DATE] revealed 250 different medications were kept in the Pyxis for emergency uses. Further review of the Pyxis Inventory Replenishment Report dated [DATE] revealed the facility had 13 tablets of tramadol 50 mg in the Pyxis. During an interview conducted on [DATE] at 10:47 AM, Nurse #2 acknowledged that she provided care for Resident #139 on [DATE] and [DATE] on the first shift from 7:00 AM to 7:00 PM and confirmed Resident #139 did not receive her scheduled daily tramadol from [DATE] to [DATE]. She recalled when she tried to administer tramadol for Resident #139 on [DATE] around 5:00 PM, she found that the last tablet was administered by Nurse #5 on [DATE]. Nurse #2 stated she initiated the refilling process through the pharmacy immediately that evening and had the whole process set up except needing the NP's signature. Then, she checked Pyxis for a tablet of tramadol for Resident #139 and unfortunately, she had issues logging in to Pyxis as she had not logged in for a while. She requested 2 other nurses working on the same shift to assist and log in to Pyxis, but they were unsuccessful. Nurse #2 acknowledged that she did not notify the Director of Nursing (DON) about the issue related to Pyxis. Nurse #2 stated she communicated with the oncoming nurse (Nurse #7) regarding the incident during shift transition. Before she started passing the evening medication around 4:00 PM on [DATE], Nurse #2 found out that the pharmacy had not delivered Resident #139's tramadol. She called the pharmacy again at 4:30 PM and was told that the pharmacy had received the prescription, and Resident #139's tramadol would be delivered on the next run arriving around midnight. She indicated Nurse #5 who had administered the last tablet of Resident #139's tramadol on [DATE] should have requested the prescription for the scheduled tramadol. Nurse #2 indicated she was shocked to learn that Nurse #6 who worked on the first shift from 7:00 AM to 7:00 PM on [DATE], did not request the prescription for Resident #139's tramadol when it had run out. Otherwise, Resident #139 would not have to be out of the scheduled tramadol for 3 days in a row. Nurse #2 explained she did not try to fill the prescription through the local back-up pharmacy on [DATE] as the pharmacy told her that they were on the way to deliver the ordered tramadol. A phone interview was attempted with Nurse #5 on [DATE] at 12:30 PM. Nurse #5 worked first shift on [DATE] and administered the last tablet of tramadol for Resident #139. Nurse #5 stated she was busy when she answered the call and requested the Surveyor to call back at 8:00 PM in the evening. When the Surveyor called again on [DATE] at 8:00 PM, Nurse #5 did not answer the call, and a voice message was left. Nurse #5 did not return the call. During a phone interview conducted on [DATE] at 12:36 PM, Nurse #6 who worked on first shift on [DATE] stated he could not remember the incident related to Resident #139's tramadol that ran out in [DATE] and unable to provide any pertinent information as he was an agency nurse. He recalled picking up a few shifts in the facility early [DATE]. During an interview conducted on [DATE] at 12:55 PM, the NP stated the missing of Resident #139's once daily scheduled tramadol for 3 days in a row could have been avoided if the staff had a sense of urgency to request a prescription for the scheduled tramadol at least 7 days before it ran out. The NP further stated she expected nursing staff to fully utilize the pharmaceutical resources in Pyxis, or the local back-up pharmacy as needed as indicated. It was her expectation for all the nurses to start the refilling process earlier to avoid any gaps in medication administration. An interview was conducted with the DON on [DATE] at 10:12 AM. She stated all the nurses should start the refilling process at least 5-7 days before the last pill was used up to avoid gaps in medication administration, especially for those controlled medications that could take a longer time. She stated the pharmacy delivered 2 times daily at 4:00 PM and mid-night. The root cause of this incident was lack of a sense of urgency among nursing staff. It was her expectation for all the residents to receive their medications as ordered in a timely manner. During an interview conducted on [DATE] at 1:11 PM, the Administrator expected all the nurses to have a sense of urgency to start the refilling process at least 5-7 days before the medication ran out to ensure continuous supply of medication as needed as indicated. She indicated the incident was caused by multiple factors. She expected nursing staff to fully utilize the resources in Pyxis and the local back-up pharmacy as needed to meet the pharmaceutical needs of the residents.

Based on record review, review of video footage, resident and staff interviews, the facility failed to protect a resident's right to be free from physical abuse when a moderately cognitively impaired resident (Resident #3) used a closed fist and punched a severely cognitively impaired resident (Resident #4) in the face. Resident #4 fell backwards, hit her head on the floor and was sent to the emergency room for further evaluation. A computed tomography (CT) scan of the head identified a small intraventricular hemorrhage (a small amount of bleeding inside the ventricles that produce fluid to protect and cushion the brain in the skull) and a scalp hematoma (a collection of blood between the skull the scalp). Neurosurgery was consulted and considered the intraventricular hemorrhage stable, and no further treatment was required, and Resident #4 returned to the facility. Additionally, the facility failed to protect a residents' right to be free from physical abuse when Resident #3 shoved a severely cognitive impaired resident (Resident #12) causing her to fall to the floor. Resident #12 was not injured as a result of the fall. A reasonable person would experience feelings of fear, pain, and anxiety as a result of being physically abused in their home. The deficient practice occurred for 2 of 4 residents (Resident #4 and Resident #12) reviewed for abuse. Findings included: a) Resident #3 was admitted to the facility on [DATE] with diagnoses including dementia, traumatic brain injury (a disruption of normal brain activity), manic depression/bipolar disorder (a mental health condition causing extreme mood changes), unspecified impulse disorder, and seizures related to diffuse traumatic brain injury. The annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #3's speech was clear, hearing and vision were adequate, he had the ability to be understood and understand others, and his cognition was moderately impaired. No physical or other behaviors had occurred during the MDS lookback period. Resident #3 was independent with transfers and walking. Manic depression/(bipolar disease) was an active diagnosis and Resident #3 was currently taking antipsychotic and antidepressant medication. A review of Resident #3's current medication orders included valproic acid 250 milligrams (mg) give one capsule three times a day for bipolar disorder, olanzapine (antipsychotic) 5 mg give one tablet twice a day related to bipolar disorder and unspecified impulse disorder, phenytoin sodium (anticonvulsant) 100 mg extended release give 3 capsules at bedtime for seizures related to diffuse traumatic brain injury. A review of a monitoring tool document dated 3/16/25 revealed Resident #3 was being monitored every 15 minutes after he shoved Resident #12 causing her to fall. The tool was initialed by staff to indicate monitoring of Resident #3 had continued from 3/16/25 and was currently ongoing. The care plan last revised on 3/21/25 revealed Resident #3 had the potential to be verbally aggressive related to a diagnoses of traumatic brain injury, depression, neurocognitive disorder with impulse control disorder. The care plan revealed Resident #3's behaviors were triggered related to his personal belongings and personal space. Interventions included frequent observation, administer medications as ordered and monitor/document for side effects and effectiveness, analyze key times, places, circumstances, triggers, and what de-escalates behavior and document. Resident #4 was admitted to the facility on [DATE] with diagnoses including dementia, metabolic encephalopathy (impaired brain dysfunction causing increased confusion) pneumonia, and respiratory failure. A review of Resident #4's current physician orders revealed no order in place for administration of anticoagulant (increase the time it takes blood to clot) or antiplatelet (reduces the ability of the blood to form a clot) medications. The admission MDS assessment dated [DATE] revealed Resident #4's hearing was highly impaired, speech was unclear, her cognition was severely impaired and sometimes she understood. During the MDS lookback period Resident #4 had demonstrated physical behaviors directed towards others and other behaviors not directed towards others for 1 to 3 days and had rejected care 1 to 3 days. Resident #4 was independent with walking and received no anticoagulant or antiplatelet medications. Resident #4's care plan last revised on 4/14/25 identified she was at risk of falls due to poor safety awareness. Interventions included physical therapy to evaluate and treat as ordered and as needed. The care plan identified Resident #4's behaviors of yelling out, resisting care, refusing medications, impaired cognitive function and communication problems related to dementia and metabolic encephalopathy. Interventions included anticipate and meet the resident's needs, cue, reorient and supervise as needed. Be conscious when Resident #4 was in groups, activities, or the dining room to promote proper communication with others. A review of the video camera footage on 4/24/25 at 12:46 PM revealed on 4/6/25 at 6:30 PM Resident #3 was sitting in a wheelchair in the hallway approximately six feet away from the nurse station on the upper unit. Several nurse and Nurse Aide (NA) staff were around the area and Resident #3 was calm and did not attempt to hit or grab others when they passed. At 6:54 PM Resident #4 came from a room and pointed her finger at Resident #3 and continued to walk pass the nurse station towards Resident #3. As Resident #4 got closer Resident #3 used both arms to create a circular space in front of his chest. Resident #4 continued towards Resident #3 until she stood approximately two feet away facing the left side of Resident #3's wheelchair. Resident #3 extended his left arm and pointed his finger at Resident #4's face. NA #1 stood in front of the nurse station approximately five or six feet away from Resident #3 and #4 and looked up and started to walk towards them. Resident #4 leaned forward to get closer to Resident #3 and without hesitation Resident #3 extended his left arm, used his fist, and hit Resident #4 in the mouth. Resident #4's body fell backwards causing her head to hit the floor. A progress note dated on 4/6/25 at 7:41 PM written by Nurse #1 read in part, Resident #4 was standing next to Resident #3 and as staff tried to redirect Resident #3 punched Resident #4 in the mouth. Resident #4 fell backwards and hit her head on the floor. The note revealed Resident #4 had swelling and bleeding to mid lip, a bump (hematoma) on the back of the head, and a quarter size skin tear on the left elbow. A review of the emergency room report revealed on 4/7/25 a diagnostic CT scan of Resident #4's head identified a small volume, right lateral intraventricular hemorrhage, and scalp hematoma. After neurosurgery consult it was noted the brain bleed was stable and Resident #4 was safe to return to the facility. Discharge instructions recommended Resident #4 to return to the neurosurgery clinic and have a repeat CT scan in 3 to 4 weeks. A review the current physician orders revealed Resident #4's repeat CT scan was scheduled on 5/1/25 at 10:00 AM. A review of the emergency room discharge report revealed Resident #3 was evaluated on 4/6/25 for aggressive behaviors noted as punching another resident. The note revealed Resident #3 denied any physical altercation occurred. A urinalysis identified a moderate amount of leukocyte esterase (white blood cells associated with a urinary tract infection). A physician's order was included for cefuroxime (antibiotic) 500 mg give one tablet twice a day for 7 days (14 doses) to treat or prevent infection and recommended Resident #3 follow up with his primary physician. Resident #3 was discharged back to the facility on [DATE]. A review of Resident #3's electronic Medication Administration Record (MAR) revealed the physician's order for cefuroxime 500 mg give one tablet twice a day for 7 days was scheduled to be administered at 9:00 AM and 9:00 PM. Nurses initialed the first dose was administered on 4/8/25 at 9:00 PM and continued to be administered as ordered with the last dose given on 4/15/25 at 9:00 AM (14 doses). A phone interview was conducted on 4/25/25 at 1:46 PM with NA #1. NA #1 confirmed she had worked on the upper unit from 7:00 AM through 7:00 PM on 4/6/25. NA #1 revealed she was at the nurse station giving report when she heard someone call out, grab her. NA #1 revealed when she turned around she saw Resident #3 use his fist to punch Resident #4 in the face causing Resident #4 to fall backwards onto the floor. During a phone interview on 4/24/25 at 9:27 AM Nurse #1 revealed the altercation between Resident #3 and Resident #4 occurred on the upstairs unit during shift changed around 7:00 PM on 4/6/25 when she was giving report and counting medications with the oncoming nurse. Nurse #1 described Resident #4 had walked around most of the day and was known to exhibit wandering behaviors including getting into others personal space but, meant no harm. Nurse #1 revealed Resident #3 was sitting in his wheelchair in the hallway near the nurse station and Resident #4 had walked towards him. Nurse #1 stated she heard someone yell out, get her and before anyone did Resident #3 reached up and punched Resident #4 in the mouth causing Resident #4 to fall straight back hitting her head hard on the floor. Nurse #1 revealed after the altercation she checked Resident #4 for injury and her mouth was bleeding and swollen, there was a pump knot on the back of her head, and a skin tear on the left elbow. Nurse #1 revealed Resident #4 was sent to the emergency room after the fall and Resident #3 was sent within approximately an hour afterwards for evaluation of aggressive behaviors. Nurse #1 revealed Resident #3 had a history of aggressive behaviors, but she had not witnessed him hit another resident before the altercation on 4/6/25. Nurse #1 revealed Resident #4's room was relocated to the downstairs unit and Resident #3's room remained upstairs. Nurse #1 revealed she was educated to monitor Resident #3's whereabouts and redirect other residents and keep them away. Nurse #1 described Resident #3's behaviors as impulsive and not being able to understand how to interact with other residents with dementia. During a phone interview on 4/25/25 at 11:50 AM Nurse #2 revealed the altercation between Resident #3 and Resident #4 occurred on the upstairs unit on 4/6/25 at shift change when she was getting report and counting medications with the previous shift nurse. Nurse #2 stated she heard someone tell a NA, pull Resident #4 away from Resident #3 and when she looked up saw Resident #3 punch Resident #4 in the face causing her to fall backwards onto the floor. Nurse #2 described Resident #3 usually stayed to himself, did not like anyone touching him, and mostly stayed in either his room or the main dining room. Nurse #2 revealed she had not witnessed Resident #3 do anything like that before. Nurse #2 stated she had previously received education to separate residents in attempt to prevent resident-to-resident abuse and she tried to keep other residents away from Resident #3 to ensure they were not standing over him or got close and she did not leave other residents alone with Resident #3. Nurse #2 described Resident #4 like to roam and after the altercation a sitter was placed with her to observe for behaviors or a change of condition. A review of the facility's initial 24 hour report revealed it was completed by the previous Director of Nursing (DON) and dated 4/6/25 at 7:00 PM to indicate the time the facility became aware. The details revealed a resident was wandering and got in the face of another resident and was pushed hard causing a fall. The report indicated both residents were sent to the hospital. A review of the 5-day investigation completed by the previous DON indicated Resident #4's diagnosis of dementia and Resident #3's diagnosis of traumatic brain injury and newly identified acute urinary tract infection were contributing factors that lead to their altercation and unsubstantiated the allegation. During a phone interview on 4/23/25 at 4:46 PM the previous Director of Nursing (DON) confirmed she completed the initial 24 hour report and investigation that involved Resident #3 and Resident #4. She described Resident #3 had a history of traumatic brain injury and did not like others in his space and Resident #4 had wandering behaviors and on 4/6/25 got in Resident #3's face. She had watched the video camera and saw Resident #3 use hand gestures to redirect Resident #4 to move away and when Resident #4 did not she was pushed hard and fell on her back and hit head on the ground. The DON revealed both Resident #3 and #4 were sent to the hospital after the altercation and the hospital was asked to complete a psychiatric evaluation of Resident #3 for aggressive behaviors. She revealed Resident #3 returned with antibiotic treatment for a urinary tract infection. She revealed Resident #4 had small brain bleed the hospital said would resolve without treatment and to follow up with neurosurgery. The DON revealed Resident #4 had no changes in her level of consciousness or mobility after the altercation and room changes were made to prevent future interactions with Resident #3. She revealed facility staff were already educated on what triggered Resident #3's behaviors and to watch his hand gestures, and when another resident was around to move them away. During an interview on 4/24/25 at 3:32 PM the current DON revealed she started her position on 4/12/25 and on 4/6/25 she was the Assistant DON. She revealed Resident #3's location was being monitored prior to 4/6/25 and it was expected he was within eyesight of staff when up and out of his room. She described Resident #4 ambulated without assistance, had dementia, and might not understand hand gestures made by Resident #3 and after the altercation Resident #4 was relocated to a room on the downstairs unit. During an interview on 4/24/25 at 2:32 PM and 3:57 PM the Administrator revealed Resident #3's location on the unit was being monitored every hour prior to the altercation on 4/6/25. The Administrator revealed she did not think Resident #3's reaction was willful or that he intended to hurt Resident #4 because of his diagnosis of traumatic brain injury. The Administrator revealed Resident #3's hourly monitoring of location on the unit was ongoing and he was already on psychiatric caseload and the next scheduled visit was a tele-health visit on 4/28/25. Observations and interviews of Resident #3 were conducted on 4/23/25 at 5:00 PM and 4/24/25 at 7:45 AM. Resident #3's room was located on the upper unit. He was observed in the main dining room/common area sitting in his wheelchair alone at a table or with the wheelchair placed directly in front of the television. He was calm with no signs of increased agitation. When asked if he recalled hitting someone in the face with his fist Resident #3 denied he had hit anyone. Attempts to interview Resident #4 were unsuccessful. Observations of Resident #4 were conducted on 4/23/25 at 5:21PM and 4/24/25 at 8:08 AM. Resident #4's room was located on the lower unit. She was observed to ambulate without assistance. Nurse and NA Staff were observed to provide reassurance and cues for redirection. Resident #4 was not observed to wander. b) Resident #3 was admitted to the facility on [DATE] with diagnoses including dementia, traumatic brain injury (a disruption of normal brain activity), manic depression/bipolar disorder (a mental health condition causing extreme mood changes), unspecified impulse disorder, and seizures related to diffuse traumatic brain injury. The annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #3's speech was clear, hearing and vision were adequate, he had the ability to be understood and understand others, and his cognition was moderately impaired. No physical or other behaviors had occurred during the MDS lookback period. Resident #3 was independent with transfers and walking. Manic depression/(bipolar disease) was an active diagnosis and Resident #3 was currently taking antipsychotic and antidepressant medication. The care plan last revised on 3/21/25 identified Resident #3 had the potential to be verbally aggressive related to a diagnoses of traumatic brain injury, depression, and neurocognitive disorder with impulse control disorder. The care plan revealed Resident #3's behaviors were triggered related to his personal belongings and personal space. Interventions included frequent observation, administer medications as ordered and monitor/document for side effects and effectiveness, analyze key times, places, circumstances, triggers, and what de-escalates behavior and document. A review of Resident #3's current medication orders included valproic acid 250 mg give one capsule three times a day for bipolar disorder, olanzapine 5 mg give one tablet twice a day related to bipolar disorder and unspecified impulse disorder, phenytoin sodium 100 mg extended release give 3 capsules at bedtime for seizures related to traumatic brain injury. Resident #12 was admitted to the facility on [DATE] with diagnoses including dementia and cognitive communication deficit. The quarterly MDS assessment dated [DATE] revealed Resident #12's cognition was severely impaired and had demonstrated wandering behaviors that occurred 1 to 3 days during the lookback period. The MDS revealed Resident #12 was able to walk independently without assistance and did not take anticoagulant or antiplatelet medications. Resident #12's care plan last revised on 3/16/25 identified she was an elopement risk/wanderer related to poor safety awareness. Interventions included distract from wandering by offering activities, food, identify wandering patterns and intervene as appropriate and provide structured activities. The care plan identified Resident #12's cognitive/thought process was impaired related to dementia and included interventions to anticipate needs and allow adequate time to respond. A review of the nurse progress note dated 3/16/25 at 9:15 AM revealed Resident #12 was demonstrating behaviors that included going in resident rooms and taking tables, wheelchairs, and walkers and putting them in the hallway, pacing back and forth and was unable to redirect. A review of the incident report for Resident #12 revealed on 3/16/25 in the common area located on the upper unit Resident #12 started moving Resident #3's belongings and got in his personal space and was pushed that resulted in Resident #12 falling to the ground. No injuries were observed and 1:1 monitoring was initiated to ensure Resident #12's safety and implement redirection. The previous DON completed the report. A review of Resident #12's weekly skin assessment dated [DATE] noted normal skin color that was intact with no redness or bruising. A review of the facility's initial 24 hour report revealed the facility was made aware of an allegation of resident abuse on 3/16/25 at 12:50 PM. The details of incident revealed Resident #12 touched Resident #3's face and when Resident #3 asked Resident #12 to stop Resident #12 did not and was pushed causing her to fall. The previous DON completed the report. A review of a monitoring tool dated 3/16/25 at 2:00 PM revealed staff initialed Resident #3 was being monitored every 15 minutes after shoving Resident #12 causing her to fall. The monitoring times increased to every 30 to 45 minutes to every hour and was currently ongoing. A review of the facility's 5-day investigation revealed the altercation did not result in physical injury, harm or mental anguish and the allegation was unsubstantiated. The facility indicated the root cause of the abuse was Resident #12's insomnia and being newly diagnosed with a urinary tract infection contributed to increased wandering and an invasion of others personal space. The report was completed by the previous DON and included witness statements from NA #2 and a Speech Therapist. A review of Resident #12's MAR revealed cephalexin (antibiotic) 500 mg give one tablet every 12 hours was scheduled to be administered at 9:00 AM and 9:00 PM. Nurses initialed the first dose was given on 3/18/25 at 9:00 PM and continued every 12 hours until the last dose given on 3/25/25 at 9:00 AM to equal 14 doses. Melatonin 5 mg give one tablet at bedtime for insomnia was started on 3/24/25. During a phone interview on 4/25/25 at 12:57 PM, NA #2 confirmed she wrote the witness statement involving a physical altercation between Resident #3 and Resident #12 that happened on 3/16/25. NA #2 stated she saw was Resident #12 falling to the floor but did not see Resident #3 shove or push Resident #12. NA #2 revealed she was talking with the Speech Therapist who was standing in front of her and had a better view of what happened. NA #2 revealed she moved Resident #3 away from the area and obtained Resident #12's vital signs. NA #2 revealed she had not observed Resident #3 hit or push another resident prior to the incident on 3/16/25 and stated, he usually did not bother others. NA #2 described Resident #12 walked independently and wandered and stated, we try to redirect wanderers from getting into other residents' personal space and rooms. She described Resident #12 as unable to cognitively understand to stay away from Resident #3 including if he gestured for her to go away. During a phone interview on 4/25/25 at 2:40 PM, the Speech Therapist confirmed she wrote the witness statement involving a physical altercation between Resident #3 and Resident #12. The Speech Therapist stated she would refer to what was written on her statement was correct and Resident #3 shoved Resident #12 causing her to fall. The Speech Therapist revealed after the incident nursing took over. The Speech Therapist stated she had not observed Resident #3 be aggressive towards another resident and did not recall observing a prior physical altercation between residents. During a phone interview on 4/24/25 at 5:06 PM the previous DON stated after the altercation on 3/16/25 Resident #3's location was being monitored and was ongoing every hour to protect other residents. The DON stated Resident #3 did not typically bother others unless they got in his personal space or face. The DON revealed Resident #12 was not injured and she educated staff about what triggered Resident #3's behaviors and to redirect residents when they got close and in his personal space. A Nurse Practitioner (NP) progress note dated 3/18/25 revealed the NP saw Resident #3 for an angry outburst. The NP noted Resident #3's diagnoses of bipolar, impulse disorder, and traumatic brain disorder and was taking phenytoin. The NP considered the use of phenytoin was for bipolar disorder and made no changes to Resident #3's medications. A NP progress note dated 3/24/25 revealed Resident #3 medications were reviewed. Resident #3 continued to receive divalproex sodium 250 mg three times a day for seizures and behaviors related to bipolar and was followed by psychiatry. The NP noted a neurology consult was scheduled in June and during the exam Resident #3 was calm and cooperative with no behaviors and made no changes to his medications. During an interview on 4/24/25 at 3:32 PM the current DON revealed she started her position on 4/12/25 and previously was the Assistant DON. She revealed Resident #3 typically stayed to himself or near staff. She revealed Resident #3's location was being monitored, and it was expected he was within eyesight of staff when up and out of his room. She revealed Resident #3's room was relocated after the altercation with Resident #12 to prevent further interactions between the two. During an interview on 4/24/25 at 2:32 PM and 3:57 PM the Administrator revealed staff continued to monitor Resident #3's location on the unit every hour. The Administrator revealed she did not think Resident #3's actions were willful because of his diagnosis of traumatic brain injury and his room was relocated downstairs to separate him from Resident #12. The Administrator revealed Resident #3 was already on psychiatric caseload and the next scheduled visit was a tele-health visit on 4/28/25. Attempts to interview Resident #12 were unsuccessful. An observations of Resident #12 on 4/24/25 at 8:16 AM revealed her room was located on the lower unit. Resident #12 was asleep in bed and not observed to wander on the unit.

Based on observations, record review, staff and physician interviews the facility failed to notify the physician of an increase in the size of a sacral pressure ulcer for 1 of 3 residents, which resulted in a missed opportunity for a change in treatment (Resident #48). Findings included: Resident #48 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. The most recent quarterly Minimum Data Set ((MDS) dated [DATE] indicated Resident #48 had moderately impaired cognition and needed total assistance with transfers, eating, toileting, and personal hygiene and extensive assistance for bed mobility. The MDS also indicated an unhealed stage IV pressure ulcer was present upon admission. The MDS measurements revealed the length was 0.6cm (centimeters), the width was 0.6cm, and the depth was 1.0cm. Review of the revised care plan for Resident #48 dated 08/09/17 revealed a problem of impaired skin relate to a stage IV Pressure Ulcer (PU) to the sacrum. The interventions were for the nurse to measure and monitor the wound status and the progression or deterioration every week. The nurse was to notify the physician of worsening despite the treatment and wound care consults as indicated. The goal was for the pressure ulcer to show evidence of healing by a reduction in size or stage through the next review date. A review of the skin evaluation form dated 08/04/17 revealed the sacral PU had no drainage and the length was 0.6cm and the width was 0.6cm and depth was 1.0cm with no odor. The next skin evaluation dated 08/11/17 revealed the wound had serosanguineous (a thin, watery, pink or red in color) drainage with a mild odor and measured 1.0cm x 0.5cm x 1.5cm. The next documented evaluation dated 08/14/17 revealed a mild odor with serosanguineous drainage and measured 1.0cm x 0.5cm x 1.5cm. There were no skin evaluations forms documented for the week of 08/21/17 and week 08/28/17. The next documented skin evaluation dated 09/01/17 revealed a foul odor with sanguineous drainage and measured 1.6cm x 0.6cm x 1.8cm. A review of the communication book used to inform the MD confirmed there had been no documentation from 08/11/17 thru 09/08/17 that identified any changes to the sacrum wound for Resident #48. During an interview conducted on 09/08/17 at 8:06 AM Nurse #1 confirmed the last measurements she had documented were on the skin evaluation form dated 09/01/17. Nurse #1 also confirmed she had not notified the MD of any changes to Resident #48 wound. During an interview conducted on 09/08/17 at 2:54 PM the Director of Nursing (DON) revealed it was her expectation the nurses report any wound changes directly to her. The DON also revealed it was her responsibility to review the weekly wound measurements for a change. The DON could not explain why the increase to the sacral PU had not been reported to the MD. During an interview conducted on 09/08/17 at 3:56 PM the MD stated he had not been notified of the increased size of the sacral PU. He relied on the nurses to do weekly wound assessments and expected to be kept informed and notified of any wound changes. The MD also indicated he would have ordered a wound care consult for Resident #48 if he had been notified of the increased size of the sacral PU.

Based on observations, record review, staff, and physician interviews the facility failed to assess and document the condition of a resident's stage 4 sacral pressure ulcer (PU) weekly per the plan of care and failed to report the pressure ulcer was worsening despite treatment to the resident's physician (Resident #48) and the facility failed to assess an additional pressure ulcer weekly as indicated in the care plan (Resident #39) for 2 of 3 sampled residents reviewed for pressure ulcers. Findings included: 1.Resident #48 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. The most recent quarterly Minimum Data Set ((MDS) dated [DATE] indicated Resident #48 had moderately impaired cognition and needed total assistance with transfers, eating, toileting, and personal hygiene and extensive assistance for bed mobility, and was incontinent of bladder and bowel. The MDS also indicated an unhealed stage 4 PU was present upon admission and measured as follows: length was 0.6cm (centimeter), the width was 0.6cm, and the depth was 1.0cm. Review of the revised care plan for Resident #48 dated 08/09/17 revealed a problem related to impaired skin related to a stage 4 PU to the sacrum. The goal was for the PU to show evidence of healing by a reduction in size or stage through the next review date. The interventions were for the nurse to measure and monitor the wound status and the progression or deterioration every week. The nurse was to notify the physician of worsening despite the treatment and wound care consults as indicated. A review of the skin evaluation form dated 08/04/17 revealed the sacral PU had no drainage and the length was 0.6cm and the width was 0.6cm and depth was 1.0cm with no odor. The next skin evaluation dated 08/11/17 revealed the wound had serosanguineous (a thin, watery, pink or red in color drainage) with a mild odor and measured 1.0cm x 0.5cm x 1.5cm. The next documented evaluation dated 08/14/17 revealed a mild odor with serosanguineous drainage and measured 1.0cm x 0.5cm x 1.5cm. There were no skin evaluations forms provided or documented for the week of 08/21/17 and week of 08/28/17. The next documented skin evaluation dated 09/01/17 revealed a foul odor with bloody, sanguineous drainage and measured 1.6cm x 0.6cm x 1.8cm. A review of the physician order [REDACTED]. Review of Resident #48's treatment records revealed no change in treatment to the resident's sacral wound from 8/13/17 to 09/01/17. During an interview conducted on 09/07/17 at 4:28 PM the Medical Doctor (MD) indicated he had seen Resident #48 approximately twice since admission to the facility. The MD also stated there had been no verbal or written communication related to the increase of the sacral PU. An observation was made on 09/08/17 at 7:18 AM of Nurse #1 and Nurse #2 providing wound care and measuring the sacral PU for Resident #48. Nurse #1 confirmed the wound care supplies she had were a foam dressing, calcium alginate, [MEDICATION NAME] ointment, a bottle of wound cleanser spray, and 4 x 4 gauze. An intact foam dressing dated 09/08/17 with initials was noted on the sacrum of Resident #48. Nurse #1 removed the soiled dressing and revealed a small amount of bowel movement with a small amount of bloody drainage. There was no foul odor noted. Nurse #1 sprayed wound cleanser to the sacrum wound and proceeded to pat the area dry with 4 x 4 gauze. Nurse #1 changed position with Nurse #2. Nurse #2 put on clean gloves and measured the wound. The measurements were confirmed as follows: length 1.6cm and width 1.0 cm and depth 1.8 cm. Nurse #1 proceeded to apply [MEDICATION NAME] ointment to the inside of the wound, insert a small strip of calcium alginate, and covered with a foam dressing. An interview was conducted on 09/08/17 at 7:18 AM with Nurse #2 who revealed she used the sacral PU measurements to reevaluate Resident #48 skin condition by checking the last evaluation and compared measurements to check for healing or increasing. Nurse #2 revealed the skin evaluation generated a 24 hour report and all nurses had access to the report. She also indicated a verbal report would be given to the oncoming nurse supervisor and the MD would be notified using a written communication tool. The tool was used by the nurses to inform the MD of residents who needed to be seen, or had any changes and would be reviewed by the MD when at the facility. A review of the written communication tool the nurses used to inform the MD confirmed there had been no documentation from 08/04/17 thru 09/08/17 of the resident's sacrum wound condition changes worsening for Resident #48. An interview was conducted on 09/08/17 at 8:06 AM with Nurse #1 who confirmed the last measurements she had documented on the computer generated skin evaluation form was on 09/01/17. Nurse #1 revealed the wound had not changed, but she had not compared the wound measurements to the previous evaluation. It was noted Nurse #1 could not navigate the computer skin evaluation form to show all previous measurements to compare for wound changes. Nurse #1 indicated she would report wound changes to the oncoming nurse. Nurse #1 also confirmed she had not notified the MD of any wound changes. During an interview conducted on 09/08/17 at 2:54 PM the Director of Nursing (DON) revealed it was her expectation the nurses report any wound changes directly to her. The DON also revealed it was her responsibility to review the weekly wound measurements for a change. The DON could not explain why the increase of the sacral PU had not been reported to the MD. During an interview conducted on 09/08/17 at 3:56 PM the MD stated he had not been notified of the increase of the resident's sacral PU until 09/08/17. The MD state he hadn't seen the resident's PU and didn't look at the PU unless the nurses notified him of a change to the PU. The MD specified that he last examined the resident on 5/19/17 and he relied on the nurses to do weekly wound assessments and expected to be kept informed and notified of any wound changes. The MD also indicated he would have ordered a wound care consult for Resident #48 if he had been notified of the increased size of the sacral PU. 2. Resident #39 was admitted to the facility 05/16/17 with [DIAGNOSES REDACTED]. The admission Minimum Data Set assessment dated [DATE] noted Resident #39 had one unstageable pressure sore on admission and was at risk of developing pressure sores. The Care Area Assessment (dated 05/29/17) associated with the admission MDS included a review of pressure sores which noted, pressure sore triggered due to extensive assistance required with bed mobility; always incontinent of bowel and bladder; at risk for developing pressures ulcers; unstageable area present on admission; requires assistance with bed mobility, transfers and toilet use; status [REDACTED]. The Care Area Assessment (CAA) noted Resident #39 had a [DIAGNOSES REDACTED]. The CAA noted Resident #39 had a new pressure sore identified on 05/27/17 as a stage 2 to the coccyx, was always incontinent of bowel and bladder, had a surgical incision to the left hip and was started on antibiotic therapy on 05/24/17 for surgical wound infection. A decision was made to proceed to the care plan for interventions. The care plan for pressure sores included a problem area dated 05/17/17 which noted: Resident has impaired skin integrity related to eschar noted to left great toe on admission. On 05/27/17 the problem area was updated to include resident noted to have stage II pressure ulcer on coccyx. The goal for this problem area was, pressure ulcer will show evidence of healing as evidenced by reduction in size or stage by next review. Approaches to this problem area included, nurse to measure and monitor wound status progression or deterioration every week. Notify physician or authorized assistant of worsening despite treatment. Review of skin assessments in the medical record of Resident #39 from 05/16/19-06/09/17 included: 05/17/17-1 centimeter X 1 centimeter pressure sore with dark scab noted on left toe 05/27/17-stage II pressure ulcer found on coccyx area with a moderate amount of serosanguinous drainage with mild odor and moderate amount of exudate which measured 2 centimeters X 3 centimeters X .1 centimeter with wound edge peeling and surrounding skin red and moist Review of physician orders [REDACTED].#39 from 05/16/19-06/09/17 noted treatments were done as ordered and up through the time of discharge on 06/09/17. These included: 05/17/17-[MEDICATION NAME] twice daily for intact black left great toe 05/29/17-Apply a [MEDICATION NAME] dressing-change every 3 days and as needed Review of all nurse's notes, assessments and skin assessments for Resident #39 from 05/16/19-06/09/17 noted no further skin assessments of the area on the left toe and coccyx after the initial assessment. Weekly assessments of the left toe were not present 05/24/17, 05/31/17 and 06/07/17. Weekly assessment of the coccyx was not present on 06/03/17. There was no documentation present to reflect whether there was an improvement or decline in the size or stage of the pressure ulcers. On 09/08/17 at 2:50 PM the Director of Nursing (DON) and Minimum Data Set assessment nurse were interviewed about the weekly skin assessments for Resident #39. The DON explained there was not a wound nurse at the facility and nurses on duty were responsible for weekly assessments and treatments. The DON explained there was a weekly schedule for staff to review and the expectation was for the nurse on duty to do a skin assessment based on this schedule. The DON stated they realized weekly skin assessments were not being done and the facility was in the process of addressing the concern. The DON stated management staff would discuss all wounds on a weekly basis with discussion including the condition of the wound. The DON stated because of the lack of assessments she could not tell if the left great toe and coccyx improved or worsened for Resident #39.

Based on observations, record review and staff interview, the facility failed to implement interventions identified on the resident's plan of care for three (3) of eight (8) sampled residents. (Residents #2, #6 and #7). The findings include: 1. Resident # 6 was admitted on [DATE] with [DIAGNOSES REDACTED]. According to the initial admission Minimum Data Set ((MDS) dated [DATE] the resident had severely impaired cognitive skills for daily decision-making, short term and long term memory problems and required extensive assistance of two (2) staff for bed mobility and transfers. He was also identified as having no pressure ulcers at that time. A review of the admission nursing assessment revealed that he had no pressure ulcers on admission. A review of the admission pressure ulcer risk assessment dated [DATE] revealed that he was not assessed as high risk for skin breakdown. A review of the most recent MDS dated [DATE] revealed the resident was identified as high risk for skin breakdown as reflected on the most recent pressure ulcer risk assessment dated [DATE]. He was coded as not having any skin breakdown at that time. Further review of the medical record revealed a care plan dated 12/27/10 which included an intervention that had been added on 01/03/11 which stated: "Podus boot (a pressure-relieving device used to alleviate pressure on the heel) on right foot at all times except dressing change, showers, skin checks." A physician's orders [REDACTED]." A review of the Resident Care Key, which provides instruction for the Nursing Assistant (C.N.A.) of each resident's needs, indicated the following for Resident #6: "AFO boot (same as Podus boot) R (right) foot AAT (at all times), except for showers, dsg.(dressing) Change, skin checks. Limit sitting to 1hr 3X (three times) a day." Observations of the resident on 01/04/11 at 12:10 p.m., 2:18 p.m., 3:04 p.m. and 3:55 p.m. revealed the resident sitting in his personal recliner with the Podus boot lying on the bed. Continuous observation of the resident on 01/05/11 from 9:00 a.m. to 10:25 a.m. revealed the resident sitting in a wheelchair wearing a sock and bedroom slipper on his right foot. The Podus boot was not on the right foot. Interview with the Director of Nursing (DON) on 01/06/11 at 11:30 a.m. revealed the AFO boot is commonly called a Podus boot and is a pressure relieving device used to alleviate pressure on the heel. She stated Resident #6 should have it on at all times except during showers, dressing changes and skin checks. NA #1 was assigned to care for Resident #6 on 01/05/11 on the 7 a.m. - 3 p.m.shift. In an interview with NA #1 on 01/06/11 at 9:55 am, she revealed that she referred to the "Resident Care Key" when she cared for a resident to check for any special needs or devices being used for that particular resident. She stated she was unaware that Resident #6 was to wear a Podus boot when out of bed. 2. According to the admission Minimum Data Set ((MDS) dated [DATE], Resident #2 has impaired short term and long term memory and severely impaired cognitive skills for daily decision making. The MDS also indicated the resident requires extensive assistance of two (2) staff for bed mobility and transfers. A nurse's note dated 10/23/10 at 10:45 p.m. included the following notation: "Supervisor called to room. Resident sitting on floor beside bed with back against it. Open area to right knee cleansed with normal saline. Bed alarm intact." A review of the Resident Care Key (a care plan reference guide used by nursing assistants) indicated the resident should have an alarm at all times. A review of the admission physician's orders [REDACTED]." Observations of the resident on 01/04/11 at 12:10 p.m., 2:18 p.m., 3:04 p.m. and 3:55p.m. revealed the resident sitting in his personal recliner with no alarm in place. Continuous observation of the resident on 01/05/11 from 9:00 a.m. till 10:25 a.m. revealed the resident sitting in a wheelchair in front of the nurse's station and in the Resident Lounge. Resident would occasionally lean forward in the chair. He did not have an alarm in place on the chair. Observation of the resident on 01/06/11 at 9:20 a.m. revealed he was sitting in a wheelchair in the Resident Lounge with no alarm on the chair. In an interview with NA #2 on 01/06/11 at 9:25 a.m. she stated: " I didn't know he was supposed to have an alarm when he was in the chair." An interview with the Director of Nursing (DON) on 01/06/11 at 9:35 a.m. and observation of the resident confirmed he did not have an alarm on the wheelchair. The DON stated he should have an alarm in place at all times. An interview with LN #3 revealed she had noticed he didn ' t have the alarm earlier that morning and was trying to get one from Central Supply. In an interview with NA #1 on 01/06/11 at 1:39 p.m., she acknowledged the resident did not have an alarm on his chair on 01/0/5/11 and she stated: "I didn't know he was supposed to have an alarm." NA #1 and NA #2 stated they referred to the Resident Care Key for information on special care needs of residents. 3. Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the annual Minimum Data Set ((MDS) dated [DATE] revealed the resident had short and long term memory problems and moderately impaired cognitive skills for daily decision making. The MDS also revealed that Resident #7 required extensive assistance with bed mobility and transfer. The MDS further revealed that resident #7 had fallen in the past 180 days. Review of the Nursing Care Plan (NCP) updated on 12/09/10, resident #7 was care planned for Activities of Daily Living (ADLs) and Rehabilitation including the intervention, "2-person assistance for transfers." On 01/05/11 at 9:40 a.m. Nursing Assistant (NA) #3 was observed helping Resident #7 to the bathroom for toileting. NA #3 assisted Resident #7 to a standing position instructing resident to hold onto the hand rail then assisted down onto the toilet. After completing the toileting, NA #3 assisted Resident #7 to a standing position. Resident #7 became unsteady of her feet and the NA helped her back onto the toilet. A second attempt was made to assist into a standing position and resident continued to be unsteady on her feet. Assistance was called using the emergency pull cord. Two (2) additional staff members responded to the alarm and aided the resident into her Geri-chair. On 01/05/11 at 10:00 a.m., an interview with NA #3 revealed NAs use the "Resident Care Key" to provide care to the residents. NA #3 indicated that Resident #7 was listed as one assist for transfers. On 01/05/11 at 3:30 p.m., the Director of Nursing (DON) was interviewed and confirmed Resident #7 was a 2-person transfer and would prefer the NA to err on side of precaution when transferring a resident. Interview additionally revealed that the Physical Therapist recommends the level of assistance required for transfer. An interview with the Physical Therapist on 1/5/11 at 3:45 p.m. revealed Resident #7 was maximum assist, able to perform at twenty-five percent (25%) capacity or less and would require 2-person assist with transfers.

F314 - S/S: G Based on observations, record review and staff interviews, the facility failed to identify a resident as being at risk for development of pressure sores, failed to implement measures to prevent development of pressure sores for that resident and failed to ensure ordered treatments were being implemented for one (1) of eight (8) sampled residents. (Resident #6). The findings include: Resident # 6 was admitted on [DATE] with [DIAGNOSES REDACTED]. According to the initial admission Minimum Data Set ((MDS) dated [DATE] the resident had severely impaired cognitive skills for daily decision-making, short term and long term memory problems and required extensive assistance of two (2) staff for bed mobility and transfers. He was also identified as having no pressure ulcers at that time and did not have a history of pressure ulcers in the past 90 days. A review of the admission nursing assessment revealed that he had no pressure ulcers on admission. A review of the admission pressure ulcer risk assessment dated [DATE] revealed that he was not assessed as high risk for skin breakdown. However, the pressure ulcer risk assessment instrument in use by the facility indicated that he was coded as a "0" under risk factors due to [DIAGNOSES REDACTED]. The initial care plan dated 08/16/10 did not identify any risk for skin breakdown and did not indicate that any preventative measures were put into place to prevent skin breakdown. A review of the most recent MDS dated [DATE] revealed the resident was identified as high risk for skin breakdown as reflected on the most recent pressure ulcer risk assessment dated [DATE]. He was coded as not having any skin breakdown at that time. Subsequent care plans dated 11/03/10 and 11/18/10 identified the resident as being at risk for skin breakdown but did not indicate that any preventative measures were implemented to prevent the development of pressure sores. A nurse's note dated 11/20/10 indicated the resident was found to have a Stage II pressure ulcer on his right buttock measuring 2.5cm (centimeters) by 1.0cm by 0.1cm. Another nurse's note dated 11/23/10 indicated the resident was found to have a 9.0cm by 5.5cm blister on his right heel. A care plan dated 11/24/10 listed the following interventions: "Jay Cushion (a pressure reduction cushion) in w/c (wheelchair) at all times to re-distribute pressure and consult with wound care specialist if needed." No interventions were indicated on that care plan to address the blister on his right heel. A review of the physician's orders [REDACTED]." A care plan dated 11/29/10 had the following interventions added: "No shoes or sock on right foot; No TED (anti-embolitic) hose to right leg; AFO boot to right foot at all times; keep legs elevated when in bed." Physician orders [REDACTED]." A progress note dated 11/29/10 and signed by the physician wound consultant indicated a leaking blister on Resident #6's right heel was debrided with removal of thick, adherent necrotic tissue of partial thickness. Physician orders [REDACTED]." A care plan dated 12/27/10 continued those interventions with the following change noted on 01/30/11: "AFO boot to right foot when in bed" was crossed out and "Podus boot right foot at all times except showers, dressing change, skin checks" was added to the care plan. Observations of Resident #6 on 01/04/11 at 12:10 p.m., 2:18 p.m., 3:04 p.m. and 3:55 p.m. revealed the resident to be sitting in his personal recliner with the foot rest up and his heels resting on the footrest. The Podus boot was lying on his bed. Observation of the resident's buttocks during incontinence care on 01/04/11 at 4:00 p.m. revealed no dressing in place to the Stage II pressure ulcer on his right buttock. Continuous observation of Resident #6 on 01/05/11 from 9:00 a.m. until 10:30 a.m. revealed the resident sitting in a wheelchair at the nurse's station wearing a sock and bedroom slipper on his right foot. He did not have the Podus boot on his right foot. Interview with LN # 2 on 01/04/11 at 4:10 p.m confirmed that Resident #6 should have had [MEDICATION NAME] in place to his right buttock. Interview with NA #1 on 01/06/11 at 9:55 a.m. revealed Resident #6 was already in his wheelchair when she came on duty at 7 a.m. on 01/05/11 and she forgot to check to see if the Podus boot was on until she provided incontinence care before he went to lunch at about 11:30 a.m. Interview with the MDS nurse and Director of Nursing (DON) on 01/06/11 at 11:00 a.m. verified the Podus boot should be in place at all times and sitting should be limited to one hour three times a day. The DON further stated: " One hour is unreasonable. He should be up for meals only. " When the DON reviewed the initial pressure ulcer risk assessment she stated: "He should have had a minimum score of eight (8) which would have resulted in preventative measures being put into place at the time of admission such as monitoring feet, floating heels and ensuring shoes were not too tight."

Based on staff interviews the facility's Quality Assurance program failed to implement a plan of action for an identified problem with the number of facility acquired pressure ulcers. The findings are: Cross Reference F314. On 01/06/11 at 2:00 p.m. the Administrator was interviewed and reported he oversaw the facility's monthly Quality Assurance (QA) committee meeting. He specified the committee consisted of himself, the Director of Nurses (DON), the Assistant Director of Nurses, the Medical Director and other department heads. He reported the committee identified areas for improvement, implemented plans of action and monitored progress. The Administrator stated he was aware of the high number of facility acquired pressure ulcers and confirmed this was a concern discussed monthly during the QA meeting. He reported he was unaware of what steps the committee had taken to attempt to reduce the number of facility acquired pressure ulcers. The Administrator was unable to specify if the committee had developed a plan of action for reducing the number of facility acquired pressure ulcers. On 01/06/11 at 3:00 p.m. the DON was interviewed and specified the number of facility acquired pressure ulcers was a problem she had identified in 8/10. The DON stated she had attempted to reduce the number of facility acquired pressure ulcers and confirmed these attempts had not been successful. She confirmed the problem was ongoing. She specified she reported and discussed pressure ulcers monthly in the QA meeting and stated that she had not developed a formal plan for reducing the number of facility acquired pressure ulcers. The DON was unable to provide documentation of interventions, assessments or monitoring of pressure ulcers acquired in the facility. On 01/06/11 at 3:30 p.m. the Medical Director was interviewed and reported he attended the monthly QA meetings and confirmed the concern of the high number of pressure ulcers were discussed at each meeting. He reported he had made specific recommendations to the QA committee to improve the number of pressure ulcers; but he was unaware if the facility implemented his recommendations. He confirmed he would expect the facility to develop a plan of action for reducing for the number of facility acquired pressure ulcers.