Every finding on record at River Oaks Healthcare Center

Based on resident interview, observation and staff interview facility failed to ensure meals are prepared and served in methods to conserve nutritive value, flavor, appearance and in a pleasing, palatable presentation. This was found during the annual facility survey process. This failed practice had the potential to affect more than a limited number of residents. Resident identifiers: #61, #72, #33, #81, #28, #11, #66, #15, #80, #87, #94 and #74. Facility census: 110. a) Review of the food preparation policy revealed the following: All staff will practice proper handwashing techniques and glove use. Dining services staff will be responsible for food preparation procedures that avoid potentially harmful physical, biological, and chemical contamination. Cooks will be responsible for food preparation techniques which minimize the amount of time that food items are exposed to temperatures greater than 41 degrees Fahrenheit and or less than 130 degrees Fahrenheit. Review of policy for meal preferences. Policy statement reads: Individual dining, food and beverage preferences are identified for all residents/patients. Review of procedures reads in part: The dining service director, or designee, will interview the resident or resident representative to complete a Food Preference Interview within (72) hours of admission. Food allergies, food intolerance, food dislikes, and food and fluid preferences will be entered into the resident profile in the menu management software system. The individual tray assembly ticket will identify all food items appropriate for the resident/patient based on diet order, allergies and intolerances, and preferences. Upon meal service, any resident/patient who expresses or shows refusal of food and/or beverage will be offered an alternate selection of comparable nutritional value. Observations and resident interviews on 05/26/26 around 12:00 PM in the dining room revealed: b) Resident #61 The surveyor observed Resident #61 sitting at the table not eating the meal, who reported, If I could chew the pork I would but it's too tough. The ticket says I was supposed to have gravy on the meat but there is none. Observation of the plate revealed no gravy on the pork. c) Resident #72 The surveyor observed Resident #72 sitting at the table not eating the meal, reporting, The pork is always tough, and without gravy I can't eat it. c) Resident #33 The sureveyor observed Resident #33 not eating the meal served, reported, This meat is too tough; we can't eat this slop. I like gravy but never get it. Observation of the plate revealed no gravy on the pork. d) Resident #81 The surveyor observed Resident #81 not eating the meal served, reporting, This food is slop, they never add gravy to the meats.Observation of the plate revealed no gravy on the pork e) Resident #28 The surveyor observed Resident #28 sitting at the table not eating the meal, who reported, No one can eat this mess. There is no gravy on our food. Observation of the meal revealed no gravy on the pork Staff interview with the District Manager for Food and Nutrition DMFN# 131 verified there should have been gravy on the pork per recipe and meal ticket. Reporting I will re-educate them to ensure they are following recipes and meal tickets. f) Resident #11 On 05/26/26 at around 3:30 PM during an interview with Resident #11, they reported, This food is really bad, it used to be good up until about six or seven months ago. When I ask for alternates sometimes they get me something sometimes they don't, I could not eat the pork today it was too tough, the ticket said we were to have gravy but did not g) Resident #66 On 05/26/26 at around 1:30 PM during an interview with Resident #66, they reported, The food is not good, they don't season the food. Today, this pork chop was too tough, and there was no gravy on it to help. h) Resident #15 and #80 On 05/27/26 at around 12:10 PM during dining room observations, Resident #15 and Resident #80 were served their meal in the dining room. The meal ticket read: Cranberry orange chicken. Garlic & rosemary roasted red skin potatoes. Seasoned cabbage with dinner roll. Both residents replied I do not like chicken, I wish they would stop sending it. Nurse assistant (11) reported that the residents dislike chicken and the kitchen has been told. Staff interview with the dietary manager reported, I do not remember if anyone told me, I will update their preferences. Questioned the dietary manager how often meal preferences are obtained. Dietary manager reports We do them upon admission, and the dietician reviews with them when she does assessments. I will go talk with some one if nursing tells me they want to talk g) Resident #87 On 05/27/26 at around 1:30 PM during an interview with Resident #87, they reported, This chicken is too tough, very bland. I can't chew it. Resident #87 reported, I am so sick of chicken, I told them this but I still get it. This surveyor questioned if someone from dietary came to talk with her, she reports No, not for a while. h) Resident #94 On 05/27/26 at around 2:00 PM during an interview with Resident #94, they reported, I have told the nurses and kitchen I am tired of this chicken, they can't cook too well, especially chicken and pork. This surveyor asked Resident #94 if someone from the kitchen came to update preferences, they reported, No, no one has yet. i) Resident #74 On 05/27/26 at around 2:30 PM during an interview with Resident #74, they reported, I really don't like chicken anymore, they serve it all the time. This surveyor questioned if anyone had updated the meal preferences, she reported, No, not for a while. The surveyor interviewed the dietary manager and District Manager #131 regarding updating meal preferences for the above residents. The dietary manager reported, I will begin working on updating the preferences.

Based on resident interview, observation and staff interview facility failed to ensure meals are prepared and served in methods to conserve nutritive value, flavor, appearance and in a pleasing, palatable presentation. This was found during the annual facility survey process. This failed practice had the potential to affect more than a limited number of residents. Resident identifiers: #61, #72, #33, #81, #28, #11, #66, #15, #80, #87, #94 and #74. Facility census: 110. Findings included: a) Review of the food preparation policy revealed the following: All staff will practice proper handwashing techniques and glove use. Dining services staff will be responsible for food preparation procedures that avoid potentially harmful physical, biological, and chemical contamination. Cooks will be responsible for food preparation techniques which minimize the amount of time that food items are exposed to temperatures greater than 41 degrees Fahrenheit and or less than 130 degrees Fahrenheit. Review of policy for meal preferences. Policy statement reads: Individual dining, food and beverage preferences are identified for all residents/patients. Review of procedures reads in part: The dining service director, or designee, will interview the resident or resident representative to complete a Food Preference Interview within (72) hours of admission. Food allergies, food intolerance, food dislikes, and food and fluid preferences will be entered into the resident profile in the menu management software system. The individual tray assembly ticket will identify all food items appropriate for the resident/patient based on diet order, allergies and intolerances, and preferences. Upon meal service, any resident/patient who expresses or shows refusal of food and/or beverage will be offered an alternate selection of comparable nutritional value. Observations and resident interviews on 05/26/26 around 12:00 PM in the dining room revealed: b) Resident #61 The surveyor observed Resident #61 sitting at the table not eating the meal, who reported, If I could chew the pork I would but it's too tough. The ticket says I was supposed to have gravy on the meat but there is none. Observation of the plate revealed no gravy on the pork. c) Resident #72 The surveyor observed Resident #72 sitting at the table not eating the meal, reporting, The pork is always tough, and without gravy I can't eat it. c) Resident #33 The sureveyor observed Resident #33 not eating the meal served, reported, This meat is too tough; we can't eat this slop. I like gravy but never get it. Observation of the plate revealed no gravy on the pork. d) Resident #81 The surveyor observed Resident #81 not eating the meal served, reporting, This food is slop, they never add gravy to the meats.Observation of the plate revealed no gravy on the pork e) Resident #28 The surveyor observed Resident #28 sitting at the table not eating the meal, who reported, No one can eat this mess. There is no gravy on our food. Observation of the meal revealed no gravy on the pork Staff interview with the District Manager for Food and Nutrition DMFN# 131 verified there should have been gravy on the pork per recipe and meal ticket. Reporting I will re-educate them to ensure they are following recipes and meal tickets. f) Resident #11 On 05/26/26 at around 3:30 PM during an interview with Resident #11, they reported, This food is really bad, it used to be good up until about six or seven months ago. When I ask for alternates sometimes they get me something sometimes they don't, I could not eat the pork today it was too tough, the ticket said we were to have gravy but did not g) Resident #66 On 05/26/26 at around 1:30 PM during an interview with Resident #66, they reported, The food is not good, they don't season the food. Today, this pork chop was too tough, and there was no gravy on it to help. h) Resident #15 and #80 On 05/27/26 at around 12:10 PM during dining room observations, Resident #15 and Resident #80 were served their meal in the dining room. The meal ticket read: Cranberry orange chicken. Garlic & rosemary roasted red skin potatoes. Seasoned cabbage with dinner roll. Both residents replied I do not like chicken, I wish they would stop sending it. Nurse assistant (11) reported that the residents dislike chicken and the kitchen has been told. Staff interview with the dietary manager reported, I do not remember if anyone told me, I will update their preferences. Questioned the dietary manager how often meal preferences are obtained. Dietary manager reports We do them upon admission, and the dietician reviews with them when she does assessments. I will go talk with some one if nursing tells me they want to talk g) Resident #87 On 05/27/26 at around 1:30 PM during an interview with Resident #87, they reported, This chicken is too tough, very bland. I can't chew it. Resident #87 reported, I am so sick of chicken, I told them this but I still get it. This surveyor questioned if someone from dietary came to talk with her, she reports No, not for a while. h) Resident #94 On 05/27/26 at around 2:00 PM during an interview with Resident #94, they reported, I have told the nurses and kitchen I am tired of this chicken, they can't cook too well, especially chicken and pork. This surveyor asked Resident #94 if someone from the kitchen came to update preferences, they reported, No, no one has yet. i) Resident #74 On 05/27/26 at around 2:30 PM during an interview with Resident #74, they reported, I really don't like chicken anymore, they serve it all the time. This surveyor questioned if anyone had updated the meal preferences, she reported, No, not for a while. The surveyor interviewed the dietary manager and District Manager #131 regarding updating meal preferences for the above residents. The dietary manager reported, I will begin working on updating the preferences.

Based on observation and staff interviews, the facility failed 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 with regards to the resident's personal products and unsanitary practices. This failed practice was a random opportunity of discovery. Resident identifiers: #128, and #128. Facility census: 110.a) Resident Wheelchairs:On 05/26/26 at approximately 2:12PM, a facility walk-through revealed Resident # 128 's wheelchair sitting in her room with cracks in the front left seat pad and right arm pad exposing the inner padding.On 05/26/26 at approximately 2:16PM, a facility walk-through revealed Resident # 2 's wheelchair sitting in his room with cracks in the front left hand rest, exposing the inner padding. 05/26/26 10:46 AM 2 wheelchairs and 1 Geri-chair had holes with exposed inner padding. An interview was conducted on 05/26/26 at 2:25PM, with the facility Director Of Nursing with the Chief Executive Officer present. She acknowledged and confirmed the wheelchairs in Resident #2 and #128's room had exposed padding. During the facility walk-through on 05/27/26 at approximately 2:25 PM, the surveyor observed that the [NAME] Hall clean linen cart had opened pouches/wipes, trash bags, and an opened bag of briefs mixed with clean linen on the top shelf. A further observation of the clean linen cart on the [NAME] Fort Hall revealed an opened plastic container of Sani-Cloth wipes with one wipe exposed on the top shelf. The second shelf held 3 tubes of hydro-shield barrier creme inside a plastic bag, 2 open boxes of plastic gloves and a loose roll of clear plastic trash bags.In an interview with the Infection Control Preventionist on 05/27/26 at 2:25 PM, she confirmed the items were found on both of the clean linen cart shelves and stated that only clean linen and Hoyer slings were to be stored on the hallway linen carts. During a facility walk-through on 06/01/26 at 3:00 PM, a wound patch was observed left on the drain underneath the shower chair in the Long Hall shower room. An Interview with Registered Nurse (RN) #61 was conducted on 06/02/26 at 1:55 PM and RN #61 confirmed the wound patch left on the drain and stated it was left there after the last resident's shower then removed it. During an interview with Resident #129 in room [ROOM NUMBER] on 06/03/26 at 2:40PM, upon resident's request to check her closet for returned laundry, a Hoyer lift Sling was found on the floor in the corner of the shared closet. An Interview was conducted with Registered Nurse(RN) Employee #32 on 06/03/26 at 2:55 PM. She confirmed the Hoyer lift sling was on the floor in the corner of room [ROOM NUMBER]'s shared closet and stated it definitely should not have been left there. She also stated lift slings should be returned to dirty linen once used for residents. In an interview with Nurse Aide (NA) Identifier #101 on 06/03/26 at 2:55 pm, she stated she had left the Hoyer lift sling in the closet floor, apologized and began to remove it.

Based on observations and staff interviews. Facility failed to ensure meals are served in a sanitary way in accordance with professional standards for food service safety. This was found during the annual facility survey process. This failed practice had the potential to affect more than a limited number of residents. Facility census 110. a) Review of policy for Food: Preparation.Review of procedures reads in part. 1. All staff will practice proper hand washing techniques and glove use. 2. All utensils, food contact equipment, and food contact surfaces will be cleaned and sanitized after every use. b) Review of Environment Policy All food preparation areas, food service areas, and dining areas will be maintained in a clean and sanitary condition. The Dining Service Director will ensure that all employees are knowledgeable in the proper procedures for cleaning and sanitizing of all food service equipment and surfaces. All food contact surfaces will be cleaned and sanitized after each use. The Dining Service Director will ensure that a routine cleaning schedule is in place for all cooking equipment, food storage areas, and surfaces. During observations in the dining room during meal service on 05/26/26 at around 11:45 AM, [NAME] #121 was serving meals to residents. [NAME] #121 removed gloves walked into the kitchen to retrieve bowls for a resident, and upon returning to the workspace, changed gloves without hand washing being witnessed. At 12:15 PM this [NAME] (#121) again went into the kitchen to obtain a missing item, removed gloves, and then replaced them when returning to the workspace; hand washing was not witnessed. During an interview regarding glove and hand washing use [NAME] #121 verified hand washing was not performed when leaving and returning to the work space before re-applying gloves. [NAME] #121 stated,I thought if I just changed my gloves that was fine or use the alcohol rub. The surveyor had an Interview with the dietary manager regarding the policy for hand washing and glove use. During that time the DM said, I will re educate them on proper hand washing. During observation of the kitchen area on 06/02/26 at around 10:30 AM the surveyor observed the prep table and the table with rollers for the tray line. On the bottom shelf of the prep tables, a moderate amount of food debris and sticky substance was observed, including dried yellow substance, dried bread crumbs, and other debris. The surveyor questioned the dietary manager regarding equipment cleaning. The dietary manager reported, We clean this at least after each meal and/or shift. During follow up kitchen observations at 11:30 AM debris persist on prep table and table with rollers for the tray line, also on bottom shelf of the prep tables with moderate amount of debris and sticky substance observed. Dietary manager verified this was needing cleaned. During observation of the kitchen during lunch meal service on 06/02/26 at around 12:30 PM, the surveyor observed [NAME] #121 step aside to obtain a hamburger bun while plating a meal. [NAME] #121 opened the package with gloved hands, proceeded to handle the hamburger bun with a gloved hand, then walked to the trash can, threw the old gloves away and put on a new set of gloves without washing hands first. When questioned, [NAME] (#121) reported, I did not think to wash my hands.

Based on observation, staff interview and record review the facility failed to ensure it had a complete and accurate medical record related to capturing correct Diagnosis upon admission. This failed practice was found true for (1) one of (2) two residents reviewed for correct diagnosis upon admit during the Long-Term Care Survey Process. Resident identifier # 78 . Facility Census 110.Finding Included: a) Resident # 78 During a facility walk through on 05/26/26 at 2:15 PM, the surveyor observed that Resident #78's room had signage for Enteric Precautions around her door. A record review on 05/26/26 at 3:30 PM, revealed that Resident #78's list of diagnosis did not coincide with the enteric precautions orders. Further record review revealed that Resident #78 was admitted to the facility on [DATE] and the hospital Discharge summary dated [DATE] listed the diagnosis of Clostridium difficile colitis.A review of Resident #78's list of diagnoses on 06/02/26 found that the diagnosis of Enterocolitis due to clostridium difficile was added to the list with a creation date of 05/27/26 but was updated on 05/26/26. During an interview on 06/02/26 at 11:38 AM, the Administrator confirmed that Resident #78's medical record did not capture the diagnosis of c-diff upon admission [DATE] and was not added to the electronic record until 05/26/26.

Based on observation and staff interviews, the facility failed to ensure the resident environment remains as free of accident hazards as is possible This failed practice was a random opportunity for discovery and had the potential to affect more than a limited number of residents living in the facility during the survey process. Resident identifier: #4. Facility Census: 110 During a walkthrough of the facility conducted on 05/28/26 at approximately 10:15 a.m. the state surveyor observed a medication cart located on the 100 hallway near the nursing station to be unlocked and unattended. The medication cart was observed with no staff member present or actively supervising the cart at the time of the observation. The unsecured medication cart created the potential for unauthorized access to medications by residents, visitors, or other individuals within the facility. The state surveyor immediately inquired with staff members present near the nursing station regarding which nurse was assigned responsibility for the medication cart. Staff members identified RN #61, as the nurse responsible for the cart during this shift. At approximately 10:17 a.m., RN #61 approached the medication cart and confirmed that she was the staff member assigned responsibility for the medication cart. RN #61 communicated to the state surveyor, I've given my keys to another nurse to use. RN #61 then locked the medication cart after being made aware of the observation by the state surveyor. The state surveyor verified the observation and staff assignment with the Assistant Director of Nursing (ADON) at approximately 10:25 a.m. Findings Included: During resident interviews conducted on 05/26/26 at 2:20PM, it was observed 3(three) tubes of Bio-Freeze ointment on Resident #4's bedside shelf. Resident #4 stated a couple of days ago, his wife had brought them to him to use for pain. He also stated he should have put them away. The Bio-Freeze ointment tubes were in sight and within reach of anyone who might wander into his room. In an interview on 06/26/26 at 2:29PM with the DON and the CEO present. She confirmed the Bio-Freeze was on the Resident's shelf and stated she would contact his family about bringing in medications. She also stated This can not be left in his room and removed it.

Based on observation, record review, and staff interview, the facility failed to ensure a resident's care plan was revised in the area of enteric precautions for a Clostridium difficile Infection. This failed practice was true for 1 of 2 residents reviewed during the survey process. Resident identifier: # 78. Facility Census:110 Findings Included:During a facility walk through on 05/26/26 at 12:45PM, It was observed signage of Enteric precautions were placed on the wall by resident #78's entrance door. A record review on 05/26/26 at 1:45 PM, of Resident #78's electronic medical record found her admit date was 05/18/26 and according to the Hospital Discharge summary dated [DATE], She was admitted with a diagnosis of Clostridium difficile infection. A Further record review of Resident #78's Care plan found:Focus: resident has c-diff and is in enteric isolation. date initiated: 05/26/2026 During an interview on 06/02/26 at 11:35 AM, The Chief Executive Office (CEO) confirmed the diagnosis of clostridium difficile infection and enteric precautions were not captured nor addressed in Resident #78's care plan until 05/26/26.

Based on observation and record review, the facility failed to ensure Lovenox and inhalers were administered according to professional standards. This was true for one (1) resident's medication administration of 34 observed medication administrations. Resident identifier: #11. Facility census: 110. Findings included: a) Resident #11On 06/02/26 at 9:20 AM the surveyor observed Licensed Practical Nurse (LPN) #91 administer Lovenox (blood thinner) into Resident #11 lower abdominal fold. The lower abdominal fold was very large and had multiple bruises. LPN #91 wiped the skin with an alcohol pad, removed the cap on the Lovenox, expressed the air bubble from the Lovenox syringe, and injected the medication. After removing the syringe, the LPN #91 then swabbed the injection site with the alcohol pad. The following were the manufacture instructions when administering Lovenox:Choose a Site: Pick an area on the right or left side of the abdomen, at least 2 inches away from the belly button. Alternate sides daily to reduce bruising and irritation. Clean: Wipe the area with an alcohol swab and let it air dry completely.Pinch: Use your thumb and index finger to gently pinch a 1-inch fold of skin to isolate the fatty tissue. Inject: Hold the syringe like a pencil and insert the needle straight down into the skin fold at a 90-degree angle. Push the plunger down in a slow, steady motion. Remove: Pull the needle straight out at the same angle it went in, then release the skin fold.Dispose: Discard the used syringe into an approved sharps container. Do not recap the needle. Important Safety Information:Do not expel the air bubble: Lovenox pre-filled syringes contain a small air bubble designed to ensure the full dose is received. Do not push this bubble out before injecting.In an interview with the Director of Nursing (DON) on 06/02/26 at 12:35 PM, the DON confirmed LPN #91 did not administer the Lovenox correctly. the DON stated the Lovenox should not be given within two (2) inches of the umbilicus (belly button).The attending physician ordered Budesonide-Formoterol Fumarate Inhalation aerosol 150-4.5 mcg/act two (2) puffs inhaled orally two (2) times per day for Chronic Obstructive Pulmonary Disease (COPD). Rinse mouth after use. Start date of 03/26/26. During the medication pass LPN #91, gave Resident #11 one (1) puff of the inhaled medication. She then gave the resident her oral medication with water. After waiting approximately 3-5 minutes LPN #91 gave the resident her second puff after which she gave the resident water which she instructed her to swish and then spit out the water in the cup. In an interview with the DON on 06/02/26 at 12:35 PM the DON had no response when informed of the giving of water to swallow the oral medications between puffs of the inhaler.

Based on observation and staff interviews, the facility failed to provide a safe, clean, comfortable, and homelike environment relating to disrepair in the resident's dining room. This was a random opportunity for discovery. Facility census: 110.Findings Included: On 06/01/26 at 11:15AM the following issues were observed in the Resident Dining Room:The right-side wall had peeling paint. There were three deep unrepaired gouges in approximately 2 to 2 1/2 inches long in the sheet rock between each of the floor to ceiling windows PTAC (Packaged Terminal Air Conditioner) Units:The PTAC units were cracked and missing caulking around the 2 units. There was water damage with loose and peeling paint approximately 3 inch round hole in the lower left door facing. In an interview with the Dietician #134 on 06 /01/26 at approximately 11:25 AM, she acknowledged the peeling paint, sheet rock gouges, cracked/missing caulking, water damage and hole at the back exit door, and stated she would make a report to the maintenance department. On 06/02/26 at approximately 8:45 AM, during a walk through with the Administrator, he stated he was made aware of the issues in the resident dining room and confirmed the maintenance department had started repairs.

Based on observations and staff interviews, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public in the resident dining room. This was a random opportunity for discovery with the ability to effect a limited number of residents. Facility Census 110.Findings Included:a) The surveyor observed an issue on 06/01/26 at approximately 11:15 AM, in the resident dining room. The surveyor observed an approximate 3 inch round hole in the lower left doorfacing at the back exit door with sheet rock dust and chunks falling out and into the floor. This was easily accessible to all residents in the dining room. On 06/01/26 at approximately 11:25 AM, an interview with the dietician verified this finding. This finding was also acknowledged by the facilityadministrator on 06/03/26 at approximately 8:35 AM.

Based on observation, resident interview, and staff interview, the facility failed to ensure residents receive and provide at least 3 meals daily at regular times comparable to normal meal times in accordance with residents needs, preferences, requests, and plan of care. This failed practice was a random opportunity for discovery.Resident Identifier #67. Facility Census 110. a) Resident #67 During an interview with Resident #67 on 05/26/26 at 1:45 pm he reported he did not receive lunch that day. He stated he went to therapy in the morning and when he returned to his room, his tray was left for him on his bedside table but his roommate was eating both meals. He stated he asked for another tray and was told they would see what they could do for him. Resident #67 stated he felt the staff had forgotten about him and that it was too late to get anything because dinner was approaching. Resident #67 said, It's almost 2:00 now. A record review of meal times on 05/26/26 at 3:00 pm revealed lunch trays were delivered between 12:15 PM and 12:30 PM daily. In an interview with Certified Nurse Aide #106, on 05/26/26 at 1:45 PM, she stated she did not know Resident # 67 needed a tray and apologized. She offered to get him a sandwich since he was concerned about dinner being so close. He accepted. The sandwich and drinks were delivered at approximately 2:40 PM.

Based on observation, record review and staff interview, the facility failed to ensure nutritional supplements were being offered per physician orders. This was found during the annual facility survey process. This failed practice had the potential to affect more than a limited number of residents. Facility census: 110. Resident identifiers: #53, #67, #100, #41, #49, #75, #100 and #75. Findings include- A)-Policy review for Snacks. -Policy statement reads in part: Snacks and beverages will be provided as identified in the individual plans of care.-Procedure reads in part: Nursing services is responsible for delivering the individual snacks to the identified resident and for offering evening snacks to all other residents. B) -On 05/26/2026 at around 2:00PM during observation in nourishment room on the 100 unit hall. In the freezer part of the refrigerator observed (9) nine, frozen nutrient cups, (magic cups) unopened with label and date that was to be delivered and or offered. Staff interview with Unit Manager,(10), she verified these were to have been offered, reporting sometimes they refuse and the aides just put them in here. I then questioned her if these were all refusals, and if they were would the medical record reflect the refusal, she replied I would think soC)- record review revealed:-Resident #53 frozen nutrient cup dated to be given at 8:00PM on 05/24/2026. Record review of the medication administration record (MAR) has marked for 100% consumption.-Resident #67 frozen nutrient cup dated to be given at 8:00PM on 05/24/2026. Record review of the(MAR)has marked for 100% consumption.-Resident #100 frozen nutrient cup dated to be given at 8:00PM on 05/24/2026. Record review of the (MAR) has marked for 100% consumption.-Resident #41 frozen nutrient cup dated to be given at 8:00PM on 05/24/2026. Record review of the (MAR) has marked for 100% consumption.-Resident #49 frozen nutrient cup dated to be given at 8:00PM on 05/24/2026. Record review of the (MAR) has marked for 100% consumption.-Resident #75 frozen nutrient cup dated to be given at 8:00PM on 05/22/2026. Record review of the (MAR) has marked for 100% consumption.-Resident #100 frozen nutrient cup dated to be given at 8:00PM on 05/22/2026. Record review of the (MAR) has marked for 100% consumption.-Resident #75 frozen nutrient cup dated to be given at 8:00PM on 05/24/2026. Record review of the (MAR) has marked for 100% consumption.-Resident #49 frozen nutrient cup dated to be given at 8:00PM on 05/22/2026. Record review of the (MAR) has marked for 100% consumption.- Staff interview with Unit Manager (#10).I requested her to review these findings and she verified these were to have been offered, reporting sometimes they refuse and the aides just put them in here. I then questioned her if these were all refusals, she replied I would think so I then questioned her if it would reflect in the residents (MAR) any refusals, she replied yes, they would mark them as refused.

Based on observations and staff interviews, the facility failed to provide a safe, clean, comfortable, and homelike environment for one (1) of two (2) resident showers rooms located in the [NAME] Fort Hall. Facility Census: 113. Findings Included:a) On 03/16/26 at approximately 1:20 PM, Surveyor observed a damaged area of the wall in the central shower room on [NAME] Fort (300-400 Hall) that was covered up with black tape.b) On 03/16/26 at approximately 1:20 PM, Surveyor observed stained/discolored tile grout located in the shower stall of the central shower room on [NAME] Fort (300-400 Hall).c) On 03/16/26 at approximately 1:25 PM., an interview with the facility's Director of Plant Maintenance verified these findings. These findings were also acknowledged by the facility's Administrator at approximately 1:25 PM, and upon the exit conference on 03/17/26 at approximately 3:45 PM.

F880Based upon Observations and Interviews the facility FAILED to have a safe, sanitary, and comfortable environment and to help prevent the development and transmission of disease and infection. This is evidenced by A) Two open soda cans on a PPE cart outside a residents room. B) Three lift pads left on top of a clean linen cart; and C) PPE/EBP signs on multiple doors with out identifying the resident to whom the precaution applies to.These were all random opportunities for discovery, with the ability to affect more than a single person.Census: 116A) The PPE cart outside RM [ROOM NUMBER] had two soda cans sitting on it. (zero sugar shasta)B) Outside RM [ROOM NUMBER] there were three lift pads on top of the linen cart exposed and not covered. An interview w/employee #105 stated that they definitely should not be on top of that cart, they should be at least inside under the cover. Ill make sure they are taken care of.C) There were PPE/PBE signs throughout the building that are not marked with whom the precautions go to. An interview with #213 stated that they just assume both residents are covered by the sign and not sure how they (the facility) marks them honestly. Another Interview with the DON stated that there should be a 1 or a 2 and sometimes a blue dot on them and she will let the IP person know they need to be addressed.

F689Based upon Observations and Interviews the facility FAILED to ensure an environment that remains free from accident hazards as evidenced by A) Day room (end of hall room) of [NAME] court - Sani wipes (purple top) cleaners left on top of vending machines. B) Internet cafe/storage area with multiple equipment beds, lifts, pumps, chairs, and broken picture frame with sharp edges on counter. The area is open to residents and poses multiple hazards. C) Wiring exposed in a wall box without a cover outside RM [ROOM NUMBER]. This was a random opportunity of discovery with the ability to affect more than one person. Census 116 Findings include:A) In the day room at the end of hall room of [NAME] court there were Sani wipes (purple top) cleaners left on top of vending machines. Interview with employee #105 stated that no they should not be left on top of the machines, even if most residents are in wc and cant reach them. B) In the Internet cafe storage area was open to residents with multiple equipment beds, lifts, pumps, chairs, and broken picture frame with sharp edges on the counter which posed multiple hazards. Interview RN #58 - No that room is open and available to all residents and also used for training staff. C) There was wiring exposed in wall box with out a cover outside RM [ROOM NUMBER]. An interview with HSW #213 stated that the wires have been there a while, they are repainting the hallway.

Based on record review, resident interview, and staff interview, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice. Soiled briefs were being left in residential rooms following staff providing incontinence care. This was true for two (2) out of (2) residents reviewed. Resident identifiers: #92 and #78. Facility census: 115. Findings included: a) Resident #92 Record review completed on Monday, 04/07/25 at 1:30 PM revealed a resident grievance dated 01/16/25. Resident #92 alleged Nurse Aides do not pick up after themselves. Her roommate's soiled briefs are being left on the floor. The facility's Infection Preventionist and Social Service Designee #5 investigated the allegation and reported their findings to the Director of Nursing (DON). Nurse Aide #133 was re-educated, and the incident was logged as a teachable moment. Further review of Resident #92's electronic medical record revealed: -A physician determination of capacity, dated 05/20/24, stating resident had capacity to make decisions. -A quarterly MDS, dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating that resident was cognitively intact. During an interview on 04/09/24 at 12:05 PM, Resident #92 reported that her roommate's soiled briefs are still being left in the room. Resident #92 stated that the issue had improved but there were still a few staff members who were not picking up after themselves and are leaving briefs in the room which leaves an undesirable odor for her to endure. b) Resident #78 A record review completed on Monday, 04/07/25 at 2:15 PM revealed a resident grievance had been filed on 02/10/25. Resident #78 reported that nursing staff would change a brief and discard it in the room rather than removing it. The DON and Assistant DON investigated this allegation. The facility provided staff education regarding the proper way to complete incontinence care which would include removing soiled briefs from the resident room. Further review of Resident #78's electronic medical record revealed: -A physician determination of capacity, dated 01/03/25, stating resident had capacity to make decisions. -A quarterly MDS, dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of 13, indicating that resident was cognitively intact. During an interview on 04/09/24 at 9:40 AM, Resident #78 reported that her roommate's soiled briefs are still being left in the room. Resident #78 stated that the issue had improved but there were still a few staff members who were not picking up after themselves and are leaving briefs in the room which leaves an undesirable odor for her to endure. In fact, it just happened again the other day, the resident stated. Resident #78 reported she found it necessary to bag the brief herself and place it outside of her room in the hallway for staff to pick up so her room would not smell so bad. c) Anonymous Staff Interviews Anonymous staff interviews were conducted on 04/08/25 with the following results: -Staff Member #55 reported that briefs are still being left in resident trash cans within their rooms. -Staff Member #121 reported that even though it had been a lot worse many months ago, that briefs were still occasionally being left in resident rooms and not being removed as per facility protocol. -Staff Member #56 reported that she sometimes finds briefs left in resident rooms throughout the course of her shift. -Staff Member #13 reported that briefs are still being left in resident rooms despite the re-education that has been given to staff.

Based on observation, resident and staff interviews, the facility failed to incorporate an effective pest control program. This had the potential to affect all residents residing in the facility. Facility census: 107. Findings included: a) Gnats On 12/02/24 12:13 PM during the initial tour there were gnats all over the walls and ceiling in room [ROOM NUMBER]. The window was open, and a flying insect plug in was observed with multiple gnats trapped on the sticky pad. On 12/03/24 at 11:40 AM an observation and interview with the Central Supply Coordinator verified the gnats in the dining room and on resident trays. She stated they also have an issue with gnats in rooms where residents wet themselves On 12/03/24 at 12:11 PM during an interview with the exterminator, he stated he was never called to treat gnats in the facility prior to this date. He verified the gnats through the facility at this time. During an interview on 12/03/24 at approximately 12:45 AM, the Administrator verified they tried to exterminate the gnats with the plug in and opened the window. He stated he moved Resident #108 out of room [ROOM NUMBER] on 11/29/24 due to the gnats. During an interview, on 12/04/24 at 11:05 AM, Resident #29 reported she had resorted to killing the gnats in her room (on the 400 hall) with a fly swatter. Resident #29 also stated she had met with the Administrator to discuss the gnats as well as her dissatisfaction with the fact that the garbage in her room had not been taken out for three (3) days, and that she had resorted to bagging it up herself and placing it in the hallway. The resident stated she never received verbal or written follow-up from the Administrator regarding her concerns.

Based on record review and staff interview the facility failed to follow through with their plan of correction when a deficient practice was identified and investigated. This was true for ten (10) of ten (10 records reviewed. Resident Identifiers: #19, #25, #30, #43, #64, #69, #77, #255, #256, and #258. Facility Census: 107 Findings Include: a) Resident #19, #25, #30, #43, #64, #69, #77, #255, #256, and #258 On 12/04/24 at 11:23 AM a facility reported incident concerning a multi-resident medication error was reviewed. The incident report alleged Registered Nurse (RN) #404 failed to pass Physician ordered medications to ten (10) residents. This occurred on each night shift from 04/06/24 through 04/09/24. On 12/09/24 during an interview with the Director of Nursing (DON), she stated the error was identified when a random audit of the medication cart was performed by herself. It was found that the dated medication packets which come from the pharmacy were still in the medication cart, unopened. She then performed an audit of the Medication Administration Report (MAR) and found that the medication had been documented as given. The RN was suspended immediately pending the investigation of the alleged medication error. He resigned his position on 04/09/24 without proper notice. During the investigation the facility reported the error to the Physician, the Nurse Practioner (NP), the Pharmacy, the residents or their Medical Power of Attorney (MPOA)/Health Care Surrogate (HCS). It was reported to Adult Protection Services (APS), the Ombudsman and the Office to Health Facility Licensure and Certification (OHFLAC). The ten (10) residents identified were assessed for any adverse reactions to not receiving their scheduled medications, The remaining residents on the hall the RN was assigned to were assessed and interviewed and it was determined no other residents to have had missed medications. Witness statements were obtained from four (4) nurses that routinely relieve RN #404 when they report to work for the day shift relating to a past history of finding medications in the medication cart that had not been administered. There were no prior incidents recalled from the witness statements. On the five (5) day follow up report submitted to OHFLAC the facility plan of correction was as follows: Residents were assessed for adverse reactions to not receiving their scheduled medications by the NP on 04/10/24 and 04/12/24. The Physician, NP, Pharmacy were notified by interim Director of Nursing (IDON) on 04/10/24. MPOA's and Health Care Surrogates (HCS) were notified by Licensed Practical Nurses (LPN) on 04/10/24. The employee alleged to have failed to appropriately pass medication was suspended pending investigation. This incident was reported on 04/10/24 of OHFLAC, Ombudsman, and APS by the Executive Director (ED). Nursing completed assessments on all residents on the hall the incident occurred, on 04/10/24 and 04/11/24 by floor nurses. No additional residents were determined to have missed medications. All staff will be re-educated with a posttest to validate understanding on the policy related to Medication Administration by IDON/designee. All staff not available at this time will have education with posttest to validate understanding on the Medication Administration policy prior to next shift scheduled by ED/designee. All new staff will have education with posttest to validate understanding provided during orientation by SDC/designee. Medication carts will be audited daily for two (2) weeks including weekends, then three (3) times a week for two (2) weeks, and then randomly thereafter with corrective action upon discovery. Findings will be reviewed at the facilities QAPI meeting each month. The facility policy and procedure for NS-1197-05 Nursing Medication Administration stated on page seven of seven (7 of 7) as follows: IV. Documentation a. Documentation of medication will be current for medication administration. b. Documentation of medications will follow accepted standards of nursing practice. Registered Nurse #404 was reported to the [NAME] Virginia Board of Registered Nurses. A review of the Medication Administration Report (MAR) for the ten (10) residents identified as missing medications were reviewed. The following medications/dosages were identified as not being administered on each of the dates of alleged errors (04/06/24 - 04/09/24). Resident #19 Mirtazapine 7.5 milligram (mg) for dementia Singular 10 mg for allergies Nifedipine 0.2% cream for hemorrhoids Nutritional supplement for weight loss Ocusoft lid scrub to both eyes for dry eyes Systane Ultra Solution 0.4-0.3% 2 drops in both eyes for dry eyes Sulfasalazine 500 mg for inflammation Resident #25 Catapres-TTS-s transdermal patch weekly for hypertension Lantus insulin 50 units for diabetes Levothyroxine 25 micrograms (mcg) for hypothyroidism Lipitor 20 mg for hyperlipedemia Resident #30 Eliquis 5 mg for Atrial fibrillation Entresto 49-51 mg for congestive heart failure Med pass supplement for weight loss 90 ml for weight loss Resident #43 Celexa 40 mg for depression Senna-S 8.6-50 mg for constipation Acetaminophen 1000 mg for pain Eliquis 5 mg for anticoagulation Fluticasone Proprionate Suspension 50 mcg 1 spray in each nostril for congestion Quetiapine Fumarate 100 mg for schizophrenia Seroquel 125 mg for schizophrenia Symbicort Inhalation Aerosol 160-45 mcg for COPD Tegretol 100 mg/5 ml for delusions Resident #64 Lipitor 20 mg for hyperlipedemia Refresh Ophthalmic Ointment 1 application in each eye for dry eyes Spiriva inhalation 18 mcg for COPD Trazodone 50 mg for depression Tylenol Extra Strength 10000 mg for pain Eliquis 5 mg for Atrial fibrillation Norco 10-325 mg for pain Requip 1 mg restless leg syndrome Rewetting eyedrops 2 drops in both eyes for dry eyes Resident #69 Med pass product 90 ml for weight loss Rivaroxaban 2.5 mg for circulation Tylenol 1000 mg for pain Resident #77 Celexa 20 mg for anxiety and depression Sennosides 8.6 mg for constipation Med Pass product 90 ml for supplement Metoprolol Tartrate 25 mg for hypertension Pantoprazole 40 mg for GERD Tegretol-XR 100 mg for anxiety Tramadol 50 mg for pain Ativan 0.5 mg for anxiety Carafate 1 gram for digestive aid Resident #255 Acetazolamine 250 mg for kidney disease Budesonide inhalation solution 0.5 mg/2 ml for COPD Guaifenesin ER 600 mg for mucus Ipratropium Albuterol Solution 05.-2.5 mg/3 ml for COPD Pantoprazole Sodium 40 mg for reflux Spironolactine 25 mg for congestive heart disease Torsemide 20 mg for congestive heart disease Ipratropium Albuterol solution 0.5-2.5 mg/ml for COPD Resident #256 Levothyroxine 125 mcg for hypothyroidism Senna 8.6-50 mg for constipation Famotidine 20 mg for acid indigestion Lantus insulin 35 units for diabetes Meclizine 12.5 mg for dizziness Resident #258 Atrovastatin 10 mg for hyperlipedemia Metformin 500 mg for diabetes Pantoprazole 40 mg for acid indigestion Tamsulosin 0.4 mg for urinary health Trazadone 50 mg for depression Carvedilol 25 mg for hypertension Magnesium Oxide 400 mg for supplement The above findings were confirmed on 12/10/24 at 9:10 AM with the DON and the Regional Director of Clinical Operations #400 who confirmed they do not have documentation of staff re-education or the medication cart audits. Administration failed to follow through with their plan of correction when a deficient practice was identified and investigated.

Based on observation and staff interview the facility failed to store garbage and refuse in a proper manner. The dumpster area was polluted with garbage and used medical supplies. This has the potential to affect all residents that reside in the facility. Facility census: 107. Findings included: a) Dumpster area An observation on 12/09/24 2:57 PM found the dumpster area was polluted with garbage and used medical supplies. On 12/09/24 at 3:16 PM during an Interview the Administrator verified the trash / medical supplies on the ground around the dumpster.

Based on observation, resident interview, and staff interview, the facility failed to protect and promote a dignified dining experience and failed to answer a resident's call light on a timely basis. These were random opportunities for discovery. Resident identifiers: #24, #71, #37, #45, #68, #27, #42, and #51. Facility census: 107. Findings included: a) During an interview on 12/03/24 at 10:30 AM, Residents #24 and Resident #31 reported that they had gone to the dining room for their Thanksgiving meal. They reported that one of the more confused residents from the 400 hall, Resident #45, had a soiled brief in her lap as she wheeled into the dining room. Resident #45 reportedly lifted the soiled brief, spread it on the table in front of her, and started playing in the feces as though she was finger painting. Both residents reported two activity aides were in the room but failed to do anything to intervene. They reported that Resident #71 went to the [NAME] hallway to ask staff to address it, and was told, Hey, that's not our problem. When asked what they thought that meant, both residents reported that Resident #45 was a resident on the [NAME] Fort 400 Hallway and the [NAME] hallway staff expected the other unit to handle the problem. After that, Resident #31 wheeled herself down the [NAME] Fort 400 hallway and was successful in finding CNA #83 who agreed to help and accompanied the resident to the dining room to take care of Resident #45. Both residents reported that they recalled Resident #37 was also in the dining room. During an interview on 12/04/24 at 11:30 AM, Resident #71 reported she recalled being in the dining room when the above-mentioned incident happened during the Thanksgiving meal. She reported she went to the [NAME] hallway to ask for staff assistance and was told, Hey, that's not our problem. She wheeled herself back into the dining room and reported she had not been successful in getting a staff member to help. That was when Resident #31 left to go get help from the 400 hallway. Resident #71 reported that there were two (2) activity staff in the room but that they did not intervene in any way. During a telephone interview on 12/04/24 at 12:42 PM, CNA #83 confirmed that Resident #31 had come and asked for her assistance in the dining room during the Thanksgiving meal. CNA #83 reported as she entered the dining room, Resident #45 had the dirty brief on the table and was playing in the feces. CNA #83 reported two activity staff members (#49 and #92) were present and sitting at the first table when she entered the room. Additionally, CNA #83 reported that CNA #10 assisted in helping clean Resident #45 up in the bathroom once they were back on the 400 hall. It was at this time that they identified Resident #45 had a brief on and that they could not be sure WHOSE dirty brief Resident #45 had been playing in while in the dining room. During an interview on 12/09/24 at 3:18 PM, Resident #37 confirmed her presence in the dining room during the Thanksgiving meal when the incident occurred. A subsequent record review found that Resident #31, Resident #24, Resident #71 and Resident #37 were all cognitively intact and would be able to accurately recall the events in the dining room and the fact that it did not provide a dignified dining experience to anyone that was present. The record review also determined that Resident #45 had severely impaired cognitive function. Using a reasonable person concept, one could determine that the facility failed to protect Resident #45's dignity when staff did not immediately intervene when she began playing in the dirty brief in a public setting. 49467 b) Overflow Dining Room Lunch Service At approximately 12:00 PM on 12/02/2024, during meal service observation in the lounge (which is used as the overflow dining room), all residents eating lunch in the overflow dining room had their plates and drinks placed on serving trays, and were eating their meals off of the serving trays, as the staff did not remove the items after serving the residents. At approximately 12:05 PM on 12/02/2024, an interview was conducted with Nurse Aide (NA) #73. NA #73 was asked if the residents regularly ate off of the serving trays in the overflow dining room, to which she replied Yes, it 's like this every day. 45171 c) Observations on 12/03/24 at 11:48 AM revealed the following residents were sitting at the large table: Resident #16, #101, #50, #74, #30, #40, #23, #76, #42, and #27. Resident #16 was eating her lunch meal. No other residents at the table had their food yet. Beginning at 12:10 PM, the lunch meal was delivered to Resident # 's 101, #50, #74, #30, #40, #23 and #76. Resident #42 was crying and asking for food. She was crying and saying, I want some food, please give me some food She did not receive her meal until 12:30 PM. Resident #27 was sitting at the end of the table with her arms crossed and head down. At 12:20 PM, she asked why she did not receive her food. Her meal tray was served at 12:30 PM. These issues were discussed with the Administrator on 12/03/24 at 2:10 PM. 50795 d) Resident #68 During an interview on 12/03/24, at approximately 9:35 AM, Resident #68 reported experiencing an upset stomach and diarrhea. At around 9:38 AM, she used her call light to request assistance. Nursing Assistant (NA) #41 responded at approximately 9:57 AM. When interviewed, NA #41 explained that there were 32 rooms in the hallway and that all the NAs were occupied providing care. In a further interview with Licensed Practical Nurse (LPN) #14 on 12/03/24, at approximately 11:30 AM, LPN #14 stated that the NA coverage was adequate, as four (4) NAs were assigned to the hallway. Additionally, during interviews with Resident #47 and Resident #13, both indicated that the response time for assistance could be as long as 30 minutes. Resident #47 mentioned that he was fortunate to have a catheter; otherwise, he would not have been able to avoid soiling his bed.

Based on record review, observation and interviews the facility failed to prevent a fall for a resident who is dependent on staff for bed mobility from a fall. The fall resulted in injury to the resident. This involved one of six residents (#71) identified by the facility as having a fall in the last 30 days. Findings include: Review of the medical record for Resident #71 revealed the resident was originally admitted to the facility on [DATE]. The resident was hospitalized related to a cardio vascular accident (CVA) and readmitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. Review of the most recent Minimum Data Set (MDS), a comprehensive assessment dated [DATE], revealed the resident scored an 11 out of 15 on the Brief Interview for Mental Status (BIMS), is able to make herself understood and is able to understand others. The resident was also assessed to require extensive assist of two staff members for bed mobility, transfers, dressing and toilet use. Resident #71 was assessed to require extensive assist of one staff member for personal hygiene. The MDS also revealed the resident has functional limitations to one side of the upper and lower extremities. Review of the care plan for Resident #71 revealed a plan of care dated 05/11/12 related to the resident's risk for falls due to an unsteady gait, pain and a history of falls. Interventions included 2 person assist for transfers, explain procedure and go slowly, bed buddies on the left side of the bed to assist the resident in awareness of bed parameters, bed to be positionined in the low position, encourage and assist as needed to wear non slip footwear, encourage to transfer and change position slowly, fall mats and staff education on 2 person assist with turning, and transfers with sling lift. A plan of care also dated 05/11/12 was reviewed related to Resident #71's self care deficit which included interventions of a 2 person assist with all transfers. Further review of the medical record revealed nurses notes dated 06/03/12 at 8:35 A.M., which stated a Certified Nurse Aide (CNA) was providing incontinence care to Resident #71 hen the resident fell out of bed and landed on the floor. According to the nurses notes, Resident #71 did not lose consciousness, however, did complain of right leg pain and did have a laceration to her left temple area near the left ear. First aide was provided by the facility staff and an ambulance service was notified to transport Resident #71 to the emergency room for evaluation of the injuries sustained from the fall. The nurses notes revealed Resident #71 returned from the emergency roiagnom on [DATE] with the [DIAGNOSES REDACTED]. Review of a document titled Patient Information Worksheet (PIW), and identified by the facility as as a document staff can use as a guide to the care required by residents residing in the facility, revealed Resident #71 requires two staff members for all transfers. The resident information found in the kiosk, an electronic health information device, stated Resident #71 required the assistance of two staff members for activities of daily living (ADLs). Resident #71 was observed in bed on 06/04/12 at 10:42 A.M., and 6/5/12 at 12:19 P.M., with bolsters to both side of the bed. On 6/6/12 at 8:46 A.M., Resident #71 was observed in bed with the foot of the electronic bed elevated with the Resident's knees bent, the head of the bed was slightly elevated as was the height of the bed elevated. At the time of the observation CNA #112 came to the room to retrieve the breakfast tray and did not acknowledge the height of the Resident's bed. At 8:54 A.M. on 06/06/12 Licensed Practical Nurse #70 was notified by the surveyor of the height of the bed. LPN #70 verified during interview the height of the bed was too high and was not in accordance with the current plan of care related to Resident #71's history of falls from the bed. During interview with the facility Administrator on 06/06/12 at 12:31 P.M., it was verified a CNA, who is currently on suspension from work due to the fall, was alone providing incontinence care to Resident #71 while she was in bed. The investigation into the fall was reviewed with the Administrator at the time of the interview. According to the investigation and the CNA's statement taken by the Administrator, the CNA had been standing on the left side of Resident #71 and had pushed the Resident onto her right side rolling her off the right side of the bed. The statement went on to say the CNA had left the room and alerted LPN #70 of what had occurred. During interview with LPN #70 on 06/06/12 at 12:57 P.M., with the Administrator present, it was verified the CNA who had rolled Resident #71 out of bed had been the one to alert her of the incident. According to LPN #70, when she entered the room Resident #71 was lying on her back on the floor between the bed and wall and had stated the aide was being mean to her when providing care. LPN #70 verified the injury to the left side of the Resident's head and could not be sure what Resident #71's head had come in contact with to cause the laceration. LPN #70 stated during the interview that she had notified the physician and received an order to send Resident #71 to the emergency room for evaluation of her injuries. During interview with LPN # 54 on 06/07/12 at 8:34 A.M., it was verified Resident #71 requires two staff members when providing care. During interview with CNAs #16, #112 and #109 on 06/07/12 at 9:07 A.M., it was stated there must be 2 staff members to provide care for Resident #71. The CNAs also stated they get information on how to care for residents residing in the facility from the "PIW" and the "kiosk" that are hanging on the walls in the hallway. .

Based on resident interview, observation, record review, and staff interview, the facility failed to provide care and services to assist each resident in attaining or maintaining the highest physical well being possible for three (3) of thirty-seven (37) Stage II sample residents. Resident #55 expressed experiencing pain in his leg that kept him awake at night, and he had an order for [REDACTED]. Resident #62 did not eat for three (3) days, and staff failed to assess for possible causes and failed to notify the physician, although the resident did not have a known terminal illness; the resident died twenty-four (24) hours after the physician was notified. Resident #153 was not appropriately assessed for fall risk and sustained two (2) falls. These actions resulted in actual harm to Resident #55 and #62. Resident identifiers: Residents #55, #62, and #153. Facility census: 97. Findings include: a) Resident #55 In an interview conducted at 3:00 p.m. on [DATE], Resident #55 stated he had pain in his left leg and that it often kept him awake at night. At that time, the resident was observed rubbing his left thigh. The resident's medical record, when reviewed on [DATE], contained a current physician's orders [REDACTED]. Based on this order, facility staff should have been aware of the possibility of leg pain and should have provided ongoing assessments for this resident's specific pain. Review of the care plan, at the same time, revealed no care plan or other mention of leg pain. In an interview at 10:45 a.m. on [DATE], a registered nurse (RN - Employee #136) revealed she had no knowledge of the resident experiencing left leg pain. Employee #136 reviewed the resident's pain scores (pain assessments) for [DATE] and reported there was no documentation of pain thus far in April. She confirmed that the pain score record did not specifically indicate assessment of left leg pain. Employee #136 then visited the resident in his room. At 11:00 a.m. on [DATE], the RN reported the resident stated to her that he has left leg pain at night and that the leg pain kept him awake at night. The resident's care plan was again reviewed, this time with Employee #136. At 5:30 p.m. on [DATE], Employee #136 confirmed the facility was not aware the resident was having pain and confirmed that ongoing assessments for left leg pain had not been occurring for this resident. Employee #136 stated she would assess the resident and implement appropriate interventions. The following morning, another interview was conducted with the resident, at 9:00 a.m. on [DATE]. He stated he had been given pain medication for his leg pain "last night" and that it had "really helped". He stated, "I slept like a log." At the time of the survey, the facility had not assessed the resident's left leg pain and had not developed and implemented a care plan to ensure the resident was as free as possible of pain. b) Resident #62 Closed record review revealed Resident #62 was admitted on [DATE] for rehabilitation related to a fractured left hip for which she had undergone internal fixation at an area hospital on [DATE]. She had been in an assisted living facility at the time of the fall and was 100-years old. The resident's discharge summary from the hospital, in the area of "condition on discharge", stated she was "stable". Additional medical [DIAGNOSES REDACTED]. The resident / responsible party's goal at the time of admission, according to the social work assessment of [DATE], was for the resident to be able to return to the assisted living facility where she resided prior to the fall. At the time of admission, the resident's diet was noted to be regular mechanical soft. Shortly after admission, the resident was noted to be having some difficulty with swallowing. A speech evaluation was conducted on [DATE], and the resident's diet was changed to pureed with honey-like liquids. An interdisciplinary progress note, dated [DATE], stated that resident was in thirty (30) day window for the minimum data set assessment (MDS) and she "continues to work with all therapy services. She continues to show progress." The medical record contained a Living Will document completed by the resident on [DATE], stating she desired to receive no life-prolonging interventions should she be diagnosed by two (2) physicians to have a terminal condition and/or to be in a vegetative state. She had included no limitations or special directives on this declaration. Review of the resident's physician orders [REDACTED]. party on [DATE], stated the resident was not to be resuscitated in Section A. In Section B, "Limited Additional Interventions" were requested, which direct staff to "use medical treatment, IV fluids and cardiac monitoring as needed. Transfer to hospital if indicated. Avoid intensive care." In Section C, antibiotics were requested, and in Section D, no feeding tube was requested, although IV fluids for a defined trial period were also requested. Nursing notes from the time of admission described the resident as mostly "resting in bed", meds taken crushed, and voicing no complaints. Family was noted to be visiting frequently. A nursing note, on [DATE] at 7:00 p.m., stated, "Resting in bed. PO (by mouth) meds taken crushed (sic) without difficulty. No complaints noted. VSS (vital signs and symptoms) per flow sheet. Foley cath patent draining yellow urine. ADL's (activities of daily living) per staff. Call bell in reach." At 9:20 a.m. on [DATE], a nursing note stated, "This nurse called to notify MD that resident has refused to eat for 3 days and that this nurse held am (morning) meds (medications) due to swallowing difficulty." At 1:00 p.m. on [DATE], an addition nursing note stated the family was in to visit and "explained to MPOA (medical power of attorney representative ) that resident has refused to eat for 3 days and that nurse held morning meds." The resident had not eaten for three (3) days before staff notified the physician. There was no noted response from the physician after he was notified of the resident's failure to eat for three (3) days. Although documentation stated that family was made aware and was with the resident frequently, there was no evidence that, when made aware of this failure to eat, the resident's physician or facility personnel met with the family to discuss their desire to attempt to [DIAGNOSES REDACTED]. There was no discussion about obtaining lab work or other minimally invasive diagnostic tests to ascertain why this resident - with no known terminal diagnosis - was not eating. There was no discussion related to implementation of IV fluids for a trial period, as requested on the resident's POST form. The resident died at the facility within twenty-four (24) hours of this physician's notification of her failure to eat for three (3) days. c) Resident #153 The medical record of Resident #153, when reviewed on [DATE], disclosed this [AGE] year old resident had been admitted to the facility on [DATE]. The resident's medical [DIAGNOSES REDACTED]. Further review of the record revealed a history and physical completed at the time of her last hospitalization following admission, which stated: "Her dementia seems to be progressing rather quickly" and "she is confused to place and time". Following admission to the facility, documentation on a social work assessment and history form stated the resident was alert and oriented to person with short and long term memory impairment. An admission nursing note, dated [DATE] at 2:00 p.m., stated, "Alert to self and to familiar people. Confused to time and place." A nursing note, on [DATE] at 5:00 a.m., stated, "Very forgetful", and at 2:45 p.m. on [DATE], a facility nurse documented in a nursing note, "Forgetful of things you have just explained to her." The resident's care plan was reviewed, and staff had recognized, on [DATE], that the resident was "at risk for falls due to cognitive impairment, adjustment to new environment, use of [MEDICAL CONDITION] medications, unsteady gait". Interventions to prevent falls included checking on resident frequently, providing assist to transfer and ambulate as needed, and reinforce need to call for assistance. On [DATE] at 9:00 a.m., a nursing note described finding the resident sitting on her buttocks in front of the toilet. The resident was assessed and determined to have no injuries. The resident also attempted to leave the building on two (2) occasions on this day, at 10:20 a.m. and again at 3:30 p.m., and a nursing note stated, "Resident alert, confused to time and place." At 4:30 p.m. on [DATE], a nursing note stated, "CNA (certified nursing assistant) took resident to bathroom and instructed to ring when done, resident got up from toilet on own - roommate stated res.(resident) walked to w/c (wheelchair) and fell to floor on back." The resident was transferred by emergency medical services to a local hospital emergency room for evaluation and returned to the facility at 8:35 p.m. on [DATE] with an order for [REDACTED]. The director of nurses (DON) and assistant director of nurses (ADON) were interviewed related to these findings at 10:00 a.m. on [DATE]. Following review of the resident's medical record and statements related to cognitive status as described above, the DON and ADON confirmed the care plan interventions for this resident (to call for assistance) and instructions by a nursing assistant (to call for assistance when done toileting) were not appropriate for this cognitively impaired resident. The resident did not have the ability to comprehend the instructions to call for assistance. .