Every finding on record at River View Post Acute

Based on observation, interview, and record review, the facility failed to implement Enhanced Barrier Precautions (EBP, infection-control measures that require the use of a gown and gloves during specified high-contact resident care activities) and ensure staff used the required personal protective equipment (PPE, protective clothing or equipment worn to reduce exposure to infectious organisms) for 2 of 17 residents on EBP, when:1. Licensed Nurse (LN) 1 failed to wear a gown while administering medications through Resident 1's G-tube (gastrostomy tube, a tube inserted through the abdomen directly into the stomach to provide nutrition, fluids, or medications), as required under EBP; and,2. Certified Nursing Assistant (CNA) 1 failed to wear a gown while assisting Resident 2 with a transfer to the wheelchair.These failures had the potential to increase the risk for transmission of infectious organisms between residents and staff.Findings1. Review of Resident 1's admission Record indicated Resident 1 was admitted to the facility with multiple diagnoses, including dysphagia (difficulty swallowing), attention to gastrostomy (care and management of a feeding tube inserted directly into the stomach), and history of traumatic brain injury (a prior brain injury caused by trauma that may affect physical, cognitive, or communication function).Review of Resident 1's Medication Review Report' indicated Resident 1 was on EBP related to the G-tube.Review of Resident 1's care plan indicated Resident 1 was on EBP related to the G-tube and other identified devices. The care plan directed staff providing high-contact care to follow EBP and wear appropriate PPE, including a gown and gloves, when handling the G-tube, and to maintain visible EBP signage outside Resident 1's room.During an observation on 8/13/2026 at 9:53 a.m., Resident 1 was in bed. An EBP sign was posted outside Resident 1's room. LN 1 was observed administering medication through Resident 1's G-tube while wearing gloves; however, LN 1 was not wearing a gown as required under EBP.During an interview on 8/13/2026 at 9:54 a.m., LN 1 stated he administered medication through Resident 1's G-tube. LN 1 verified that the EBP sign was posted outside Resident 1's room and acknowledged that he did not wear a gown while administering the medication. LN 1 stated it was important to wear a gown when handling the G-tube to prevent the spread of infection to other residents.During an interview on 8/13/2026 at 10:00 a.m., the Infection Preventionist (IP) verified Resident 1 was on EBP because of the G-tube. The IP stated staff were expected to follow the EBP protocol by wearing the required PPE during high-contact resident care activities and stated failure to follow EBP placed residents at risk for the spread of infection.2. Review of Resident 2's admission Record indicated Resident 1 was admitted to the facility with multiple diagnoses, including hemiplegia and hemiparesis following cerebral infarction (paralysis or weakness on one side of the body following a stroke (a sudden lack of oxygen to the brain)), generalized muscle weakness (reduced strength affecting multiple muscle groups), and difficulty walking (difficulty safely walking or moving from one location to another).Review of Resident 2's Medication Review Report' indicated Resident 2 was on Enhanced Barrier Precautions (EBP) for a midline (a medium-length, flexible catheter inserted into a large vein in the upper arm) to the right arm. Review of Resident 2's care plan indicated Resident 2 was on EBP related to the intravenous site. The care plan directed staff to maintain EBP according to facility policy and infection-prevention guidelines, wear appropriate PPE including gown and gloves when indicated by EBP, and ensure proper EBP signage was visible outside the Resident 2's room.During an observation on 8/13/2026 at 9:45 a.m., CNA 1 was observed exiting Resident 2's room with a Hoyer lift (a mechanical lift used to move residents who have limited movement) without wearing a gown. Resident 2 was subsequently moved out by another staff to the nursing station. During an interview on 8/13/2026 at 9:47 a.m., CNA 1 verified that an EBP sign was posted outside Resident 2's room. CNA 1 stated she assisted Resident 2 with a transfer to the wheelchair and acknowledged that she did not wear a gown while assisting with the transfer. CNA 1 stated it was important to follow the EBP guidance to help prevent the spread of infection to other residents.During an interview on 8/13/2026 at 10:00 a.m., the IP verified Resident 2 was on EBP because of the midline. The IP stated staff were expected to follow the EBP protocol by wearing the required PPE during high-contact resident care activities and stated failure to follow EBP placed residents at risk for the spread of infection.During an interview on 8/13/2026 at 10:23 a.m., the Director of Nursing (DON) stated it was important for staff to follow the facility's infection-control policy and stated her expectation was for staff to follow the applicable guidelines.Review of the facility's Enhanced Barrier Precautions signage indicated, .Providers and staff must also: Wear gloves and a gown for the following High-Contact Resident Care Activities.Transferring.Device care or use: central line .feeding tube.Review of the facility policy titled Enhanced Barrier Precautions, revised August 2022, indicated, .EBPs employ targeted gown and glove use during high contact resident care activities.transferring.device care or use (central line .feeding tube .).Review of the facility policy titled Administering Medications, revised April 2019, indicated, .Staff follows established facility infection control procedures (e.g., handwashing .gloves, isolation precautions, etc.) for the administration of medications, as applicable .

Based on interview, and record review, the facility failed to provide appropriate pharmaceutical services for one of four sampled residents (Resident 1) when, Resident 1 did not receive as needed (PRN) medications for constipation when indicated.This failure placed Resident 1 at risk for prolonged discomfort, nausea, and vomiting associated with untreated and unresolved constipation. Findings:A review of Resident 1's admission RECORD, indicated Resident 1 was admitted to the facility with diagnoses including aftercare following joint replacement surgery, difficulty in walking, need for assistance with personal care, and constipation.During a phone interview on 7/29/26, at 8:52 a.m., with Resident 1, Resident 1 stated she went without a bowel movement for probably 11 days before any medicine was given to address her constipation.During a record review of Resident 1's Documentation Survey Report, dated for February and March 2026, the report indicated Resident 1 went without a bowel movement from 2/20/26 to 2/25/26. Further review of the record indicated Resident 1 went without a bowel movement from 3/14/26, to 3/17/26.During an interview on 7/29/26, at 4:15 p.m., with the Assistant Director of Nursing (ADON), the ADON stated when Resident 1 was constipated by the third day; it was her expectation for the licensed nursing staff to utilize magnesium hydroxide, a suppository (a small, solid piece of medicine shaped like a bullet that you put into your body through your bottom to treat constipation), or an enema. The ADON further stated that if medications to relieve constipation were not utilized when indicated, Resident 1 could have experienced nausea, vomiting, or a bowel obstruction. During a concurrent interview and record review on 7/29/26, at 4:36 p.m., with the Director of Nursing (DON), Resident 1's Order Summary, was reviewed. The DON confirmed Resident 1 had an order for magnesium hydroxide (an oral laxative that softens hard stool by pulling water into the gut). The magnesium hydroxide order dated for 2/20/26, indicated, .Give 30 ml [ml, a unit of measurement] by mouth as needed for difficulty passing stool, use as first intervention. The DON further confirmed Resident 1 also had an order for fleet enema (sodium phosphates, a liquid medication inserted rectally that quickly clears out stool from the bowels). The fleet enema order dated for 2/20/26, indicated, .insert 1 unit rectally as needed for constipation.3rd day. During a subsequent concurrent interview and record review on 7/29/26, at 5 p.m., with the DON, Resident 1's, Document Survey Report, dated 2/26, and 3/26, were reviewed. The DON confirmed that Resident 1 did not receive the as needed (PRN) medication for constipation from 2/20/26, to 2/25/26, and from 3/14/26, to 3/17/26. The DON stated the nursing staff should have used either or both Resident 1's order for fleet enema or Resident 1's order for magnesium hydroxide which were both available on a PRN basis. The DON further stated not giving Resident 1's PRN medication for constipation when indicated placed Resident 1 at risk for prolonged constipation, pain, and nausea.A review of the facility policy and procedure titled, Administering Medications, dated 10/22, indicated, .Medications are administered in a safe and timely manner, and as prescribed.Medications are administered in accordance with prescriber orders, including any required time frame.

Based on observation, and interview, the facility failed to ensure a clean, comfortable, and home-like environment for a census of 94 when the facility baseboards had not been reinstalled after the flooring was replaced in November 2025, leaving exposed peeling drywall and holes in the walls with accumulated dust and debris.These failures had the potential to negatively affect the residents' physical and psychosocial well-being.Findings:During an interview on 7/17/26, at 7:26 AM, with Resident 1, Resident 1 stated she was admitted to the facility, in Room B, in early July. Resident 1 further stated her room was missing baseboards all the way around. Resident 1 stated there was a hole in the wall near the bathroom which allowed her to see inside the wall, Resident 1 further stated she was afraid insects would crawl out of it. Resident 1 stated she packed up her stuff and left the facility the next morning.During a concurrent observation and interview on 7/17/26, at 10AM, with the Housekeeping Supervisor (HSKS), in Room C, the walls in room C were observed to have missing baseboards, with chipped plaster and peeling paper. The HSKS confirmed the baseboards were missing and stated there was no way to clean the portion of the walls where the baseboards had been because the areas were papery and would chip off. The HSKS stated the staff cleaned above the baseboard area only. The HSKS further stated the floors were redone sometime last year, and the baseboards had been missing since then.During a concurrent observation and interview on 7/17/26, at 10:05 AM, with Resident 2, in Room B, Resident 2 stated she felt like she was living in a hole, but it was better since her family brought pictures. Resident 2 shook her head and frowned when asked how she felt about the missing baseboards and the hole in the wall near the bathroom.During a concurrent observation and interview on 7/17/26, at 10:40 AM, with the HSKS, in Room B, the HSKS confirmed the hole in the wall, approximately 6 inches in length, near the bathroom contained dust and debris and could not be cleaned by the housekeeping staff. The HSKS stated the staff could only clean above the opened area.During an interview on 7/17/26, at 2:21 PM, with the Director of Nurses (DON), the DON confirmed the baseboards in the facility hallways and bedrooms had not been replaced after the new flooring was installed in November. The DON stated the lack of baseboards and open areas in the walls could allow pests to enter the resident rooms and did not provide a homelike environment. The DON further stated the open areas in the walls did not promote a safe and sanitary environment and had the potential for bacteria to grow in the open areas especially in rooms with isolation precautions (special measures taken to prevent the spread of disease from an infected person).A review of a facility policy and procedure (P&P) titled, Homelike Environment, revised 2/2021, indicated, .Residents are provided with a safe, clean, comfortable and homelike environment.The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include.clean, sanitary and orderly environment.A review of a facility P&P titled, Policies and Practices-Infection Control, revised 10/2018, indicated, .This facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary and comfortable environment and to help prevent and manage transmission of diseases and infections.The objectives of our infection control policies and practices are to.maintain a safe, sanitary, and comfortable environment for personnel, residents, visitors, and the general public.

Based on interview, and record review, the facility failed to ensure professional standards of care were met for one of three sampled residents (Resident 1) when Resident 1 was admitted to the facility following knee replacement surgery and the facility was unable to provide Resident 1's prescribed medications.This failure had a negative effect on Resident 1's psychosocial well-being and had the potential to negatively affect her health.Findings:A review of Resident 1's admission RECORD, indicated she was admitted to the facility with diagnoses which included joint replacement surgery.During an interview on 7/17/26, at 7:26 AM, with Resident 1, Resident 1 stated she was admitted to the facility with an order for hydrocodone (potent pain medication) and it was not provided during her stay at the facility. Resident 1 further stated the facility did not provide her with any of her routine medications. Resident 1 stated the morning after she was admitted she packed up her belongings to leave. Resident 1 further stated the nurse came in mid-morning and brought two Tylenol tablets (over the counter pain medication) for Resident 1's pain and told her something had happened in the transfer of her medications.During a review of Resident 1's clinical document from the transferring facility titled, Depart Summary.Medication Instructions, the document indicated, .Changed.gabapentin [medication to treat nerve pain].1 capsule(s).three times a day.Next Dose 7/2 2200 [July second at 10 PM]. and .Unchanged.acetaminophen-HYDROcodone.1 tablet(s).Every 4 hours scheduled as needed for pain.During a review of Resident 1's Medication Administration Record (MAR), dated 7/1/26-7/31/26, the MAR indicated the following medications were scheduled to be administered on 7/2/26 at 8 PM and were not:Atorvastatin Calcium tablet (medication to lower cholesterol to prevent heart attack and strokes)Gabapentin capsule (medication for nerve pain)The MAR further indicated following medications were due to be administered on 7/3/26 and were not: 7:30 AM:Omeprazole capsule (medication for gastric reflux, heart burn) 8 AM:Fluticonase Propionate Nasal spray (allergy medication)Gabapentin capsule (medication for nerve pain)Glycolax powder (medication for constipation)Loratadine tablet (medication for allergies)Losartan Potassium tablet (medication for high blood pressure) During a review of Resident 1's clinical document titled, Nurse's Notes, dated 7/2/26, at 5:55 PM, the document indicated, .Upon admission and review of discharge summary/medication list, multiple medications noted to require clarification.NP [nurse practitioner] informed awaiting response.During a review of Resident 1's clinical document titled, Nurse's Notes, dated 7/3/26, at 8:03 AM, the document indicated, .No response from NP this AM regarding admit order clarification.Informed NP again and requested clarification, pending response.During a review of Resident 1's clinical document titled, Nurse's Notes, dated 7/3/26, at 9 AM, the document indicated, .No response from NP regarding admit order clarification. Call placed to Dr. [doctor name], spoke to [name] after hours answering service who sent page out to MD [Medical Doctor]. Awaiting response.During a review of Resident 1's clinical document titled, Nurse's Notes, dated 7/3/26, at 1:13 PM, the document indicated, .At approx. 0900 [9 AM] this writer was notified by house keeping that resident was stating she was going home, this writer went to residents room, resident was getting ready to leave facility, resident was upset about medications, this writer notified her that we had her medication and were pending clarification with hospital orders, Resident continued to express desire to leave the facility AMA [against medical advice] despite recommendation to remain for further evaluation/ or treatment.During an interview on 7/17/26, at 10:20 AM, with licensed Nurse (LN) 1, LN 1 stated the admissions coordinator (AC) uploaded residents' medication orders in the electronic health record (EHR) as part of the pre-admission process. LN 1 further stated the admitting nurse tried to review the orders prior to the admission. LN 1 stated medications were not ordered from the pharmacy until the resident was in the facility and the medications were activated in the EHR. LN 1 further stated narcotic (potent pain medications with addictive qualities) medications required a special form to be signed by the physician before the pharmacy could dispense the medication. LN 1 stated Resident 1 had several medications that required clarification before they could be administered and the hydrocodone for Resident 1 required a signed form from the physician. LN 1 further stated Resident 1's physician did not sign forms electronically and it was difficult to reach him after hours and on the weekends.During an interview on 7/17/26, at 10:34 AM, with the AC, the AC stated she reviewed referral information and verified insurance for new admissions, but she did not review medication orders. The AC further stated she tried to obtain the medication orders two hours prior to an admission and uploaded them in the EHR for the LN to review. The AC stated sometimes the orders were not available until right before the resident arrived.During an interview on 7/17/26, at 10:53 AM, with LN 2, LN 2 stated the housekeeper came to her on the morning of 7/3/26 and asked if she had spoken to Resident 1 because Resident 1 was packing her belongings. LN 2 further stated she explained to Resident 1 that they had her medications, but the medications needed clarification before they could be given her. LN 2 stated Resident 1's medications should have been clarified at the hospital prior to transfer to the facility.During an interview on 7/17/26, at 2:21 PM, with the Director of Nurses (DON), the DON stated the facility had issues with medication orders from Resident 1's transferring facility. The DON further stated the LNs needed the signed order form for Resident 1's hydrocodone in order to receive it from the pharmacy. The DON stated Resident 1's physician was not comfortable signing electronic forms and was not available when the LNs tried to contact him. The DON further stated it was important to have medications available to manage Resident 1's pain after her surgical procedure.During a review of a facility policy and procedure (P&P) titled, Reconciliation of Medications on Admission, revised 7/2017, the P&P indicated, .The purpose of this procedure is to ensure medication safety by accurately accounting for the resident's medications, routes and dosages upon admission or readmission to the facility.Medication reconciliation reduces medication errors and enhances resident safety by ensuring that the medications the resident needs and has been taking continue to be administered without interruption.during the admission/transfer process.

Based on observation, interview, and record review, the facility failed to timely identify a right hip fracture (a broken or cracked bone) for one of three residents (Resident 3) following an unwitnessed fall on 1/14/26, when nursing staff failed to conduct a comprehensive post-fall assessment (a thorough evaluation completed after a fall to identify possible injuries, pain, causes of the fall, and changes in the resident's condition), failed to adequately reassess Resident 3's reported hip pain and changes in condition, failed to complete required post-fall neurological monitoring (neuro checks - assessments used to identify changes in alertness, thinking, behavior, movement, sensation, and function following a fall) within required timeframes, and failed to complete a weekly summary (a routine nursing documentation that provides an overview of a resident's condition during the previous week) due on 1/19/26. Despite Resident 3 reporting hip pain following the fall and later experiencing severe, worsening pain, nursing staff failed to identify a potential fracture until the physician identified a right hip deformity on 1/21/26, which prompted diagnostic imaging on 1/21/26 that confirmed an acute right hip fracture.These failures delayed identification of Resident 3's fracture, resulting in severe pain and delayed implementation of appropriate interventions to address pain and promote comfort.Findings:Review of Resident 3's admission RECORD indicated Resident 3 was admitted to the facility with diagnoses including open wound to the right thigh, unstageable pressure ulcer (pressure sore covered with dead tissue that prevents determination of the wound depth) to the left hip, stage 4 pressure ulcer (severe pressure sore extending into muscle, tendon, or bone) to the right hip, stage 3 pressure ulcer (pressure sore involving full thickness skin loss) to the right buttock, stage 3 pressure ulcer to the right lower back, severe protein calorie malnutrition (not getting enough protein and calories for the body's needs), pressure deep tissue injuries (injury to skin and underlying tissue caused by pressure) to the right and left heels, palliative care (care focused on comfort and quality of life), need for assistance with personal care, and muscle weakness.Review of Resident 3's Minimum Data Set (MDS, an assessment tool) Brief Interview for Mental Status (BIMS - an assessment of a resident's thinking and memory), dated 1/13/26, indicated Resident 3's BIMS score was 5, reflecting severe cognitive impairment (13-15 = Intact, 8-12 = Moderate Impairment, 0-7 = Severe Impairment), which limited the resident's ability to communicate pain, describe how the fall occurred, or report signs and symptoms of injury following the fall.Review of Resident 3's communication log with hospice indicated that on 1/14/26 at 2:09 PM, the facility contacted hospice to report that Resident 3 had sustained an unwitnessed fall and complained of hip pain.Review of Resident 3's Post Fall Evaluation, dated 1/14/26, at 2:11 PM, indicated Resident 3 had an unwitnessed fall on 1/14/26 at 1:25 PM in Resident 3's room while attempting to get out of bed, but there was no assessment of factors that may have contributed to Resident 3's attempt to get out of bed, and no indicators pain was documented despite Resident 3's communication log with hospice dated 1/14/26 at 2:09 PM indicating Resident 3 complained of hip pain following the fall. Resident 3's Post Fall Evaluation also did not reflect that a comprehensive post-fall assessment was completed, as there was no detailed musculoskeletal assessment, assessment for signs of injury, identification of resident-specific fall risk factors, review of medications associated with falls, and documentation describing how Resident 3 was found after the fall, including the resident's position on the floor.During an interview on 6/9/26 at 4 PM, Registered Nurse (RN) 1 stated she worked the AM shift on 1/14/26 and that part of her responsibilities included assisting licensed nurses (LNs) with thorough and complete assessments for residents experiencing a change in condition. RN 1 stated no one notified her of Resident 3's fall on 1/14/26, and she was not asked to assist the LN with a thorough and complete post-fall assessment. RN 1 stated that without a thorough and complete post-fall assessment, injuries, pain, and changes in a resident's condition may not be identified.Review of the facility's JOB DESCRIPTION Registered Nurse [RN] - SNF [Skilled Nursing Facility] or Sub-acute DEPARTMENT: Nursing, revised on 3/1/14, indicated, .Assist the Charge Nurse as required which includes but is not limited to assessment of residents on change of condition.Review of the facility's undated procedure titled NEURO CHECK [assesses mental status, reflexes, and movements to check nervous system function] PROTOCOL, indicated, .NEURO CHECKS TO BE DONE ON ALL RESIDENTS WHO HAVE UNWITNESSED FALLS.NEURO CHECKS TO BE DONE FOR 72 HOURS.NEURO CHECKS SHOULD BE DONE AS FOLLOWS.Q [every] 15 MINUTES X [times] 4.Q 30 MINUTES X 2.Q 1 HOUR X 2.Q 2 HOURS X 2.THEN Q SHIFT FOR THE REMAINDER.Review of Resident 3's .Neuro Checks, from 1/14/26 through 1/16/26, indicated that neuro checks were not completed on 1/14/26 at 1:55 PM, 1/14/26 at 2:25 PM, 1/14/26 at 2:55 PM, 1/14/26 at 3:25 PM, 1/14/26 at 4:25 PM, 1/14/26 at 5:25 PM and required Q shift neuro checks on 1/15/26 and 1/16/26 were not completed. Review of neuro checks dated 1/14/26 at 7:33 PM indicated inconsistent documentation, as the pain evaluation was marked No for verbal expression of pain, grimacing, withdrawal, and non-verbal signs of pain while the pain score was documented as 10.Review of Resident 3's progress notes from 1/14/26 at 2:01 PM through 1/17/26 at 5:10 PM indicated there was no Interdisciplinary Team (IDT - a group of healthcare professionals from different disciplines who collaborate to provide resident care) documentation following the fall to identify possible causes of Resident 3's fall on 1/14/26 and implement appropriate interventions to address Resident 3's pain and comfort needs.During a concurrent interview and record review on 6/9/26 at 4:15 PM with the hospice nurse (HN), Resident 3's hospice physician orders dated 1/19/26 were reviewed and indicated morphine sulfate (strong pain medication) 100 milligrams/5 milliliters (mg/mL - unit of measure) 0.25 mL for mild pain or shortness of breath (SOB), 0.5 mL for moderate pain or SOB, or 1 mL for severe pain or SOB was increased from every 4 hours as needed to every 2 hours as needed. Resident 3's order for Oxycodone hydrochloride (strong pain medication) 10 milligrams/tablet was increased from every 8 hours to every 6 hours. The HN stated the facility contacted hospice on 1/19/26 because Resident 3 was screaming in pain, and pain medications were increased by hospice during the visit.Review of Resident 3's SBAR Communication Form (a communication tool used to communicate a resident's condition to the provider using Situation, Background, Assessment, and Recommendation), dated 1/14/26 ,at 1:30 PM, indicated Resident 3 had a fall and was found on the floor near the bed. Resident 3's SBAR did not reflect that a comprehensive physical assessment was completed, as the areas for behavioral, respiratory, cardiovascular, abdominal, genitourinary (GU/urine), skin, pain, and neurological assessments were all marked Not clinically applicable to the change in condition being reported.During an interview on 6/10/26 at 10:45 AM, the Medical Director (MD) stated nursing staff were expected to conduct complete assessments for residents following a fall, including an assessment and description of pain, in order to identify potential injuries or changes in condition. The MD further stated that delayed fractures may occur following a fall and that a bone deformity caused by a fracture would be expected to be noticeable by the second or third day following a fall.Review of Resident 3's progress notes dated 1/21/26, at 11:36 AM, indicated that during the provider's visit with Resident 3, the provider observed a deformity of Resident 3's right hip and documented concern for a possible fracture or dislocation (an injury in which a bone is forced out of its normal position in a joint).Review of Resident 3's right hip x-ray (an imaging test that uses radiation to create pictures of bones and identify fractures or other abnormalities), dated 1/21/26, at 3:59 PM, indicated Resident 3 had an acute intertrochanteric hip fracture (a break in the upper portion of the thigh bone near the hip joint) with moderate displacement (movement of the broken bone fragments out of normal alignment), which was identified seven days after the fall.During a concurrent interview and record review on 6/11/26, at 2:03 PM ,with the Director of Nursing (DON), Resident 3's weekly nursing summary and neuro checks were reviewed for the month of January, 2026. Resident 3's weekly summary showed that Resident 3 did not have a weekly summary from 1/14/26 through 1/21/26. The DON stated Resident 3's weekly summary was due on 1/19/26 and was not completed by nursing. Resident 3's neuro checks were also reviewed with the DON. The DON stated that Resident 3 had missing neuro checks that were not completed within the required timeframes. The DON further stated that failure to complete weekly summaries and neuro checks could result in missed critical information regarding changes in condition. The DON acknowledged that Resident 3's Post Fall Evaluation dated 1/14/26 at 2:11 PM did not reflect that a complete and thorough assessment was completed following the fall on 1/14/26 and that failure to perform a thorough post-fall assessment could result in missed or delayed identification of injuries and delayed implementation of appropriate interventions.Review of the facility's policy and procedure (P&P) titled Comprehensive Assessments, revised 3/22, the P&P indicated, .Comprehensive assessments are conducted and coordinated by a registered nurse.Review of the facility's P&P titled Resident Examination and Assessment, revised 2/14, the P&P indicated, .The following information should be recorded in the resident's medical record.All assessment data obtained during the procedure.Review of the facility's P&P titled Falls - Clinical Protocol, revised 3/18, the P&P indicated, .the nurse shall assess and document/report the following.Musculoskeletal function, observing for change in normal range of motion.Neurological status.Pain.Precipitating factors, details on how fall occurred.All current medications, especially those associated with dizziness or lethargy, and.All active diagnoses.The staff will evaluate and document falls that occur.when and where they happen, any observations of the events.For an individual who has fallen, the staff and practitioner will begin to try to identify possible causes within 24 hours of the fall.The staff will follow up on any fall with associated injury until the resident is stable and delayed complications such as late fractures have been ruled out.Delayed complications such as late fractures may occur hours or days after a fall.

Based on interview and record review, the facility failed to ensure the required licensed nurses' 72-hour progress notes (post-incident monitoring and assessment) for resident-to-resident altercations was completed for all required shifts for two of two residents (Resident 1 and Resident 2) when Resident 2, who had a history of aggression and cognitive impairment, struck Resident 1 on the arm.This failure placed Resident 1 and Resident 2 at risk for emotional distress, delayed identification of injuries and changes in condition, and increased the risk for additional resident-to-resident altercations within the facility.Findings:Review of Resident 1's admission RECORD indicated Resident 1 was admitted to the facility with diagnoses including mood disorder (condition that affects emotions and mood), epilepsy, history of falling, depression, anxiety disorder, muscle weakness, need for assistance with personal care, and difficulty in walking.Review of Resident 1's [Facility Name] Progress Notes., dated 12/31/25 at 10:34 AM indicated that on 12/24/25 at approximately 10:30 AM, Resident 1 asked Resident 2 about the contents of Resident 2's pink gift box, causing Resident 2 to become upset and strike Resident 1 on the right arm.Review of Resident 1's Minimum Data Set (MDS, an assessment tool) Brief Interview for Mental Status (BIMS - to check a resident's thinking and memory), dated 4/29/26, Resident 2 BIMS score was 14 which showed that Resident 1 had intact cognition (13-15 = Intact, 8-12 = Moderate, 0-7 = Severe).Review of Resident 1's progress notes, in the section titled IDT [Interdisciplinary Team - a group of staff from different departments who work together to plan and review resident care] Review, dated 12/26/25 at 5:45 PM, indicated .IDT Recommendations.Complete 72-hour nursing.monitoring.Review of Resident 2's admission RECORD indicated Resident 2 was admitted to the facility with diagnoses including metabolic encephalopathy (a condition that affects brain function due to a medical illness), altered mental status (changes in thinking), need for assistance with personal care, adjustment disorder with mixed disturbance of emotions and conduct (difficulty coping with stress that affects emotions and behavior), major depressive disorder, and primary insomnia (trouble falling asleep or staying asleep).Review of Resident 2's MDS Brief Interview for Mental Status, dated 4/13/26, Resident 2 BIMS score was 10 which showed that Resident 2 had moderately impaired cognition (13-15 = Intact, 8-12 = Moderate, 0-7 = Severe).Review of Resident 2's Progress Notes, in the section titled IDT Review, dated 12/26/25 at 5:38 PM, indicated, IDT Recommendations.Complete 72-hour nursing. observations.Review of Resident 2's Care Plan, in the section titled Focus, initiated on 1/25/24, indicated, .Resident 2 has periods of delirium [sudden confusion and changes in thinking] manifested by inattention, aggression, threatening behavior toward healthcare staff and other residents, and disorganized thinking. In the section titled Interventions, indicated, .Monitor, record, and report new onset s/sx [signs and symptoms] of delirium, changes in behavior, altered mental status [changes in thinking, awareness, or behavior], wide variation in cognitive function throughout the day, communication decline, disorientation [confusion about person, place, or time], lethargy [unusual drowsiness], restlessness, and agitation.During a concurrent interview and review of the facility's abuse binder on 6/8/26 at 3:17 PM with the Director of Nursing (DON), the abuse binder contained abuse reporting instructions which indicated, .Monitor and document for 72 hours q [every] shift prog [progress] notes on both residents and document if victim feels safe. The DON stated the abuse binder was maintained at the nurse's station to provide nursing staff with clear instructions to follow when an allegation of abuse occurred. The DON stated licensed nurses (LN) were expected to complete 72-hour progress notes following resident-to-resident altercations to monitor for changes in condition and evaluate the effectiveness of interventions. Resident 1's progress notes dated 12/24/25 through 12/27/25 were reviewed with the DON. Resident 1's progress notes indicated required 72-hour progress notes were not completed during the 12/24/25 night shift, 12/25/25 night shift, and 12/26/25 night shift. Resident 2's progress notes dated 12/24/25 through 12/27/25 were also reviewed with the DON. Resident 2's progress notes indicated required 72-hour progress were not completed during the 12/24/25 night shift, 12/25/25 night shift, and 12/26/25 night shift, and12/27/25 AM and night shifts. The DON acknowledged Resident 1, who had diagnoses of mood disorder, depression, and anxiety, was at risk for emotional harm if behavioral changes were not identified due to the missing monitoring. The DON also acknowledged that Resident 2 had care plan interventions for aggression that included monitoring and documenting behavioral changes, and failure to complete the required 72-hour nursing progress notes could result in those interventions not being implemented. The DON stated that failure to complete the required 72-hour nursing progress notes for Residents 1 and Resident 2 could result in changes in condition not being identified and increase the risk for additional resident-to-resident altercations. The DON further acknowledged that failure to complete the required monitoring was not consistent with the facility's requirement to take actions necessary to protect residents following an allegation of abuse. Review of the facility's policy and procedure (P&P) titled Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, revised 9/24, the P&P indicated .Upon receiving any allegations of abuse.the administrator is responsible for determining what actions (if any) are needed for the protection of residents.

Based on interview and record review, the facility failed to ensure a physician-ordered anticonvulsant medication (medication to prevent a seizure [a sudden, uncontrolled surge of electrical activity in the brain]) was implemented and administered as ordered for one of three sampled residents when, Resident 1 returned from the hospital on 4/27/26 with physician instructions to resume medication for a seizure disorder and the nursing staff failed to implement the order, obtain physician order clarification, notify the physician of the medication omission, and administer the medication, resulting in Resident 1 not receiving the ordered anticonvulsant medication for approximately 25 days, from 4/27/26 through 5/21/26.This failure had the potential to result in uncontrolled seizure activity, injury, neurological decline, delated physician intervention, hospitalization, and the need for emergency medical treatment. Findings:A review of Resident 1's admission Record, indicated Resident 1's diagnoses included epilepsy (a condition that causes repeated episodes where a person may shake, stare, or become unaware of their surroundings). A review of Resident 1's Medication Review Report, [includes physician's orders] dated 4/1/26 through 4/26/26 and the Medication Administration Record, (MAR - records used to document medications administered to residents) dated 4/1/26 through 4/30/26, indicated Resident 1 routinely received physician-ordered oxcarbazepine (anti-seizure medication). Physician's orders included: Oxcarbazepine 150 milligram (mg, unit of measurement) - Give 1 tablet by mouth in the afternoon for seizures and 1 tablet at 1 PM (150 mg total at noon [12 PM]). Oxcarbazepine 300 mg - Give 1 tablet by mouth one time a day for seizures (450 mg total at noon). Oxcarbazepine 600 mg - Give 1 tablet by mouth at bedtime for seizures.A review of Resident 1's Inter-Facility Transfer Report (IFT - transfer document containing resident medical information and instructions when moving between healthcare facilities), dated 4/27/26, indicated Resident 1 returned to the facility with instructions to resume home medications, including oxcarbazepine. A review of Resident 1's Medication Review Report, dated 4/27/26 through 5/21/26, and the MAR, dated 4/2026 through 5/2026, indicated oxcarbazepine was not entered into the electronic medical record upon Resident 1's return to the facility on 4/27/26. Further review of the records indicated there was no documented administration of oxcarbazepine from 4/27/26 through 5/21/26.During a concurrent interview and record review on 5/22/26 at 1:44 PM with the Assistant Director of Nursing (ADON), Resident 1's Hospitalist Discharge summary, dated [DATE]; the Medication Review Report, dated 4/27/26 through 5/21/26; and the MAR, dated 4/2026 through 5/2026, were reviewed. The ADON stated she reviewed the hospital discharge orders when Resident 1 returned to the facility on 4/27/26. The ADON stated she did not enter the oxcarbazepine order into the electronic medical record because she wanted clarification regarding the medication order. The ADON stated she contacted the physician regarding the medication order; however, she was unable to provide documentation or other evidence to support physician communication occurred and confirmed the medication order was not entered into the electronic medical record until 5/22/26. The ADON further acknowledged Resident 1 did not receive oxcarbazepine from 4/27/26 through 5/21/26. A review of Resident 1's Progress Notes, dated 4/27/26 through 5/21/26; the Medication Review Report, dated 4/27/26 through 5/21/26; and entire clinical record during that timeframe indicated there was no documentation that the attending physician was notified that Resident 1 had not received the physician-ordered oxcarbazepine. Further review revealed no documentation of physician clarification, medication error reporting, incident reporting, corrective action, investigation, or follow-up regarding the medication omission.During an interview on 5/22/26 at 2:11 PM with the Director of Nursing (DON), the DON stated nursing staff were expected to review and implement physician's orders, obtain physician clarification when questions arose regarding medication orders, notify the physician of significant medication issues, and document physician communication in the resident's medical record.During a concurrent telephone interview and record review on 5/22/26 at 3:34 PM with the Pharmacy Consultant (PC), Resident 1's Medication Review Report, dated 4/27/26 through 5/21/26; the Hospitalist Discharge summary, dated [DATE], and the MAR, dated 4/2026 through 5/2026 were reviewed. The PC verified Resident 1 returned to the facility with physician instructions to continue oxcarbazepine for seizure disorder; however, the medication order was not entered into the electronic medical record until 5/22/26 and the medication was not administered from 4/27/26 through 5/21/26. The PC stated nursing staff should have contacted the attending physician and/or pharmacy for clarification if questions existed regarding the medication order. The PC further stated failure to administer the physician-ordered anticonvulsant medication had the potential to result in seizure activity.A review of the facility policy titled, Adverse Consequences and Medication Errors, revised 2/2023, indicated, .2. Examples of medications errors include: a. Omission - a drug is ordered but not administered; . 6. Promptly notify the provider of any significant error or adverse consequence Review of the facility policy titled, Administering Medications, revised 4/2019, indicated, Medications are administered in a safe and timely manner, and as prescribed . 4. Medications are administered in accordance with prescriber orders, including any required time frame .

Based on observation and interview the facility failed to ensure a clean, comfortable, and home-like environment for a census of 89 when: 1. Room W had peeling paint on the wall behind the trash can, 2. Room X had a shelf across from bed B, where personal items were stored, with a broken front edge with jagged edges, 3. Room Y had peeling paint on the closet doors and adjacent wall, the air vent had black discoloration around the perimeter, an electric outlet cover was pulling away from the wall, the bathroom sink was detached from the wall, an area of the bathroom wall had an approximate 10 inch by 8 inch unpainted area covered with white spackle, 4. Room Z had multiple areas of peeling, flaking paint along the wall behind the head of the bed and, 5. The back hall shower room had peeling plaster behind the shower head; the non-skid tape on the floor was torn and peeling, and the wood on the outside of the door near the handle was splintering. The front hall shower room had dust and debris on the ceiling air vent, the shower curtain had rust stains and the water pipe on the ceiling had rust along the length of it. These failures had the potential to negatively affect the residents' physical and psychosocial well-being. Findings: 1. During a concurrent observation and interview on 5/15/26 at 9:14 AM in room W with Resident 4, the wall behind the trash can was noted with peeling paint along the length of the wall. Resident 4 stated the wall was not pretty to look at. 2. During a concurrent observation and interview on 5/15/26 at 9:21 AM in room X with Resident 5, a broken segment, approximately 6 inches (unit of measurement) long and 1 inch wide, with jagged edges, was observed on the front of a shelf holding personal belongings. Resident 5 stated she had been in the room since September of 2025, and the shelf had been broken since then. 3. During a concurrent observation on 5/15/26 at 9:27 AM in room Y with Resident 6, Resident 6 stated the window in his room was filthy and the wall and closet looked dirty. The resident further stated the room felt dirty and needed to be cleaned and updated. Peeling paint was observed on the closet doors and adjacent wall. The wall vent had a black discoloration around the perimeter. The bathroom sink was pulling away from the wall and an approximate 10 inches by 8 inches area of the wall was unpainted and coated in white spackle. 4. During an observation on 5/15/26 at 10:15 AM in room Z, with Resident 7, the paint was observed peeling and flaking away from the wall behind the head of the bed. Resident 7 stated he did not like the way it looked and he would not have peeling paint in his house. During a concurrent observation and interview on 5/15/26 at 1:07 PM with the Director of Nurses (DON), the DON confirmed the following: -The back hall shower room, behind the shower head, had an area approximately 12 inches long of plaster peeling; the non-skid tape on the floor was torn and peeling, and the wood on the outside of the door near the handle was splintering. -The front hall shower room ceiling vent was observed with dust and debris, the shower curtain had rust stains from the shower hooks and the water pipe on the ceiling had rust along the length of it. -The DON further confirmed Room W, Room X, Room Y and Room Z required upkeep and repairs. The DON confirmed the observed areas did not provide a homelike environment for the residents. During an interview on 5/15/26 at 2:01 PM with the Infection Preventionist (IP), the IP stated the dust and debris around the air vents in the front shower room and room Y, the rust on the pipe and shower curtain in the front shower room, the sink pulling away from the wall in room Y, and the plaster missing around the shower head in the back hall shower room, created a susceptibility for bacterial growth which could lead to the potential for infection to the staff and residents. A review of a facility policy and procedure (P&P) titled, Homelike Environment, revised 2/2021, indicated, .Residents are provided with a safe, clean, comfortable and homelike environment.The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include.clean, sanitary and orderly environment. A review of a facility P&P titled, Policies and Practices-Infection Control, revised 10/2018, indicated, .This facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary and comfortable environment and to help prevent and manage transmission of diseases and infections.The objectives of our infection control policies and practices are to.maintain a safe, sanitary, and comfortable environment for personnel, residents, visitors, and the general public.

Based on interview and record review, the facility failed to notify the resident representative (RR, a person who is responsible for another person's medical and/or financial decisions) for one of three sampled residents (Resident 1) regarding a change in Resident 1's new lab tests (blood test to screen for or diagnose illness) and new medication orders. This failure resulted in Resident 1's RR being uninformed of a change in Resident 1's medical treatment and did not allow the RR to participate in medical care decision making.Findings: A review of Resident 1's admission RECORD, indicated Resident 1 was admitted to the facility with diagnoses which included cognitive communication deficit (impaired communication due to a brain injury). During an interview on 5/15/26 at 10:45 AM with Family Member (FM) 1, FM 1 stated they visited Resident 1 daily and spent several hours of the day in Resident 1's room. FM 1 further stated they received minimal communication from the facility staff. FM 1 stated they were not informed of new lab tests or medication orders for Resident 1. FM 1 further stated they discovered there were new orders when they read the discharge medication list at home after Resident 1 had been discharged from the facility. FM 1 stated they should have been informed of the new medication orders and of any follow up that was needed. During a review of Resident 1's clinical progress notes titled, Nurses Notes, dated 5/7/26 at 5:44 PM, the note indicated, NP [nurse practitioner] reviewed labs and new orders received and placed in [electronic health record]. Levothyroxine [medication used to replace thyroid hormone] .daily.CBC [complete blood count, lab test] in one week, Vitamin D levels [lab test to determine Vitamin D deficiency] in 3 months. During an interview on 5/15/26 at 1:21 PM with the Director of Nurses (DON), the DON stated it was her expectation that Resident 1's RR would have been informed when the new orders were received. The DON further stated the RR needed to know what medications were ordered, how to administer the medications correctly, and what side effects to monitor for. During an interview on 5/15/26 at 1:36 PM with Licensed Nurse (LN) 1, LN 1 stated she received the order for levothyroxine and lab tests on 5/7/26. LN 1 further stated she did not inform the RR because Resident 1 was going home the next day. LN 1 stated she usually informed the RR because they needed to be informed any time there was a new order. A review of a facility policy titled, Change in Resident's Condition or Status, revised 2/2021, indicated, .Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and /or status.Regardless of the resident's current mental or physical condition, a nurse or healthcare provider will inform the resident of any changes in his/her medical care or nursing treatments.

Based on interview and record review, the facility failed to ensure immediate notification was made to the residents physician of a significant x-ray report for one of three sampled residents (Resident 1), when Resident 1 had a STAT (immediate) x-ray completed on 2/8/26 of the left leg that indicated a fracture (break) of the left lower leg as well as osteomyelitis (a severe infection within the bone, causing inflammation (swelling) and destruction of bone tissue) of the left lower leg and left heel. This failure resulted in delayed care and placed Resident 1 at risk for pain, suffering, and medical complications related to the identified injury and infection.Findings:A review of Resident 1's admission RECORD, indicated Resident 1 was admitted to the facility with diagnoses that included but were not limited to hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominate side (severe weakness or completed loss of the ability to move the left side of the body following a right-side brain stroke (blood flow to the brain is blocked), pressure ulcer of the left ankle stage 4 (a severe, deep, and open wound that exposes underlying muscle, tendon, or bone), type 2 diabetes mellitus (a chronic condition where the body cannot properly manage the sugar in the blood, leading to consistently high blood sugar level), peripheral vascular disease (a slow, progressive circulatory condition where blood vessels outside the heart and brain-usually in the legs-become narrowed, blocked, or spasmed), and anemia (a common blood condition where you don't have enough healthy red blood cells or hemoglobin to carry adequate oxygen to your body's tissues).A review of Resident 1's Minimum Data Set (MDS, an assessment tool), dated 1/20/26, the section titled BIMS (Brief Interview for Mental Status, an assessment tool used by facilities to screen and identify the memory, orientation, and judgment status of the resident), had a score of 11 out of 15 total indicating that Resident 1 was moderately cognitively impaired.A review of Resident 1's clinical document titled Nurse's Note, dated 2/8/26 indicated .approx [sic] 1100 [11 AM] writer called by the CNA [Certified Nursing Assistant] staff member to check on resident's L [left] foot. upon [sic] checking writer and supervisor nurse see's the L foot in a twisted position down from the ankle, resident has a stage 4 wound on L foot which was being treated.skin color purple and skin cold to touch.MD [medical doctor] ordered a [sic] x-ray order carried out pending results at the time of writing.A review of Resident 1's physician order dated 2/8/26 indicated that a verbal order was given by Resident 1's physician to a licensed nurse (LN) and was entered in Resident 1's clinical record at 12:34 PM for a STAT x-ray to the left ankle, left foot, and left knee.A review of Resident 1's clinical document titled Radiology [ a medical specialty that uses imaging techniques] Results Report, dated 2/8/26, indicated the results of the x-ray was reported to the facility on 2/8/26 at 10:20 PM. The report indicated that Resident 1 had a fracture and osteomyelitis of the distal (a body part located farther away from the center of the body or the point of attachment to the trunk) lower leg. During a concurrent interview and record review on 3/4/26, at 7:59 AM, with LN 3, Resident 1's clinical document titled Daily Skilled Note, dated 2/8/26 and Resident 1's clinical document titled Nurse's Note, dated 2/9/26 were reviewed. LN 3 confirmed that on 2/8/26 during the handoff report Resident 1's foot injury was communicated and that the x-ray had been taken, but the results were still pending. LN 3 stated that STAT x-ray results are uploaded by the x-ray company automatically in the resident's electronic health record when the results are ready to be reviewed. LN 3 stated that when an x-ray is ordered STAT, it was also faxed to nurses' station 1. LN 3 stated that the LN working at station 1 was informed of the pending results and asked if the nurse would notify LN 3 when the results came in. LN 3 stated that on 2/8/26 at around 8 PM, LN 3 checked in Resident 1's electronic health record and the fax machine at station 1 and did not see any results for the x-ray. LN 3 denied checking again and confirmed that a call to the x-ray providing company to see when the results were going to be ready was not made. LN 3 stated that on 2/9/26 at 1 AM the LN from station 1 brought the x-ray result that had been faxed to LN 3. LN 3 confirmed that Resident 1's physician was notified of the result on 2/9/26 at 1:40 am via text message. LN 3 confirmed that no other attempt to contact the physician regarding the abnormal result was done for the rest of the shift. LN 3 stated that the facility procedure is to report abnormal x-ray results immediately to a resident's physician. LN 3 stated that immediate meant right away and that if the results of the Resident 1's left foot x-ray were ready from review on 2/8/26 at 10:20 PM, that reporting those results to Resident 1's physician on 2/9/26 at 1:40 am did not meet the expectation of immediate reporting. LN 3 stated that Resident 1's physician had not contacted the facility after LN 3 sent the text message with a picture of the results of the x-ray. LN 3 confirmed that no phone call was made by LN 3 to the physician when the physician did not respond to the text message. LN 3 stated the lack of direct confirmation of the receipt of the x-ray results with Resident 1's physician placed Resident 1 at risk for complications from the injury and the acute infection and potentially delayed Resident 1's transfer to the acute hospital.During a concurrent interview and record review on 2/17/26, at 10:22 AM with LN 1, Resident 1's clinical document titled Nurse's Note, dated 2/9/26, was reviewed. LN 1 stated that when he arrived on 2/9/26 for his shift, he received handoff report (process of transferring patient-specific information, authority, and responsibility from one healthcare provider or team to another) from the night shift licensed nurse, that Resident 1's x-ray result had come in, and the physician had not responded to the message. LN 1 stated that after the handoff report process was completed, he spoke to the shift supervisor and was told to contact the Assistant Director of Nurses (ADON). LN 1 stated he called the ADON at approximately 9 AM and was told that the ADON would call Resident 1's physician. LN 1 stated that he never heard back from the ADON but that around 9:45 AM the supervisor informed him that the MD had given an order to transfer Resident 1 to the acute hospital. LN 1 confirmed that Resident 1 left the facility at approximately 10 AM.During a concurrent interview and record review on 2/17/26 at 11:02 AM with LN 2, Resident 1's clinical document titled eINTERACT [a set of dashboards, checklists, and automatic triggers designed to work together to assist care teams in preventing unnecessary resident hospitalizations] SBAR [Situation Background Assessment Recommendation; a communication tool used primarily in healthcare to ensure accurate, efficient, and standardized reporting of resident information] Summary for Provider, dated 2/9/26 was reviewed. LN 2 confirmed that she received a phone call from the ADON, who stated that the MD had been contacted and to send Resident 1 to the acute hospital for further evaluation. LN 2 confirmed that the eINTERACT SBAR Summary for Provider was completed for Resident 1 on 2/9/26 at 9:45 AM after speaking with the ADON.During an interview on 2/17/26 at 11:38 AM, with the ADON, the ADON stated that Resident 1's physician had sent a text message on 2/9/26 at 8:19 AM to the ADON's cell phone instructing the facility to send Resident 1 to the hospital. The ADON stated that right after receiving that message, she contacted LN 2 and informed LN 2 of the physician's order to transfer Resident 1 to the acute hospital.During an interview on 2/17/26 at 12:30 PM, with the Director of Nurses (DON), the DON stated that the LN should have been looking for the STAT X-Ray results to come through to the fax machine and into Resident 1's radiology portal through the electronic health record system. The DON stated that the LN that received the results of the STAT X-Ray should have been an immediate notification to Resident 1's physician and when the physician didn't respond within 30 minutes, the LN should have called again. The DON stated that the LN not calling and speaking to Resident 1's physician delayed the order to transfer Resident 1 to the acute hospital by twelve hours which placed Resident 1 at risk for pain and increased the risk for complications based on the nature of the injury.During a review of the facility's policy and procedure (P&P) titled, Guidelines for Notifying Physician of Clinical Problems, dated 9/19, the P&P indicated, .The charge nurse or supervisor should contact the attending physician if a clinical situation appears to require immediate discussion and management.The practitioner is responsible for:.Responding in a timely manner to calls; especially regarding Immediate Notification problems.Immediate implies that the physician should be notified as soon as possible.these situations include: Sudden in onset OR a marked change.compared to usual (baseline) status.Any lab result for which the physician requests immediate or STAT reporting.During a review of the facility's P&P titled, General Guidelines for Reporting Abnormal Test Results to Physicians, dated 9/17, the P&P indicated that an .X-ray.New or unsuspected finding such as fracture. fell under the Immediate category for reporting to a physician.During a review of the facility's P&P titled, Lab and Diagnostic Test Results - Clinical Protocol, dated 11/18, the P&P indicated that .A nurse will identify the urgency of communicating with the Attending Physician based on physician request, the seriousness of any abnormality.Nursing staff will consider the following factors to help identify situation requiring prompt physician notification.whether the physician has requested to be notified as soon as a result is received.Whether the result should be conveyed to a physician regardless of other circumstances (that is, the abnormal result is problematic regardless of any other factors).Whether the resident/patient's clinical status.has signs and symptoms of acute illness or condition change.Direct voice communication with the physician is the preferred means for presenting any results requiring immediate notification.

Based on staff interviews and clinical record review and facility polity review, the facility failed to ensure that a comprehensive assessment was completed for one of three sampled residents (Resident 1) when, a Licensed Nurse failed to reassess Resident 1's left foot after receiving Resident 1's x-ray results which indicated a left lower leg fracture and acute osteomyelitis of the left heel. This failure placed Resident 1 at risk for experiencing pain, suffering and further medical declines.Findings:A review of Resident 1's admission RECORD, indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included but were not limited to hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominate side (severe weakness or completed loss of the ability to move the left side of the body following a right-side brain stroke (blood flow to the brain is blocked), pressure ulcer of the left ankle stage 4 (a severe, deep, and open wound that exposes underlying muscle, tendon, or bone), type 2 diabetes mellitus (a chronic condition where the body cannot properly manage the sugar in the blood, leading to consistently high blood sugar level), peripheral vascular disease (a slow, progressive circulatory condition where blood vessels outside the heart and brain-usually in the legs-become narrowed, blocked, or spasmed), and anemia (a common blood condition where you don't have enough healthy red blood cells or hemoglobin to carry adequate oxygen to your body's tissues).A review of Resident 1's Minimum Data Set (MDS; an assessment tool) indicated that Resident 1's clinical document titled BIMS (Brief Interview for Mental Status, an assessment tool used by facilities to screen and identify the memory, orientation, and judgment status of the resident), dated 1/20/26, had a score of 11out of 15 total indicating that Resident 1 was moderately cognitively impaired.A review of Resident 1's clinical document titled Nurse's Note, dated 2/8/26 indicated approx [sic] 1100 [11:00 AM] writer called by the CNA [Certified Nursing Assistant] staff member to check on resident's L [left] foot. upon [sic] checking writer and supervisor nurse see's the L foot in a twisted position down from the ankle, resident has a stage 4 wound on L foot which was being treated.skin color purple and skin cold to touch.MD [medical doctor] ordered a [sic] x-ray order carried out pending results at the time of writing.A review of Resident 1's physician order dated 2/8/26 indicated that a verbal order was given to a licensed nurse (LN) by Resident 1's physician and entered in Resident 1's clinical record at 12:34 PM for a STAT (immediately or without delay) X-Ray to the left ankle, left foot, and left knee.A review of Resident 1's clinical document titled Radiology Results Report, dated 2/8/26, indicated the results of the X-Ray was reported to the facility on 2/8/26 at 10:20 PM. The report indicated that Resident 1 had a fracture (break of a bone) and osteomyelitis (a severe infection within the bone, causing inflammation (swelling) and destruction of bone tissue) of the distal (a body part located farther away from the center of the body or the point of attachment to the trunk) lower leg. A review of Resident 1's clinical document titled Nurse's Note, dated 2/9/26 indicated that Resident 1's physician was notified of the results of the X-Ray at 1:40 AM, but did not indicate that Resident 1's foot had been reassessed for changes or that Resident 1 had been assessed for pain, following the initial assessment completed on 2/8/26 at 11 AM.During an interview on 3/4/26 at 7:59 AM with LN 3, LN 3 indicated that LN 1 had reported during the handoff report (process of transferring patient-specific information, authority, and responsibility from one healthcare provider or team to another) that Resident 1's left foot was in an abnormal position and was twisted around. LN 3 indicated that together they went in to look at Resident 1's foot. LN 3 stated that a comprehensive assessment was not completed by her at that time. LN 3 confirmed that the results of the STAT x-ray, taken on 2/8/26, was reported to Resident 1's physician on 2/9/26 at 1:40 AM. LN 3 confirmed that a comprehensive assessment was not completed prior to or after sending the abnormal x-ray result to Resident 1's physician. LN 3 stated that a comprehensive assessment on Resident 1's left leg and foot should have been completed before notifying Resident 1's physician of the abnormal x-ray results so that the physician would have a complete picture of Resident 1's condition. LN 3 stated not completing a comprehensive assessment placed Resident 1 at risk for developing sepsis, pain, and further decline in Resident 1's overall medical condition.During a concurrent interview and record review on 2/13/26, at 2:22 PM, with the Director of Nursing (DON), Resident 1's x-ray result dated 2/8/26 and Resident 1's nurses progress notes dated from 2/8/26 through 2/9/26 were reviewed. The DON stated that the Registered Nurse assigned to Resident 1 during 2/8/26 through 2/9/26 should have completed and documented a comprehensive assessment using the SBAR Communication Form (SBAR stands for Situation, Background, Assessment, and Recommendation. It's a structured communication tool used to convey essential information quickly and clearly) on Resident 1's left leg and foot, and the assessment should have contained a description of how the leg and foot looked, if there was any evidence of circulation in the left leg and foot, if there was any bleeding, necrosis or further twisting of the foot or leg, and if Resident 1's was expressing any pain or discomfort during the assessment process. The DON further stated that the facility does not always have a Registered Nurse scheduled that can complete a full comprehensive assessment of resident's when they have had a significant change of condition.During a review of the facility's policy and procedure (P&P) titled, Change in a Resident's Condition or Status, dated 2/21, the P&P indicated .the nurse will notify the resident's attending physician or physician on call when there has been a(an): discovery of injuries of an unknown source .significant change in the resident's physical/emotional/mental condition.prior to notifying the physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider, including (for example) information prompted by the Interact SBAR Communication Form.During a review of the facility's job description titled, JOB DESCRIPTION Licensed Vocational Nurse (LVN) DEPARTMENT: Nursing, dated 3/1/14, the job description indicated .Under the direct supervision of the RN, assists with the planning, coordination, and provision of individualized resident care in accordance with the established policies and procedures of the facility.complete initial and ongoing assessments by gathering data.During a review of the facility's job description titled, JOB DESCRIPTION Registered Nurse - SNF or Sub-acute DEPARTMENT: Nursing, dated 03/01/14, the job description indicated .the primary function of the Registered Nurse is to insure effective and efficient nursing care is provided as prescribed by the physician and as required by the facility's policies and procedures.Assist the Charge Nurse as required which includes but is not limited to assessment of residents on change of condition.During a review of the facility's job description titled, JOB DESCRIPTION Nursing Supervisor DEPARTMENT: Nursing, dated 11/25, the job description indicated, .The role provides shift-level leadership to ensure safe, effective, and compliant care delivery within the legal scope of LVN practice.the LVN Nursing Supervisor may: Observe residents for changes in condition and initiate required notifications.

Based on observation, interview, and record review, the facility failed to ensure garbage and refuse were properly disposed for a census of 85, when:1. A garbage dumpster lid was not closed; and,2. A trash can in the kitchen did not have a working cover lid on it. These failures had the potential to expose the residents' environment to pests, odors, or diseases.Findings:1. During a concurrent observation and interview on 12/16/25, at 8:57 AM, with the Certified Dietary Manager (CDM) in the outside dumpster area of the facility, a garbage dumpster was observed to have a lid open. The CDM confirmed that the garbage dumpster's lid was open.During an interview on 12/18/25, at 9:53 AM, with the CDM, the CDM stated that the dumpster lid should always be closed when not in use. The CDM further stated that she did not want people getting into the dumpsters. The CDM stated that the risk of cross-contamination would be increased with having the dumpster lids left uncovered.During an interview on 12/18/25, at 1:30 PM, with the Registered Dietician (RD), the RD stated that by not having the dumpster lids closed, pest and other debris issues could arise. The RD further stated that the dumpster lids should have been closed securely after each use and should not have been left open.During a review of the facility's policy and procedure (P&P) titled, MISCELLANEOUS AREAS, dated 2023, the P&P indicated, .Garbage and trash cans must be inspected daily that no debris is on the ground or surrounding area, and that the lids are closed.2. During a concurrent observation and interview on 12/16/25, at 8:56 AM, with the Certified Dietary Manager (CDM) in the kitchen, a trash can was observed without a lid covering. The CDM confirmed that the trash can lid was broken.During an interview on 12/18/25, at 9:53 AM, with the CDM, the CDM stated that that the trash cans should have had working cover lids and be closed. The CDM further stated that the bugs could enter the facility by not having the trash cans closed securely.During an interview on 12/18/25, at 1:30 PM, with the RD, the RD stated that the trash cans in the kitchen should have lids on them. The RD further stated cross-contamination risks would increase by not having a working cover lid on the trash cans. The RD stated that pests could potentially enter the facility if trash cans were not closed properly. The RD stated that a foot-pedal trash can would have been the best choice to use in the kitchen.During a review of the facility's P&P titled, MISCELLANEOUS AREAS, dated 2023, the P&P indicated, .All food waste must be placed in sealed leak-proof, non-absorbent, tightly closed containers (i.e., plastic bags) and shall be disposed of as necessary to prevent a nuisance or unsightliness.Adequate, clean, vermin-proof areas must be provided for storage of garbage and rubbish.The trash collection area is a potential feeding ground for vermin and rodents and must be kept clean.During a review of the facility's P&P titled, SANITATION, dated 2023, the P&P indicated, .Kitchen wastes which are not disposed of by garbage disposal units shall be kept in leakproof, non-absorbent and tightly closed containers and shall be disposed of as necessary to prevent a nuisance or unsightliness.

Based on observation, interview, and record review, the facility failed to ensure pharmacy services were maintained for a census of 85 when:1. Non-narcotic (medications that are not opioids-not addictive) prescription medication destruction records were either not signed and/or co-signed by licensed nurses in 17 out of 24 destruction records reviewed in one of two medication rooms (Med Room Unit 1) observed; and,2. Three unidentified pills were found in a medication cup on top of a storage container beside Resident 40's bed unattended and unsupervised.This failure had the potential for drug diversion (unlawful use of prescription drug by unauthorized individuals) or misuse of prescribed medications due to unsafe disposition practices and Resident 40 not receiving important medication as prescribed.Findings:1. During an interview and record review on 12/18/25, at 9:58 a.m. with Licensed Nurse (LN) 4, the non-narcotic destruction records from 2024 and 2025 titled, Medication Disposition Sheet, dated 7/18/24, 1/2/25, 1/30/25, 3/1/25, 6/18/25, 7/10/25, and 9/26/25 were reviewed. There were 17 out of 24 sheets reviewed that did not have signature of a licensed nurse who disposed the medication and/or a signature of a licensed nurse who witnessed the disposal of the medication. LN 4 confirmed the non-narcotic destruction records reviewed were not signed and/or co-signed by a licensed nurse. LN 4 stated licensed nurses should be signing the destruction sheets and should have 2 signatures. LN 4 stated it was important to have 2 signatures because improper disposition of unused and discontinued prescription medications could increase the risk for drug diversion and/or misuse.During an interview on 12/18/25, at 1:56 p.m. with the Director of Nursing (DON), the DON stated she expected destruction records of non-narcotic prescription drugs should have 2 licensed nurses' signatures because risk for drug diversion and misuse would be increased.During a record review of the facility's policy and procedure (P&P) titled, Disposal of Medications and Medication-Related Supplies Medication Destruction, revised 11/11, the P&P indicated, .Medication destruction occurs only in the presence of at least two licensed healthcare professionals.The licensed healthcare professionals witnessing the destruction ensure that the following information is entered on the [medication disposition form].Signatures of witnesses.2. During a review of Resident 40's clinical record titled, admission RECORD, indicated Resident 40 was admitted to the facility with diagnosis of, but not limited to diabetes mellitus (a chronic condition where the body either doesn't use insulin effectively [insulin resistance] or can't produce enough insulin, leading to high blood sugar [hyperglycemia]), hypotension (low blood pressure [below 90/60 mmHg], occurs when blood pressure is too low to supply vital organs with enough oxygenated blood, causing symptoms like dizziness, fainting, fatigue, nausea, or blurry vision) atrial fibrillation (a common type of irregular heartbeat [arrhythmia] where the heart's upper chambers quiver instead of beating effectively, leading to a rapid, erratic pulse that can feel like fluttering or pounding in the chest, causing fatigue, dizziness, or shortness of breath), and metabolic encephalopathy (a brain dysfunction from a chemical imbalance, often due to liver, kidney, or diabetes issues, causing confusion, memory problems, mood changes, or coma).During a concurrent observation and interview on 12/16/25, at 9:55 AM, with Resident 40, in her room, three unidentified pills were found in a medication cup on top of a storage container beside her bed. Resident 40 stated she did not know how long the medications were in her room or what they were for.During a concurrent observation and interview on 12/16/25, at 10:11 AM, with Certified Nurse Assistant (CNA) 1 and CNA 2, Resident 40's storage area in her room was observed. CNA 1 and CNA 2 both confirmed that three pills were in a medication cup on top of a storage container. CNA 2 stated she was not sure how long the pills had been there.During a concurrent observation and interview on 12/16/25, at 10:15 AM, with LN 2, LN 2 confirmed that three pills were in a medication cup on top of a storage container. LN 2 stated that she was unsure of how the medications were placed on the storage container. LN 2 then proceeded to remove the pills from the room and returned to the medication cart.During an interview on 12/18/25, at 11:59 AM, with the DON, the DON stated that pills should not have been left unattended in a resident's room. The DON further stated that her expectations were for the nurses to watch the residents take the medication prior to leaving the room. The DON stated that other residents could take the medications and that possible allergic reactions or overdoes could occur.During a review of the facility's P&P titled, STORAGE OF MEDICATIONS, revised 08/2014, the P&P indicated, .Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications .Nurses may not transfer medications from one container to another or return partially used medication to the original container.During a review of the facility's P&P titled, MEDICATION ADMINISTRATION-GENERAL GUIDELINES, revised 08/2014, the P&P indicated, .Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so .The facility has sufficient staff and a medication distribution system to ensure safe administration of medications without unnecessary interruptions .The resident is always observed after administration to ensure that the dose was completely ingested.

Based on observation, interview, and record review, the facility failed to provide safe and effective use of medications including administering, storing, and dispensing, of all drugs and biologicals for a census of 85 when:1. A bag for IV (intravenous, into the vein) infusion containing 0.9% normal saline (electrolyte supplement in water) and a vial of ertapenem (antibiotic for infection) one gram (a unit of measurement) connected to the bag had a label indicating DO NOT USE AFTER 12/15/25 was stored in the Med (medication) Room Unit 1 together with other active medications and available for use; and,2. Prescribed medications found in the pharmaceutical waste container (where unused and/or discontinued prescribed medications were held for ultimate safe disposal) in Med Room Unit 1 were not disposed of properly when bottles, insulin pens, pills, solutions were still recognizable and retrievable by hand.These failures had the potential for medication errors due to inadvertent administration of an expired medication, or misuse of prescribed medications due to unsafe disposition practices.Findings: 1. During an concurrent observation and interview, in the medication room on Unit 1, on 12/18/25, at 9:58 a.m., with Licensed Nurse (LN) 3, a bag for IV infusion containing 0.9% normal saline and a vial of ertapenem one gram connected to the IV bag had a label indicating DO NOT USE AFTER 12/15/25 was found stored together with other active medications and available for use. LN 3 confirmed the date on the label was beyond the use date and the IV bag with the antibiotic should have been removed from the active medications in the medication room and should have been placed in a separate area for destruction. LN 3 stated the medication was expired and should not be used after 12/15/25. LN 3 further stated the medication should have been removed from the medication room. During an interview on 12/18/25, at 1:56 p.m., with the Director of Nursing (DON), the DON stated she expected as a standard of care to remove and destroy expired medications in a timely manner. The DON further stated the expired medications if stored with other active medications could potentially be administered to a resident. The DON stated that administering an expired medication could have adverse effects (undesirable outcome) on the resident. During a review of the facility's policy and procedure titled, Medication Storage in the Facility Storage of Medications, revised November 2011, indicated, .All expired medications will be removed from the active supply and destroyed in the facility, regardless of amount remaining. The medication will be destroyed in the usual manner . 2. During an concurrent observation and interview, in the medication room on Unit 1, on 12/18/25, at 9:58 a.m., with LN 3, prescribed medications found in the pharmaceutical waste container were not disposed of properly when bottles, insulin pens, pills, and solutions were still recognizable and retrievable by hand. LN 3 confirmed the medications in the waste container were still recognizable. LN 3 stated the medications discarded in the waste containers should have been mixed to make it unretrievable. During an interview on 12/18/25, at 1:56 p.m., with the DON, the DON explained the pharmaceutical waste containers should have an absorption pads, charcoal packets, and/or coffee grounds that would bind with the discarded medications to make it unrecognizable and unretrievable to prevent diversion and misuse of medications. The DON stated the liquid medications should have been poured out and it was not a standard of practice to throw medications in the pharmaceutical waste containers that were still whole and recognizable. During a review of the facility's policy and procedure titled, Disposal of Medications and Medication-Related Supplies Medication Destruction, revised November 2011, indicated, .Remove medication from their original containers.Mix drugs with an undesirable substance, such as cat litter or used coffee grounds.Put the mixture into a disposable container with lid, such as a 5-gallon bucket.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety when:1. A microwave was placed in the kitchen,2. A bun toaster was dirty with black residue,3. The kitchen walls were chipped and had cracking paint,4. Multiple pots, pan, and other cooking items were flaky and had black residue buildup,5. The stove top and drip pan were dirty and had grease buildup,6. The walk-in refrigerator and freezer had ice buildup; and,7. Vents and fans were dirty in the food prep area.These failures had the potential of leading to food borne illness (an illness that comes from eating contaminated food) for the 81 residents eating facility prepared meals.Findings:1. During a concurrent observation and interview on 12/16/25, at 8:53 AM, with the Certified Dietary Manager (CDM), in the kitchen, a microwave was observed placed next to the stove top range oven. The CDM confirmed that there was a microwave in the kitchen.During an interview on 12/18/25, at 9:53 AM, with the CDM, the CDM stated that the microwave should not have been in the kitchen.During an interview on 12/18/25, at 1:30 PM, with the Registered Dietician (RD), the RD stated there should not have been a microwave in the kitchen. The RD further stated that if the staff were to use the microwave, certain food items would not reach the proper cooking temperatures. The RD stated that she did not think the staff were checking the temperatures on all food items being prepared in the kitchen. The RD further stated that there would be a cross-contamination risk by having a microwave in the kitchen.2. During a concurrent observation and interview on 12/16/25, at 8:53 AM, with the CDM, in the kitchen, a bun toaster was observed having black residue, food crumbs, and other debris. The CDM confirmed that the bun toaster was dirty.During an interview on 12/18/25, at 9:53 AM, with the CDM, the CDM stated that she was unable to get the black residue and debris off of the bun toaster. The CDM further stated that the facility may need to get rid of the current bun toaster and potentially get a new one. The CDM stated that the debris and residue could get on the bread and other food items.During an interview on 12/18/25, at 1:30 PM, with the RD, the RD stated that the bun toaster should not have been dirty. The RD further stated that the bun toaster should have been cleaned routinely. The RD stated that the bun toaster should have been on a cleaning schedule.During a review of the facility's policy and procedure (P&P) titled, ELECTRICAL FOOD MACHINES, dated 2023, the P&P indicated, .Keep and maintain all food machines in good operating, sanitary condition. This includes mixers, grinders, slicers, and toasters.Clean daily.Remove crumbs from the crumb tray daily and wipe the toaster case with a soft, clamp cloth. If the case is greasy, use a non-abrasive cleaning compound to clean it .3. During a concurrent observation and interview on 12/17/25, at 11:45 AM, with the CDM, in the kitchen, the kitchen walls were noted to have been chipped and had cracking paint. The CDM confirmed that the kitchen walls were chipped and had faded paint. The CDM stated that removing the microwave from the kitchen allowed for better visuals of the kitchen walls. The CDM further stated she had not noticed how the walls were discolored and had fading paint issues.During an interview on 12/18/25, at 9:53 AM, with the CDM, the CDM stated that the kitchen walls should be as smooth as possible and not have any holes or missing parts.During an interview on 12/18/25, at 1:30 PM, with the RD, the RD stated that having chipped paint and scraped walls posed a hazard in the kitchen. The RD further stated the kitchen should not have chipped walls.During an interview on 12/19/25, at 9:05 AM ,with the Director of Maintenance (DM), the DM stated that the kitchen walls should have been smooth and not chipped.During a review of the facility's P&P titled, WALLS, CEILINGS, AND LIGHT FIXTURES, dated 2023, the P&P indicated, .Walls and ceilings must be free of chipped and/or peeling paint.It is important to repair peeling paint areas as soon as they appear.4. During a concurrent observation and interview on 12/16/25, at 8:48 AM, with the CDM, in the kitchen, various pots, pans, and other food holding containers were noted to have black residue buildup and dirty edges. The CDM confirmed that multiple pots, pans, and other food holding containers were dirty and damaged due to use.During an interview on 12/18/25, at 9:53 AM, with the CDM, the CDM stated that the pots, pans, and cooking trays should have been clean and not flaky. The CDM further stated that the flakes of the cooking trays could get into the food or be cooked into the food and become dangerous for the residents.During an interview on 12/18/25, at 1:30 PM, with the RD, the RD stated that the cookware should not have been chipped or discolored. The RD further stated that the lining of the cooking utensils could get in the food.During a review of the facility's P&P titled, SANITATION, dated 2023, the P&P indicated, .All utensils, counters, shelves, and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seam, cracks, and chipped areas. Plastic ware, china, and glassware that becomes unsightly, unsanitary, or hazardous because of chips, cracks, or loss of glaze shall be discarded.During a review of the facility's P&P titled, KITCHEN SAFETY, dated 2023, the P&P indicated, .All chipped enamelware should be discarded in favor of stainless steel or other non-chip pots and pans. All chipped or cracked dishes should also be discarded when found.5. During a concurrent observation and interview on 12/16/25, at 8:54 AM, with the CDM, in the kitchen, the stove top and the drip pan had grease, black residue, and other food debris. The CDM confirmed that the stove top and the drip pan were dirty and had grease accumulation.During an interview on 12/18/25, at 9:53 AM, with the CDM, the CDM stated that the drip pan and stove top should have been clean. The CDM further stated that there were years of grease and food buildup. The CDM stated that there was a fire risk with all the grease accumulation. The CDM further stated that food items could be contaminated with the dirty stove top.During an interview on 12/18/25, at 1:30 PM, with the RD, the RD stated that there was a fire risk having grease buildup in the drip pan and stove top. The RD further stated that a specialized cleaning company should have come to the facility to clean the stove top range oven.During a review of the facility's P&P titled, RANGES AND OVENS, dated 2023, the P&P indicated, .Range drip pans must be emptied and washed on a routinely scheduled basis.Grills must be cleaned after each use.Always empty and wash the grease pan after each use.6. During a concurrent observation and interview on 12/16/25, at 8:52 AM, with the CDM, in the kitchen, the walk-in refrigerator and freezer had ice buildup throughout. The CDM confirmed that there was ice buildup on the door frames and hinges between the walk-in refrigerator and freezer. The CDM further confirmed that there were icicles forming under the compressor unit in the freezer. During an interview on 12/18/25, at 9:53 AM, with the CDM, the CDM stated that the ice buildup in the walk-in refrigerator and freezer could contaminate the food that was stored there. The CDM further stated that the door between the walk-in refrigerator and freezer should have been sealing properly and not have ice buildup. The CDM stated that the staff have to constantly clean the water that is leaking from the compressor unit. During an interview on 12/18/25, at 1:30 PM, with the RD, the RD stated that the compressor in the freezer should have been replaced a while back. The RD further stated that cross-contamination could happen with the icicles that were formed over the stored frozen food. The RD stated that the temperatures of the food items could be impacted by not having a properly sealing freezer door. During a review of the facility's P&P titled, REFRIGERATOR AND FREEZER, dated 2023, the P&P indicated, .Maintaining a clean refrigerator and freezer can improve the safety and quality of your foods .Periodically, check door gaskets and replace, if damaged.Clean the evaporator and condensing coils at least twice a year.During a review of the facility's P&P titled, PROCEDURE FOR REFRIGERATED STORAGE, dated 2023, the P&P indicated, .Refrigeration equipment should be routinely cleaned. Refrigerator doors are to close tightly and should be opened as little as possible to prevent storage temperature fluctuations.During a review of the facility's P&P titled, PROCEDURE FOR FREEZER STORAGE, dated 2023, the P&P indicated, .Freezer doors are to close tightly and should be opened as little as possible to prevent storage temperature fluctuations.Food items should be stored on clean surfaces in a manner that protects it from contamination.During a review of the facility's P&P titled, SAFETY AND INFECTION CONTROL, dated 2023, the P&P indicated, .The kitchen will be equipped with safe equipment, which is to be maintained in good working order.7. During a concurrent observation and interview on 12/16/25, at 8:42 AM, with the CDM, in the kitchen, two fans and two vents were dirty, dusty, and had grayish colored debris. The CDM confirmed that the fans and vents in the kitchen were dirty and dusty.During an interview on 12/18/25, at 9:53 AM, with the CDM, the CDM stated that the dust and debris from the fans and vents could end up in the food. The CDM further stated that the maintenance department was responsible for cleaning the fans and vents.During an interview on 12/18/25, at 1:30 PM, with the RD, the RD stated that the fans and the vents should have been clean and maintained on a cleaning or maintenance schedule.During an interview on 12/19/25, at 9:05 AM, with the DM, the DM stated that the kitchen fans and vents should have been cleaned and not dirty.During a review of the facility's P&P titled, HOODS, FILTERS, AND VENTS, dated 2023, the P&P indicated, .Vents must be free of dust and dirt .

Based on observation, interview, and record review, the facility failed to provide and maintain a safe, clean, comfortable, and homelike environment for a census of 85, when:1. Resident 19's overbed headlight remained continuously on because the pull string was broken; and,2. Resident 40, and Resident 7 had chipped walls and cracked paint behind their bed frames.These deficient practices demonstrated a lack of effective systems to identify, report, and correct environmental concerns resulting in Resident 19, Resident 40, and Resident 7 not feeling supported, treated with dignity and comfort, or provided a home-like living environment.Findings: 1. A review of Resident 19's admission RECORD, indicated Resident 19 was admitted to the facility with diagnoses of, but not limited to need for assistance with personal care, and generalized muscle weakness. During an interview on 12/16/25, at 10 AM, in Resident 19's room, with Resident 19, Resident 19 stated that for the past three days, the overbed headlight remained continuously on because the pull string was broken. Resident 19 stated the issue was reported to two certified nursing assistants (CNAs); however, no staff came to the room to assess or repair the light. Resident 19 further stated she had reported the issue to another CNA today and when the CNA checked the maintenance logbook, they found that nothing had been reported. Resident 19 stated she was unable to sleep well at night due to the constant light exposure. Resident 19 further stated that not sleeping well made her feel tired and affected her ability to join activities. During a concurrent observation and interview on 12/16/25, at 10:09 AM, in Resident 19's room, with the Director of Staff Development (DSD), the DSD confirmed Resident 19's overbed headlight was on and the pull string was broken. The DSD stated that staff who noticed problems or received complaints would write them in the maintenance logbook and the Director of Maintenance (DM) would then check and fix the issues, signing off once completed. The DSD further stated Resident 19 could not turn the overbed headlight on and off because the pull string was broken. The DSD stated that the broken pull string prevented Resident 19 from turning the overbed headlight on and off and this issue affected Resident 19's safety and comfort and made it difficult to sleep. During an interview on 12/17/25, at 8:15 AM, in Resident 19's room, with Resident 19, Resident 19 stated she had not been able to sleep well last night because the light was continuously on. Resident 19 stated it was easy to fix the broken pull string, but no one came back yesterday even though the certified nursing assistant (CNA) and the licensed nurse (LN) had reported it in the maintenance logbook. During an interview on 12/18/25, at 12:09 PM, with certified nurse assistant (CNA) 3, CNA 3 stated that on the morning of 12/15/25, Resident 19 told her that the overbed headlight wasn't turning off. Resident 19 stated she had already reported the broken pull string to two other CNAs. CNA 3 stated that she checked the maintenance logbook to see if anyone reported Resident 19's broken pull string and found nothing documented. CNA 3 stated on 12/15/25, she made a report stating that Resident 19's overbed headlight needed to be fixed. During an interview on 12/18/25, at 1:31 PM, with the Medical Record Director (MRD), the MRD stated that when she made her morning rounds with Resident 19, the overbed headlight was still broken. The MRD stated that she checked the maintenance logbook and found that CNA 3 reported it on 12/15/25, and the DSD reported it on 12/16/25. The MRD stated that on 12/17/25, at around 7:30 AM, the MRD saw that the pull string was still not fixed and stated that she added another report to the maintenance logbook. The MRD stated that when Resident 19's overbed headlight was still not fixed, it caused many problems like grumpiness, frustration, poor sleep, discomfort, and tiredness. During a concurrent interview and record review on 12/18/25, at 4:10 PM, with the Assistant Director of Nursing (ADON), the ADON stated that she expected the broken light string over Resident 19's bed to be fixed quickly. The ADON confirmed that the broken pull string for Resident 19's overbed headlight had been reported three times in the maintenance logbook on 12/15/25, 12/16/25, and 12/17/25, with all entries signed off as completed. The ADON stated that documenting the issue as fixed when it wasn't was incorrect and unacceptable. The ADON further stated that failing to fix Resident 19's broken pull string for the overbed headlight in a timely manner affected Resident 19's comfort, health, and safety and potentially harmed Resident 19's trust in the facility, which should not have happened. During an interview on 12/19/25, at 8:12 AM, with the Administrator (ADM), the ADM stated that fixing Resident 19's broken pull string for the overbed headlight was an urgent issue. The ADM further stated he expected the problem to be fixed the same day it was first reported in the maintenance logbook. The ADM stated that issues like the broken pull string in Resident 19's room, which affected Resident 19's health, safety, and well-being, were important and needed immediate attention. Review of a facility's document titled, JOB DESCRIPTION Maintenance Director, revised 3/1/14, indicated, .POSITION: The Maintenance Director is responsible to maintain the facility in good repair at all times .The interior and the exterior surfaces, fixtures and mechanical systems are the responsibility of the Maintenance Director.ESSENTIAL JOB FUNCTIONS.Ensure that all interior fixtures in good repair including.light fixtures.in accordance with established procedures. Review of a facility P&P titled, Homelike Environment, revised 2/21, indicated, .Policy Statement: Residents are provided with a safe, clean, comfortable and homelike environment.Policy Interpretation and Implementation Staff provides person-centered care emphasizes the residents' comfort, independence and personal needs and preferences.The facility staff and management maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include a. clean, sanitary and orderly environment; b. comfortable (minimum glare) yet adequate (suitable to the task) lighting .Comfortable and adequate lighting is provided .to promote a safe, comfortable and homelike environment. The lighting design emphasizes.sufficient general lighting in resident-use areas; task lighting as needed; even light levels.night lighting to promote safety and independence. 2a. During a concurrent observation and interview on 12/16/25, at 9:55 AM, with Resident 40, in her room, the wall behind her bed was observed to be chipped and had cracked paint. Resident 40 stated that she would have already painted the walls in her room if she had the means to do so. Resident 40 further stated that the walls in her room should have been only one color and not multiple colors because of the chips and cracks. During a concurrent observation and interview on 12/16/25, at 10:11 AM, with CNA 1 and CNA 2, the walls in Resident 40's room were observed. CNA 2 stated that she had been working at the facility for two years and the walls in Resident 40's room had always been chipped and had missing paint. During a concurrent observation and interview on 12/18/25, at 11:07 AM, with the DSD, the walls in Resident 40's room were observed. The DSD confirmed that the walls in Resident 40's room had chipped and cracked paint. The DSD stated that the appearance of the walls in Resident 40's room did not feel like a homelike environment. The DSD further stated that the walls should have been smooth and even as possible. During a concurrent observation and interview on 12/19/25, at 9:04 AM, with the DM, the wall in Resident 40's room was observed. The DM confirmed that the paint was chipped and cracking. The DM stated that the walls should have been nice and smooth. During an interview on 12/18/25, at 11:59 AM, with the Director of Nursing (DON), the DON stated that her expectations for the walls in resident rooms were to be reasonably smooth and provide a homely environment. The DON further stated the walls in the affected rooms should have been fixed in a timely manner. 2b. During a concurrent observation and interview on 12/16/25, at 10:41 AM, with Resident 7, in her room, the wall behind her bed was observed to be chipped and had cracked paint. Resident 7 stated that the wall in her room had been scraped for a while. Resident 7 further stated that it would have been nice to have a wall that was fixed and not like it currently was. During a concurrent observation and interview on 12/18/25, at 11:05 AM, with the DSD, the walls in Resident 7's room were observed. The DSD confirmed that the walls in Resident 7's room had chipped and cracked paint. The DSD stated that the appearance of the walls in Resident 7's room did not feel like a homelike environment. The DSD further stated that the walls should have been smooth and even as possible. During a concurrent observation and interview on 12/19/25, at 9:03 AM, with the DM, the wall in Resident 7's room was observed. The DM confirmed that the paint was chipped and cracking. The DM stated that the walls should have been nice and smooth. During a review of the facility's P&P titled, Resident Rights, revised 02/2021, the P&P indicated, .Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to.a dignified existence. During a review of the facility's P&P titled, Homelike Environment, revised 02/2021, the P&P indicated, .Staff provides person-centered care that emphasizes the residents' comfort, independence and personal needs and preferences.The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include.clean, sanitary and orderly environment .inviting colors and décor.personalized furniture and room arrangements.

Based on interview, and record review, the facility failed to ensure the Preadmission Screening and Resident Review (PASARR- a service to ensure that individuals with mental illness are able to receive specialized services) Level II screening was completed for 1 of 24 sampled residents (Resident 6).This failure had the potential for Resident 6 not to receive adequate services to prevent mental health decline.Findings:A review of Resident 6's admission RECORD, indicated Resident 6 was admitted to the facility with a diagnosis of, but not limited to unspecified schizophrenia (a serious, chronic brain disorder that disrupts thinking, feeling, and behavior, making it hard to distinguish reality from imagination, often involving hallucinations [like hearing voices] and delusions [false beliefs]).During a review of Resident 6's clinical record titled, Preadmission Screening and Resident Review (PASRR) Level I Screening, dated 2/25/25, the record indicated, .Result of Level I Screening : Level I - Positive for SMI (Serious Mental Illness).Diagnosis and symptoms of Schizophrenia Disorder.Combative/Abusive Behavior.Grandiose Delusions, Irritability & Anger.The individual has been prescribed psychotropic medications for serious mental illness.Case State : Level II.During a review of Resident 6's clinical record titled, SUBJECT: NOTICE OF PASRR LEVEL I SCREENING RESULTS, dated 2/25/25, the record indicated, .Your Level I Screening indicates that a SMI Level II Mental Health Evaluation is required.Your facility will be contacted within two to four days to set up an appointment for an evaluator to conduct a Level II Mental Health Evaluation.During a review of Resident 6's clinical record titled, SUBJECT: NOTICE OF ATTEMPTED EVALUATION, dated 3/2/25, the record indicated, .UNABLE TO COMPLETE LEVEL II EVALUATION FOR SERIOUS MENTAL ILLNESS (SMI).Facility staff were unresponsive to two or more separate attempts of communication within 48 hours of the Level I Screening.During a concurrent interview and record review on 12/18/25, at 11:19 AM, with the Director of Staff Development (DSD), Resident 6's clinical record was reviewed. The DSD confirmed that Resident 6 had a diagnosis of Schizophrenia, and his Level I screening was positive. The DSD further confirmed that a Level II screening did not occur. The DSD stated that a Level II screening should have taken place for Resident 6 in a reasonable time frame and that he should not have had to wait 10 months to potentially get a screening done. The DSD further stated that all residents should be able to get the help that they need so the facility would know what interventions would be needed to care for them.During an interview on 12/18/25, at 11:59 AM, with the Director of Nursing (DON), the DON explained that the PASSR was a screening tool used mostly to help residents that are dealing with mental health issues. The DON stated that 10 months was too long to wait to conduct a screening and that it should have been done in a timely manner for Resident 6. The DON further stated the level of care that should have been provided for Resident 6 would not be met by being unable to assess the specific needs for him. During a review of the facility policy and procedure (P&P) titled, admission Criteria, revised 3/2019, the P&P indicated, .All new admissions and readmissions are screened for mental disorders (MD), intellectual disabilities (ID) or related disorders (RD) per the Medicaid Pre-admission Screening and Resident Review (PASARR) process. The facility conducts a Level I PASARR screen for all potential admissions, regardless of payer source, to determine if the individual meets the criteria for a MD, TD or RD. If the level I screen indicates that the individual may meet the criteria for a MD, LO, or RD, he or she is referred to the state PASARR representative for the level II (evaluation and determination) screening process.

Based on interview, and record review, the facility failed to develop or revise a comprehensive care plan for 1 of 24 sampled residents (Resident 34) when a care plan (guide that healthcare workers use to ensure a resident receives the best possible care tailored to their individual needs and goals) was not developed for pain.This failure placed Resident 34's physical and emotional well being at risk.Findings:A review of Resident 34's admission RECORD, indicated Resident 1 was admitted to the facility with diagnoses including, but not limited to muscle weakness (generalized), cerebral infarction (a type of stroke where a blood clot blocks a brain artery, cutting off oxygen and nutrients, causing brain cells to die), hemiplegia (one-sided weakness) and hemiparesis (one sided paralysis) following a cerebral infarction affecting right dominant side, aphasia (disorder that affects the ability to communicate).During a review of Resident 34's clinical record titled, Order Summary Report, dated 12/17/2025, indicated Resident 34 was prescribed Tramadol, a prescription pain medication.During a concurrent interview and record review on 12/17/25, at 11:45 a.m., with the Director of Nursing (DON), Resident 34's care plan and pain levels documented from the last 30 days were reviewed. The DON confirmed Resident 34 did not have a care plan in place for pain. The DON stated Resident 34's pain should have been care planned to identify goals, monitor progression, and to evaluate the effectiveness of interventions. The DON further stated not care planning for Resident 34's pain put Resident 34 well being at risk both physically and mentally.During a review of the facility's policy and procedure titled, Pain Assessment and Management, dated 10/2022, the policy and procedure indicated, .defined as the process of alleviating the residents pain based on his or her clinical condition and established treatment goals.Developing and implementing approaches to pain management.Monitoring for the effectiveness of interventions.Modifying approaches as necessary.

Based on interview and record review, the facility failed to ensure that residents received appropriate medical evaluation and treatment for a reported vision concern for 1 out of 24 sampled residents (Resident 65) when Resident 65 was not seen or examined by an ophthalmologist (a medical doctor who specializes in diagnosing and treating all eye diseases).This failure placed Resident 65 at risk for continued visual impairment, functional decline, and psychosocial distress.Findings:A review of Resident 65's admission RECORD, indicated Resident 65 was admitted to the facility with a diagnosis of, but not limited to diabetes mellitus (a condition where the body cannot control blood sugar levels), dry eye syndrome (when your eyes don't make enough good quality tears to stay lubricated leading to a scratchy, burning feeling, redness, and blurry vision), depression (a condition causing persistent sadness and loss of interest), anxiety disorder (a mental condition where you experience excessive, persistent worry, fear or nervousness that doesn't go away and interferes with daily life), need for assistance with personal care, and generalized muscle weakness.During an interview on 12/16/25, at 10:23 AM, in Resident 65's room, with Resident 65, Resident 65 stated that she had seen an optometrist (an eye healthcare provider who performs eye exams and prescribes corrective glasses) earlier in the year. Resident 65 further stated she was diagnosed with cataracts (a clouding of the eye's natural lens) and that wearing glasses did not help much. Resident 65 stated she could see better before coming to the facility, but now her vision was very poor. Resident 65 further stated that watching TV was just like seeing shadows, her vision kept worsening, and she had trouble reading books and moving around her room. Resident 65 stated that both her Medical Doctor (MD) and the optometrist told her she needed to see an ophthalmologist because her vision was getting worse. Resident 65 further stated no one helped her make an appointment and she had not seen an ophthalmologist yet. Resident 65 stated that she loved watching TV, reading books and enjoyed walking outside. Resident 65 further stated that she felt that seeing an ophthalmologist was very important for her and not being able to see one affected her emotionally and physically.During an interview on 12/18/25, at 9:47 AM, with the Activity Director (AD), the AD stated Resident 65 was not completely blind and with the help of a magnifying lens, Resident 65 still enjoyed reading novels and watching TV in her room. The AD confirmed that Resident 65's preference for activities such as reading and watching TV was very important to Resident 65.During a concurrent interview and record review on 12/18/25, at 10:11 AM, with the Minimum Data Set (MDS - clinical assessment tool used in nursing homes) Coordinator, the MDS Coordinator confirmed that on 8/14/24, the MD had ordered a referral for Resident 65 to see an ophthalmologist. The MDS Coordinator stated she did not find any record showing that Resident 65 had been referred to or seen by an ophthalmologist after the doctor made the order. The MDS Coordinator further stated there was no record showing that Resident 65 was informed about the ophthalmologist appointment, refused it, or that the appointment was being scheduled.During a concurrent interview and record review on 12/18/25, at 2:26 PM, with the Social Service Director (SSD), the SSD confirmed that an optometrist had seen and evaluated Resident 65 on 4/25. The SSD stated the optometrist recommended that Resident 65 be seen by an ophthalmologist due to cataracts in both eyes. The SSD further stated that they had informed the Receptionist Clerk (RC) about the optometrist's referral for Resident 65 to see an ophthalmologist and admitted that this referral was not communicated until today (12/18/25). The SSD stated that there was no system in place for managing referrals. The SSD further stated that no follow-up was done when the MD first ordered the ophthalmologist referral on 8/14/24 and when the optometrist recommended an ophthalmologist consult due to Resident 65's cataracts in both eyes on 4/25. The SSD stated that not referring Resident 65 to an ophthalmologist promptly increased the risk of her vision getting worse.During an interview on 12/18/25, at 3:38 PM, with the Receptionist Clerk (RC), the RC stated she was helping with referrals and appointments related to ancillary services. The RC confirmed that she received the communication to refer Resident 65 to an ophthalmologist today (12/18/25).During an interview on 12/18/25, at 3:55 PM, with the Assistant Director of Nursing (ADON), the ADON stated that she expected the MD order and the optometrist's recommendation for Resident 65 to see an ophthalmologist to be addressed immediately to meet Resident 65's care needs. The ADON further stated that Resident 65 was at an increased risk for worsening vision, decreased mobility, higher risk of falls, risk of infection, potential loss of eyesight, and negative impact on her lifestyle. The ADON stated that the delay in referring Resident 65 to an ophthalmologist showed a failure in the facility's process.During an interview on 12/19/25, at 8:04 AM, with the Administrator (ADM), the ADM stated that not sending Resident 65 to an ophthalmologist as ordered by the MD and recommended by the optometrist was unacceptable. The ADM stated that the delay in referring Resident 65 to an ophthalmologist was a clear gap in leadership.Review of a facility policy and procedure (P&P) titled, Visually Impaired Resident, Care of, revised 3/21, indicated, .Policy Interpretation and Implementation.it is our responsibility to assist the resident.scheduling appointments.to obtain needed services.Review of a facility P&P titled, Referrals, Social Services, revised 12/08, indicated, .Policy Statement: Social Services personnel shall coordinate most resident referrals with outside agencies.Policy Interpretation and Implementation.Referrals for medical services must be based on physician evaluation of resident need and a related physician order.Social services will collaborate with the nursing staff or other pertinent disciplines to arrange for services that have been ordered by the physician.Social services will document the referral in the resident's medical record.

Based on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 76) was provided with appropriate care and services with enteral feeding (also referred to as G-Tube feeding, gastrostomy tube feeding, the delivery of food and nutrients through a feeding tube directly into the stomach or part of the intestines) when Resident 76's enteral feeding orders were not carried out as recommended by the Registered Dietitian (RD).This failure had the potential for Resident 76 not to receive adequate enteral nutrition and hydration.Findings:A review of Resident 76's admission RECORD, indicated Resident 76 was admitted to the facility with diagnoses including, but not limited to end stage renal disease (when kidneys are failing and cannot filter waste and extra fluid from the blood anymore), dependence on renal dialysis (medical treatment that acts like artificial kidneys filtering waste products and extra fluid from blood when kidneys can no longer do it), dysphagia (difficulty swallowing foods or liquids), and encounter for attention to gastrostomy (a surgical procedure to create an opening from the outside of the abdomen directly into the stomach, usually to insert a tube (a G-tube) for long-term feeding, medication delivery, or stomach drainage when a person cannot eat or swallow properly).During a review of Resident 76's clinical record titled, Progress Notes, dated 11/25/25, the progress note by the RD indicated, .Stop feeds [sic] from 0600-1200 on dialysis days (MWF) due to dialysis as well as ADL [activities of daily living] care, which is about 20 min [minutes] per shift per day. Recommend stopping feeds if patient will need to be transported for any reasons authorized by SNF [skilled nursing facility]. Please notify RD if feeds stop for non-ADL care or non-dialysis reasons so he may make recommendations to the medical provider on adjusting rate in order for patient to still meet at least 75% of estimated nutritional needs .During an observation on 12/18/25, at 10:01 a.m., in Resident 76's room, Resident 76's enteral feeding was not running.During a concurrent interview and record review on 12/18/25, at 11:15 a.m., with the Assistant Director of Nursing (ADON), Resident 76's order summary was reviewed. The ADON confirmed Resident 76's enteral feed order was missing, and the tube feeding should have been running, today is not a dialysis day for Resident 76. The ADON further stated Resident 76 was at risk of not meeting nutritional needs if the enteral feeding order was not carried out as the RD recommended.During a concurrent observation and interview on 12/18/25, at 11:20 a.m., with the ADON in Resident 76's room, the ADON confirmed Resident 76's enteral feed was not running. The ADON stated it was her expectation for the RD recommendations to be followed.During an interview on 12/18/25, at 1:30 p.m., with the RD, the RD stated Resident 76 was at risk of weight loss, wounds, and dehydration if the RD recommendations were not carried out.During a review of the facility's policy and procedure (P&P) titled, Enteral Nutrition, dated November 2018, the P&P indicated, .Adequate nutritional support through enteral nutrition is provided to residents as ordered.Enteral nutrition is ordered by the provider based on the recommendations of the dietitian.

Based on interview and record review, the facility failed to provide a safe environment for one of three sampled residents (Resident 2), when a blanket was caught in the wheel of a chair used to transport Resident 2 from the shower, causing the chair to stop abruptly and tip forward. This failure resulted in Resident 2's fall on 7/25/24, with a fracture to her left medial malleolus (bony bump on the inner side of the ankle) and left fibula (leg bone between the knee and ankle), increased pain, and decreased mobility, with the potential for skin breakdown and other negative health outcomes. Findings: A review of Resident 2's clinical record, ADMISSION RECORD, indicated Resident 2 was admitted to the facility in 2022 with diagnoses which included bilateral (affecting both sides) osteoarthritis of the knee (disease that causes joint pain and stiffness) and age-related osteoporosis (a condition in which bones become weak and brittle). A review of Resident 2's clinical record, Minimum Data Set [MDS-a resident assessment tool which identifies care needs] dated 6/13/24, indicated, .Section J- Health Conditions .Pain Management .at any time in the last 5 days, has the resident .A. Received a scheduled pain medication regimen? . The documentation indicated, 0 [for No] .B. Received PRN pain medication OR was offered and declined? . The documentation indicated, 0 [for No] .C. Received non- medication intervention for pain? . The documentation indicated, 0 [for No] .Pain Presence .Have you had pain or hurting at any time in the last 5 days? . The documentation indicated, 0 [for No]. A review of Resident 2's clinical record, MDS dated [DATE], in section C, Brief Interview for Mental Status (BIMS) Evaluation, indicated a score of 15, which suggested Resident 2's memory was intact. A review of Resident 2's clinical record, Progress Notes, dated 7/25/24, at 3:35 PM, indicated .resident had a fall on hallway during transport on shower chair to room after shower around 1530 [3:30 PM]. Per CNA [Certified Nurse Assistant] she saw resident going forward and she grabbed her upper body and assisted her to the ground meanwhile her left leg got cough [sic] on the shower chair, another staff member helped to get leg down, writer hear the yelling of resident and assisted resident and assessed, per resident her left knee down to her ankle were in pain, with the assistance of other staff members patient was assisted to her wheelchair and taken to room . A call was made to MD [Medical Doctor] who gave order for stat [urgent] X-ray . A review of Resident 2's clinical record, Progress Notes, dated 7/25/24, at 8:04 PM, indicated, .Post Fall Evaluation .Fall Details: Date/Time of Fall: 07/25/2024 3:15 PM Fall was witnessed .Activity at time of fall: being transported in shower chair [transport chair] Reason for fall was evident. Reason for fall: shower blanket got wrapped in transport chair and caused resident to fall forward .Pain: Vocal complaints of pain .left knee. Pain score 8 [a scale of 0-10 used to measure pain. 7-10 is considered severe] . A review of Resident 2's care plan dated 7/25/24, indicated . [Resident 2] has had an actual fall with serious injury .contributing factors .During transport in shower chair with bath blankets possibly dragging on floor .Monitor/document/report .to MD for s/sx [signs and symptoms] Pain, bruises, Change in mental status, New onset: confusion, sleepiness, inability to maintain posture, agitation . A review of resident 2's clinical record, Progress Notes, dated 7/25/2024, at 9:59 PM, indicated .resident arrived back from [hospital name] . At approximately 2110 [9:10 PM] . Discharge diagnosis closed fracture [fracture where the skin remains intact with no protrusion of bone] of proximal [upper] end of left fibula . sprain of left ankle . Resident arrived to facility with a left knee immobilizer in place as well as an ace bandage [stretchable cloth used to wrap around a sprain to provide gentle pressure and reduce swelling] wrapped around left ankle . Resident stated her pain remains at an 8 . A review of Resident 2's care plan dated 7/26/2024, indicated . [Resident 2] has actual/potential for acute pain r/t [related to] Closed fracture of proximal left fibula .Sprain of left ankle .Residents pain will be alleviated with interventions .Administer . norco [a narcotic pain reliever] .as per orders .give 1/2 hour before treatments or care . A review of Resident 2's care plan dated 7/26/2024, indicated .The resident has potential for impairment to skin integrity of the (left leg) r/t immobilizer use .Monitor left leg skin for any changes . A review of Resident 2's x-ray reports dated 7/29/24, indicated .Subacute [beginning to heal] fracture of the proximal left fibula .Avulsion fracture [occurs when a small chunk of bone attached to a tendon or ligament gets pulled away from the main part of the bone] of the left medial malleolus. The age of the fracture is indeterminate (not clearly known) . During an interview on 7/30/2024, at 11:42 AM, in Resident 2's room, Resident 2 stated at the time of the fall she was being transferred in a shower chair, from the shower room to her bedroom. Resident 2 further stated she had a blanket covering her and the blanket became caught under a wheel which caused the chair to stop abruptly and pitch her forward. Resident 2 stated she landed on her knees and hands. During an interview on 7/30/24, at 2:50 PM, CNA 2 stated at the time of the fall she had been transferring Resident 2 in the shower chair, from the shower room to her bedroom. CNA 2 further stated she had placed bath blankets over the front and the back of Resident 2. CNA 2 stated during transport the chair suddenly tilted forward, and CNA 2 reached out to catch Resident 2 who fell on to her knees. A review of Resident 2's clinical record, Order Listing Report, indicated: .Norco Oral Tablet 5-325 MG [milligrams-a unit of measure] .Give 1 tablet by mouth every 6 hours as needed for pain management .Order Date 7/18/24 DC [discontinued] Date 7/26/2024 . .HYDROcodone [narcotic pain reliever]-Acetaminophen [non-narcotic pain reliever] Tablet [brand name for norco] 5-325 MG .Give 1 tablet by mouth every 6 hours as needed for pain management .Order Date 7/25/24 DC Date 7/26/2024 . .Norco Oral Tablet 5-325 MG .Give 1 tablet by mouth every 6 hours for pain management .Order Date 7/26/24 DC Date 7/29/2024 . .Norco Oral Tablet 5-325 MG Give 1 tablet by mouth every 8 hours .Order Date 7/29/24 .DC Date 7/30/2024 . .tramadol HCL [narcotic pain reliever] Oral Tablet 50 MG Give 1 tablet by mouth every 8 hours as needed for breakthrough pain/moderate pain .Order Date 7/29/2024 . A review of Resident 2's Medication Administration Record (MAR) for July 2024 indicated .MONITOR FOR PAIN 0-3 = MILD 4-6=MODERATE 7-10=SEVERE every shift-Order Date-3/10/2023 . The pain levels were documented as follows: From July 1-18 the MAR indicated pain levels of zero on both AM (day shift) and PM (evening) shift (12-hour shifts) On July 19 the AM shift documented a pain level of 7. From July 19 PM shift- July 23, the MAR indicated levels of zero On July 24 the MAR indicated a level of 8 on the PM shift On July 25 the MAR indicated a level of 8 on PM shift On July 26 the MAR indicated a level of 6 on the AM shift and 4 on the PM shift. On July 27 the MAR indicated a level of 5 on the AM shift and an 8 on the PM shift On July 28 the MAR indicated a level of 6 on the AM shift and a 7 on PM shift On July 29 the MAR indicated a level of 7 on the AM shift and of 8 on the PM shift On July 30 the MAR indicated a level of 8 on the AM shift and 7 on the PM shift. A review of Resident 2's MAR for July 2024, indicated medication administration as follows: 7/25/24 Norco 5-325 mg was administered at 4:10 PM for a pain level of 9. 7/26/24 Norco 5-325 was administered at 12:07 AM for a pain level of 8 and at 6:31 AM for a pain level of 9. 7/26/24 hydrocodone -APAP 5-325 mg was administered at 1:52 PM for a pain level of 9. 7/26/24 Norco 5-325 was administered at 6 PM for a pain level of 9. 7/27/24 Norco 5-325 mg was administered on a routine schedule per a change in physician orders, at 12 AM, 6 AM, 12 PM and 6 PM. All pain levels were recorded as 5. 7/28/24 Norco 5-325 mg was administered on a schedule at 12 AM, 6 AM, 12 PM and 6 PM. Pain levels were recorded as 12 AM = 9, 6 AM = 9, 12 PM = 6, and 6 PM = 7. 7/29/24 Norco 5-325 mg was administered on a schedule at 12 AM, 6 AM, and 12 PM. All pain levels were recorded as 7. 7/29/24 Norco 5-325 mg was administered on a revised schedule at 8 PM. The pain level was recorded as 8. 7/30/24 Norco 5-325 mg was administered on a schedule at 4 AM and 12 PM. Pain levels were recorded at 4 AM as 8 and at 12 PM as 5. During an interview on 7/30/24, at 4:36 PM, the Director of Nurses (DON) confirmed Resident 2's fall and subsequent injuries were due to the bath blanket becoming caught in the wheel of the shower chair. The DON stated it was her expectation that staff would ensure blankets were tucked in and not hanging below the resident's knees when they were transported in shower chairs. During a telephone interview on 8/1/24, at 8:22 AM, the Medical Director (MDir) stated Resident 2's fall was an unfortunate event and could have been prevented. The MDir further stated the fall affected Resident 2's lower extremity mobility and caused her increased pain. The MDir stated the pain medications prescribed were not enough at first. The MDir further stated he had to change Resident 2's pain medication to be given on a schedule. The MDir stated the scheduled medication was not enough and Resident 2 began to experience confusion and due to Resident 2's confusion, he ordered a different pain medication. The MDir stated it still was not enough. Resident 2 was uncomfortable and too confused. The MDir stated Resident 2 was transferred to the hospital on 7/31/24 due to confusion. A review of a facility policy titled, Safety and Supervision for Residents, Revised April 2021, indicated .Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities .The facility-oriented and resident-oriented approaches to safety are used together to implement a systems approach to safety, which considers hazards identified in the environment and individual resident risk factors, and then adjusts interventions accordingly . A review of a facility policy titled Accidents and Incidents-Investigating and Reporting, dated July 2017, indicated .All accidents or incidents involving residents .shall be investigated and reported to the Administrator .supervisor shall promptly initiate and document investigation of the accident or incident .Incident/Accident reports will be reviewed by the Safety Committee for trends related to accident or safety hazards in the facility and to analyze any individual resident vulnerabilities . Based on interview and record review, the facility failed to provide a safe environment for one of three sampled residents (Resident 2) when a blanket was caught in the wheel of a chair used to transport Resident 2 from the shower, causing the chair to stop abruptly and tip forward. This failure resulted in Resident 2's fall on 7/25/24, with a fracture to her left medial malleolus (bony bump on the inner side of the ankle) and left fibula (leg bone between the knee and ankle), increased pain, and decreased mobility, with the potential for skin breakdown and other negative health outcomes. Findings: A review of Resident 2's clinical record, ADMISSION RECORD, indicated Resident 2 was admitted to the facility in 2022 with diagnoses which included bilateral (affecting both sides) osteoarthritis of the knee (disease that causes joint pain and stiffness) and age-related osteoporosis (a condition in which bones become weak and brittle). A review of Resident 2's clinical record, Minimum Data Set [MDS-a resident assessment tool which identifies care needs] dated 6/13/24, indicated, .Section J- Health Conditions .Pain Management .at any time in the last 5 days, has the resident .A. Received a scheduled pain medication regimen? . The documentation indicated, 0 [for No] .B. Received PRN pain medication OR was offered and declined? . The documentation indicated, 0 [for No] .C. Received non- medication intervention for pain? . The documentation indicated, 0 [for No] .Pain Presence .Have you had pain or hurting at any time in the last 5 days? . The documentation indicated, 0 [for No]. A review of Resident 2's clinical record, MDS dated [DATE], in section C, Brief Interview for Mental Status (BIMS) Evaluation, indicated a score of 15, which suggested Resident 2's memory was intact. A review of Resident 2's clinical record, Progress Notes, dated 7/25/24, at 3:35 PM, indicated .resident had a fall on hallway during transport on shower chair to room after shower around 1530 [3:30 PM]. Per CNA [Certified Nurse Assistant] she saw resident going forward and she grabbed her upper body and assisted her to the ground meanwhile her left leg got cough [sic] on the shower chair, another staff member helped to get leg down, writer hear the yelling of resident and assisted resident and assessed, per resident her left knee down to her ankle were in pain, with the assistance of other staff members patient was assisted to her wheelchair and taken to room . A call was made to MD [Medical Doctor] who gave order for stat [urgent] X-ray . A review of Resident 2's clinical record, Progress Notes, dated 7/25/24, at 8:04 PM, indicated, .Post Fall Evaluation .Fall Details: Date/Time of Fall: 07/25/2024 3:15 PM Fall was witnessed .Activity at time of fall: being transported in shower chair [transport chair] Reason for fall was evident. Reason for fall: shower blanket got wrapped in transport chair and caused resident to fall forward .Pain: Vocal complaints of pain .left knee. Pain score 8 [a scale of 0-10 used to measure pain. 7-10 is considered severe] . A review of Resident 2's care plan dated 7/25/24, indicated . [Resident 2] has had an actual fall with serious injury .contributing factors .During transport in shower chair with bath blankets possibly dragging on floor .Monitor/document/report .to MD for s/sx [signs and symptoms] Pain, bruises, Change in mental status, New onset: confusion, sleepiness, inability to maintain posture, agitation . A review of resident 2's clinical record, Progress Notes, dated 7/25/2024, at 9:59 PM, indicated .resident arrived back from [hospital name] . At approximately 2110 [9:10 PM] . Discharge diagnosis closed fracture [fracture where the skin remains intact with no protrusion of bone] of proximal [upper] end of left fibula . sprain of left ankle . Resident arrived to facility with a left knee immobilizer in place as well as an ace bandage [stretchable cloth used to wrap around a sprain to provide gentle pressure and reduce swelling] wrapped around left ankle . Resident stated her pain remains at an 8 . A review of Resident 2's care plan dated 7/26/2024, indicated . [Resident 2] has actual/potential for acute pain r/t [related to] Closed fracture of proximal left fibula .Sprain of left ankle .Residents pain will be alleviated with interventions .Administer . norco [a narcotic pain reliever] .as per orders .give 1/2 hour before treatments or care . A review of Resident 2's care plan dated 7/26/2024, indicated .The resident has potential for impairment to skin integrity of the (left leg) r/t immobilizer use .Monitor left leg skin for any changes . A review of Resident 2's x-ray reports dated 7/29/24, indicated .Subacute fracture of the proximal left fibula .Avulsion fracture [occurs when a small chunk of bone attached to a tendon or ligament gets pulled away from the main part of the bone] of the left medial malleolus [inner ankle]. The age of the fracture is indeterminate (not clearly known) . During an interview on 7/30/2024, at 11:42 AM, in Resident 2's room, Resident 2 stated at the time of the fall she was being transferred in a shower chair, from the shower room to her bedroom. Resident 2 further stated she had a blanket covering her and the blanket became caught under a wheel which caused the chair to stop abruptly and pitch her forward. Resident 2 stated she landed on her knees and hands. During an interview on 7/30/24, at 2:50 PM, CNA 2 stated at the time of the fall she had been transferring Resident 2 in the shower chair, from the shower room to her bedroom. CNA 2 further stated she had placed bath blankets over the front and the back of Resident 2. CNA 2 stated during transport the chair suddenly tilted forward, and CNA 2 reached out to catch Resident 2 who fell on to her knees. A review of Resident 2's clinical record, Order Listing Report, indicated: .Norco Oral Tablet 5-325 MG [milligrams-a unit of measure] .Give 1 tablet by mouth every 6 hours as needed for pain management .Order Date 7/18/24 DC [discontinued] Date 7/26/2024 . .HYDROcodone [narcotic pain reliever]-Acetaminophen [non-narcotic pain reliever] Tablet [brand name for norco] 5-325 MG .Give 1 tablet by mouth every 6 hours as needed for pain management .Order Date 7/25/24 DC Date 7/26/2024 . .Norco Oral Tablet 5-325 MG .Give 1 tablet by mouth every 6 hours for pain management .Order Date 7/26/24 DC Date 7/29/2024 . .Norco Oral Tablet 5-325 MG Give 1 tablet by mouth every 8 hours .Order Date 7/29/24 .DC Date 7/30/2024 . .tramadol HCL [narcotic pain reliever] Oral Tablet 50 MG Give 1 tablet by mouth every 8 hours as needed for breakthrough pain/moderate pain .Order Date 7/29/2024 . A review of Resident 2's Medication Administration Record (MAR) for July 2024 indicated .MONITOR FOR PAIN 0-3 = MILD 4-6=MODERATE 7-10=SEVERE every shift-Order Date-3/10/2023 . The pain levels were documented as follows: From July 1-18 the MAR indicated pain levels of zero on both AM (day shift) and PM (evening) shift (12-hour shifts) On July 19 the AM shift documented a pain level of 7. From July 19 PM shift- July 23, the MAR indicated levels of zero On July 24 the MAR indicated a level of 8 on the PM shift On July 25 the MAR indicated a level of 8 on PM shift On July 26 the MAR indicated a level of 6 on the AM shift and 4 on the PM shift. On July 27 the MAR indicated a level of 5 on the AM shift and an 8 on the PM shift On July 28 the MAR indicated a level of 6 on the AM shift and a 7 on PM shift On July 29 the MAR indicated a level of 7 on the AM shift and of 8 on the PM shift On July 30 the MAR indicated a level of 8 on the AM shift and 7 on the PM shift. A review of Resident 2's MAR for July 2024, indicated medication administration as follows: 7/25/24 Norco 5-325 mg was administered at 4:10 PM for a pain level of 9. 7/26/24 Norco 5-325 was administered at 12:07 AM for a pain level of 8 and at 6:31 AM for a pain level of 9. 7/26/24 hydrocodone -APAP 5-325 mg was administered at 1:52 PM for a pain level of 9. 7/26/24 Norco 5-325 was administered at 6 PM for a pain level of 9. 7/27/24 Norco 5-325 mg was administered on a routine schedule per a change in physician orders, at 12 AM, 6 AM, 12 PM and 6 PM. All pain levels were recorded as 5. 7/28/24 Norco 5-325 mg was administered on a schedule at 12 AM, 6 AM, 12 PM and 6 PM. Pain levels were recorded as 12 AM = 9, 6 AM = 9, 12 PM = 6, and 6 PM = 7. 7/29/24 Norco 5-325 mg was administered on a schedule at 12 AM, 6 AM, and 12 PM. All pain levels were recorded as 7. 7/29/24 Norco 5-325 mg was administered on a revised schedule at 8 PM. The pain level was recorded as 8. 7/30/24 Norco 5-325 mg was administered on a schedule at 4 AM and 12 PM. Pain levels were recorded at 4 AM as 8 and at 12 PM as 5. During an interview on 7/30/24, at 4:36 PM, the Director of Nurses (DON) confirmed Resident 2's fall and subsequent injuries were due to the bath blanket becoming caught in the wheel of the shower chair. The DON stated it was her expectation that staff would ensure blankets were tucked in and not hanging below the resident's knees when they were transported in shower chairs. During a telephone interview on 8/1/24, at 8:22 AM, the Medical Director (MDir) stated Resident 2's fall was an unfortunate event and could have been prevented. The MDir further stated the fall affected Resident 2's lower extremity mobility and caused her increased pain. The MDir stated the pain medications prescribed were not enough at first. The MDir further stated he had to change Resident 2's pain medication to be given on a schedule. The MDir stated the scheduled medication was not enough and Resident 2 began to experience confusion and due to Resident 2's confusion, he ordered a different pain medication. The MDir stated it still was not enough. Resident 2 was uncomfortable and too confused. The MDir stated Resident 2 was transferred to the hospital on 7/31/24 due to confusion. A review of a facility policy titled, Safety and Supervision for Residents, Revised April 2021, indicated .Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities .The facility-oriented and resident-oriented approaches to safety are used together to implement a systems approach to safety, which considers hazards identified in the environment and individual resident risk factors, and then adjusts interventions accordingly .