Every finding on record at River Edge Rehabilitation and Nursing

Based on clinical record review, interview, and facility documentation review, the facility failed to implement its abuse prevention and investigation policies to ensure the safety of two of three residents (Resident (R) 109 and R81) reviewed for abuse out of 29 sample residents. This had the potential to affect all residents in the facility who were at risk for abuse. The facility's Administrator was informed on 05/07/26 at 1:33 PM that Immediate Jeopardy existed which also constituted Substandard Quality of Care (SQC) related to the facility's failure to ensure R109 and R81 were free from sexual abuse by R15 and was determined to exist on 03/15/25. The facility provided an Immediate Jeopardy Removal Plan that was accepted on 05/07/26 at 5:42 PM. The survey team validated implementation of the removal plan through interviews, and review of training records. Immediate Jeopardy was removed on 06/07/26 at 6:10 PM. After removal of the Immediate Jeopardy, the deficiency remained at a ''G'' scope and severity for isolated actual harm.The findings include:1. Review of R15's Face Sheet located in the electronic medical record (EMR) under the Profile tab revealed the resident was re-admitted on [DATE] with diagnosis of unspecified dementia. Review of R15's annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/18/25 and located under the MDS tab of the EMR, revealed a Brief Interview for Mental Status (BIMS) score of three out of 15, which indicated the resident was severely cognitively impaired. 2. Review of R109's Face Sheet located in the electronic medical record (EMR) under the Profile tab revealed the resident was admitted on [DATE] with diagnosis of non-Alzheimer's dementia. Review of R109's quarterly MDS with an ARD of 12/03/25 and located under the MDS tab of the EMR, revealed a BIMS was unable to be completed since the resident was rarely/never understood. Review of facility's Reported Incident (FRI) revealed date of incident 06/07/25 and date of report 06/10/25. Describe incident It was reported to Administration today that on 06/07/25, R15 was found with his hand down R109's shirt and in her pants. The employee immediately separated them. This occurred in the Activity Room after lunch. It was also identified that on 06/08/25, R15 was found with his hand up the pant leg of R109's to her knee. When noticed staff immediately separated them. Review of facility's Five Day Letter, dated 06/17/25 and written by Administrator, revealed it was reported that R15 was found with his hand down R109's shirt and in her pants on 06/07/25. This occurred in the Activity Room after lunch. The employee that saw this immediately redirected him and separated them. It was also identified that on 06/08/25, that R15 was found with his hand up the pant leg of R109 to her knee. This occurred by the nursing station. Staff immediately redirected and separated them. Further review revealed the conclusion that R15 had no other behaviors as described above. Safety checks were no longer occurring. Will continue to monitor both residents' psychosocial well-being. R15 will also continue to be monitored by psych services. Review of facility's Witness Statement, dated 06/08/25 and written by Certified Nurse Aide (CNA) 10, revealed she came around the corner, and saw R15 with his hand up R109's pants leg. CNA10 stopped him and moved him away from R109 and reported it to Unit Manager (UM)/Licensed Practical Nurse (LPN) 2. Review of facility's Witness Statement, dated 06/07/25 and written by CNA9, revealed after picking up trays and starting on rounds, she passed the activity room and saw R15 with his hand down R109's shirt and into her pants. R15 was rubbing his hand around and she told him to stop, and he ignored her, so she moved him away. She took him to his room and laid him down and returned to R109 and asked her if she was ok, but she did not respond. Reported to the nurses on duty. Review of facility's Witness Statement, dated 06/08/25 and written by Assistant Director of Nursing (ADON), revealed it was reported by CNA9 and UM/LPN2 that R15 was observed with his hand down the shirt and pants of R109. R15 had gotten out of his wheelchair and walked over to R109. R15 was removed from area and R109 did not appear distressed. R15 was care planned for inappropriate sexual behavior. Will document on 72-hour note. Review of Nurse's Note, dated 06/07/25 at 2:29 PM and located under the Progress Notes tab of the EMR, revealed that a Certified Nurse Aide (CNA) reported to UM/[LPN2] that [R15] was in activity room with other residents and was sticking his hand down the shirt of [R109] and had his hand in her pants. Resident removed from room, ADON notified. Review of Nurse's Note, dated 06/08/25 at 10:29 AM and located under the Progress Notes tab of the EMR, revealed that [R15] observed sticking his hand up [R109's] pants. Resident removed and physician notified of increased sexual behavior. During an interview on 05/06/26 at 1:40 PM, UM/LPN1 said staff came and got her on 06/08/25 and reported that staff observed R15 putting his hand in R109's pants. She said R109 was nonverbal and would not have been able to call for help or report the incident. LPN1 stated both residents had already been separated but there was no change in R15's level of supervision. She said she was unaware if this had happened before and did not know there was a similar situation that occurred the day before on 06/07/26. LPN1 said there was no increase in R15's level of supervision on that day that she was aware of any restrictions on his access to R109 or any other residents. She stated she did not report this incident, but she was unsure why. During an interview on 05/06/26 at 1:40 PM, UM/LPN2 stated he was working during the day shift on 06/07/25 when a CNA came and reported to him that R15 had his hand in R109's pants and in her shirt. He stated he went to the activity room and sure enough, he observed R15 with his hand in the crotch area of R109's pants and his hand in her shirt by her chest/breasts. He said he immediately separated them. He said R15 was taken back to his room. LPN2 said R109 was a nonverbal resident and would not have been able to report this incident. He said he was unaware if this had happened before with any other residents. He stated R15 had a history of inappropriateness towards staff and female residents. LPN2 said there had been no increase in R15's level of supervision that he had been aware of or any restrictions on his access to R109 or any other residents. He stated he reported it to ADON. LPN2 stated he did not complete any training at that time related to the facility abuse protocol. During an interview on 05/07/26 at 11:15 AM, CNA10 stated she was unaware of any inappropriate incidents that have occurred with R15 and she stated there had been no issues with his behaviors towards other residents. But when presented with the statement she wrote on 06/08/25, she stated she remembered observing R15 taking his hand and putting it up the bottom of R109's pants leg. She said R109 was sitting in her chair, due to another aide leaving her in the hallway to answer another residents' call light. R109 was nonverbal and cognitively impaired and would not have been able to yell out. She told R15 no and removed him and placed him by the nurses' station and reported it to UM/LPN1. She said R15 was capable of self-propelling and could move throughout the facility freely. She said she was not told to keep checking on him after what she observed and she had no idea if there were any changes in his level of care or supervision. And she stated she was unaware of any history of any behaviors or any other incidents involving R109. 3. Review of R81's Face Sheet located in the EMR under the Profile tab revealed the resident was admitted on [DATE] with diagnosis of unspecified dementia. Review of R81's quarterly MDS with an ARD of 04/11/26 and located under the MDS tab of the EMR, revealed a BIMS score of three out of 15, which indicated the resident was severely cognitively impaired. Review R81's Nurse's Note, dated 03/17/25 at 6:42 AM, written by LPN2 and located under the Progress Notes tab of the EMR, revealed R15 had to be redirected for sexual behavior after he was observed attempting to rub another resident's leg. The resident was redirected and moved beside staff for closer observation. During an interview on 05/06/26 at 2:40 PM, CNA3 stated she worked the 11:00 PM to 7:00 AM shift on 03/17/25. She said she did not remember what happened specifically that night, but she was aware of concerns about R15's behaviors towards female residents. CNA3 stated she was not aware of any concerns with R109, but she was aware of concerns with R81. She said she observed R15 putting his hand in R81's pants and in her shirt. CNA3 stated that it happened on more than one occasion. She said R15 was just redirected and was moved to the nurse's station or back to his room. CNA3 said she never reported it because nurses observed this behavior too and they were aware. She stated she was never aware of any increase in R15's supervision or any changes in his plan of care or restrictions in his interactions with other residents. During an interview on 05/06/26 at 4:40 PM, the Director of Nursing (DON) said she was unaware that an incident occurred on 03/17/25 and did not become aware of the incidents that occurred to R109 on 06/07/25 and 06/08/25 until 06/10/25. Therefore, she confirmed that although the facility's policy required reporting and investigation of allegations of abuse, the investigation was not conducted until 06/10/25. She further stated no protective measures or increase in R15's level of supervision was put into place prior to that date. Review of the facility's policy titled, Abuse, Neglect and Exploitation, revised 02/11/26, revealed it is the policy of this facility to provide protection 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. No additional information was provided.

Based on clinical record review, interview, and facility documentation review, the facility failed to protect two of three residents (Resident (R) 109 and R81) reviewed for abuse from being sexually abused by R15 when the facility allowed the resident to sexually abuse vulnerable residents by not supervising R15, who had a known history of sexual inappropriateness out of 29 sample residents. This had the potential to affect all residents in the facility who were at risk for abuse. The facility's Administrator was informed on 05/07/26 at 1:33 PM that Immediate Jeopardy existed which also constituted Substandard Quality of Care (SQC) related to the facility's failure to ensure R109 and R81 were free from sexual abuse by R15 and was determined to exist on 03/15/25. The facility provided an Immediate Jeopardy Removal Plan that was accepted on 05/07/26 at 5:42 PM. The survey team validated implementation of the removal plan through interviews, and review of training records. Immediate Jeopardy was removed on 05/07/26 at 6:10 PM. After removal of the Immediate Jeopardy, the deficiency remained at a ''G (isolated actual harm) scope and severity level, as the deficient practice resulted in harm. The findings include:1. Review of R15's Face Sheet located in the electronic medical record (EMR) under the Profile tab revealed the resident was re-admitted on [DATE] with diagnosis of unspecified dementia. Review of R15's annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/18/25 and located under the MDS tab of the EMR, revealed a Brief Interview for Mental Status (BIMS) score of three out of 15, which indicated the resident was severely cognitively impaired. 2. Review of R109's Face Sheet located in the EMR under the Profile tab revealed the resident was admitted on [DATE] with diagnosis of non-Alzheimer's dementia. Review of R109's quarterly MDS with an ARD of 12/03/25 and located under the MDS tab of the EMR, revealed a BIMS was unable to be completed because the resident was rarely/never understood. Review of R109's Nurse's Note, dated 06/07/25 at 2:29 PM and located under the Progress Notes tab in the EMR, revealed that a Certified Nurse Aide (CNA) reported to Unit Manager (UM)/[Licensed Practical Nurse (LPN) 2] that [R15] was in activity room with other residents and was sticking his hand down the shirt of [R109] and had his hand in her pants. Resident removed from room, Assistant Director of Nursing (ADON) notified. Review of R109's Nurse's Note, dated 06/08/25 at 10:29 AM and located under the Progress Notes tab in the EMR, revealed that [R15] observed sticking his hand up [R109's] pants. Resident removed and physician notified of increased sexual behavior. During an interview on 05/06/26 at 1:40 PM, UM/LPN1 said staff came and got her on 06/08/25 and reported that staff observed R15 putting his hand in R109's pants. She said R109 was nonverbal and would not have been able to call for help or report the incident. She stated both residents had already been separated but there was no change in R15's level of supervision. LPN1 said she was unaware if this had happened before and did not know there was a similar situation that occurred the day before on 06/07/25. She said there was no increase in R15's level of supervision on that day that she was aware of or any restrictions on his access to R109 or any other residents. LPN1 stated she did not report this incident, and she was unsure why. During an interview on 05/06/26 at 1:40 PM, UM/LPN2 stated he was working during the day shift on 06/07/26 when a CNA came and reported to him that R15 had his hand in R109's pants and in her shirt. He stated he went to the activity room and sure enough, he observed R15 with his hand in the crotch area of R109's pants and his hand in her shirt by her chest/breasts. He said he immediately separated them. He said R15 was taken back to his room. LPN2 said R109 was a nonverbal resident and would not have been able to report this incident. He said he was unaware if this had happened before with any other residents. He stated R15 had a history of inappropriateness towards staff and female residents. He said there had been no increase in R15's level of supervision that he had been aware of or any restrictions on his access to R109 or any other residents. He stated he reported it to ADON. LPN2 stated he did not complete any training at that time related to the facility abuse protocol. During an interview on 05/07/26 at 11:15 AM, CNA10 stated she was unaware of any inappropriate incidents that have occurred with R15 and she stated there had been no issues with his behaviors towards other residents. But when presented with the statement she wrote on 06/08/25, she stated she remembered observing R15 taking his hand and putting it up the bottom of R109's pants leg. CNA10 said R109 was sitting in her chair, due to another aide leaving her in the hallway to answer another residents' call light. She stated R109 was nonverbal and cognitively impaired and would not have been able to yell out. She stated she told R15 no and removed him and placed him by the nurses' station and reported it to UM/LPN1. CNA10 said R15 was capable of self-propelling and could move throughout the facility freely. She said she was not told to keep checking on him after what she observed and she had no idea if there were any changes in his level of care or supervision. And she stated she was unaware of any history of any behaviors or any other incidents involving R109. 3. Review of R81's Face Sheet located in the EMR under the Profile tab revealed the resident was admitted on [DATE] with diagnosis of unspecified dementia. Review of R81's quarterly MDS with an ARD of 04/11/26 and located under the MDS tab of the EMR, revealed a BIMS score of three out of 15, which indicated the resident was severely cognitively impaired. Review R81's Nurse's Note, dated 03/17/25 at 6:42 AM, written by LPN2 and located under the Progress Notes tab in the EMR, revealed R15 had to be redirected for sexual behavior after he was observed attempting to rub another resident's leg. The resident was redirected and moved beside staff for closer observation. During an interview on 05/06/26 at 2:40 PM, CNA3 stated she worked the 11:00 PM to 7:00 AM shift on 03/17/25. She said she did not remember what happened specifically that night, but she was aware of concerns about R15's behaviors towards female residents. CNA3 stated she was not aware of any concerns with R109, but she was aware of concerns with R81. She said she observed R15 putting his hand in R81's pants and in her shirt. She stated that it happened on more than one occasion. CNA3 said R15 was just redirected and was moved to the nurse's station or back to his room. She said she never reported it because nurses observed this behavior too and they were aware. She stated she was never aware of any increase in R15 supervision or any changes in his plan of care or restrictions in his interactions with other residents. During an interview on 05/06/26 at 4:40 PM, the Director of Nursing (DON) said the facility concluded that R15 sexually groped R109 on two separate occasions. She stated she was unaware there had been any incidents that involved R81. She said she did not think that R15 was currently a risk to other residents in the facility because there had not been any other incidents reported by staff. She confirmed that the two incidents that involved R109 and the incidents involving R81 were never reported to her. Review of the facility's policy titled, Abuse, Neglect and Exploitation, revised 02/11/26, revealed it is the policy of this facility to provide protection 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. No additional information was provided.

Based on clinical record review, interview, and facility documentation review, the facility failed to conduct thorough abuse investigations for three of three residents (Resident (R) 15, R109, and R81) reviewed for abuse out of 29 sample residents. This had the potential to affect all residents in the facility who were at risk for abuse. The findings include:1. Review of R15's Face Sheet located in the electronic medical record (EMR) under the Profile tab revealed the resident was re-admitted on [DATE] with diagnosis of unspecified dementia. Review of R15's annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/18/25 and located under the MDS tab of the EMR, revealed a Brief Interview for Mental Status (BIMS) score of three out of 15, which indicated the resident was severely cognitively impaired. 2. Review of R109's Face Sheet located in the EMR under the Profile tab revealed the resident was admitted on [DATE] with diagnosis of non-Alzheimer's dementia. Review of R109's quarterly MDS with an ARD of 12/03/25 and located under the MDS tab of the EMR, revealed a BIMS was unable to be completed since the resident was rarely/never understood. Review of facility's Reported Incident (FRI) revealed date of incident 06/07/25 and date of report 06/10/25. Describe incident It was reported to Administration today that on 06/07/25, [R15] was found with his hand down [R109's] shirt and in her pants. The employee immediately separated them. This occurred in the Activity Room after lunch. It was also identified that on 06/08/25, [R15] was found with his hand up the pant leg of R109's to her knee. When noticed staff immediately separated them. Review of facility's Five Day Letter, dated 06/17/25 and written by Administrator, revealed it was reported that R15 was found with his hand down R109's shirt and in her pants on 06/07/25. This occurred in the Activity Room after lunch. The employee that saw this immediately redirected him and separated them. It was also identified that on 06/08/25, that R15 was found with his hand up the pant leg of R109 to her knee. This occurred by the nursing station. Staff immediately redirected and separated them. Further review revealed that the incidents on 06/07/25 and 06/08/25 were not investigated until 06/10/25. Additionally, the 06/10/25 investigation was not thorough and did not include interviews with all staff who had knowledge of the incidents or any other staff who may have had knowledge of R15's behavior or known about other residents that may have been affected. 3. Review of R81's Face Sheet located in the EMR under the Profile tab revealed the resident was admitted on [DATE] with diagnosis of unspecified dementia. Review of R81's quarterly MDS with an ARD of 04/11/26 and located under the MDS tab of the EMR, revealed a BIMS score of three out of 15, which indicated the resident was severely cognitively impaired. Review of R81's Nurse's Note, dated 03/17/25 at 6:42 AM and located under the Progress Notes tab of the EMR, revealed R15 had to be redirected for sexual behavior after he was observed attempting to rub another resident's leg. The resident was redirected and moved beside staff for closer observation. During an interview on 05/06/26 at 4:40 PM, the Director of Nursing (DON) said the facility did not investigate the incidents that occurred on 06/07/25 and 06/08/25 until 06/10/25. She also stated she did not interview all the staff with knowledge of these incidents nor did she try to interview other staff who may have had knowledge of other incidents involving this resident or potential other residents. She stated she should have interviewed all staff with any knowledge. She confirmed the incident that occurred on 03/17/25 was never investigated and it should have been. Review of the facility's policy titled, Abuse, Neglect and Exploitation, revised 02/11/26, revealed an immediate investigation is warranted when suspicion of abuse, neglect, or exploitation, or reports of abuse, neglect or exploitation occur. Written procedures for investigations include 1. Identifying staff responsible for the investigation. 2. Exercising caution in handling evidence that could be used in a criminal investigation 3. Investigating different types of alleged violations. 4. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations' 5. Focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent, and cause; and 6. Providing complete and thorough documentation of the investigation. The facility will make efforts to ensure all residents are protected from physical and psychosocial harm during and after the investigation. Examples include but are not limited to: A. Responding immediately to protect the alleged victim and integrity of the investigation. B. Examining the alleged victim for any sign of injury, including a physical examination or psychosocial assessment if needed. C. increased supervision of the alleged victim and residents. D. Room or staffing changes, if necessary, to protect the resident(s) from the alleged perpetrator. E. Protection from retaliation. F. Providing emotional support and counseling to the resident during and after the investigation, as needed. No additional information was provided.

Based on clinical record review, interview, and facility documentation review, the facility failed to report allegations of abuse in a timely manner for two of three residents (Resident (R) 109 and R81) reviewed for abuse out of 29 sample residents. This had the potential to affect all residents in the facility who were at risk for abuse. The findings include:1. Review of R15's Face Sheet located in the electronic medical record (EMR) under the Profile tab revealed the resident was re-admitted on [DATE] with diagnosis of unspecified dementia. Review of R15's annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/18/25 and located under the MDS tab of the EMR, revealed a Brief Interview for Mental Status (BIMS) score of three out of 15, which indicated the resident was severely cognitively impaired. 2. Review of R109's Face Sheet located in the EMR under the Profile tab revealed the resident was admitted on [DATE] with diagnosis of non-Alzheimer's dementia. Review of R109's quarterly MDS with an ARD of 12/03/25 and located under the MDS tab of the EMR, revealed the BIMS was unable to be completed since the resident was rarely/ never understood. Review of facility's Reported Incident (FRI) revealed date of incident 06/07/25 and date of report 06/10/25. Describe incident It was reported to Administration today that on 06/07/25, [R15] was found with his hand down [R109's] shirt and in her pants. The employee immediately separated them. This occurred in the Activity Room after lunch. It was also identified that on 06/08/25, R15 was found with his hand up the pant leg of R109's to her knee. When noticed, staff immediately separated them. Review of Nurse's Note, dated 06/07/25 at 2:29 PM and located under the Progress Notes tab of the EMR, revealed that a Certified Nurse Aide (CNA) reported to Unit Manager (UM)/Licensed Practical Nurse [(LPN) 2] that [R15] was in activity room with other residents and was sticking his hand down the shirt of [R109] and had his hand in her pants. Resident removed from room, Assistant Director of Nursing (ADON) notified. Review of Nurse's Note, dated 06/08/25 at 10:29 AM and located under the Progress Notes tab of the EMR, revealed that [R15] observed sticking his hand up [R109's] pants. Resident removed and physician notified of increased sexual behavior. During an interview on 05/06/26 at 1:40 PM, UM/LPN1 said staff came and got her on 06/08/25 and reported that staff observed R15 putting his hand in R109's pants. She stated she did not report this incident, and she was unsure why. During an interview on 05/06/26 at 1:40 PM, UM/LPN2 stated he was working during the day shift on 06/07/25 when a CNA came and reported to him that R15 had his hand in R109's pants and in her shirt. He reported it to ADON. During an interview on 05/06/26 at 4:03 PM the former ADON stated the incident that occurred on 06/07/25 was reported to her by nursing staff but she did not do anything further with that information because she considered herself management. She was under the impression making her aware was all that had to be done, and she never reported it to the Director of Nursing (DON), the Administrator, or the state survey agency (SSA). She understood now that it should have been reported. 3. Review of R81's Face Sheet located in the EMR under the Profile tab revealed the resident was admitted on [DATE] with diagnosis of unspecified dementia. Review of R81's quarterly MDS with an ARD of 04/11/26 and located under the MDS tab of the EMR, revealed a BIMS score of three out of 15, which indicated the resident was severely cognitively impaired. Review R81's Nurse's Note, dated 03/17/25 at 6:42 AM and located under the Progress Notes tab of the EMR, revealed R15 had to be redirected for sexual behavior after he was observed attempting to rub another resident's leg. The resident was redirected and moved beside staff for closer observation. During an interview on 05/06/26 at 4:40 PM the DON said none of the incidents that occurred on 03/17/25, 06/07/25, and 06/08/25 were reported to her but they should have been. Review of the facility's policy titled, Abuse, Neglect and Exploitation, revised 02/11/26, revealed The facility will have written procedures that include Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes: a. 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, or b. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. No additional information was provided.

Based on staff interview and clinical record review, the facility staff failed to review and revise the comprehensive plan of care for four of forty-one residents in the survey sample (Residents #2, #13, #20 and #24).The findings include:1. Resident #2's plan of care was not revised to include the resident's do not resuscitate status, enrollment in hospice services, or that a fall occurred on 7/4/25. Resident #2 (R2) was admitted to the facility with diagnoses that included dementia, psychotic disturbance, mood disorder, anxiety, chronic kidney disease, gastroesophageal reflux disease, obesity, congestive heart failure, peripheral vascular disease and cognitive communication deficit. The minimum data set (MDS) dated [DATE] assessed R2 with severely impaired cognitive skills. R2's clinical record documented a DDNR (Durable Do Not Resuscitate) form signed on 6/3/25, indicating no resuscitation was to be initiated in case of cardiac arrest. R2's clinical record documented a physician's order dated 6/3/25 for the DNR status and an order for no hospitalizations. R2's clinical record documented the resident was found on the floor on 7/4/25, with neurological checks initiated. R2's clinical record documented the resident was enrolled in hospice services on 7/25/25. R2's plan of care (revised 7/15/25) documented the resident's resuscitation status as Full Code, which contradicted the physician ordered DNR/do not hospitalize status. R2's care plan did not indicate the resident fell on 7/4/25 and the care plan had not been revised indicating the resident's enrollment in hospice services. On 8/6/25 at 10:35 a.m., the licensed practical nurse (LPN #2) caring for R2 was interviewed about the resident's resuscitation status. LPN #2 stated R2 currently had a DNR order. LPN #2 stated the unit manager was responsible for updating care plans. On 8/6/25 at 10:40 a.m., the unit manager (LPN #3) caring for R2 was interviewed about the plan of care. LPN #3 stated R2 was a full code when admitted but orders were entered on 6/3/25 changing the resident's status to DNR. LPN #3 stated the care plan should have been updated to indicate the DNR status. LPN #3 stated R2 was currently receiving hospice services and that the care plan should have been revised to include hospice. LPN #3 stated, It [care plan revisions] just got missed somehow. On 8/7/25 at 8:30 a.m., LPN #3 was interviewed about R2's fall on 7/4/25. LPN #3 stated R2 was found on the floor on 7/4/25 and therapy assessed the resident following the fall, regarding chair cushions and the use of a reclining chair. LPN #3 stated the fall of 7/4/25 should have been added to the care plan. This finding was reviewed with the administrator, director of nursing and regional nurse consultant during a meeting on 8/6/25 at 4:10 p.m. with no further information presented prior to the end of the survey. 2. The facility staff failed to revise R24's care plan to reflect the current care needs. On 8/6/25 at 3:00 p.m., a clinical record review was conducted. R24's care plan, last revised on 4/11/24, indicated that R24 was to utilize assistive bars for bed mobility. However, no assistive bars were present on his bed. The care plan also listed a fall intervention to remind R24 to lock his wheelchair brakes. Yet, R24 has been bedridden for over three years, uses a stretcher for transport outside of his room, and does not have a wheelchair. The care plan further documented a pressure-relieving mattress and a concave mattress on his bed; however, orders were for a standard pressure reduction mattress. The care plan also included a wound treatment to the left above-knee amputation site, despite R24 having no wounds. On 8/6/25, during an end-of-day meeting with the administrator, director of nursing, and corporate staff, these care plan discrepancies were discussed. No additional information was provided. On 8/7/25 at 10:20 a.m., an interview was conducted with the Minimum Data Set (MDS) Coordinator, Licensed Practical Nurse #4 (LPN4). LPN4 stated she had updated R24's assessment on 7/2/25 and the care plan was updated at that time. When asked about the assistive bars for bed mobility, LPN4 said, They aren't on there. I didn't know they had been removed. LPN4 further stated that R24 had no trunk strength and could not sit up in a wheelchair. When asked why the fall intervention to lock wheelchair brakes was still in the care plan, LPN4 responded, He has not had a wheelchair for a while; I'm not sure why locking the brakes is still on the care plan. 3. For Resident #13 (R13), the facility staff failed to review and revise the care plan to accurately reflect the ordered seating system. On 8/5/25, 8/6/25, and 8/7/25, observations were conducted of R13. R13 was observed in each of the observations to be sitting in the tv room on the unit, in a broda chair [type of wheelchair capable of reclining]. On 8/6/25, a clinical record review was conducted, which noted that R13 had a fall on 6/9/25. According to the progress note which read, Resident rolled onto floor. Bed was in lowest position. Abrasion to right thigh and small abrasion to top of head. Review of R13's care plan identified R13 as a fall risk, but didn't reference that he had a fall and sustained injuries on 6/9/25. There was no mention of the abrasions, nor the treatment required for those injuries. Within the activities of daily living care plan were interventions regarding the residents' seating when out of bed, that was contradictory and unclear. One intervention dated 8/6/25 read, [R13's name redacted] is to be in a full tilt/reclining position when up in his broda chair except mealtimes when he can be upright. Another active intervention dated 1/23/25 read, Resident has geri chair r/t [related to] muscle weakness from Huntington's Disease. On 8/6/25 at approximately 2:30 p.m., an interview was conducted with registered nurse #2 (RN #2) and licensed practical nurse #4 (LPN #4), who were both care plan coordinators. RN #2 and LPN #4 both explained that the care plan is to personalize care and make sure individual needs are met. They explained that everyone uses the care plan. They said, With the certified nursing assistants we make sure everything is put on their activities of daily living care plan, like how they transfer, if they are continent, etc. It tells the staff what care needs they have and how to take care of the resident. When RN #2 and LPN #4 were made aware of the varying seating for R13 on the care plan, RN #2 said, I've only been here since the end of April. They explained that the unit managers are responsible for daily updates. They confirmed that when the broda chair was implemented they failed to remove the geri chair. They confirmed that the care plan did not reflect the resident's fall with injury on 6/9/25. On 8/6/25, interviews were conducted with three of the nursing assistants on the unit. Only one, certified nursing assistant #3 (CNA #3) reported having worked on the unit for more than a month. During the interview with CNA #3, she reported she had worked at the facility for at least two years and was very familiar with R13. CNA #3 reported that R13 had been in a broda chair when out of bed for at least two years and a geri chair was not used. 4. For Resident #20 (R20), who sustained two falls, one resulting in a hip fracture, the facility staff failed to review and revise the care plan to include the falls sustained or the hip fracture. On 8/6/25, during a clinical record review, it was noted that R20 was discharged on 4/26/25 and was readmitted on [DATE]. According to a hospital Discharge summary dated [DATE], which noted that R20 was hospitalized and underwent a right intertrochanteric femur fracture with cephalomedullary implant [hip fracture with surgical repair]. Within R20's clinical chart the only documentation regarding a fall that resulted in a hip fracture was from the on-call provider in a progress note dated 4/26/25, which read in part, . Patient fell unwitnessed and fell on right hip. Abrasion and hematoma to right knee. Patient complained of 10/10 sharp stabbing pain to right hip and leg. Fall unwitnessed. Administered pain medication not effective. Recommendation/request: Sent to ER [emergency room] . According to a Post Fall Review under the assessment tab dated 5/30/25, R20 had a fall that required first aide. According to R20's care plan there was no documentation of the falls on 4/26 or 5/30. There was no revisions to include R20's hip fracture and non-weight bearing status to his right lower extremity as documented in the physician orders. On 8/6/25 at approximately 2:30 p.m., an interview was conducted with registered nurse #2 (RN #2) and licensed practical nurse #4 (LPN #4), who were both care plan coordinators. RN #2 and LPN #4 both explained that the care plan is to personalize care and make sure individual needs are met. They explained that everyone uses the care plan. They said, With the certified nursing assistants we make sure everything is put on their activities of daily living care plan, like how they transfer, if they are continent, etc. It tells the staff what care needs they have and how to take care of the resident. R20's care plan was discussed with RN #2 and LPN #4. Both confirmed that during daily clinical meetings progress notes, physician orders, and new admissions are reviewed and discussed, and care plans are to be updated by the unit managers. Both confirmed that the care plan should have been reviewed and revised following falls and to reflect the hip fracture. According to the facility policy titled, Care Plan Revisions Upon Status Change, which read in part, 1. The comprehensive care plan will be reviewed, and revised as necessary, when a resident experiences a status change. a. Upon identification of a change in status, the nurse or any member of the interdisciplinary team will notify the MDS Coordinator, the physician, and resident representative, if applicable. d. The care plan will be updated with the new or modified interventions. F. Care plans will be modified as needed by the MDS Coordinator or other designated staff member. On 8/6/25, during an end of day meeting, the facility administrator and director of nursing were made aware of the above concerns. No additional information was provided.

Based on observations and staff interview the facility staff failed to follow menu for residents on two of two units. The findings included:On 8/5/25 at 12:00 p.m., an observation of the posted menu was conducted. The menu listed Salisbury steak, steamed rice, squash, brown gravy, dinner roll, strawberry shortcake, condiments and beverage of choice. However, during the observations of the lunchtime meal being plated and served, the food provided did not match the posted menu.On 8/5/25 at 12:30 p.m., the dietary manager was interviewed about the menus. The dietary manager stated that the cook changed the menus without informing me. The dietary manager stated he would have changed the posted menus if he was aware of the changes. The dietary manager stated the cook; after preparing the meal, told me the ground beef was not thawed to make the Salisbury steak today, so he swapped today's menu with tomorrow's menu. The dietary manager stated that the residents were supposed to be informed when the meal menus were changed.On 8/5/25 at 1:00 p.m., an interview was conducted with several residents in the main dining room. The residents reported that they were not aware the lunch menu had been changed for the day and had been expecting a Salisbury steak meal. They stated that, although the menu on the board was sometimes served as posted, there were occasions when the posted menu was not provided, and they were not informed of the change in advance.On 8/6/25 at 4:30 p.m., an end of day meeting was held with the administrator, director of nursing and corporate staff. They were made aware of the above concerns.No additional information was provided.

Based on observation, staff interview, clinical record review, and facility documentation review, the facility staff failed to maintain the dignity of multiple residents on one of two units during meal distribution. The findings included:The facility staff failed to serve all residents at the table at the same time. The facility staff failed to knock prior to entering resident rooms. The facility staff failed to provide adequate supervision during meals and failed to sit next to residents while assisting with meals. On 8/5/25 at 12:07 p.m., observations were conducted of the lunch meal service on the A-wing. At 12:07 p.m., the first cart of meal trays had just arrived on the unit and Resident #18 (R18) was observed sitting in the tv room with six other residents. R18 was served her meal. The facility staff then continued distributing meal trays to residents eating in their room. During the distribution of meal trays facility staff entered multiple resident rooms without knocking on the door or announcing themselves prior to entering the rooms. Multiple observations were made of facility staff assisting residents with meal set-up, exiting the room, retrieving another meal tray from the cart, and then distributing the tray to another resident without performing any hand hygiene. On 8/5/25 at 12:30 p.m., a second resident (Resident #16) was observed being served in the tv room was served their meal. On 8/5/25 at 12:36 p.m., when the third cart of meal trays arrived at the unit and staff started distributing food to additional residents in the tv room. Resident #16 (R16) reported to facility staff that Resident #17(R17) had taken her fork from her meal tray. The staff retrieved the fork from R17 and agreed to get R16 another fork so she could eat. On 8/5/25 at 12:51 p.m., the remaining residents in the tv room received their meal trays. This included one resident (Resident #13) who was totally dependent on facility staff to be fed, his tray was sat on the table in front of him without staff immediately available to assist him to eat. Resident #2 was observed pouring his tea/beverage over his food and a few minutes later when staff noticed, the staff responded by asking him to sit the cup down, no offer to provide a replacement meal was made. On 8/5/25 at 12:53 p.m., the unit manager was assisting to feed resident #15, standing next to the resident, who was seated. There was an available unoccupied chair next to the resident and two others against the wall. On 8/5/25 at 1 p.m., additional observations revealed two additional facility staff assisting to feed residents in the tv room and they were both standing next to the residents while feeding them. There were three available and unoccupied chairs in the tv room. On 8/5/25 at 2:34 p.m., an interview was conducted with the facility's director of nursing (DON), in the presence of the regional direct of clinical operations. When asked to explain how meal distribution is to be performed, the DON stated that the residents who need assistance were to be served last. The DON explained by doing that it gives the staff time to distribute the meal and then to sit and assist with feeding the residents who need assistance. When asked about serving residents in the tv room, the DON reported they were to be served last. When asked about supervision in the tv room the DON explained that staff should be supervising . to make sure they don't choke or anything. The DON was made aware of the lack of supervision as evidenced by one resident taking another resident's fork when no staff were present in the room and that while the unit manager was assisting to feed another resident, R2 poured his beverage over his food. The DON went on to explain that when staff are assisting residents to eat, they should be sitting beside the resident. The DON explained that it is . more personable when they are at eye level, we don't want them to feel like we are rushing them by standing over them. The DON explained that when staff enter a room, they are to knock prior to entering. When asked about hand hygiene, the DON said she expected hand hygiene to be performed between each resident during meal distribution. Review of the facility policy titled, Promoting/Maintaining Resident Dignity During Mealtimes, was conducted. This policy read in part, It is the practice of this facility to treat each resident with respect and dignity and care for each resident in a manner and in an environment that maintains or enhances his or her quality of life, recognizing each resident's individuality and protecting the rights or [sic] each resident. 1. All staff members involved in providing feeding assistance to residents promote and maintain resident dignity during mealtimes . 5. All staff will be seated, if possible, while feeding a resident. The facility was asked to provide a policy as it relates to the distribution of meals, but it reported they didn't have such a policy. On 8/6/25, during an end of day meeting, the facility administrator and director of nursing were made aware of the above concerns. No additional information was provided.

Based on observation, staff interview, clinical record review, and facility documentation review, the facility staff failed to follow infection control practices during meal distribution on one of two wings (A-wing). The findings included:On 8/5/25 at 12:07 p.m., observations were conducted of the lunch meal service on the A-wing by the surveyor who was accompanied by a federal surveyor. Resident #18 (R18) who was sitting in the tv room was served her meal. On 8/5/25 at 12:19 p.m., certified nursing assistant #4 (CNA #4) took a tray from the meal tray cart and entered the room of resident #14 (R14). R14's room door had signage to indicate the resident was on enhanced barrier precautions and personal protective equipment was outside of the door. CNA #4 left the door open, and the surveyor observed the meal tray sitting on the over bed table. A few minutes later, CNA #4 exited the room, carrying the meal tray and returned the tray to the cart. The cart contained approximately ten additional meal trays that had yet to be distributed. Following this observation, the surveyor approached CNA #4 and interviewed her about returning the tray to the cart with other trays. CNA #4 stated that she had not pulled the over bed table in front of R14 so therefore it was ok to place it back on the cart. CNA #4 went on to explain that since the trays aren't touching that it was ok. During the above observations, another staff member approached the meal cart and placed the tray of R18, that had been eaten from that contained her uneaten food, plate, utensils, and paper trash, into the meal tray cart, which still had resident's meals that had yet to be distributed. On 8/5/25 at 2:34 p.m., an interview was conducted with the director of nursing (DON) in the presence of the regional director of clinical services/nurse consultant (RDCS). The DON stated that all resident trays should be distributed before they begin retrieving meal trays from residents who have eaten. When asked why, the DON explained that you can't put dirty trays with trays that have not been distributed. When asked why this is, the DON said, Because of infection control. On 8/5/25 at 2:40 p.m., the facility administrator entered the DON's office and the administrator, DON and RDCS were made aware of the above observations. A review of the facility policy titled, Food Safety Requirements was conducted. The policy read in part, . 5. Foods and beverages shall be delivered to residents in a manner to prevent contamination. No additional information was provided.

Based on resident interviews, staff interviews, clinical record review and facility documentation review the facility staff failed to maintain a complete and accurate clinical record for four residents, Resident #31 (R31), Resident #2 (R2), Resident #20 (R20) and Resident #21 (R21) out of a survey sample of 41 residents. The findings included:1. Daily documentation for R31's treatment was not present on the treatment administration record. On 8/6/25 at 2:00 p.m., an interview was attempted with R31. R31 was not able to recall whether treatments had been completed and was also unable to remember that he had wounds requiring daily treatment. On 8/6/25 at 1:50 p.m., an interview was conducted with licensed practical nurse, LPN#1 (LPN1), who was the wound nurse. She stated that she completed the resident's treatments daily during the week, and the floor nurses provided the treatments on weekends. She further stated that if the treatment was not signed off, it meant it was not done, then later clarified that if it was not signed off, it may simply mean it was not documented. LPN1 stated she would check the nurse's notes for evidence of the treatment being completed. LPN1 was unable to find any documentation for the treatments being completed on the days that the treatment administration record was not signed off. On 8/6/25 at 2:00 p.m., LPN#5 (LPN5) was interviewed regarding R31's daily treatment. LPN5 stated that there were occasions when she arrived for her shift and the treatment had not been completed, estimating that this occurred once or twice per week. She added that R31 does not refuse treatment and generally does not interact with others. On 8/6/25, a review of R31's clinical record, including the Treatment Administration Record (TAR), was conducted. In April, the treatments on the 5th, 19th and 26th were not signed off. In May, the treatment on the 23rd was not signed off. In July, the treatment on the 18th, 26th, and 31st were not signed off. The progress notes were reviewed, and there were no entries on the dates when the TAR for R31's treatment was not signed off to indicate that the treatment was completed. 2. R2's clinical record included no documentation of a fall, and no resident assessment performed at the time of the incident. Resident #2 (R2) was admitted to the facility with diagnoses that included dementia, psychotic disturbance, mood disorder, anxiety, chronic kidney disease, gastroesophageal reflux disease, obesity, congestive heart failure, peripheral vascular disease and cognitive communication deficit. The minimum data set (MDS) dated [DATE] assessed R2 with severely impaired cognitive skills. R2's clinical notes on 6/17/25 had no documentation regarding the fall and included no record of an immediate assessment of the resident, or circumstances surrounding the fall. Notes made no mention of how staff were aware the resident did not hit his head. There were no neurological assessments initiated or completed following this fall. The last note documented prior to the practitioner's note on 6/18/25 was on 6/12/25. The nurse practitioner assessed R2 on 6/18/25 with no injuries or complications from the fall. On 8/7/25 at 8:30 a.m., the licensed practical nurse unit manager (LPN #3) was interviewed about R2's fall on 6/17/25. LPN #3 reviewed the clinical record and stated she did find a nursing note about the fall. LPN #3 stated she found no resident assessment or documentation regarding the circumstances surrounding the fall in the clinical record prior to the practitioner's note on 6/18/25. LPN #3 stated she did not see where neurological assessments were initiated or completed following the fall. LPN #3 stated regarding the lack of documentation, You would think there would be a note. LPN #3 stated nurses were expected to document a fall in the nursing notes along with any assessments, notifications and actions taken regarding the incident. LPN #3 stated a risk management/incident form was completed for the fall of 6/17/25 that listed assessments done, but nothing was documented in the clinical record. On 8/7/25 at 10:00 a.m., the director of nursing (DON) was interviewed about lack of documentation regarding R2's fall on 6/17/25. The DON stated it was a standard of practice for nurses to document incidents at the time they happened, including falls. The DON stated the circumstances of the fall, and any resident assessments should have been documented in the clinical record. The DON presented the incident form for R2's fall on 6/17/25. This incident form documented R2 was found on the floor beside his bed on 6/17/25 at 11:00 p.m., that the resident was assessed with no injuries and notifications were made to the physician and family. This form documented neurological checks were initiated but none were documented in the clinical record. This form was labelled Not Part of the Medical Record. The facility's policy titled Fall Prevention Program (revised 12/1/24) documented, .When any resident experiences a fall, the facility will .Assess the resident .Complete a Post-fall Review and a Post Fall Follow UP note in PCC [electronic health record] .Notify physician and family .review the resident's care plan and update as indicated .Document all assessments and actions . This finding was reviewed with the administrator and DON on 8/7/25 at 12:30 p.m. with no further information presented prior to the end of the survey. 3a. For Resident #21 (R21), the facility staff failed to maintain a complete clinical record to include documentation of an orthopedic appointment. On 8/6/25 R21 was visited in her room. R21 reported that the doctor had told her yesterday she no longer needed to wear the sling, and the sling was observed lying on the bed. During the interview R21 was noted to have cognitive impairments and was unable to recall the details of the event resulting in the fracture, when she had gone to the doctor, etc. R21 was also unclear if she had been receiving therapy services regarding her right humeral fracture. On 8/5/25-8/6/25, a clinical record review was conducted. According to a progress note dated 6/25/25, it read, Resident observed in floor across from nurses' station and non-witnessed at 2020 [8:20 p.m.]. Vital signs/neuros obtained with pupils equal reactive to light, ROM limited right arm with arm swollen elbow/shoulder. Supervisor, resident son emergency contact #1 made aware approved to send to [hospital name redacted] ER [emergency room] for evaluation right arm pain/discomfort with swelling and limited ROM [range of motion]. Tylenol administered and ineffective. According to a progress note from the nurse practitioner dated 6/25/25, the resident was admitted to the facility on [DATE] and had sustained three falls since admission. According to R21's physician orders, she had orders to see the orthopedic surgeon on 7/1/25, 7/15/25 and 8/5/25. There was a report from the visit on 7/1/25 with the orthopedic doctor that noted the resident was non-weight bearing to her right upper extremity. There was no documentation within the record as to the appointment on 7/15/25. On 8/6/25, the unit manager looked in R21's chart and could not find any documentation and stated that medical records may have it and it had not been uploaded into the clinical record. On 8/6/25, the surveyor visited the medical records employee who reported she didn't have anything for R21 with regards to the orthopedic appointment on 7/15/25. The medical records employee did state that sometimes the staff up front assist with uploading documents, she would check with them. On 8/6/25 at 2:59 p.m., an interview was conducted with the occupational therapy assistant/other employee #8 (OE#8) and the rehab director/other employee #5 (OE#5). They reviewed R21's therapy chart and reported that R21 was on occupational therapy caseload and was non-weight bearing. On the morning of 8/7/25, the facility's assistant director of nursing provided the surveyor with a progress note from the orthopedic surgeon dated 7/15/25. When asked where they had found the note, the ADON reported they called the doctor's office and had them fax it over. Review of the note dated 7/15/25 read in part, . sling may be removed for hygiene and physical therapy. Orders written for therapy to start assisted active range of motion as guided by pain. 3b. For R21 who sustained a fall, the facility failed to document neuro checks accurately as the document titled, neuro checks only recorded vital signs. On 8/5/25-8/6/25, a clinical record review was conducted. Within the documents tab was a document labeled as neuro checks. The document was accessed and titled, Neuro Checks, which only recorded vital signs that included blood pressure, temperature, pulse, respirations. On 8/6/25, interviews were conducted with a licensed practical nurse #8 (LPN #8). LPN #8 explained that neuro checks included checking pupil response, range of motion, hand grasp and signs or symptoms of head injury such as nausea and vomiting. LPN #8 was shown the document titled, Neuro checks and she agreed that it was not neuro checks it was vital sign recordings. On 8/6/25, an interview was conducted with the unit manager, licensed practical nurse #3 (LPN #3). LPN #3 confirmed that the document titled neuro checks was not that it was vital signs and had gaps that indicated the resident was sleeping. The neurological record under the assessment tab of R21's chart was also incomplete. LPN #3 was asked about the notations that R21 was asleep when the neuro check was due, LPN #3 said, Absolutely we should be waking them up to do a neuro assessment. On 8/6/25 at 4:05 p.m., an interview was conducted with the director of nursing (DON). The DON explained that neuro checks are to be conducted on any resident who had an unwitnessed fall or hit their head. She also stated that staff are to do a post-fall documentation for three days following a fall. She explained that it was important to identify if there are any latent injuries. The DON was shown R21's document that was titled, neuro checks and she agreed it was not accurate, that it only documented vital signs. The DON then accessed the neurological record in R21's chart under the assessment tab and confirmed they were incomplete. The DON was unsure of the frequency of neuro checks and stated she would like to reference their policy. The facility policy was requested. On 8/6/25, during an end of day meeting, the facility's regional director of clinical services reported to the survey team that they did not have a policy for neuro checks. The above findings were reviewed and discussed. According to the facility policy titled, Fall Prevention Program, which read in part, . 9. When any resident experiences a fall, the facility will: a. asses the resident. B. complete a post-fall review and post fall follow up note in PCC [the electronic health record system]. 3. Complete an incident report in PCC [electronic health record]. D. Notify the physician and family. E. Review the residents' care plan and update as indicated. F. Document all assessments and actions.i. begin neurologic assessment using Neurological Record assessment tool in PCC. No additional information was provided. 4. For Resident #20 (R20), who had two falls, one that resulted in a hip fracture, the facility failed to maintain a complete and accurate clinical record to include the fall details and injuries sustained. On April 26, 2025, Resident #20 experienced a fall, which resulted in a hip fracture and subsequent hospitalization. Review of the medical record revealed no documentation of the fall incident, the circumstances surrounding the fall, or the immediate actions taken by the staff. Additionally, there was no record of the residents' condition before and after the fall. On 8/6/25, an interview was conducted with R20, but he had no recall of the fall resulting in a hip fracture. On 8/6/25 a clinical record review was conducted of R20's chart. According to the census tab and progress notes, R20 was admitted to the facility on [DATE], following hospitalization after a car accident and sustaining a right scapula fracture and T11 compression fracture. According to the census tab, R20 discharged on 4/26/25 and was readmitted on [DATE]. According to a hospital Discharge summary dated [DATE], it noted that R20 was hospitalized for a right intertrochanteric femur fracture with cephalomedullary implant [hip fracture with surgical repair]. Within R20's clinical chart the only documentation regarding the fall that resulted in a hip fracture was from the on-call provider in a progress note dated 4/26/25, which read in part, . Patient fell unwitnessed and fell on right hip. Abrasion and hematoma to right knee. Patient complained of 10/10 sharp stabbing pain to right hip and leg. Fall unwitnessed. Administered pain medication not effective. Recommendation/request: Sent to ER [emergency room] . There was no documentation within R20's clinical record as to the circumstances of the fall, the location and details of the fall, condition resident was found in, facility staff's assessment of the resident, nor that the resident was being sent to the hospital for evaluation. According to a Post Fall Review under the assessment tab dated 5/30/25, R20 had a fall that required first aide. The assessment listed a fall date of 5/30/25, noted it was unwitnessed and required first aide. The residents' vital signs were populated into the form. Questions 5-6 that would have noted the description of the fall was blank. Sections B & C with the interdisciplinary team review and interventions was blank. On 8/6/25, during an interview with the facility's director of nursing (DON), in the presence of the regional director of clinical services, the DON was made aware of the above findings. The DON accessed R20's clinical record and confirmed the above findings. The DON did provide the surveyor with an incident report, which she did confirm was not part of R20's clinical record. The DON stated that the expectation is that the facility staff would document any fall incidents in the resident's chart. On 8/6/25, during an end of day meeting, the facility administrator was made aware of the above findings. No additional information was provided.

Based on observations and staff interviews the facility staff failed to store, label and distribute food in a sanitary manner in the main kitchen. The findings included:On 8-5-25 at 11:45 AM, a tour of the main kitchen revealed multiple deficiencies related to food storage and labeling practices. Several opened food items in the reach-in refrigerator, walk-in refrigerator, and walk-in freezer were found without proper labels or dates indicating when they were opened.Specifically, personal beverages and snacks were stored in the reach-in refrigerator alongside facility food items. In the walk-in refrigerator, items such as three-bean salad, vanilla pudding, cooked spaghetti noodles, corn, ham slices, mayonnaise, and cottage cheese were observed without any labels or open dates.Additionally, in the walk-in freezer, sandwich meats, meatballs, and peppers were also stored without proper labeling. Some containers showed signs of spoilage, such as a film on top of the water in the ham container. These practices pose significant risks including potential cross-contamination, food spoilage, and foodborne illness.On 8-5-25 at 11:50 AM, the dietary manager was interviewed regarding the observed unlabeled and undated food items. The dietary manager acknowledged awareness of the items lacking labels and dates. He stated that all food items must be labeled with an open date and a use-by date prior to placement in the walk-in freezer, walk-in refrigerator, or reach-in refrigerator.On 8/6/25 at 4:30 p.m., an end of day meeting was conducted with the administrator, director of nursing and corporate staff. They were made aware of the above concerns.No additional information was provided.

Based on observation, resident interview, staff interview, clinical record review and facility documentation review, the facility staff failed to follow physician orders for six residents (Resident #13- R13, Resident #14-R14, Resident #20-R20, Resident #21-R21, Resident 2-R2, and Resident #24-R24) in a survey sample of forty-one residents. The findings included:1. For R13, the facility staff failed to assess and obtain neurological checks following a fall. On 8/5/25 at 12:10 p.m., R13 was observed in the dining room seated in a Broda chair [a wheelchair with reclining capabilities]. Attempts were made to converse with R13 but were not successful. On 8/6/25, a clinical record review was conducted of R13's chart. This review revealed a progress note dated 6/9/25 at 1:30 a.m., that read, Resident rolled onto floor. Bed was in lowest position. Abrasion to right thigh and small abrasion to top of head. On call nurse notified as well as the resident's sister who is emergency contact. [On-call medical provider name redacted] contacted as well. Vital signs were 115/83; 97.3; 123; 18; 90% RA. Will continue to monitor resident closely. According to a 6/9/25 entry, the on-call medical provider documented orders as, Neuro checks, monitor for mental status changes, N/V [nausea and vomiting], HA [headache] Head to toe assessment to identify any injuries. Monitor for c/o [complaints of] pain or s/s [signs and symptoms of] injury. According to a document titled, Neurological Record found under the assessment tab of R13's chart, a neurological evaluation/assessment was conducted at 2:15 a.m., which was 45 minutes after documentation of the fall in the nursing progress notes. According to the facility protocol, evaluations are to be conducted at the time of the fall and every fifteen minutes for an hour. The second scheduled neurological evaluation was also dated and time stamped as 2:15 a.m., noting that the level of consciousness was not assessed. According to this neurological record, the next recorded assessment of R13's neurological status post the fall did not occur until 7:45 p.m. that evening. 2. For R20, who had two unwitnessed falls, one with injury resulting in a hip fracture, the facility staff failed to have evidence of an assessment of the resident, including neurological assessments as indicated by facility protocol. On 8/6/25, during a clinical record review, it was noted that R20 was discharged on 4/26/25 and was readmitted on [DATE]. According to a hospital Discharge summary dated [DATE], which noted that R20 was hospitalized and underwent a right intertrochanteric femur fracture with cephalomedullary implant [hip fracture with surgical repair]. Within R20's clinical chart, the only documentation regarding a fall that resulted in a hip fracture was from the on-call provider in a progress note dated 4/26/25, which read in part, . Patient fell unwitnessed and fell on right hip. Abrasion and hematoma to right knee. Patient complained of 10/10 sharp stabbing pain to right hip and leg. Fall unwitnessed. Administered pain medication not effective. Recommendation/request: Sent to ER [emergency room] . There was no documentation or evidence of a nursing assessment of R20 following the fall. For the second fall that occurred on 5/30/25, there was a post-fall review under the assessment tab of the clinical record. It noted that the fall was unwitnessed, first aide was performed, but the vital signs noted were from the previous day and there no evidence that any further assessment was performed. Also found was an assessment titled, Neurological record dated 5/30/25, but it was incomplete. The first four evaluations were completed every 15 minutes as per the facility protocol and assessment form. The next scheduled assessment was to be done thirty minutes later at 1:15 a.m. on 5/30/25, but noted that the recorded vital signs were from 5/29/25 at 2:38 p.m. The subsequent two assessments still had recorded the same vital signs from 5/29/25 at 2:38 p.m., indicating that the vital signs were not obtained. This documented revealed that the neurological evaluation numbers 9-12 and number 17 were not performed. On 8/6/25 at 4:05 p.m., an interview was conducted with the director of nursing (DON). The DON explained that neuro checks are to be conducted on any resident who had an unwitnessed fall or hit their head. She also stated that staff are to do a post-fall documentation for three days following a fall. She explained that it was important to identify if there are any latent injuries. The DON was unsure of the frequency of neuro checks and stated she would like to reference their policy. The facility policy was requested. On 8/6/25, during an end of day meeting, the facility's regional director of clinical services reported to the survey team that they did not have a policy for neuro checks. The above findings regarding R13 and R20 were reviewed. On 8/7/25, interviews were conducted with licensed practical nurses #9 & #10 (LPN #9 & LPN #10). Both explained that when a resident falls the nurse is to complete a full head to toe assessment, initiate neurological evaluations, notify the doctor and family of the resident and document all the details of the fall, assessment, etc. in the resident's medical record. When asked about the frequency of the neurological evaluations, LPN #10 provided the surveyor with a document titled, Post Fall Assessment Checklist that noted post-fall assessments were to be completed every eight hours for 72 hours following a fall. LPN #10 also provided an untitled document and stated the neurological evaluations and vital signs were to be obtained according to the frequency noted on that form that was initially after the fall, every 15 minutes four times (for a total of an hour), then every thirty minutes twice (for an hour), every hour for four hours, every four hours for six occurrences and then the subsequent two shifts. According to the facility policy titled, Fall Prevention Program, which read in part, . 9. When any resident experiences a fall, the facility will: a. asses the resident. B. complete a post-fall review and post fall follow up note in PCC [the electronic health record system]. 3. Complete an incident report in PCC [electronic health record]. D. Notify the physician and family. E. Review the residents' care plan and update as indicated. F. Document all assessments and actions.i. begin neurologic assessment using Neurological Record assessment tool in PCC. No additional information was provided. 3a. For Resident #21, who fell and sustained a right proximal humerus (shoulder) fracture, facility staff failed to ensure that the therapy ordered by the orthopedic surgeon for range of motion was carried out. On 8/6/25, R21 was visited in her room. R21 reported that the doctor had told her yesterday she no longer needed to wear the sling, and the arm sling was observed lying on the bed. During the interview, R21 was noted to have cognitive impairments and was unable to recall the details of the event resulting in the fracture, when she had gone to the doctor, etc. R21 was also unclear if she had been receiving therapy services regarding her right humeral fracture. On 8/5/25-8/6/25, a clinical record review was conducted. According to a progress note dated 6/25/25, which read, Resident observed in floor across from nurses' station and non-witnessed at 2020 [8:10 p.m.]. Vital signs/neuros obtained with pupils equal reactive to light, ROM limited right arm with arm swollen elbow/shoulder. Supervisor, resident son emergency contact #1 made aware approved to send to [hospital name redacted] ER [emergency room] for evaluation right arm pain/discomfort with swelling and limited ROM [range of motion]. Tylenol administered and ineffective. According to a progress note from the nurse practitioner dated 6/25/25, the resident was admitted to the facility on [DATE] and had sustained three falls since admission. According to the physician orders, R21 had orders to see the orthopedic surgeon on 7/1/25, 7/15/25, and 8/5/25. There was a report from the visit on 7/1/25 with the orthopedic doctor that noted the resident was non-weight bearing to her right upper arm. There was no documentation within the record as to the appointment outcome on 7/15/25. On 8/6/25, the unit manager reviewed R21's chart but could not find any documentation, stating that medical records may have it and it had not been uploaded into the clinical record. On 8/6/25, the surveyor visited the medical records employee who reported that she didn't have anything for R21 with regards to the orthopedic appointment on 7/15/25. The medical records employee did state that sometimes the staff up front assist with uploading documents, she would check with them. On 8/6/25 at 2:59 p.m., an interview was conducted with the occupational therapy assistant/other employee #8 (OE#8) and the rehab director/other employee #5 (OE#5). They reviewed R21's therapy chart and reported that R21 was on occupational therapy caseload and was non-weight bearing. On the morning of 8/7/25, the facility's assistant director of nursing provided the surveyor with a progress note from the orthopedic surgeon dated 7/15/25. When asked where they had found the note, the ADON reported they called the doctor's office and had them fax it over. Review of the note dated 7/15/25 revealed in part, . sling may be removed for hygiene and physical therapy. Orders written for therapy to start assisted active range of motion as guided by pain. On 8/7/25 at 9 a.m., a follow-up interview was conducted with the rehab director and occupational therapy assistant. Both reported they were not aware of the orders from the orthopedic surgeon to start range of motion on 7/15/25, but the resident was going to be re-evaluated that day. 3b. For R21, the facility staff failed to obtain weights as ordered by the physician. On 8/6/25, during a clinical record review it was noted that on 6/24/25, a physician order was written that read, Daily weights for three days. There was another order dated 6/24/25, with an effective date of 6/30/25 that read, Weekly weight every day shift every Mon for monitoring for 4 weeks. According to the weight and vital sign tab of R21's chart, the only weights obtained were on 6/24/25, 7/2/25, 7/10/25, and 7/15/25, indicating that the order for daily weights for three days was not carried out. These dates also indicated that the order for weekly weights on Mondays was not carried out as none of the three weights in July were obtained on a Monday. On 8/6/25, in the afternoon, the surveyor met with the unit manager. The unit manager reviewed R21's chart and confirmed the order for daily weights for three days was not completed. She also verified that the weekly weights on Monday order was not carried out, confirmed that the weights recorded were not obtained on Mondays, and weights had not been done for four weeks as ordered. The unit manager stated that if the order was written for weights to be done on Mondays the expectation would be for them to be obtained on Monday. 4. For R14, who had physician orders for daily weights for three days, the facility staff failed to obtain the weights in accordance with the order. On 8/7/25, during a clinical record review, it was noted that R14 had a physician order dated 7/31/25 that ready Daily weight x 3 days. According to the treatment administration record, the area for the weight to be recorded was blank for 7/31 and 8/2. On 8/1/25 it noted NA not applicable. According to the weight tab in R14's chart, only one weight was recorded since admission and that was on 7/28/25. On 8/7/25, an interview was conducted with the unit manager. After reviewing R14's physician orders and documentation, the unit manager stated that the weights had not been obtained as ordered by the doctor. A review of the facility policies titled, Provision of Physician Ordered Services and Weight Monitoring was conducted, but neither addressed following physician orders other than for diagnostic procedures. On 8/7/25, during an end of day meeting, the facility administrator and director of nursing were made aware of the above findings regarding R21 and R14. No additional information was provided. 5. Resident #2 did not have neurological assessments initiated and/or thoroughly completed after having unwitnessed falls as required in the plan of care. Resident #2 (R2) was admitted to the facility with diagnoses that included dementia, psychotic disturbance, mood disorder, anxiety, chronic kidney disease, gastroesophageal reflux disease, obesity, congestive heart failure, peripheral vascular disease and cognitive communication deficit. The minimum data set (MDS) dated [DATE] assessed R2 with severely impaired cognitive skills. R2's clinical record documented a nurse practitioner's note dated 6/18/25 stating that R2 fell yesterday, was assessed with no injuries and had neurological checks initiated. R2's clinical record documented the resident had an unwitnessed fall on 7/4/25 when he was found on the floor in the day room. R2's clinical record documented no neurological (neuro) assessments following the resident's unwitnessed fall on 6/17/25. Neuro checks were initiated immediately following the fall of 7/4/25, but were not completed as scheduled. R2's Neurological Record started on 7/4/24 at 2:15 p.m. listed spaces for assessments over the next 72 hours following the fall (every 15 minutes x 4, every 30 minutes x 2, every hour x 4, every 4 hours x 6 and every shift x 2) for monitoring possible neurological complications resulting from the unwitnessed fall. R2 had neuro assessments completed seven times following the fall of 7/4/25. The remaining eleven scheduled assessments were not completed. R2's neuro checks on 7/4/25 at 2:15 p.m., 2:30 p.m., 2:45 p.m. and 3:00 p.m. documented the resident's pupil assessments indicating reactivity and response to light, were not done. R2's plan of care (revised 7/15/25) documented the resident was at risk of falls and had experienced falls due to poor gait/balance. Interventions to prevent injury and maintain current status included neuro checks per protocol. On 8/6/25 at 8:05 a.m., the director of nursing (DON) was interviewed about neuro assessments following falls. The DON stated if a fall resulted in head trauma or if the fall was unwitnessed, neurological assessments were expected to be completed for 72 hours following the incident. On 8/6/25 at 4:00 p.m., the licensed practical nurse unit manager (LPN #3) caring for R2 was interviewed. LPN #3 reviewed the clinical record and stated the neuro assessments started for R2 on 7/4/25 were started but were not completed. On 8/6/25 at 4:30 p.m., LPN #2 that performed the initial four assessments for R2 on 7/4/25, was interviewed about why pupil checks were not done. LPN #2 reviewed the assessment form and stated, I just didn't assess them [pupils]. LPN #2 offered no explanation of why the pupils were not assessed and again stated the pupil assessments were just not done. On 8/7/25 at 8:30 a.m., the unit manager (LPN #3) was interviewed about any neurological assessments following R2's 6/17/25 unwitnessed fall. LPN #3 reviewed the clinical record and stated she did not find neurological checks following the fall of 6/17/25. LPN #3 stated, I don't see where they [neuro checks] were started. The facility's policy titled Fall Prevention Program (revised 12/1/24) documented, .When any resident experiences a fall, the facility will .Assess the resident .Document all assessments and actions .Begin neurologic assessment using Neurological Record assessment tool in PCC [electronic health record] . This finding was reviewed with the administrator and director of nursing on 8/7/25 at 12:30 p.m. with no further information provided prior to the end of the survey. 6. Facility staff failed to follow a physician's order to obtain vital signs every morning for R24. On 8/7/25 at 8:20 a.m., an interview was conducted with R24. R24 was asked if the facility staff were taking his vital signs every morning. R24 said, they check my blood pressure here, but I have full sets at dialysis on Monday, Wednesday and Friday. On 8/7/25 at 9:00 a.m., an interview was conducted with a licensed practical nurse, LPN#5 (LPN5). LPN5 was asked what does monitoring vital signs mean and she said, it means a full set of vitals, but we only check blood pressure on [R24 name was redacted]. LPN5 said, the order needs to be changed to just blood pressure not vitals. On 8/7/25 a clinical record review was conducted. R24's physician's order dated 6/14/25 read, Monitor Vital Signs every morning at 9am in the morning, and the order was to start on 6/15/25. The review of R24's medication administration record indicated only the blood pressure monitoring not the full set of vital signs. On 8/7/25 at 10:00 a.m., the above concerns were brought to the administrator, director of nursing and corporate staff. On 8/7/25 the policy for Following Physician Orders was requested twice but was never received. No additional information was provided.

Based on staff interviews and clinical record review the facility staff failed to obtain an x-ray timely for one resident, Resident ##26 (R26) out of a survey sample of 41 residents.The findings included:There was an x-ray ordered stat (as soon as possible), and the facility did not follow up and the x-ray was not obtained timely.On 8/7/25 at 8:10 a.m., an interview was conducted with the nurse practitioner (NP). The NP stated if concern for a fracture we ordered the x-ray stat, and the expectation was for the x-ray to be obtained within eight hours. If the x-ray was longer than eight hours, we will send out to the emergency department and will send out sooner if the family wants the resident sent out for evaluation. NP also said, I will give more orders like frequent vitals, neuro checks and if pain is not controlled to send out.On 8/7/25 at 8:30 a.m., interview was conducted with a licensed practical nurse, LPN#7 (LPN7). LPN7 stated that R26 was in the dining room and fell. She stated that R26 was complaining about her left lower extremity and left hip area hurting. LPN7 stated that the nurse practitioner was notified and ordered a stat x-ray of the hip unilateral with or without pelvis on 6/17/25 at 3:51 p.m. LPN7 stated that R26 was receiving scheduled Tylenol and being repositioned frequently. The daughter was visiting the evening of 6/18/25 and was upset because the x-ray had not been obtained and her mother was in pain. LPN7 stated that R26 was complaining about discomfort in her left hip area while the daughter was in to visit. LPN7 stated that it was typical for the mobile x-ray to take a day to come to the facility to obtain an x-ray. LPN7 stated that there was no warmth or bruising in the left hip area and she was more concerned with R26 left lower extremity, from the knee down to the ankle and that area was bruised, red and swollen. LPN7 stated that R26 was not returned to the facility as a resident and said, I do believe she had a fracture to her left hip.On 6/17/25 at 3:51 p.m., a stat x-ray was ordered for R26 left hip. On 6/17/25 at 4:40 p.m., an x-ray order was obtained for an x-ray to ankle complete and knee 1 or 2 views. The x-rays were ordered due to pain from trauma. On 8/7/25 at 8:45 a.m., an interview was conducted with LPN#1 (LPN1). LPN1 stated that R26 had a fall in the dining room area. She stated that R26 was assessed after her fall and first aid was provided in the dayroom. LPN1 stated R26 was complaining of left knee pain, left hip pain and a x-ray was ordered. LPN1 said, [R26 name was redacted] was complaining of aches and pains. She was not screaming too much in the dining room with pain not enough screaming for 911 to be called. LPN1 stated R26 had a fall with a fracture and didn't return to the facility.On 8/7/25 a meeting was held with the administrator, director of nursing (DON) and corporate staff and they were informed of the above concerns. The administrator and DON were going to see if they had any other information concerning the x-ray. The DON provided two x-ray orders that were sent to the mobile x-ray company by LPN7 on 6/17/25. The DON was not able to provide evidence of facility staff following up with mobile x-ray company about the x-rays ordered prior to R26 being sent out to the emergency department.On 8/7/25 a clinical record review was conducted. The progress notes on 6/17/25 from LPN7 read, Resident was reportedly ambulating in dining room without assistance and fell into the floor. Fall was witnessed by family member, reports no head trauma. Resident voices c/o left hip pain while bearing weight, ROM WNL. First aid provided to left hand skin tear by wound nurse. Neuro checks WNL. On call provider notified of fall, order given to obtain 2 views Left hip Xray to rule out fracture. [director of nursing name redacted] and [resident's daughter name redacted] VS 160/78-98.1-78-18-96%RA. Post falls note on 6/18/25 at 11:23 a.m., read, Note Text: Current Vital Signs 145/76 - 6/18/2025 08:23 Position: Sitting l/arm 98.0 - 6/18/2025 08:24 Route: Tympanic 80 - 6/18/2025 08:24 Pulse Type: Regular R 18 - 6/18/2025 08:24PainResident reports pain. Resident states pain is 4/10.Non-verbal pain indicators: Comments: pain with weight bearing Observations Bruising (specify location below) Skin Tear(s) (specify location below) Observation notes (Action taken and resident response to observations listed above: First aid provided Physician Orders New orders post fall: Xray ordered for Left ankle, knee, and hip Resident was not referred to therapy.On 6/18/25 at 4:26 p.m., LPN7 wrote a note when R26 was going to be sent out to the emergency department. The note read, Patient's daughter came into the facility to visit. Insisted that she be sent to [name of hospital redacted] for evaluation d/t left sided pain from fall. VM left for RP [responsible person] to contact facility. There was no note in the clinical record when R26 was sent out to the emergency department. R26's discharge date was 6/19/25.According to the facility policy titled, Fall Prevention Program, which read in part, . 9. When any resident experiences a fall, the facility will: a. asses the resident. B. complete a post-fall review and post fall follow up note in PCC [the electronic health record system]. 3. Complete an incident report in PC. D. Notify the physician and family. E. Review the residents' care plan and update as indicated. F. Document all assessments and actions.i. begin neurologic assessment using Neurological Record assessment tool in PCC.On 8/7/25 at 12:00 p.m., an end of day meeting was held with the administrator, DON and corporate staff. The above concerns were discussed.No additional information was provided.

Based on resident interview, staff interview, clinical record review and facility documentation review the staff failed to provide care and services related to dialysis for three residents, Resident # 24 (R24), #25 (R25) and #14 (R14) out of a survey sample of 41 residents.The findings included:1. There was no order for facility staff to monitor R24's dialysis fistula site in the left upper arm. On 8/7/25 at 8:40 a.m., an interview was conducted with R24. R24 was asked if his fistula site was monitored and he said, Dialysis checks it every Monday, Wednesday and Friday, but here no. Maybe once or so a nurse came in listen to it but don't see that nurse often here. On 8/7/25 at 9:00 a.m., an interview was conducted with a licensed practical nurse, LPN#5 (LPN5). LPN5 stated that the dialysis access site was to be monitored. She stated the bruit and thrill at the fistula site was to be checked. LPN5 stated that the dressing on the fistula site was to be removed every 24 hours and checked. She stated this treatment was to be signed off on the treatment administration record. LPN5 said, when he was readmitted that the admitting nurse forgot to add order and I would bring this to their attention or get batch orders to check dialysis site. She stated R24 was just recently readmitted from the hospital and LPN5 checked the date it was 6/14/25. On 8/7/25 a clinical record review was conducted. R24's physician's orders was reviewed and there were no orders for monitoring R24's dialysis fistula site to left upper arm. On 8/7/25 at 10:00 a.m., the above findings were discussed with the administrator and no additional information was provided. 2. There was no transportation set up for R25 to go to his scheduled dialysis appointments. On 8/5/25 at 3:00 p.m., an interview was conducted with the administrator. The administrator stated that upon admission the facility was not aware R25 was a dialysis patient. On that day, 6/28/23 I was trying to get transport set up by stretcher for R25 but was not able to get transport and dialysis center to accommodate at the same day and time. The administrator said, Error on our part we didn't know from hospital that he was dialysis. Notified nurse practitioner as soon as it happened and received orders to send out to emergency department. We were between social workers. On 8/5/25 at 3:20 p.m., an interview was conducted with the director of nurses (DON). The DON stated she was not aware of whether transport was set up for R25 to go to his scheduled dialysis appointments. The DON stated to check with the transport coordinator, and she can see if she has a transport sheet for R25. On 8/5/25 at 3:30 p.m., an interview was conducted with the transport coordinator, other staff #3 (OS3). OS3 stated that she was not over transportation set up then but was unable to find a transport sheet for that time (6/28/23). She stated that transportation was not set up for R25 at that time. On 8/6/25 at 4:30 p.m., at the end of day meeting the administrator stated that the facility was aware that R25 went to dialysis but was not aware he had to go by stretcher which was the issue of getting transport for him that day. 3. For Resident #14(R14), the facility staff failed to monitor the dialysis access port in accordance with professional standards of practice and failed to notify the medical provider when the resident declined to attend a dialysis treatment session. On 8/5/25, R14 was identified and placed in the survey sample due to being a dialysis patient. On 8/6/25, a clinical record review was conducted, which revealed R14 was admitted on [DATE]. The only indication that R14 had a dialysis access site was in the nursing admission assessment which noted a right upper arm av fistula and within the care plan developed on 8/3/25. There was no mention in the nursing progress notes of checking for thrill and bruit, no physician order, nor did the care plan address this. According to a nursing progress note written by licensed practical nurse #8 (LPN #8) dated 7/30/25 at 6:46 a.m., read, CNA [certified nursing assistant] in to do rounds on resident and get resident up for dialysis. Resident refusing to go to dialysis due to not feeling well and being in pain. This nurse gave resident PRN [as needed] oxycodone. Transport arrived and alerted that resident was refusing to go. There was no indication that the medical provider/doctor was made aware of this missed dialysis appointment. On 8/6/25 at 11:12 a.m., an interview was conducted with LPN #8. LPN #8 confirmed that on 7/30/25 R14 did not go to her scheduled dialysis appointment. When asked if the doctor was made aware of this, LPN #8 stated no. LPN #8 confirmed that this would be important because the resident would be at risk for side effects due to missing dialysis and the doctor may want to order for lab work to be done. During the above interview with LPN #8 she was asked about checking the dialysis access site, LPN #8 stated they should be listening for thrill and bruit every shift and document on the treatment administration record. LPN #8 indicated it is important to make sure the access is working properly; there is no blockage or anything. LPN #8 went on to say, We need to monitor for signs and symptoms of bleeding/hemorrhage. LPN #8 reviewed R14's chart and confirmed that there was no evidence that nursing staff had been checking for thrill and bruit. LPN #8 stated she would enter it into R14's orders at that time so that staff could start checking and documenting it. The facility policy titled, Peritoneal Dialysis with a revision date of 12/15/23, was reviewed. It read in part, . 15. Before, during and after receiving the peritoneal dialysis, the facility staff must, based on physician's orders and professional standards of practice, do the following: a. Obtain vital signs, weights, assess the resident's stability, level of consciousness, and comfort or distress. B. Monitor for post-dialysis complications and symptoms such as, but not limited to dizziness, nausea, fatigue, or hypotension. d. Documentation of ongoing evaluation of the peritoneal catheter, including assessment of catheter related infections and tunnel for condition, monitoring for patency, leaks, infection, and bleeding at the site. 16. The facility will communicate with the attending physician, dialysis facility and/or nephrologist of any canceled or postponed dialysis treatments and document any responses to the changes in treatment in the medical record. According to the nursing standard of practice, When assessing an arteriovenous (AV) fistula, it's important to check for both a thrill and a bruit to ensure the fistula is functioning properly. Thrill: This is a palpable vibration over the fistula. You should feel a continuous, gentle, rhythmic vibration when you place your fingers over the fistula site. The presence of a thrill indicates that blood is flowing through the fistula. Bruit: This is a sound heard using a stethoscope. It is a whooshing or swishing sound caused by turbulent blood flow through the fistula. A continuous bruit indicates good blood flow, while changes in the sound can indicate potential issues like stenosis or thrombosis. Regular monitoring of these signs is crucial as they help in early detection of complications. If you notice any changes in the thrill or bruit, it should be reported immediately for further evaluation. Accessed online at allnurses.com On 8/6/25, during an end-of-day meeting, the facility administrator and director of nursing were made aware of the above findings. No additional information was provided.

Based on observation, staff interview, clinical record review, and facility documentation review, the facility staff failed to dress a resident in their personal clothing to maintain dignity for one resident (Resident #2-R2) in a survey sample of forty-one residents. The findings included:Based on observation, staff interview, clinical record review, and facility documentation review, the facility staff failed to dress a resident in their personal clothing to maintain dignity for one resident (Resident #2-R2) in a survey sample of forty-one residents. The findings included: On 8/5/25 at 12:07 p.m., observations were conducted of the lunch meal service on the A-wing. Resident #2 was sitting in the tv room with six other residents for the lunch meal. R2 was sitting in a geri-chair [medical recliner] with a hospital gown on and his back exposed. On 8/6/25, during an end of day meeting, the above observation was discussed with the facility administrator and director of nursing. On 8/7/25 at 8:15 a.m., R2 was observed sitting in the geri-chair in the hallway at the nursing station. R2 had a hospital gown on, he did have a blanket but had pulled it up and his legs and thighs were exposed. On 8/7/25 at 8:30 a.m., the surveyor went to R2's room and observed two pairs of shorts in his closet and a pair of lounge pants on the bed. On 8/7/25 at 9:30 a.m., R2 was observed in the tv room, which was on the main hall from the lobby to the A-wing, sitting at the table with his hospital gown on top of the table, which left his legs, incontinence brief and stomach exposed. The doorway was open, and the resident could be easily seen from the hallway by any staff, visitors or other residents entering or exiting the A-wing. The unit manager (LPN #3) was asked to come to the tv room. When the unit manager saw R2, she said, Oh, my. The unit manager said the resident should be covered and agreed it was a dignity concern. She went on to say that she saw him at the nursing station earlier and thought the staff were going to take him to the shower but she entered her office and hadn't been back out. LPN #3 then removed R2 from the tv room. On 8/7/25 at 10:30 a.m., the surveyor went to R2's room. R2 was not in his room. R2's roommate reported to the surveyor that the resident was not in there, but staff had come in and gotten clothes for the resident. On 8/7/25 at 10:50 a.m., R2 was observed in the tv room and had been showered. R2 was fully clothed in personal clothes that included a T-shirt, jeans, socks and shoes. An interview with R2 was attempted but was not successful due to R2's cognitive impairments. On 8/7/25 at 10:55 a.m., an interview was conducted with a certified nursing assistant (CNA #2), who confirmed she had showered R2. When asked about his clothing, she reported he didn't have a lot of clothes but was dressed in his personal clothes following the shower. When asked what they do if a resident doesn't have personal clothing available, CNA #2 reported that they have a lost and found they can go retrieve clothes from. On 8/7/25 at 11 a.m., the facility administrator and director of nursing were made aware of the above findings/observations. According to the facility policy titled, Resident Rights, which read in part, . 11. The facility will ensure that all staff members are educated on the rights of residents and the responsibility of the facility to properly care for its residents. According to a facility document titled, Resident Rights it read, 1. Resident rights. The resident has the right to a dignified existence. 5. Respect and dignity. The resident has a right to be treated with respect and dignity, including: . b. The right to retain and use personal possessions, including furnishings, and clothing, as space permits, unless to do so would infringe upon the rights or health and safety of other residents. No additional information was received.

Based on staff interview, facility document review and clinical record review, the facility staff failed to follow professional standards of care for two of forty-one residents in the survey sample (Residents #2 and #20).The findings include:1. Nursing staff failed to document in the clinical record an unwitnessed fall for Resident #2, including immediate assessments, actions taken and circumstances of the fall. Resident #2 (R2) was admitted to the facility with diagnoses that included dementia, psychotic disturbance, mood disorder, anxiety, chronic kidney disease, gastroesophageal reflux disease, obesity, congestive heart failure, peripheral vascular disease and cognitive communication deficit. The minimum data set (MDS) dated [DATE] assessed R2 with severely impaired cognitive skills. R2's clinical record documented a nurse practitioner progress note dated 6/18/25 at 11:59 p.m. This note documented, .The patient sustained a fall yesterday [6/17/25], but no injuries were reported. Neuro checks initiated and have been unremarkable. Patient has been at baseline mental status since fall. Did not hit head or have LOC that staff is aware of . R2's clinical notes on 6/17/25 had no documentation regarding the fall and included no record of an immediate assessment of the resident, or circumstances surrounding the fall. The notes made no mention of how staff were aware the resident did not hit his head. There was no documentation of neurological assessments initiated or completed following this fall. The last note documented prior to the practitioner's note on 6/18/25 was on 6/12/25. The nurse practitioner documented that R2 was assessed on 6/18/25 with no injuries or complications from the fall. On 8/7/25 at 8:30 a.m., the licensed practical nurse unit manager (LPN #3) was interviewed about R2's fall on 6/17/25. LPN #3 reviewed the clinical record and stated she found a nursing note about the fall but stated she found no resident assessment or documentation regarding the circumstances surrounding the fall in the clinical record prior to the practitioner's note on 6/18/25. LPN #3 stated that she did not see where neurological assessments were initiated or completed following the fall. LPN #3 stated that regarding the lack of documentation, You would think there would be a note. LPN #3 stated nurses were expected to document a fall in the nursing notes along with any assessments, notifications, and actions taken regarding the incident. LPN #3 stated that a risk management form was completed for the fall of 6/17/25, but nothing was documented in the clinical record. On 8/7/25 at 10:00 a.m., the director of nursing (DON) was interviewed about lack of documentation regarding R2's fall on 6/17/25. The DON stated it was a standard of practice for nurses to document incidents at the time they happened, including falls. The DON stated the circumstances of the fall, and any resident assessments should have been documented in the clinical record. The DON presented the risk management form for R2's fall on 6/17/25, which was labelled Not Part of the Medical Record. This form documented R2 was found on the floor beside his bed on 6/17/25 at 11:00 p.m., that the resident was assessed with no injuries, and that notifications were made to the physician and family. Although none were found in the clinical record, this form also noted that neurological checks were initiated. The facility's policy titled Fall Prevention Program (revised 12/1/24) documented, .When any resident experiences a fall, the facility will .Assess the resident .Complete a Post-fall Review and a Post Fall Follow Up note in PCC [electronic health record] .Notify physician and family .review the resident's care plan and update as indicated .Document all assessments and actions . The Lippincott Manual of Nursing Practice 11th edition on page 15 lists that common departures from standards of care include failure to make prompt, accurate entries in a patient's medical record and documented, .A deviation from the protocol should be documented in the patient's chart with clear, concise statements of the nurse's decisions, actions, and reasons for the care provided, including any apparent deviation. This should be done at the time the care is rendered because passage of time may lead to a less than accurate recollection of the specific events . (1) This finding was reviewed with the administrator and director of nursing on 8/7/25 at 12:30 p.m. with no further information presented prior to the end of the survey. (1) [NAME], [NAME] M. Lippincott Manual of Nursing Practice. Philadelphia: Wolters Kluwer Health/[NAME] & [NAME], 2019. 2. For Resident #20 (R20), the facility staff failed to follow professional standards of practice by failure to document an incident and assessment of the resident following a fall resulting in a hip fracture. On 8/6/25 a clinical record review was conducted of R20's chart. According to the census tab and progress notes, R20 was admitted to the facility on [DATE], after being involved in a car accident and sustaining a right shoulder blade fracture with a T11 spinal compression fracture. According to the census tab, R20 discharged on 4/26/25 and was readmitted on [DATE]. According to a hospital Discharge summary dated [DATE], which noted that R20 was hospitalized and underwent a right intertrochanteric femur fracture with cephalomedullary implant [hip fracture with surgical repair]. Within R20's clinical record, the only documentation regarding a fall that resulted in a hip fracture was from the on-call provider in a progress note dated 4/26/25, which read in part, . Patient fell unwitnessed and fell on right hip. Abrasion and hematoma to right knee. Patient complained of 10/10 sharp stabbing pain to right hip and leg. Fall unwitnessed. Administered pain medication not effective. Recommendation/request: Sent to ER [emergency room] . There was no documentation within R20's clinical record as to the circumstances of the fall, the location and details of the fall, condition resident was found in, facility staff's assessment of the resident, nor that the resident's condition was discussed and orders were obtained to send the resident to the hospital for evaluation. There was no documentation that the facility nursing staff had assessed the resident, his condition at the time of the fall, injuries, pain, etc. On 8/6/25, during an interview with the facility's director of nursing (DON), in the presence of the regional director of clinical services, the DON was made aware of the above findings. The DON reviewed R20's clinical record and confirmed the above findings. The DON did provide the surveyor with an event synopsis, which she did confirm was not part of R20's clinical record. The DON stated that the expectation is that the facility staff would document any fall incidents in the resident's chart. On 8/6/25, during an end of day meeting, the facility administrator was made aware of the above findings. On the morning of 8/7/25, interviews were conducted with licensed practical nurses #9 & #10 (LPN #9 and LPN #10). Both LPN #9 and LPN #10 reported that following a fall, the facility's nursing staff assess the resident for injury, obtain vital signs and initiate neuro checks, notify the doctor and family, and then document within the clinical record all of the details. According to the facility policy titled, Fall Prevention Program, which read in part, . 9. When any resident experiences a fall, the facility will: A. Assess the resident. B. Complete a post-fall review and post fall follow-up note in PCC. C. Complete an incident report in PCC. D. Notify physician and family. E. Review the residents' care plan and update as indicated. F. Document all assessments and actions. G. Obtain witness statements in the case of injury. H. If there are signs of serious injury or there are concerns about the circumstances of the fall, notify the Director of Nursing and/or the Administrator. I. Begin neurologic assessment using the Neurological Record assessment tool in PCC. According to the American Associated of Post-Acute Care Nursing, standards of care following a fall included: . 1. Immediate Assessment: Evaluate the resident's vital signs, level of consciousness, and any visible injuries. Check for signs of head, neck, or spinal injuries, and assess for fractures or significant bleeding. 4. Documentation and Investigation: Record the circumstances of the fall, the resident's outcome, and the staff's response. Investigate the possible causes of the fall to prevent future incidents. Accessed online at aapacn.org No additional information was provided.

Based on observation, resident interview, staff interview, clinical record review and facility document review, the facility staff failed to ensure pain management for one of 21 residents in the survey sample, Resident #78. Resident #78 was not administered scheduled pain medication as ordered by the physician; Resident #78 suffered unrelieved pain and was unable to sleep, which resulted in actual harm to the resident. Findings include: Resident #78's diagnoses included, but were not limited: diverticulitis, atrial fibrillation, depression, muscle weakness, dysphagia, abnormal gait, polyneuropathy, history of falls, and musculoskeletal mastoid bone pain. Resident #78's most recent MDS (minimum data set - CMS assessment tool) was an admission assessment dated [DATE]. This MDS assessed the resident with a BIMS (Brief Interview for Mental Status) score of 15 (out of 15), indicating intact cognition function for daily decision making skills. Physical function was assessed as requiring supervision with limited assistance of one staff person for most ADL's (activities of daily living). On 11/02/22 at approximately 7:55 AM, Resident #78 was observed sitting on the side of bed with facial grimacing. Upon interview, Resident # 78 stated that she had a rough night, was in pain, and had not slept due to the pain. Having asked the night nurse for her ordered pain medication, Resident #78 states that the nurse had told her that they (the facility) didn't have any and that it was on order from the pharmacy. The resident stated that the nurse's name (identified as LPN #7) did not offer her anything else for her pain. When asked if the nurse had provided her with any non-pharmacological interventions, such a heat or ice packs or a back rub, etc., the resident stated, No. When asked to rate her pain level, resident #78 responded that her pain was a 7 out of 10, indicating severe pain. In apparent distress, the resident expressed that she hoped she didn't start crying because of the pain, but stated, .it hurts. At approximately 8:05 AM, LPN (Licensed Practical Nurse) #1 (the day shift nurse) was informed of the above information and Resident #78's present complaint of pain. LPN #1 looked in the system and confirmed that the resident had an order for Hydrocodone-Acetaminophen (a narcotic medication for moderate to severe pain) solution, scheduled at bedtime, for mastoid bone pain, with a Start Date of 10/31/22. Reviewing the EMAR (electronic medication administration record) further, LPN #1 stated that the resident #78 did not get the medication last night (11/01/22 at 10 PM) and that according to the nursing/note written by the LPN #7, the medication was on order. Stating that it shouldn't take that long for a medication to get here, LPN #1 added, It was ordered on 10/31/22, it should be here. While observed, LPN #1 looked thru the medication cart until holding a bottle and said, This is it. The bottle was labled with Resident # 78's name, medication name, and date dispensed as 10/31/22. When asked, LPN #1 pulled the narcotic count sheet and stated that none of the medication doses were documented or signed off as administered on 11/1/22. As requested, LPN #1 also checked 10/31/22 and stated that the resident had not received pain medication on that night either. On 11/02/22 at approximately 8:45 AM, LPN #1 stated that she had obtained a one time order to administer the resident's pain medication. Observed preparing the medication, LPN #1 took the medication to the Resident #78's room. Holding her hand to side of her head & grimacing, Resident #78 appeared teary-eyed. When asked what her pain level was at the time. Resident #78 responded that her pain was now at 8.5 out of 10 (indicating very severe pain), took the medication, and stated that she hoped it helped. At approximately 9:30 AM, Resident #78's clinical records were reviewed. The resident's physician's orders were reviewed and included an order for: .[order date: 10/31/22 10:32 am] Hydrocodone-Acetaminophen solution 2.5 -108 mg/5 ml (milligrams/milliliter) Give 5 ml by mouth at bedtime for mastoid bone pain Start Date: 10/31/22 . The Resident #78's MAR (medication administration records) for October and November 2022 were reviewed. On 10/31/22 and 11/01/22 at 10:00 PM, the MAR documented a '9' in the slot for the scheduled pain medication (Hydrocodone-Acetaminophen solution). According to the MAR legend, a '9' means 'Other/see nursing notes'. The review of the nursing notes included the following entries: On 10/31/22 the nursing note documented, 10/31/2022 5:00 PM .Orders - General Note .you have entered HYDROcodone-Acetaminophen Solution 2.5-108 MG/5ML Give 5 ml by mouth at bedtime for mastoid bone pain . On 11/1/2022 an EMAR note documented, .1:35 AM - Medication Administration Note .HYDROcodone-Acetaminophen Solution 2.5-108 MG/5ML Give 5 ml by mouth at bedtime for mastoid bone pain Pending pharmacy delivery @ this time. New mediation [medication] RX [prescription] . On 11/2/2022 an EMAR note documented, .12:17 AM - Medication Administration Note . HYDROcodone-Acetaminophen Solution 2.5-108 MG/5ML Give 5 ml by mouth at bedtime for mastoid bone pain Medication pending delivery @ this time. Res resting in bed w/ eyes closed . No progress notes were found to evidence that a physician was either notified that Resident #78 did not receive the physician ordered pain medication or that the ordered pain medication was not available for administration. Upon review, Resident #78's current CCP (comprehensive care plan) was reviewed. The CCP documented, .Pain Management Date initiated: 11/01/22 resident will demonstrate and verbalize knowledge of strategies for pain management .pain management date initiated: 11/01/22 .Resident will be offered non-pharmacological interventions for pain .distraction, entertainment/activity, food and fluids .repositioning .date initiated: 11/01/22 . This care plan was developed on 11/01/22. There was no other information on the resident's care plan regarding pain, including resident preferences, pain assessment, guidelines for reporting pain, treatment effectiveness, or emerging issues. No documentation was found that the above pain management interventions had been implemented or even offered. On 11/02/22 at 11:51 AM, Resident # 78 was observed laying calmly in bed, without any grimacing. When asked if she was feeling better, Resident #78 responded, 'some' and stated that her pain level was .still at a level 5, which indicated moderate pain. On 11/02/22 at 3:10 PM, the NP (Nurse Practitioner) was made aware of the above findings regarding the observation and interview with Resident #78 on 11/02/22. Adding that the resident's pain medication was found on the medication cart but had not been administered, which resulted in Resident stating that she had a rough night and was unable to sleep due to being in pain and was hoping that she didn't start crying due to the pain. In response, the NP stated that Resident #78 has mastoid bone arthritis, for which several meds had been tried, including gabapentin, .which didn't really help. The NP stated that a low dose of Norco [hydrocodone-acetaminophen] had been started, .which seemed to do better for her pain. When asked, the NP stated that when any resident is in pain and their pain medication is not available or they don't have pain medication ordered, .my [the NP] expectation would be for the nurse to call the provider to obtain an order for an alternative pain medication of something preferably in house, to prevent a delay in treating the resident's pain. The NP then stated that she had not been on call, that she had not been made aware of this, and again stating the nurse should have contacted the provider. On 11/02/22 at approximately 6:15 PM, the administrator, DON (director of nursing), ADON (assistant director of nursing) and the corporate nurse were made aware of the serious concerns with Resident #78 being observed in pain, after not receiving the scheduled pain medication as ordered, with complaints of inability to sleep and continued pain, when the medication was actually available for administration. A policy on pain management was requested at this time. At 6:35 PM, the DON stated that the expectation would be and is for the nurse to notify the provider to get an order for something for pain. On 11/03/22, the facility policy titled Pain-Clinical Protocol was provided, which documented, .staff will identify individuals who have pain .staff will evaluate how pain is affecting mood, activities of daily living, sleep .quality of life .the pain management program is based on .appropriate assessment .resident choices related to pain management .signs of pain .verbal expressions .groaning, crying .facial expressions .grimacing, frowning .limitations in her/her activity .insomnia .non pharmacological interventions may be appropriate alone or in conjunction with medications .ice packs, cool or warm compresses, baths, .relaxation .pharmacological interventions be prescribed to manage pain .administering medications around the clock rather than PRN [as needed] .implement the medication regimen as ordered . Another facility policy, which was titled Unavailable Medications, documented that staff .shall follow established procedures for ensuring residents have a sufficient supply of medications .may be unavailable for a number of reasons .Staff shall take immediate action when it is known that the medication is unavailable .Notify physician .obtain alternate treatment . No further information and/or documentation was presented prior to the exit conference on 11/03/22 to evidence that facility staff provided timely pain management to Resident # 78 when experiencing pain, in accordance with the physician's orders and the CCP. This is a harm level deficiency.

Based on observation, staff interview, resident interview, clinical record review, and facility document review, the facility staff failed to provide timely treatment for an UTI (urinary tract infection) for one of twenty-one residents, Resident #28. The findings include: Resident #28 was admitted to the facility with the following diagnoses including but not limited to: Diabetes mellitus, quadriplegia, contracture of the left hand, UTI, and chronic kidney disease. An annual MDS (minimum data set -cms assessment tool) dated 09/02/2022 documented the BIMS (Brief Interview of Mental Status) score as 15 out of 15, indicating Resident #28 was cognitively intact for daily decision making. On 11/01/2022 beginning at approximately 3:00 p.m., a review of the clinical record included progress notes with the following entries: 10/29/2022 22:20 (10:22 p.m.) Positive for UTI. Spoke with [Name redacted]; place PICC line begin ertapenem 1 GM (gram) q (every) 24 hours. 10/31/2022 (Note from nurse practitioner signed 10/31/2022 at 7:51 p.m.) .Infection and inflammatory reaction due to indwelling urethral catheter .urine culture came back with E. Coli and Pseudomonas. She is on trimethoprim 50 mg daily for UTI prophylaxis, however, she has developed a UTI again. She should continue ertapenem 1 g daily until 11/4/2022. Foley care should be performed every shift and the catheter should be changed every 28 days . 11/01/2022 01:27 (a.m.) Ertapenem Sodium Reconstituted 1 GM Use 1 gram intravenously one time a day for UTI over 4 days. IV therapy to begin tomorrow 11-1 @1700 per MD order, noted change in (computer system) as well. Resident #28 had been observed in her chair during initial tour on 11/01/2022 at approximately 12:00 p.m. No IV line was observed at that time. At approximately 5:00 p.m., Resident #28 was again observed sitting up in chair in her room. When asked if she was getting IV antibiotics for a urinary tract infection, Resident #28 stated, I am supposed to be but I haven't gotten any yet .they said they don't have any needles .I had one, I think it was last week, it started bleeding and they took it out. When asked if she was having any lower abdominal discomfort or any symptoms related to her UTI, Resident #28 stated, No, I'm okay right now. On 11/01/2022 at approximately 5:10 p.m., LPN (licensed practical nurse) #7 was in the hallway preparing medications. When asked if she was taking care of Resident #28, LPN #7 stated, Yes. When asked about Resident #28's IV antibiotics for her urinary tract infection, LPN #7 looked at the MAR (medication administration record) and stated, The order says to start that tomorrow (11/02/2022). When asked why it wasn't being started until 11/02/2022, when it was ordered on 10/29/2022, LPN #7 stated, We are waiting for the pharmacy to send us the supplies to do it. When asked to explain what she meant by supplies, LPN #7 stated ,We need the antibiotic and the supplies to start the IV. On 11/02/2022 at approximately 9:10 a.m., a review of the clinical record included a change in condition note, which contained the following and was written by the unit manager, RN (registered nurse) #1: 11/02/2022 08:56 (a.m.) Change in Condition .nursing observations, evaluation, and recommendations are: Resident presents with UTI, Foley catheter in place. Treatment with Ertapenem 1 Gm IV X (times) 4 days . On 11/02/2022 at approximately 9:30 a.m., RN #1 was interviewed. Referring to the change in condition note that she had written earlier that day, RN #1 was asked if she was aware that the antibiotics for Resident #28 had not yet been started. RN #1 looked at the physician orders and stated, Yes, it starts this evening. She was referred back to the progress notes from 10/29/2022, 10/31/2022, and 11/01/2022, regarding Resident #28's orders for an IV antibiotic and the entry in the medical record for a PICC line insertion. RN #1 reviewed the record and stated, We don't do PICC lines here .but for a four day course of antibiotics she wouldn't need a PICC. We could use a regular IV. When asked how long it took for a medication to arrive from the pharmacy, since the antibiotic had been ordered on 10/29/2022 and the resident had still not received a dose, RN #1 stated, I don't know why she hasn't gotten her antibiotic. Ertapenem is something we have here in stock and we have everything we need to start an IV. RN #1 stated that she would look into a few things and get back to the survey team. At approximately 11:30 a.m., RN #1 came to the conference room and stated, The antibiotic order was written by the on-call physician over the weekend. It looks like the original order was written on October 29 to place a PICC line and discontinue it when the antibiotics were complete. That order was discontinued. There was also an order written on October 29 for the antibiotics to be given for four days .that was discontinued and rewritten to start on November first .that order was discontinued on November 1st, the reason on the order was 'waiting on IV supplies from the pharmacy', but they were suppose to be here today .I don't know what happened .some of the notes say we were waiting on the medicine, some say waiting on IV supplies. It looks like we ordered the medicine from the pharmacy .we have that antibiotic here so it could have been started .I spoke with the nurse practitioner and we got the order clarified so we can give it IM starting today at noon. When asked if the physician or nurse practitioner had been notified that the medication had not been given before today, RN #1 stated, There isn't any documentation that notification occurred, I don't feel like that happened. When asked if the nurses had changed/canceled the orders and the start dates of the antibiotic without speaking with the physician or the nurse practitioner, RN #1 stated, Yes, that is what I think happened .the physician should have been notified. On 11/02/2022 at approximately 3:30 p.m., the nurse practitioner (NP) was interviewed. When asked if she was aware that Resident #28 had not received any doses of her antibiotics prior to the IM injection ordered earlier on 11/02/2022, the NP stated, I was told on Monday (10/31/2022) that she had an IV and that it had infiltrated .I can't tell you the nurses name who told me that, but she said there weren't any needles here to restart it and they would have to come from the pharmacy .I thought she had gotten one dose and it would resume the next day [11/01/2022]. I found out today that none had been given, so we changed the route to IM. On 11/02/2022 at approximately 4:00 p.m., RN #1 was asked if other than the clinical record there was any place the nurses could have documented that the antibiotic was not given and the physician/nurse practitioner were notified. RN #1 stated, There is a physician book. RN #1 went to the nurse's station and looked in the book, but stated, There's not any documentation in here about that. On 11/02/2022 at approximately 4:30 p.m., the DON (director of nursing) came to the conference room and stated, Here is the packing slip from the pharmacy .the antibiotics have been here the whole time .they were ordered and the pharmacy dispensed them on the 30th [10/30/2022] and they were delivered on the 31st [10/31/2022] As a matter of fact, the pharmacy delivered them twice. The bags are in the bottom drawer of the med cart. When asked why the nurse had documented that the meds were not available, the DON stated, I don't know, she is not here and we have labeled her as DNR. When asked what DNR meant, the DON stated, Do not rehire. The above information was discussed with the DON, the administrator, the ADON (assistant director of nursing) and three members of the corporate staff. Concerns were voiced that an IV antibiotic had been ordered on 10/29/2022 for four doses and the medication was not started until 11/02/2022. When asked if the physician or nurse practitioner had been notified of the delay in treatment, the DON stated that she would find out. When asked how the nurses know what meds were available in the Stat box, the DON stated that there was a list in each medication room. On 11/03/2022 at 9:30 a.m., the DON entered the conference room and was asked if she could clarify if the antibiotics were not started because the nurses thought the meds were in house or because they didn't know that IV supplies were in house. The DON responded, I've not been able to get in touch with the nurses .I don't know if the physician was notified or not, or if the problem was they didn't know we had the meds or if they thought the IV supplies weren't available.The DON then presented a list of medications available in the stat box, on which Ertapenem 1 gram was listed. No further information was obtained prior to the exit conference on 11/03/2022.

2. Facility staff failed to assist Resident #62 with wearing the physician ordered TED (thrombo-embolic deterrent) hose. On 11/02/2022 at approximately 9:30 a.m., Resident #62 was observed in her room. She was dressed for the day. No TED hose were observed. She was asked if she had white stockings that staff helped her put on in the mornings and took off in the evenings. She stated, No, I don't have that. She was asked if she had any stockings in her drawers. She opened her drawers and stated, No, I don't have any. CNA (certified nursing assistant) #1 was in the hallway. She confirmed that she was assigned to Resident #62. She was asked about the physician ordered TED hose. She stated, I didn't help her get dressed today, the nurse did. I don't know if she is supposed to be wearing TED hose or not. She was asked if she had reviewed Resident #62's kardex (daily care guide) prior to caring for her. She stated, I haven't looked at it recently .the nurses tell us what we are supposed to do .I think they put those on the residents anyway. Resident #62 was admitted to the facility with hypertension, artherosclerotic heart disease, sick sinus syndrome, presence of cardiac pacemaker, diabetes mellitus, cognitive impairment, and a history of falls. A quarterly MDS (minimum data set - cms assessment tool), with an ARD (assessment reference date) of 10/07/2022, assessed Resident #62 having a BIMS (Brief Interview for Mentals Status) score of 5/15, indicating moderately impaired cognition with daily decision making. Resident #62's clinical record was reviewed on 11/01/2022 at approximately 2:30 p.m. Review of the physician orders included the following orders written on 09/19/2022: Apply TED hose daily to BLE (bilateral lower extremities). Nursing staff to assist her with this task, one time a day for edema. Remove TED hose @ HS (hour of sleep) Nursing staff to assist with this task, one time a day for edema. The unit manager, RN (registered nurse) #1 was interviewed at approximately 9:45 a.m. When asked who was supposed to assist Resident #62 with her TED hose, RN #1 stated, The CNAs do that. When told that Resident #62 did not have her TED hose on, nor were there any in her room that the resident could find, RN #1 stated, They may be in the laundry, but there should be a spare pair in the room. The comprehensive care plan and the kardex were reviewed at approximately 10:15 a.m., the TED hose were not observed on either. At approximately 11:30 a.m., RN #1 came to the conference room and stated, [Resident #62's] TED hose did go to the laundry this morning, but there should have been a spare in there for her. RN #1 was asked how the CNA would know to apply the TED hose since they were not on the resident's kardex. RN #1 stated, It was on the nurse's MAR (medication administration record), it should have been on the TAR (treatment administration record) .the nurse tells the CNA to assist the resident, but it should be on the care plan and the Kardex. The above information was discussed with the administrator, the DON (director of nursing), the ADON (assistant director of nursing) and three corporate staff during an end of the day meeting on 11/02/2022 at approximately 5:30 p.m. No further information was obtained prior to the exit conference on 11/03/2022. 27353 Based on resident interview, staff interview, clinical record review, facility document review, the facility staff failed to provide ongoing wound assessments to monitor healing progress for one of 21 residents in the survey sample (Resident #34) and failed to follow physician's orders for applying TED hose for one of 21 residents in the survey sample (Resident #62). The findings include: 1. A complaint investigation was conducted on 11/01/22 through 11/03/22. An allegation within the complaint alleged that the facility failed to monitor for appropriate wound healing. Resident #34's diagnoses included, but were not limited to: HTN (high blood pressure), CHF (congestive heart failure), schizophrenia, asthma, Parkinson's disease, anxiety disorder, polyneuropathy, obesity, and depression. The most current MDS (minimum data set - cms assessment tool) was a quarterly review, dated prior to the discovery of the resident's wound on 07/29/22. This MDS documented the BIMS (brief Interview for Mental Status) score of 12 out of 15, indicating Resident #34 had moderate cognitive impairment in daily decision making skills. Resident #34's physical function was assessed as non-ambulatory and requiring extensive to full assistance of two staff for ADL's (activities of daily living). Resident #34's most recent full MDS (minimum data set - cms assessment tool) assessment was an annual assessment dated [DATE], which triggered in the CAAS (care area assessment summary) section for pressure ulcers, indicating the need for care plan development in this area. Resident #34's clinical records were reviewed and revealed that bilateral 'friction' wounds to the dorsal area of both feet (from shoes) were documented on a 07/29/22 weekly skin assessment. A physician progress note documented the following: .08/01/22 .seeing the resident for reports that he has abrasions to the tops of both of his feet with odor. Over the weekend, nursing staff reports that his shoes were rubbing the tops of his feet .rubbed the first layer of skin off .nursing staff have been covering with nonstick piece of gauze and tape however nursing staff reports that today it is draining .and odorous. Resident denies pain or any other acute concerns regarding this today .wearing nonskid socks instead of shoes since these abrasions started .dorsal aspects of both feet with 1st layer of skin sloughed off due to friction from his shoes .underlying skin is pink and moist with small amount of drainage on dressing .I have ordered for nursing staff to cleanse the wounds with DWC (dermal wound cleanser), apply TAO (topical antibiotic ointment), cover with nonstick gauze, and tape/wrap until healed. Due to yellow drainage and odor, I have ordered cephalexin 500 mg (milligrams) 3 times daily for 7 days .continue to keep shoes off .until wounds heal .signature of NP (Nurse Practitioner). A review of the physician's orders were revealed the following: .Cleanse .with DWC, apply TAO, cover with nonstick gauze until healed (order date: 08/01/22). The above order was changed on 08/03/22 to the following: .Cleanse .bilateral feet with DWC, apply collagen and calcium alginate, wrap with kerlix, Change QD [every day] every day shift for bilateral foot wounds .(start date: 08/03/22). The resident's MARs/TARs (medication/treatment administration records) for August 2022 were reviewed and revealed that the resident did receive the above treatments as ordered, but no documentation included wound monitoring or assessments. On 11/01/22 at 12:01 PM, Resident #34 was interviewed regarding his foot/feet wound(s) and was asked what had happened to cause the wounds. Resident #34 stated that he didn't know what happened to either foot, then stated that he doesn't walk. When questioned about wound care, Resident #34 stated that staff was cleaning and dressing it once a day, adding that he dreaded them doing it, but he did let them do it. When asked if he refused care at times, Resident #34 stated that he did not refuse care to the wounds on his feet and that the staff was taking care of them. When questioned if he had any problems with his feet before going to the hospital in August, Resident #34 stated that he didn't know. On 11/02/22 at 2:40 PM, an interview was conducted with the NP, regarding the wound development and treatment for Resident # 34. The NP stated that the resident started out with friction wounds from his shoes, for which she stated that she treated the resident with Keflex and wound care. The NP stated that the wounds seemed fine until one of the nurse's had notified another provider when maggots were found in the wound and the resident had been sent out to the hospital. The NP was then made aware that no wound assessments could be found or any evidence that the wound progress or treatment effective was being monitored. The NP was made aware that according to documentation, the wound treatments were completed, but there were no assessments documenting what the wounds looked like, during the dressing changes, on any of the days leading up to resident #34's transfer to the hospital on 08/08/22. The NP replied that she would expect them (nursing staff) to look at it and document what they saw, not necessarily measure each time, but would expect them to document wound drainage, odor, and to document specifically what they did and of what they saw during the dressing change each day. On 11/02/22 at approximately 6:15 PM, the administrator, DON (director of nursing), and corporate nurse were made aware of the complaint allegations regarding Resident #34 and that no wound assessments to monitor wound progress could be found after the initial wound assessment by the NP, which was completed on 08/01/22. Their assistance was requested in locating any ongoing wound assessments, since that date. A policy on wound care and assessments was also requested at that time. On 11/03/22 at approximately 8:15 AM, the DON presented wound policy and procedure documents. The policy documented, .Documentation of Wound Treatments .the facility completes accurate documentation of wound assessments and treatments, including response to treatment, change in condition and changes in treatment .type of wound .location .stage if pressure .if non-pressure (partial or full thickness) .measurements .description of wound characteristics .color .type of tissue .presence, amount, and characteristics of wound drainage .presence or absence of odor .presence or absence of pain .notification to physician and/or responsible party regarding wound or treatment changes . The DON also presented a weekly wound assessment dated [DATE], which only documented that the resident had an open area that was abraded to both feet from shoes. The other wound assessment dated [DATE] only documented that the resident had an open area. No other information was on this assessment, now were any other wound assessments presented. No further information and/or documentation was presented prior to the exit conference on 11/03/22 at 11:30 AM to evidence that the facility staff completed ongoing wound assessments to appropriately monitor Resident #34's wound healing. This is a complaint deficiency.

Based on staff interview, clinical record review and facility document review, the facility staff failed to develop a comprehensive care plan (CCP) for 4 of 21 residents in the survey sample (Resident #23, #78, #80, and #81). Resident #23 had no plan of care for anticoagulant (AC) medication and diabetic management, including insulin administration. Resident #78 had no plan of care developed/implemented for pain management. Resident #80 had no plan of care for anticoagulant (AC) medication. Resident #81 had no plan of care for anticoagulant (AC) medication. The findings include: 1. The facility staff failed to develop and implement a comprehensive care plan for anticoagulant therapy and diabetic management, including insulin therapy. Resident #23 was admitted to the facility with diagnoses that included COVID 19, hemiplegia/hemiparesis, chronic AFIB, DM2, cognitive communication deficit, and aphasia. The MDS (minimum data set -cms assessment tool) dated 09/05/22 was the 5 day admission assessment, which documented Resident #23 as moderately impaired cognitively for daily decision making with a score of 8 out of 15. Under Section N - Medications, the MDS documented that Resident #23 received insulin and anticoagulant medications, which are classified as high risk medications. Resident #23 clinical record was reviewed on 11/01/2022. Observed on the order summary report were the following orders: Apixaban Tablet 5 mg (milligrams) Give 1 tablet by mouth two times a day for DVT prevention. Order Date 10/5/2022 Insulin Glargine-yfgn 100 Unit/ML Solution Pen-injector. Inject 30 unit subcutaneously one time a day for DM 2. Order Date 10/12/2022. Insulin Lispro (1 Unit Dial) Solution Pen-injector 100 Unit/ML. Inject 4 unit subcutaneously four times a day for Diabetes Order Date 10/25/2022. Resident #23's medication administration records (MAR) for October and November 2022 were reviewed and documented the resident received the anticoagulant, Apixaban and both insulin (Glargine-yfgn & Lispro) as ordered/scheduled. Resident #23's comprehensive care plan (CCP) was reviewed, but had no individualized plan of care for anticoagulant (AC) medication or diabetic management, including insulin administration. On 11/02/2022 at 11:25 a.m., the licensed practical nurse (LPN #2) who routinely provided care for Resident #23 was interviewed regarding the resident's medications and care plans. LPN #2 reviewed Resident #23's clinical record and stated the resident was currently receiving both the anticoagulant and insulin. When asked why these serious medications were not included in the care plan, LPN #2 stated that the unit manager was responsible for the care plans. On 11/02/2022 at 11:30 a.m., the unit manager (LPN #3) was interviewed regarding the inclusion of high risk medications in the care plan. LPN #3 reviewed the clinical record and stated, Yes, there should be care plans for both the anticoagulant and insulin medications. I'm not sure why they were not included. On 11/02/2022 at 5:39 p.m., the above findings were reviewed during a meeting with the administrator, DON, ADON, and corporate staff. No further information was provided that indicated that the facility had provided care planning for either of the high risk medications or the diabetes management. 2. The facility failed to address the individualized need for anticoagulant medication in Resident #80's comprehensive care planning. Resident #80 was admitted to the facility with hypertension, DM2, hemiplegia/hemiparesis, AFIB, muscle weakness, and dysphagia. The minimum data set (MDS) dated [DATE] was the 5-day admission assessment, which documented Resident #80 with severely impaired cognition for daily decision making, with a BIMS (Brief Interview for Mental Status) score of 6 out 15. Under Section N - Medications, the MDS documented Resident #80 received anticoagulant medication, which has increased risk of bleeding. Resident #80's clinical record was reviewed on 11/01/022. Observed on the the order summary report was the following order: Apixaban Tablet 5 MG (milligrams) Give 1 tablet via J-Tube two times a day for cva via peg tube. Order Date 09/16/2022. Resident #80's medication administration records for September through November 2022 were reviewed and documented the resident received the anticoagulant medication, Apixaban as ordered/scheduled. Resident #80's care plans were reviewed, but had no plan of care for anticoagulant (AC) medication. On 11/02/2022 at 11:25 a.m., the licensed practical nurse (LPN #2) who routinely provided care for Resident #80 was interviewed regarding the resident's medications and care plans. LPN #2 reviewed Resident #80's clinical record and stated the resident was currently receiving the anticoagulant. LPN #2 stated the unit manager was responsible for the care plans. On 11/02/2022 at 11:30 a.m., the unit manager (LPN #3) was interviewed regarding the care plans. LPN #3 reviewed the clinical record and stated, Yes, there should be a care plan for the anticoagulant medications. I'm not sure why it was not included. On 11/02/2022 at 5:39 p.m., the above findings were reviewed during a meeting with the administrator, DON, ADON, and corporate staff. No other information was provided that care planning had been developed/implemented, in accordance with the MDS, to address the resident-centered need for anticoagulant medication. 3. The facility staff failed to include the physician ordered anticoagulant medication in Resident #81's comprehensive care plan. Resident #81 was admitted to the facility with diagnoses that included pneumonia, hypoxia, acute kidney failure, DM2, perforation of intestine, congestive heart failure and hypertension. The minimum data set (MDS - cms assessment tool) dated 10/03/2022 was the 5-day admission assessment and assessed Resident #81 as cognitively intact for daily decision making with a score of 13 out of 15. Under Section N - Medications, the MDS documented Resident #81 received anticoagulant medication, which has increased risk of bleeding. Resident #81's clinical record was reviewed on 11/01/022. Observed on the the order summary report was the following order: Apixaban Tablet 2.5 MG (milligrams) Give 2.5 mg by mouth two times a day for a-fib. Order Date 10/20/2022. Resident #81's medication administration records for October and November 2022 were reviewed and documented the resident received the anticoagulant medication, Apixaban as ordered/scheduled. Resident #81's comprehensive care plans were reviewed, but had no plan of care to address the individualized need for anticoagulant (AC) medication or the associated risk factors of this physician ordered therapy. On 11/02/2022 at 11:25 a.m., the licensed practical nurse (LPN #2) who routinely provided care for Resident #81 was interviewed regarding the resident's medications and care plans. LPN #2 reviewed Resident #81's clinical record and stated the resident was currently receiving the anticoagulant. When asked about care planning for this high risk medication, LPN #2 stated the unit manager was responsible for the care plans. On 11/02/2022 at 11:30 a.m., the unit manager (LPN #3) was interviewed regarding the care plans for the high-risk medications. LPN #3 reviewed the clinical record and stated, Yes, there should be a care plan for the anticoagulant medications. I'm not sure why it was not included. On 11/02/2022 at 5:39 p.m., the above findings were reviewed during a meeting with the administrator, DON, ADON, and corporate staff. No other evidence was presented that a plan of care for anticoagulant medication had been developed or implemented for Resident #81. 27353 4. The facility staff failed to develop and implement a CCP (comprehensive care plan) to include measurable objectives and timeframes for Resident #78 in the area of pain management. Resident #78's diagnoses included, but were not limited: diverticulitis, atrial fibrillation, depression, muscle weakness, dysphagia, abnormal gait, polyneuropathy, history of falls, and musculoskeletal mastoid bone pain. The resident #78's most recent MDS (minimum data set - cms assessment tool) was an admission assessment dated [DATE]. This MDS assessed the resident with a BIMS (Brief Interview for Mental Status) score of 15 out of 15, indicating the resident was intact for daily decision making skills. This MDS did not assess the resident with having pain and pain was not triggered in the CAAS (care area assessment summary) section of this MDS. Resident #78 was interviewed on 11/02/22 at approximately 7:55 AM. Observed grimacing, Resident #78 had stated that she was in pain and had not slept the night before due to pain. Resident #78 stated that she has been having pain and has scheduled pain medications, but did not get the pain medication as ordered. Resident #78's clinical record was reviewed and included the following physician's order: Observation: Pain- observe every shift .start date: 08/21/22 . Further review of Resident #78's physician orders revealed that a lidocaine pain patch for hip pain was started on 10/11/22, Tylenol was started on 10/17/22, and the narcotic pain medication (indicated for moderate to severe pain) hydrocodone-acetaminophen 5-325 for mastoid bone pain was started on 10/17/22. Resident #78's current CCP (comprehensive care plan) was reviewed and revealed that the resident did not have a pain care plan developed until 11/01/22, although the resident was experiencing pain, receiving pain treatments, and had been admitted with pain diagnoses. The CCP documented, .Pain Management Date initiated: 11/01/22 resident will demonstrate and verbalize knowledge of strategies for pain management: pain management date initiated: 11/01/22 .Medication management date initiated: 1/01/22 .Resident will be offered non-pharmacological interventions for pain including distraction, entertainment/activity, food and fluids offered and/or repositioning date initiated: 11/01/22 . There was no evidence in the resident's clinical record that Resident #78 had any other care plan related to pain prior to 11/01/22. On 11/02/22 at approximately 6:15 PM, the administrator, DON (director of nursing), ADON (assistant director of nursing) and the corporate nurse were made aware in a meeting with the survey team. The DON was asked why was Resident #78's pain care plan just added on 11/01/22. The DON replied that she did not update or review the care plan and wasn't sure. No further information and/or documentation was provided prior to the exit conference to evidence that a pain care plan was developed for Resident #78 prior to 11/01/22.

2. The facility staff failed to notify the physician of a delay in the treatment of a UTI (urinary tract infection) for Resident #28. Findings were: Resident #28 was admitted to the facility with the following diagnoses including but not limited to: Diabetes mellitus, quadriplegia, contracture of the left hand, UTI, and chronic kidney disease. An annual MDS (minimum data set - a cms assessment tool), dated 09/02/2022, documented the BIMS (Brief Interview for Mental Status) score of 15 (out of 15), indicating intact cognitive function for daily decision making. The clinical record was reviewed on 11/01/2022 beginning at approximately 3:00 p.m, noting the progress notes with the following entries: 10/29/2022 22:20 (10:22 p.m.) Positive for UTI. Spoke with (Name); place PICC line begin ertapenem 1 GM (gram) q (every) 24 hours. 10/31/2022 (Note from nurse practitioner signed 10/31/2022 at 7:51 p.m.) .Infection and inflammatory reaction due to indwelling urethral catheter .urine culture came back with E. Coli and Pseudomonas. She is on trimethoprim 50 mg daily for UTI prophylaxis, however, she has developed a UTI again. She should continue ertapenem 1 g daily until 11/4/2022. Foley care should be performed every shift and the catheter should be changed every 28 days . 11/01/2022 01:27 (a.m.) Ertapenem Sodium Reconstituted 1 GM Use 1 gram intravenously one time a day for UTI over 4 days. IV therapy to begin tomorrow 11-1 @1700 per MD order, noted change in (computer system) as well. Written by the unit manager, RN (registered nurse) #1, a change in condition note was observed in the clinical record at approximately 9:10 a.m. on 11/02/2022. It contained the following: 11/02/2022 08:56 (a.m.) Change in Condition .nursing observations, evaluation, and recommendations are: Resident presents with UTI, Foley catheter in place. Treatment with Ertapenem 1 Gm IV X (times) 4 days . On 11/02/2022 at approximately 9:30 a.m., RN #1 was interviewed. In reference to the 11/02/2022 change in condition note, written earlier that day, RN #1 was asked if she was aware that the antibiotics for Resident #28 had not yet been started. She looked at the physician orders and stated, Yes, it starts this evening. She was referred back to the progress notes from 10/29/2022, 10/31/2022, and 11/01/2022 regarding Resident #28's orders for an IV antibiotic. At approximately 11:30 a.m., RN #1 came to the conference room and stated, The antibiotic order was written by the on-call physician over weekend. It looks like the original order was written on October 29 to place a PICC line and discontinue it when the antibiotics were complete. That order was discontinued. There was also an order written on October 29 for the antibiotics to be given for four days .that was discontinued and rewritten to start on November first .that order was discontinued on November 1st, the reason on the order was waiting on IV supplies from the pharmacy and they were suppose to be here today .I don't know what happened .some of the notes say we were waiting on the medicine, some say waiting on IV supplies. It looks like we ordered the medicine from the pharmacy .we have that antibiotic here so it could have been started .I spoke with the nurse practitioner and we got the order clarified so we can give it IM starting today at noon. She was asked if the physician or nurse practitioner had been notified that the medication had not been given before today. She stated, There isn't any documentation that notification occurred, I don't feel like that happened. She was asked if the nurses had changed/canceled the orders and the start dates of the antibiotic without speaking with the physician or the nurse practitioner. She stated, Yes, that is what I think happened .the physician should have been notified. On 11/02/2022 at approximately 3:30 p.m., the nurse practitioner was interviewed. She was asked if she was aware that Resident #28 had not received any doses of her antibiotics prior to the IM injection earlier on 11/02/2022. She stated, I was told on Monday (10/31/2022) that she had an IV and that it had infiltrated .I can't tell you the nurses name who told me that, but she said there weren't any needles here to restart it and they would have to come from the pharmacy .I thought she had gotten one dose and it would resume the next day (11/01/2022). I found out today that none had been given, we changed the route to IM so it could start as soon as possible. On 11/02/2022 at approximately 4:00 p.m., RN #1 was asked if other than the clinical record there was any place the nurses could have documented that the antibiotic was not given and the physician/nurse practitioner were notified. She stated, There is a physician book. She went to the nurse's station and looked in the book. She stated, There's not any documentation in here about that. The above information was discussed with the DON, the administrator, the ADON (assistant director of nursing) and three members of the corporate staff. Concerns were voiced that an IV antibiotic had been ordered on 10/29/2022 for four doses and the medication was not started until 11/02/2022. The DON was asked if the physician or Nurse practitioner had been notified of the delay in treatment. She stated she would see what she could find out. On 11/03/2022 at 9:30 a.m., the DON came to the conference room. She was asked if she could clarify if the physician had been notified of the delay in treatment for Resident #28. She stated, I've not been able to get in touch with the nurses .I don't know if the physician was notified or not, or if the problem was they didn't know we had the meds or if they thought the IV supplies weren't available .either way the physician should have been notified I don't see any record of that. The facility policy Unavailable Medications contained the following information: Medications may be unavailable for a number of reasons. Staff shall take immediate action when it is known that the medication is unavailable: .Notify physician of inability to obtain medication upon notification or awareness that medication is not available .If a resident misses a scheduled dose of the medication, staff shall follow procedures for medication errors, including physician/family notification . No further information was obtained prior to the exit conference on 11/03/2022. 27353 Based on resident interview, staff interview, clinical record review and in the course of a complaint investigation, the facility staff failed to notify the physician and/or RP (responsible party) of a change in condition for three of 21 residents in the survey sample (Resident #34, Resident #78 and Resident #28). 1. The facility staff failed to notify Resident #34's RP of a wound. 2. The facility staff failed to notify Resident #78's physician of the resident being in pain and/or that the resident's pain medication was not available for administration. 3. The facility staff failed to notify the physician of a delay in the treatment of a UTI (urinary tract infection) for Resident #28. Findings include: 1. Resident #34's diagnoses included, but were not limited to: HTN (high blood pressure), CHF (congestive heart failure), schizophrenia, asthma, Parkinson's disease, anxiety disorder, polyneuropathy, obesity, and depression. The most current MDS (minimum data set) was a quarterly review (this MDS was prior to the discovery of the resident's wound). This MDS assessed the resident with a cognitive score of 12, indicating the resident had moderate impairment in daily decision making skills. The resident was also assessed as requiring extensive to full assistance with ADL's (activities of daily living) with assistance of two staff. The resident's most recent full MDS assessment with CAAS (care area assessment summary) (prior to the wound discovery) was an annual assessment dated [DATE]. The MDS assessed the resident with a cognitive score of 14, indicating the resident was intact for daily decision making skills. The resident triggered in the CAAS section of this MDS for pressure ulcers. A complaint investigation was completed on 11/01/22 through 11/03/22. An allegation within the complaint alleged that the RP/family of Resident #34 was not notified of the discovery of the resident's wound on 07/29/22. The resident's clinical records were reviewed. According to the resident's clinical records, the resident was found with bilateral 'friction' wounds to the dorsal area of both feet on 07/29/22 per the resident's weekly skin assessment (dated 07/29/22). The resident's records were further reviewed and did not evidence that the resident's RP/family had been notified of the above information. On 11/02/22 at approximately 6:15 PM, the administrator, DON (director of nursing), and corporate nurse were made aware of the above complaint allegation in a meeting with the survey team. The DON and staff were made aware that no information was found regarding notification of this incident to the resident's RP/family in the resident's records and was asked for assistance in locating any information. The DON stated that it was true, the facility staff did not notify the resident's RP/family of the resident's wounds and/or the progression of the resident's wounds that were discovered on 07/29/22. The DON stated that they had recognized notification as problem. According to the facility policy on wound care, the policy states, .notification to physician and/or responsible party regarding wound or treatment changes . No further information and/or documentation was presented prior to the exit conference on 11/03/22 at 11:30 AM to evidence that Resident #34's RP/family was notified of a change in condition regarding the resident's skin. This is a complaint deficiency. 2. Resident #78's diagnoses included, but were not limited: diverticulitis, atrial fibrillation, depression, muscle weakness, dysphagia, abnormal gait, polyneuropathy, history of falls, and musculoskeletal mastoid bone pain. The resident's most recent MDS (minimum data set) was an admission assessment dated [DATE]. This MDS assessed the resident with a cognitive score of 15, indicating the resident was intact for daily decision making skills. The resident was assessed as requiring supervision with limited assistance of one staff person for ADL's (activities of daily living). On 11/02/22 at approximately 7:55 AM, Resident #78 was interviewed in her room. The resident was sitting on the side of the bed. The resident stated that she had a rough night, was in pain and had not slept due to the pain. The resident stated that she had asked the night nurse for her ordered pain medication (hydrocodone) and stated that the nurse told her that they (the facility) didn't have any. The resident stated the nurse told her they didn't have it. The resident was asked what her pain was at the present moment and the resident stated that her pain was a 7 on a scale of 1-10 (one being minimal pain and 10 being the worst pain). The resident stated that they were supposed to change the medication order from a pill form to liquid form and that the nurse told her that it was still on order and had not arrived from the pharmacy. The resident stated that she was hurting and stated that she hoped she wouldn't start crying from it. At approximately 8:05 AM, LPN (Licensed Practical Nurse) #1 (the resident's day nurse) was made aware of Resident #78's complaints of pain and not getting any pain medication the night before, as the night shift nurse had told her the medication was not available. LPN #1 looked in the system and confirmed that the resident had an order for: .[order date: 10/31/22 10:32 am] Hydrocodone-Acetaminophen solution 2.5 -108 mg/5 ml (milligrams/milliliter) Give 5 ml by mouth at bedtime for mastoid bone pain Start Date: 10/31/22 . The LPN looked further and stated that the resident did not get the medication the night before (11/01/22 at 10 PM) and and that it looked like the medication was on order according to the nursing/EMAR (electronic medication administration record) note written by the night nurse. The LPN stated that it shouldn't take that long for a medication to get here and stated, it was ordered on 10/31/22. The LPN was asked to look on the medication cart to see if the medication was there. The LPN began looking for the ordered medication and found the bottle of medication. The LPN looked at the bottle and stated, this is it. The bottle had the resident's name and the date dispensed as 10/31/22. The LPN stated, that doesn't make sense and went on to say that the she didn't understand why the medication was not given if the medication was here. The LPN was asked to look at the narcotic sheet for this medication to see if any had been signed out. The LPN pulled the narcotic sheet for this medication. The sheet documented the date the medication was received as 10/31/22. No doses were signed off as administered. The LPN was then asked to look to see if the resident had received pain medication at bedtime on 10/31/22. The LPN looked and stated that the resident had not received pain medication on that night either. At approximately 9:30 AM, Resident #78's clinical records were reviewed. The resident's MAR (medication administration records) for October and November 2022 were reviewed. On 10/31/22 and 11/01/22 at 10:00 PM, the resident's MAR documented a '9' in the the slot for the above pain medication. The MAR legend for '9' means 'other/see nursing notes'. The resident's nursing notes were reviewed. On 10/31/22 the nursing note documented, 10/31/2022 5:00 PM .Orders - General Note .you have entered HYDROcodone-Acetaminophen Solution 2.5-108 MG/5ML Give 5 ml by mouth at bedtime for mastoid bone pain . On 11/1/2022 an EMAR note documented, .1:35 AM - Medication Administration Note .HYDROcodone-Acetaminophen Solution 2.5-108 MG/5ML Give 5 ml by mouth at bedtime for mastoid bone pain Pending pharmacy delivery @ this time. New mediation RX . On 11/2/2022 an EMAR note documented, .12:17 AM - Medication Administration Note . HYDROcodone-Acetaminophen Solution 2.5-108 MG/5ML Give 5 ml by mouth at bedtime for mastoid bone pain Medication pending delivery @ this time. Res resting in bed w/ eyes closed . There were no notes found to evidence that the resident's physician was notified that the pain medication was not given or that the pain medication was not available. On 11/02/22 at 3:10 PM, the NP (Nurse Practitioner) was made aware of the above information regarding Resident #78's interview about being in pain last night and not being able to sleep and stating that she had a rough night. The NP stated that the resident has mastoid bone arthritis and that this information was verified by the resident's daughter. The NP stated that they have tried several things to include, gabapentin -which didn't really help according to the NP. The NP stated that she did increase it that and that the resident is now on a low dose of Norco (the medication that was not administered on 10/31/22 and 11/01/22). The NP stated that other medications were tried, but stated that the Norco 2.5 mg seemed to do better for this resident. The NP was asked what would the expectation be for a situation like Resident #78's, if the resident doesn't have pain medication or the medication is not available to administer. The NP stated that with someone like her (Resident #78) she would have told the nurse to give the resident a one time dose of an alternate medication that was actually on hand. The NP stated that she was not on call and that she was not made aware. The NP stated, I do feel bad, I do think something is going on with her regarding this pain. The NP stated that the resident does have an upcoming appointment. The NP stated that when any resident is in pain and their pain medication is not available or they don't have pain medication ordered her (the NP) expectation would be for the nurse to call the provider. The NP stated that for this resident the nurse could have contacted the provider and obtained an order to give an alternative pain medication of something preferably in house and stated that staff could have crushed a pill (after contacting the provider) and put it in applesauce to give, whatever they needed to do, in order to prevent a delay in treating the resident's pain. The NP again stated the nurse should have contacted the provider. On 11/02/22 at approximately 6:15 PM, the administrator, DON (director of nursing) and the corporate nurse were made aware that the resident's pain medication was on the medication cart and was found this morning by LPN #1 and that according to the label on the medication bottle and the narcotic sheet the medication was delivered on 10/31/22 and no medication doses had been administered from it. The facility staff were made aware that according to the above information and the resident's clinical records (MARs/TARs) the resident had not received the medication for two nights and the resident's provider had not been contacted either night. On 11/02/22 at 6:35 PM, the DON stated that the expectation would be and is for the nurse to notify the provider to get an order for something pain. No other information and/or documentation was provided prior to the exit conference on 11/03/22.

Based on observation, staff interview, and clinical record review, the facility staff failed to provide treatment and services for the prevention of pressure ulcers for one of 21 residents, Resident #20 (resulting in harm); and failed, to follow infection control practices during a dressing change to a pressure ulcer for one of 21 residents, Resident #79. 1. Resident #20 did not have a skin assessment completed for 10 days. When the assessment was completed, Resident #20 had an unstageable (due to necrosis) pressure ulcer behind his right ear from his nasal cannula. The area was debrided by the wound doctor and assessed as a Stage 4 pressure ulcer (HARM). 2. A nurse failed to perform hand hygiene during a dressing change to Resident #79's pressure sores. Findings were: 1. Resident #20 did not have a skin assessment completed for 10 days. When the assessment was completed, Resident #20 had an unstageable (due to necrosis) pressure ulcer behind his right ear from his nasal cannula. The area was debrided by the wound doctor and assessed as a Stage 4 pressure ulcer (HARM). Resident # 20 was admitted to the facility on [DATE]. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A significant change MDS (minimum data set) with an ARD (assessment reference date) of 12/21/2017, assessed Resident #20 as being severely impaired in his cognitive status with a cognitive summary score of 03. The skin assessment section of the MDS contained information that Resident #20 was at risk fir skin breakdown, but there was none present at the time of the assessment. Resident #20 was observed during initial tour of the facility on 03/13/2018 at approximately 11:30 a.m. Resident #20 was sitting up in his bed waiting on his lunch tray. A Band-Aid was noted on his right ear. He was asked why the Band-Aid was on his ear. He stated, I don't know. Resident #20 was wearing a nasal cannula, the tubing around his ear was padded. The clinical record was reviewed on 03/13/2018 at approximately 1:30 p.m. The progress note section contained the following entries: 02/25/2018 15:27 (3:27 p.m.) RN [registered nurse] was notified by CNA [certified nursing assistant] that resident had a pressure injury on the upper part of his right ear from the oxygen tubing. Tubing was removed and area was cleansed with normal saline and TAO [triple antibiotic ointment] was applied. RN wrapped foam around both sides to [sic] tubing to provide more cushioning for tubing. U/O [unusual occurrence] completed and placed in manager's box. 02/26/2018 12:28 [p.m.] A skin observation was completed on [name of Resident #20] .new area identified and will be referred to nursing for intervention. DON/UM [unit manager]/Wound Nurse will be notified for f/u as applicable. Family/RP [Responsible Party] made aware. New area referred to wound nurse/DON/UM for f/u [follow-up] 02/26/2018 12:46 [p.m.] Notified daughter .regarding wound to right ear from nasal cannula. Drsg intact with wound nurse/MD aware. Oxygen to be weaned of possible. Hospice to be made aware . 02/26/2018 22:09 (10:09 p.m.) .Assessment: Resident was seen by Wound MD and Nurse today. Unstageable (due to necrosis) of the Right Posterior Ear was seen [sic]. Measurements were 0.7 X 0.7 X 0.1. There was light serous drainage present. 35 % thick yellow necrotic tissue present and 65 % granulation tissue present. Area was surgically debrided today. Resident tolerated procedure wall. Orders for a [MEDICATION(S)] 3 times a week was given. Continue with supplements as ordered. MD, Hospice and RP [responsible party] were notified of the above information. 03/05/2018 14:52 [2:52 p.m.] Resident was seen by the wound MD and nurse today. Stage 4 pressure wound of the right posterior ear was seen. Measurements were 0.7 X 0.8 X 0.1. There was light serous drainage present. 30 % thick yellow necrotic tissue present and 70% granulation tissue. Area was surgically debrided today and resident tolerated procedure well. Orders for [MEDICATION(S)] and a dry protective dressing QD [every day] was given. Wound has improved since last visit . 03/12/2018 18:52 [6:52 p.m.] Resident was seen by the wound MD and Nurse today. Stage 4 pressure wound of the right posterior ear was seen. Measurements were 9.5 X 0.4 X 0.1 [see corrected measurement note dated 03/14/2018] . There was light serous drainage present. 15 % thick yellow necrotic tissue present. 85% granulation. Area was surgically debrided today. Resident tolerated procedure well. Orders for [MEDICATION(S)] and a dry protective dressing QD times 30 days was given. Wound has improved since last visit . 03/13/2018 08:28 [a.m.] A skin observation was completed .sore behind ears from oxygen tubing resolving . The POS (Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Also contained on the POS were the following orders: DNR (12/01/2017), Hospice (12/07/2017) and Oxygen continuous at 2 liters (12/19/2017) The Weekly Skin Observation sheets were reviewed for February and March 2018. A skin sheet was completed on 02/03/2018 (no new areas), 02/09/2018 (no new areas), 02/16/2018 (no new areas), 02/26/2018 (New area right ear), 03/06/2018 (no new areas), 03/09/2018 (no new areas), 03/13/2018 (no new areas). There was a gap between assessments of ten days from 02/16/2018 until 02/26/2018, when the pressure area behind Resident #20's ear was noted. The TAR (treatment administration record) was reviewed for February and March. Skin assessments were checked off as completed on 02/06/2018, 02/13/2018, 02/20/2018, 02/27/2018, 03/06/2018 and 03/13/2018. The dates on the TAR did not match the nursing documentation dates in the clinical record or on the weekly skin observation sheets. The care plan contained the following interventions for the focus area Skin integrity: Notify nurse of change in skin integrity (revised 8/4/2017), Skin assessments as scheduled, notify MD of changes as indicated (revised 8/4/2017), Refer to wound MD and wound nurse (added 02/26/2018) At approximately 10:40 a.m., this surveyor accompanied the wound nurse, LPN (Licensed Practical Nurse) #4 to Resident #20's room to observe the dressing change to his right ear. Prior to entering the resident's room, LPN #4 was asked how the pressure area had formed. She stated, from the O2 tubing. LPN #4 was asked about the most recent measurement on the clinical record (03/12/2018) which documented an increase in wound length from 0.7 cm to 9.5 cm. She stated, I don't think that's correct .I may have entered that incorrectly. I will go back and check it. The dressing change was observed and completed by LPN #4 per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . LPN #4 stated that the area was much improved. She stated, she and the wound doctor had done the dressing together on Monday and predicted the area would likely be healed by the coming Monday. On 3/14/2018 at approximately 11:30 a.m., the pressure ulcer on Resident #20's right ear was discussed with the DON and administrator. The DON was asked about the dates of weekly skin observations on the TAR vs the dates of the weekly skin observation sheets. The DON stated, The dates on the skin observation sheets are correct and when the assessments were done .the dates should coincide with the dates on the TAR he moved from one area of the facility to the other .the room he was in had skin assessments done on Tuesday. We moved him in December after his wife passed away. The side that he's on now has skin assessments done on Friday .no one ever changed the assessment day on the order. The DON was asked why nurses where signing off that assessments were completed on dates they were not. She stated, I don't know. The DON was asked if the 10 days between 02/16 and 02/26/18 was acceptable for weekly assessment. She stated No. On 03/15/2018 at approximately 9:00 a.m., LPN #4 spoke with this surveyor. She stated. I went back and looked at the measurements you asked me about .I entered them incorrectly. I did a note last night with the corrected measurements. On 03/15/2018, the following additional progress notes were observed in the clinical record: 03/14/2018 09:55 [a.m.] Hospice Visit Note . Denies pain .Right ear wound being assessed and managed by facility wound nurse . 03/14/2018 23:12 [11:12 p.m.] Correct measurements of the Stage 4 pressure wound of the left ear were 0.5 X 0.4 X 0.1 A copy of the facility policy regarding skin assessments was requested from the DON at approximately 9:15 a.m. She left the conference room and returned stating the facility did not have a policy regarding skin assessments. The clinical record did not contain any information that the pressure ulcer was unavoidable. On 03/15/2018 at approximately 10:45 a.m., and end of survey meeting was held with the DON and the administrator. The above information was discussed. The DON and the administrator were informed that due to the facility's failure to conduct weekly skin assessments and the identification of an unstageable pressure ulcer, after a ten day span between assessments, the survey team had identified harm. No further information was presented prior to the exit conference on 03/15/2018. 2. A nurse failed to perform hand hygiene during a dressing change to Resident #79's pressure sores. Resident #79 was admitted to the facility on [DATE] with a re-admission on 11/22/17. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The minimum data set (MDS) dated [DATE] assessed Resident #79 with severely impaired cognitive skills. Resident #79's clinical record documented a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The orders required cleansing of the pressure ulcers with wound cleanser, application of Silver Hydrogel and a dry protective dressing each day. On 3/15/18 at 9:39 a.m., licensed practical nurse (LPN) #4 was observed performing dressing changes to Resident #79's left heel/ankle pressure ulcers. LPN #4 washed her hands, put on gloves and removed the old dressings from the left heel and ankle. LPN #4 removed her gloves, put on new gloves and proceeded to cleanse both of the wounds with cleanser applied to gauze. LPN #4 changed gloves, applied the Silver Hydrogel to each wound using a cotton tipped applicator and then applied a protective dressing to each wound. LPN #4 discarded used items including the dirty dressings and then washed her hands. LPN #4 did not perform hand hygiene following removal of the old dressings and prior to cleansing of the wounds. LPN #4 did not perform hand hygiene between any of the glove changes during the observation. On 3/15/18 at 9:46 a.m., LPN #4 was interviewed about hand hygiene during the dressing change observation. LPN #4 stated she changed her gloves after removing the soiled dressings but did not perform hand hygiene. LPN #4 stated she usually washed her hands after removing the old dressings but she was a little nervous. LPN #4 stated hand hygiene was supposed to be performed after removing the soiled dressings and between any glove changes. The facility's policy titled Dressing, Dry/Clean (revised October 2010) required hand washing after removing of soiled dressings and prior to cleansing wounds. This protocol documented, .Wash and dry your hands thoroughly .Put on clean gloves. Loosen tape and remove soiled dressing .Pull glove over dressing and discard into plastic or biohazard bag .Wash and dry your hands thoroughly .Pour prescribed cleansing solution over the dry, clean gauze .Put on clean gloves .Cleanse the wound .Apply the ordered dressing and secure with tape .Remove disposable gloves and discard into designated container. Wash and dry your hands thoroughly . The facility's infection control policy (effective 9/20/17) stated, It is a policy of this facility to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. This policy stated concerning hand hygiene, All staff shall wash their hands when coming on duty, between resident contacts, after handling contaminated objects, after PPE [personal protective equipment] removal, before/after eating, before/after toileting, and before going off duty. These findings were reviewed with the administrator and director of nursing during a meeting on 3/15/18 at 10:45 a.m.

Based on observation, resident interview, staff interview, facility document review and clinical record review, the facility staff failed to provide supervision and implement safety interventions for two of 12 residents in the survey sample: Resident # 109 and Resident # 107. 1. Resident # 109 sustained a fall without injury attempting to get back into bed after being left on a bedside toilet due to the call bell being out of reach. 2. Resident # 107 did not have a fall mat at the bedside to prevent injury in case of a fall. Findings include: 1. Resident # 109 was admitted to the facility 9/10/10 with a readmission date of [DATE]. [DIAGNOSES REDACTED]. The most recent MDS (minimum data set) was a quarterly review with an ARD (assessment reference date) of 1/26/11 and assessed the resident as being cognitively intact with a summary score of 13. For transfers, Section G0110B1 - Transfer: self-performance and G0110B2 - Transfer: support provided the resident was coded as totally dependent with one person physical assist. For toileting sections G0110I1 - Toilet use: self-performance and G0110I2 - Toilet use: support provided the resident was also coded as totally dependent with one person physical assist. The clinical record was reviewed 4/20/11. A nursing note dated 3/31/11 documented "CNA reported resident told her he fell . Resident stated the wound nurse put him on the potty (sic) and when he was done he couldn't reach the call bell-tried to go back to bed and fell - refused neuro checks/pain meds." The physician and resident's RP (responsible party) were notified. The care plan for falls initiated on 9/28/10 and current through the date of the fall on 3/31/11 included "Place call bell in reach with instructions on it's use..." At 10:10 a.m. on the same above date Resident # 109 was interviewed about the incident on 3/31/11. Resident # 109 verbalized the same sequence of events as documented in the nurses' note. Resident # 109 stated "I waited for about 30-40 minutes for someone to come and help me off the commode; I couldn't reach the call bell cause it was down lower on the bed than where I was sitting on the commode and I got tired of waiting for somebody to come and help me so I just got up and tried to get back in the bed myself and I fell . I think that call bell is just there for looks because even though they put it on the bed up closer to the commode I still have to really work to reach it." On this same date at 10:45 a.m. the wound nurse, LPN # 2, was interviewed about the incident. LPN # 2 stated "I put Resident # 109 on the BSC (bedside commode) and handed him the call bell and instructed him to call for assistance when he was finished. I left his room and told his CNA he was on the BSC. I have no idea what could have happened to the call bell; I don't know if he dropped it or what." At 10:55 a.m. on 4/20/11 CNA # 1 was interviewed about the incident as LPN # 2 indicated she was the CNA told that Resident # 109 was on the BSC. CNA # 1 stated she did not remember being told that, but when she went in to Resident # 109's room sometime later he told her he had fallen and she reported that to the charge nurse. These findings were shared with the administrator and DON (director of nursing) on 4/20/11 at approximately 11:15 a.m. A copy of the investigation of the incident was requested at that time. On 4/20/11 at approximately 1:00 p.m. a copy of the facility investigation was presented to this surveyor. The "Post Fall Assessment/Investigation Form" was reviewed. Resident # 109 was identified on the form as having a history of falls, and a care plan for falls was attached to the form. The form consisted of a list of questions for investigative purposes. Question # 5 of the form asked "Was the call bell within reach? Yes or No (If "no", reason)." "No" was checked beside the question and the reason written beside "No" documented "BSC (zero with a line through it to indicate "not") close enough to bed where call bell was located." The assessment of the resident revealed no injury was sustained during the fall. Included on the form was "Investigation Results (To be completed by Administrator or DON). The DON completed that section documenting "UF (unwitnessed fall)- Transferring self from BSC to bed by self. No injury-make sure call bell in reach when put on BSC. Educate pt. to ring for assistance. 1:1 with nurse and CNA that put on BSC." The resident's care plan was updated on 3/31/11 to include "Call bell in reach when on BSC. Re Educate resident to wait on staff for transfers." An "Unusual Occurrence Witness Statement" included in the investigation documented LPN # 2's written statement of the incident dated 3/31/11. The statement read "I went in to answer call bell. Rsd (resident) needed to use BSC. I assisted Rsd to BSC & instructed him to call for help when finished. I told his CNA (name of CNA here) that he was on the BSC." On 4/20/11 the charge nurse ( LPN # 1) who completed the post fall assessment form was interviewed. LPN # 1 was asked if Resident # 109 was left alone when put on the BSC or was supervision provided. LPN # 1 stated "Resident # 109 has made it clear he wants his privacy when using the bathroom and does not want staff in the room. We are making sure that his wishes are being honored and now the call bell is clipped to the bedspread close to him so he can reach it when he's finished. In light of what happened I feel we should stay in the room and just stay behind the curtain for his privacy since he is a one-person assist to toilet." No further information was provided prior to the exit conference 4/20/11 at approximately 3:00 p.m. 2. Resident #107's fall mat, an intervention used to prevent an injury from an accident, was not placed at her bedside. Resident #107 was admitted to the facility with, but not limited to, the following Diagnoses: [REDACTED]. Resident #107 was included in the standard survey, conducted on 3/1/11 through 3/3/11, as Resident #16. On 4/21/11 at approximately 9:00 a.m., Resident #107 was observed lying in a low bed, oxygen infusing at 2 liters per minute via nasal cannula, with her eyes closed. A thin gray mat was observed between Resident #107's and her roommates bed, a wooden chair was observed against the bed next to the door, and a thick blue mat was observed leaning against the bathroom door in the resident's room. On 4/21/11 at approximately 9:05 a.m., the charge / medication nurse, who was a licensed practical nurse (LPN #1) was interviewed regarding the above mentioned observation. LPN #1 stated that Resident #107 "has two mats, a thin one between the two beds and a thick one next to the door." LPN #1 proceeded to state that the thick blue mat was close to the door because, "she (Resident #107) favors that side." LPN #1 was made aware that the thick blue mat was observed by this surveyor leaning against the bathroom door in the resident's room. This surveyor accompanied LPN #1 to Resident #107's room. LPN #1 was observed removing the thick blue mat from leaning against the bathroom door. When interviewed and asked if the mat leaning against the bathroom door was supposed to be placed at the resident's bedside, LPN #1 stated, "yes" and placed the mat beside Resident #107's bed. LPN #1 stated that the CNA, who fed the resident breakfast, "must have forgot to put the mat back. I see the chair at the bedside, where she (the CNA) was sitting to feed her (Resident #107). On 4/21/11 at approximately 9:10 a.m., the certified nursing assistant (CNA #1) was interviewed regarding the fall mat placed at the resident's bedside. CNA #1 stated, "I forgot, I took the tray to the cart and I didn't come back." On 4/21/11 at approximately 9:30 a.m., a care plan (CP) updated on 2/25/11 was reviewed in the clinical record to include the following: ? Focus: At risk for falls secondary to history of falls with injury... ? Goals: Will be free from injury related to fall... ? Intervention: Fall mats on both sides of her bed... On 4/21/11 at approximately 11:05 a.m., the administrator and the director of nursing (DON) were made aware of the above findings.

Based on observation, staff interview, clinical record review, and in the course of a complaint investigation, the facility staff failed to ensure 2 of 22 residents (Residents #3 and #16) were free of accidents that resulted in fractures. The findings include: 1. The facility staff failed to transfer Resident #3 properly resulting in a fractured femur (thigh) and causing a decline in the resident's condition by decreased mobility and increased pain. Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident developed a deep vein thrombosis (blood clot) in the right leg following the femur fracture requiring injections of an anticoagulant. A Foley catheter was placed following the injury due to the resident being immobile and having increased pain. The current quarterly Minimum Data Set (MDS) with a reference date of 1/15/11 assessed the resident to have a cognitive rating of 3 of 15. The resident required total assistance of 2 persons for bed mobility, transfers, toileting , and hygiene. The clinical record was reviewed. The nurses notes contained an entry dated 2/17/11 at 2:30 p.m. The entry stated," Resident s/p fall this afternoon @ approximately 1350 (1:50 p.m.). CNA (certified nursing assistant) was assisting pt. from bed to wheelchair, unable to complete transfer, CNA had to lower resident to the floor. Three CNAs then assisted resident to wheelchair, resident c/o right shoulder and right knee pain. No edema noted on right shoulder, rt knee with positive edema, and rt knee tender to touch. DON (director of nursing) notifying RP ( responsible party). Dr (name) notified new order for xrays via (name of mobile unit)." The DON documented at 2:45 p.m., "Called to unit to evaluate pt d/t had been lowered to floor by CNA @ 1350 pt c/o R knee pain did not see any swelling of knee. hard to assess d/t any touching she says hurts. Interviewing CNA of accident. She states "got her dressed in bed, sat her on edge of bed. bed lowest position, she hugged me and I hugged her went to transfer Noted I could not do it & lowered her to the floor easily which not far bed lowest to floor Called for help & therapy aide came & helped me lift her off the floor to w/c." CNA educated that pt is supposed to be hoyer lift, signed in service sheet. Called dtr (name) to let know what happened. Told her getting x ray of rt shoulder r knee to ensure that okay & that education done with CNA. CNA does not usually work B wing & she is very sorry. Dtr voiced understanding gave permission for facility to place sign in closet and above bed "Hoyer lift". MD notified by charge nurse and ordered the xrays. Cont to monitor." The nurses notes continued that the daughter agreed to send resident to orthopedic doctor in am or to the emergency room . The resident was admitted to the hospital and discharged back to the facility on [DATE] with the decision to not surgically correct the fracture because the resident was non ambulatory. The resident returned with a knee immobilizer. The x- ray results were located in the clinical record noting, "Patient has a total knee replacement (right). There is a comminuted (several breaks in the bone) fracture distal femoral metaphysis. There are at least three major fragments." The x-ray of the right hip noted "diffuse osteopenia" (a condition of subnormal mineralized bone) and no fracture of the hip. The assistant director of nursing (RN#1) was asked for the facility investigation of the fall on 2/17/11. The investigation noted the CNA had been in-serviced on 2/15/11 to read the Kardex. The Kardex was the CNA information sheet on residents on how much assistance was needed to transfer, feed, bath, and perform any other needed activities of daily living. The investigation noted the CNA was terminated for failure to read the Kardex resulting in an improper transfer with resultant injury to Resident #3. The Kardex was reviewed. The area under "Transfers" noted the resident was a "two person, mechanical" lift with the word "Hoyer" written underneath. The assistant director of nursing (RN#1) was asked for the prior Kardex and stated there was no other. The resident was assessed to be a two person lift prior to the injury. The comprehensive care plan was reviewed. The care plan reflected interventions following the fracture with updates for fall risk, pain, use of a Foley catheter, and treatment for [REDACTED]. A CNA (CNA#3) was interviewed on 3/2/11 at 1:30 p.m. about where to find information on how a resident is to be transferred. CNA#3 stated the information was on the Kardex and if there was any question, she would ask the nurse. A CNA (CNA#1) was observed on 3/3/11 at 8:30 a.m. feeding Resident #3 in bed. CNA#1 stated she cared for the resident often and was familiar with her needs. CNA#1 stated the resident used to get up, but no longer because it hurt so much for her to move and that was why she had a catheter inserted. The resident did not speak and the CNA stated this was normal for this resident. The administrator and director of nursing were informed of the concern during the end of the day meeting with survey team on 3/2/11. No further information was offered prior to survey exit on 3/3/11. This is a complaint deficiency. 2. The facility staff failed to implement a bed alarm after a fall on 8/21/10 at 4:00 a.m. and failed to currently have 2 fall mats in place to prevent injury from falls for Resident #16. Resident #16 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The current minimum data set (MDS) with an assessment reference date (ARD) of 2/16/11 assesssed the resident as having both short and long term memory loss and needing moderate assistance with decision making. The clinical record was reviewed. A physician's telephone order dated 8/21/10 documented "Send to (name of hospital) ED (emergency department) for eval & tx (evaluation and treatment) for fall." A nurse's note dated 8/21/10 at 4:00 a.m., documented "Res (resident) heard yelling went to check on res res had slid out of bed onto floor, no injuries noted, no bruises or scratches, no hematomas (bump filled with blood). Res states she did not hit her head & the bed was in a low position, res does lean to one side a lot & this is how she fell out." "Supervisor on call MD (doctor) and daughter called and informed of incident, supervisor to get fall mat & alarm as an intervention." A second note dated 8/21/10 at 10:00 a.m., documented "Res heard yelling from room. C.N.A. in to check res & found res in floor between wall & bed. Res. had L. (Left) arm underneath chest & abd. (Abdomen) area. Res. c/o (complained of) Lt. arm pain. Res. carefully turned to backside in supine position for further assessment & eval.Lt. arm positioned against trunk (body) for support. (Name of doctor) on call notified & order rec'd (received) to send res 911 (emergency) to (name of hospital) ED for eval & tx." Resident #16's care plan effective the time of the falls was reviewed. The goal for Resident #16 stated "Will be free from injury related to fall over the next 90 days", with a target date of 9/7/10. Interventions listed to assist the facility in maintaining Resident #16's goal included, but were not limited to, "Ensure bed is in the lowest transfer position at all times, Observe for any unsafe actions and intervene as necessary, Positioning devices when in bed to aid in bed mobility." Additions made to Resident #16's care plan on 8/21/10 included "8/21/10 Fall Matts to both sides of bed 8/21/10 Found between bed and wall @ (at) 10am on floor. To (name of hospital) ER. Concave mattress. 0400 (4:00 a.m.) Resident fell from bed to floor leaning to side of bed. No (zero with a line through it written) injuries - Bed Alarm, Fall Matt." The facility's "Unusual Occurrence Committee Meeting" forms were reviewed for both incidences on 8/21/10. For 4:00 a.m. fall, the form included: ? " Day 1 - Date 8/23/10 - Found in floor. Res. leaning to side while in bed causing her to fall to floor. No (zero with line through it written) Bed alarm & floor mat put into place." ? " Day 2 - Date 8/24/10 - No (zero with a line through it written) FF (following fall) - concave mattress with fall #2." ? " Day 3 - Date 8/25/10 - No (zero with a line through it written) FF." For the 10:00 a.m. fall, the form included: ? "Day 1 - Date 8/23/10 - Found on floor between bed & wall. Res attempting to get out of bed unassisted. Bed in lowest position. Transferred to (name of hospital). Left wrist fractured. Therapy to screen. Fall #2." ? "Day 2 - Date 8/24/10 - Concave mattress & low bed. Fx. Wrist from fall - wrist splinted." ? "Day 3 - Date 8/25/10 - Ok No (zero with a line through it written) FF." An unusual occurrence incident report for 8/21/10 at 4:00 a.m., documented in part: ? "Actions taken to prevent potential for reoccurrence (referrals, change in toileting schedule) (these were examples given) - Supervisor to get fall mat, and bed alarm." An unusual occurrence incident report for 8/21/10 at 10:00 a.m., documented in part: ? "Full description of occurrence - Res. found on floor between bed and wall." ? "Actions taken to prevent potential for reoccurrence - concave mattress placed." A C.N.A. report for falls for 8/21/10 at 10:00 a.m., documented in part: ? "Alarms in Place: Not in Use circled." ? "Was Alarm Sounding?: No circled." The unusual occurrence witness statement for 8/21/10 at 10:00 a.m., documented "Heard Resident yelling went to check on her & saw her on the floor & went & got the nurse." The current care plan with the initiated date of 2/25/11 included the intervention "Fall Matts on both sides of bed." On 3/3/11 at 8:05 a.m., Resident #16 was observed in bed, in the low position, with 1 fall mat on the left side of the bed (the side closest to the door of the room). On 3/3/11 at 9:35 a.m., Resident #16 was observed in bed, in the low position, with 1 fall mat on the left side of the bed (the side closest to the door of the room). Licensed practical nurse (LPN) #1 was asked about Resident #16's fall mat intervention. LPN #1 stated they "felt it was for 1 fall mat, but would check the care plan." LPN #1 checked the care plan and advised this surveyor that the resident "is to have 2 fall mats." LPN #1 was asked what they were going to do for Resident #16, LON #1 replied "we will get them another fall mat." On 3/3/11 at 10:15 a.m., Resident #16 was observed in bed, in the low position, with 2 fall mats (1 on each side of their bed). On 3/3/11 at 11:20 a.m., the director of nursing (DON) (administration) #2 was interviewed regarding Resident #16's incidents on 8/21/10 and interventions listed. The DON stated that "fall mats are a nursing intervention and the nurses can get the fall mats, they are kept in central supply." When asked if the interventions were put in place, the DON stated I "will talk to the weekend supervisor to see if these interventions were put in place from the first fall at 4:00 a.m. to the second fall at 10:00 a.m." On 3/3/11 at 11:35 a.m., The DON advised this surveyor that the LPN #4 that was the weekend supervisor when Resident #16 had their falls. LPN #4 stated that "when new interventions are put in place, they are documented in the nurse's notes and the Kardex for the C.N.A.'s to be aware." When asked if these interventions were put in place and documented, LPN #4 stated that they "can not recall if that was documented and I don't want to give you wrong information." On 3/3/11 at 2:35 p.m., the administrator and DON were made aware of the findings during a meeting with the survey team.