Every finding on record at Rockdale Healthcare Center

Based on observations, record review,staff interviews and a review of the facility policy title Accident and Incident Prevention, Reporting, and Response and Care Plan-Comprehensive, the facility failed to ensure that appropriate care plan interventions were developed and implemented to meet the needs of two of three residents care plan reviewed. Specifically, the facility failed to develop post fall interventions for one Resident (R1) following three separate falls. In addition, the facility failed to implement and establish care plan interventions for Activities of Daily Living (ADL) for R3.Review of the policy titled Accident and Incident Prevention, Reporting, and Response, dated 05/2026. Purpose: To ensure a safe environment for all residents by implementing a proactive and systematic approach to preventing accidents and incidents in accordance with federal regulations, facility policies, and resident-centered care principles. D. Corrective Actions and Prevention: Develop and implement interventions based on the investigation findings. Revise the resident's care plan as needed to reflect new interventions.Review of the policy titled Care Plan-Comprehensive, dated 9/2025. Policy: A Comprehensive Care Plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs shall be developed for each resident. Policy Interpretation and Implementation: Care plans are revised as changes in the resident's condition dictate.Review of R1's Electronic Medical Record (EMR) revealed an admission date of 07/07/2025 with diagnoses of but not limited to lumbar compression fracture, left fracture of the distal femur.Review of the resident's most recent Minimum Data Set (MDS) quarterly/Medicare 5-day assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) was assessed as three which indicated severe cognitive impairment. Section GG Functional Abilities assessed the resident as dependent on staff for transfer. Section J resident assessed as a fall with a fracture.Review of the Risk Assessment Reports provided to the surveyor revealed R1 had an unwitnessed fall with no injury on 04/20/2026.Review of the Risk Assessment Reports provided to the surveyor revealed R1 had an unwitnessed fall with no injury on 05/17/2026.Review of the Risk Assessment Reports provided to the surveyor revealed R1 had an unwitnessed fall with no injury on 05/21/2026.Review of the care plan initiated 06/1/2021 revealed that R1 is at risk for falls. Further review of the care plan revealed no documented updated interventions implemented for the fall on 04/20/2026, 05/17/2026, or 05/21/2026.Review of R3's EMR revealed an admission with diagnoses, of but not limited to, need assistance with personal care and osteoarthritis.Review of the resident's most recent MDS quarterly assessment dated [DATE] revealed a BIMS was assessed as eight which indicated moderately impaired. Section GG Functional Abilities assessed the resident as staff does more than half of personal hygiene.Review of the care plan initiated 06/1/2021 revealed that R3 has an ADL self-care performance deficit. With an intervention one staff participation with bathing and dressing.An interview on 06/16/2026 at 11:51 AM with the family of R3, the family stated they had voiced formal concerns to the facility management on two separate occasions regarding R3 requiring more assistance with ADLs. The family stated that on two separate occasions during a visit they discovered R3 left unattended with a basin of water sitting in front of her and unclothed. The family stated water had spilled on the floor. The family expressed concerns regarding the residents' safety knowing that leaving the R3 unsupervised and unclothed with spilled water on the floor could create a slip and fall hazard.An interview on 06/17/2026 at 9:00 AM with the Unit Manager (UM) BB, stated it is her responsibility to make rounds to ensure that the residents are receiving ADLs per the plan of care.An interview on 06/17/2026 at 2:13 PM with the MDS-Coordinator CC stated, all resident falls are discussed in the morning clinical management meeting. She stated during the meeting interventions are discussed and the care plan is updated. The MDS-Coordinator confirmed that no new interventions were implemented for R1 for the fall on 04/20/2026, 05/17/2026, and 05/20/2026.An interview on 06/17/2026 at 2:52 PM with the Administrator revealed he is part of the clinical management meeting. He stated all resident falls are discussed during the meeting. He stated interventions are discussed and the care plan is updated in real time. The Administrator stated that he oversees the clinical management meeting and ensures that the care plans are updated. The Administrator did not answer when asked what happened to updating R1's care plan for three falls.Refer to F-Tag 677 and 689

Based on observation, interviews, record review, including a review of the Certified Medication Aide job description, the facility failed to ensure that professional standards of practice were maintained with one of three sampled Resident (R) (R2) during a scheduled medication pass. Specifically, the Certified Medication Aide (CMA) DD failed to maintain direct visual observation during the medication administration process, resulting in the resident being discovered holding a white pill that was actively dissolving in their hand. Findings include: A review of the Certified Medication Aide job description revealed: observe and verify that medication is ingested as directed. Review of R2's Electronic Medical Record (EMR) revealed an admission date of 4/29/2026 with diagnoses of but not limited to Alzheimer's Disease and type 2 diabetes mellitus without complications. Review of the resident's most recent Minimum Data Set (MDS) admission assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) assessed as eleven which indicated moderately impaired. Section N medication assessed the resident as taking anticoagulant, antipsychotic, and diuretic. Review of the resident's Order Summary Report revealed the current active physician orders for the following scheduled medications: Acetaminophen ordered for pain; Allopurinol ordered for the diagnosis of gout; Atorvastatin Calcium ordered for the diagnosis of hyperlipidemia; Carvedilol ordered for the diagnosis of hypertension; Eliquis ordered as an anticoagulant/blood thinner; Lasix ordered for edema; Multaq ordered for the diagnosis of arterial fibrillation; Rexulti ordered for the diagnosis of major depression disorder; and Trazodone ordered for the diagnosis of insomnia. An observation on 6/16/2026 at 10:16 am R2 was observed holding a white pill in her hand that was actively dissolving. An interview on 6/16/2026 at 10:18 am with CMA DD stated she administered R2's morning medications. The CMA stated R2 was given Acetaminophen, Allopurinol, Carvedilol, and Eliquis. The CMA stated the resident swallowed all the medications that were given. An observation on 6/16/2026 at 10:20 am of the residents' medication bubble packs was conducted alongside the CMA. The observation revealed three of the four administered morning medications (Acetaminophen, Allopurinol, Carvedilol, and Eliquis) were round white tablets. An interview on 6/17/2026 at 9:00 am with the Unit Manager (UM) BB stated the CMAs are educated on medication administration upon hire and annually thereafter. She stated the Staff Development Coordinator is responsible for the CMAs training and daily oversight. She stated the CMAs are educated not to leave medication at the residents' bedside and remain with the residents until all medications are fully consumed. The UM stated the physician was notified of R2 holding dissolved pills in her hand. She stated the physician ordered a speech therapy evaluation to ensure that the resident was not experiencing any underlined swallowing difficulties. The UM stated the resident's comprehensive care plan was also updated to reflect the incident and interventions were implemented to ensure safe medication administration moving forward. Done VRQ

Based on observations, resident, family and staff interviews, record review and a review of the facility's policy titled Accommodation Of Needs the facility failed to provide activities of daily living (ADL) for one resident (R) (R3) out of three dependent on staff for care.Findings include:Review of the policy titled Accommodation Of Needs, dated 12/2025. Policy: Our facility's environment and staff behaviors are directed toward assisting the resident in maintaining and/or achieving safe independent functioning, dignity and well-being. Procedure: 1. The resident's individual needs and preferences are accommodated to the extent possible. In order to accommodate individual needs and preferences, staff attitudes and behaviors are directed towards assisting the residents in accordance with the residents' wishes. B. Arranging toiletries and personal items so that they are in easy reach of the resident.Review of the document titled Grievance/Complaint Form dated 04/15/2026 revealed the family of R3 filed a grievance regarding their mom (R3) who was found sitting on the side of the bed with the gown on the floor with a basin of water on the table. The Family expressed that they were concerned that the resident may fall.Review of the document titled Grievance/Complaint Form dated 04/30/2026 revealed the family of R3 filed a grievance regarding their mom (R3) not receiving care and found sitting in a chair undressed with a basin of water sitting on the table.Review of R3's Electronic Medical Record (EMR) revealed an admission with diagnoses, of but not limited to, need assistance with personal care and osteoarthritis.Review of the resident's most recent Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) was assessed as eight which indicated moderately impaired. Section GG Functional Abilities assessed the resident as staff does more than half of personal hygiene.Review of the care plan initiated 06/1/2021 revealed that R3 has an ADL self-care performance deficit with an intervention of one staff participation with bathing and dressing.An observation on 06/16/2026 at 10:44 AM of R3 sitting on the side of the bed dressed in a gown trying to put on shoes. Further observation of the overbed table located at the foot of the bed with a basin of clear water. The resident's wheelchair was out of the residents reach in front of the nightstand.An interview on 06/16/2026 at 10:30 AM with Certified Nursing Assistant (CNA), CNA AA stated R3 is independent with ADLs. The CNA stated she provides the resident with a basin and water and the resident can complete her ADLs and dress herself.An interview on 06/16/2026 at 10:45 AM with R3, she stated on most days the staff will place a basin of water on the overbed table and leave the room and do not return. She stated she does use soap and deodorant but in order to reach the supplies she would have to stand and move the wheelchair that was blocking the nightstand where the supplies are located. The resident stated because she has had two falls she is afraid to try to get up and move the wheelchair. The resident stated she is able to wash her face and underarms. She stated she needs assistance with her back and legs and putting on her clothes. The resident stated she would like assistance with her bath and putting her clothes on.An interview on 06/17/2026 at 9:00 AM with the Unit Manager (UM) BB, she stated the staff are educated in-house and the online training system on ADL care. The Unit Manager stated R3 can partially complete her ADLs. The UM stated she expect staff to stand by when providing R3 with supplies for ADLs and assist the resident.

Based on record review, interviews, and the facility policy titled Accident and Incident Prevention, Reporting, and Response, the facility failed to ensure that an environment free from accident hazards was maintained, and failed to provide adequate supervision and sufficient individualized interventions to prevent accidents for one Resident (R) (R1) who was identified as a high risk for falls and a history of recurrent falls. Specifically, the facility failed to develop and implement effective post-fall safety interventions following three separate falls sustained by R1 resulting in a major injury including a lumbar two (L2) compression fracture and a left distal femur fracture.Findings include: Review of the policy titled Accident and Incident Prevention, Reporting, and Response, dated 05/2026. Purpose: To ensure a safe environment for all residents by minimizing accident hazards, providing adequate supervision and assistive devices, and implementing a proactive and systematic approach to preventing, investigating, and mitigating accidents and incidents in accordance with federal regulations, facility policies, and resident-centered care principles. The facility is committed to: Promptly identifying, reporting, documenting, investigating, and mitigating all incidents or accidents involving residents. An observation on 06/17/2026 at 10:00 AM R1 was observed neatly dressed in street clothes independently propelling herself down the hallway in a wheelchair. When approached by the surveyor and asked where she was traveling the resident presented with a pleasant demeanor and clearly stated that she was looking for a facility activity to attend. Review of R1's Electronic Medical Record (EMR) revealed an admission with diagnoses,of but not limited to, lumbar (L2) compression fracture, left fracture of the distal femur. Review of the resident's most recent Minimum Data Set (MDS) quarterly/Medicare 5-day assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) was assessed as three which indicated severe cognitive impairment. Section GG Functional Abilities assessed the resident as dependent on staff for transfer and to put on/take off. Section J resident assessed as a fall with a fracture. Review of the care plan updated on 03/12/2026 revealed that R1 is at risk for falls. With an intervention ensure non-skid footwear in place and provide toileting. On 06/16/2026 R1's care plan was updated with an intervention to provide activities that promote exercise and strength building where possible. Review of R1's Fall Risk Assessment revealed: 1/24/26 Complete 13.03/11/26 Complete 17.0 4/20/26 Complete 20.0 5/18/26 Full Assessment 17.0A score of 10 or more, the resident should be considered at high risk for potential falls. Review of the Risk Assessment Reports provided to the surveyor revealed R1 had an unwitnessed fall with no injury on 04/20/2026. The resident heard calling out for help from her room. The resident was noted in seated position on the floor at bedside. Bed rails in position and bed in lowest position. Resident calling out for help stating, I feel like I'm ice skating. Regular socks were on both feet. Resident stated she was trying to use the bathroom but feels like ice skating. There was no documentation noted on why the resident did not have non-skid footwear on per the care plan. The physician and responsible party were notified. Review of the Risk Assessment Reports provided to the surveyor revealed R1 had an unwitnessed fall with no injury on 05/17/2026. The resident observed sitting on buttocks on the floor with back against the bed. Siderails x 2 remained down in place. Resident stated, I was trying to go to the bathroom. The physician and responsible party were notified. Review of the Risk Assessment Reports provided to the surveyor revealed R1 had an unwitnessed fall with a major injury on 05/21/2026. The resident observed sitting on buttocks on the floor with back against the bed. Siderails x 2 remained down in place. Resident stated, I was trying to go to the bathroom. The resident complained of left leg pain and was transferred to the hospital. The physician and responsible party were notified. Review of the __ Hospital Progress notes dated 05/21/2026 revealed: R1 was transfer to the hospital for ground level fall and left femur fracture. Per report, patient had a ground-level fall at her living facility this morning. The computed tomography scan of abdomen showed a new lumbar (L2) compression fracture. The x-ray of the left knee showed an acute displaced periprosthetic and a fracture of the distal femur. An interview on 06/17/26 at 12:07 PM with the Administrator stated that when a resident sustains a fall in the facility, the incident must be immediately entered into the risk management system. The Administrator specified that a new intervention must be put in place at the time the fall is logged into the system. The Administrators stated the clinical management team meets every morning to review and discuss all recent falls. He stated the purpose of this daily team meeting is to verify that appropriate individualized safety interventions are in place. The Administrator stated that the team reviews and revise interventions as needed. He stated the interventions are documented in the risk management system and the residents care plan is updated in real time. Following this the Director of Nursing ensures that the designated interventions were fully implemented by the clinical staff. The Administrator stated he is responsible for the final review of the record to ensure that interventions are in place before locking the risk management file for that resident. An interview on 6/17/2026 at 2:13 PM with the MDS-Coordinator CC stated all resident falls are discussed in the morning clinical management meeting. She stated during the meeting interventions are discussed and the care plan is updated. The MDS-Coordinator confirmed that no new interventions were implemented for R1 for the fall on 04/20/2026, 05/17/2026, and 05/21/2026. During a follow-up interview on 06/17/2026 at 2:52 PM the Administrator reviewed R1's fall history alongside the surveyor. Review of the risk management fall report established that the resident sustained a total of 5 falls in 2026. The review focused specifically on R1's last three consecutive falls on 04/20/2026, 05/17/2026, and 05/21/2026 all which occurred while the resident was attempting to get up independently to use the bathroom. When asked by the surveyor to explain why the facility failed to update and revise R1's care plan interventions following the last three consecutive falls. The Administrative failed to provide an answer or clinical justification of why the care plan was not updated.

Based on staff interviews, record review, and review of the facility's policy titled Advance Directives, the facility failed to ensure the Advance Directive status was consistently documented in the clinical record for one of 45 sampled residents (R) (R71). This deficient practice had the potential to place R71 at risk of not receiving life-sustaining treatment in accordance with the resident's wishes. Findings include:Review of the facility's policy titled Advance Directives dated 7/2025 documented Policy: A resident's choice about Advance Directives will be respected. Policy Interpretation and Implementation: 3b; Do Not Resuscitate-Indicates that, in case of respiratory or cardiac failure, the resident, legal guardian, health-care proxy, or representative have directed that no cardiopulmonary resuscitation (CPR) or other life-saving methods are to be used.Review of the admission Record for R71 revealed R71 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including, but not limited to, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, acute chronic systolic congestive heart failure, and hypertensive heart and chronic kidney disease with heart failure. The Advanced Directive section documented the resident's code status was Do Not Resuscitate (DNR).Review of the Annual Minimum Data Set (MDS) for R71, dated [DATE], documented Section C (Cognitive Patterns) Brief Interview for Mental Status (BIMS) of 10, which indicated R71 had moderately impaired cognition.Review of the care plan for R71 revealed a focus area of the resident/family desires a DNR status. The goal was for the resident's desires to be met through next review date. The interventions included following the facility protocol for DNR status, and that the resident is DNR-will not be resuscitated per resident/family request. Review of the Clinical Physician's Orders for R71 revealed an order dated [DATE] and discontinued [DATE] of Code Status: Full Code. Further review revealed an order dated [DATE] of Code Status: DO NOT RESUSCITATE.Review of R71's electronic medical record (EMR) header documented Code Status: (Advance Directives) CODE STATUS: DO NOT RESUSCITATE.Review of a Physician's Orders for Life-Sustaining Treatment (POLST) for R71, dated [DATE], documented DNR Allow Natural Death (AND) - Do Not Attempt Resuscitation. The document was signed by a physician and a concurring physician. Review of a POLST for R71, dated [DATE], documented Full code: Attempt Resuscitation (CPR). The document was signed by a physician and the resident.In an interview on [DATE] at 2:59 pm, the Social Services Assistant (SSA) AA confirmed there was a DNR order in the EMR and a DNR status in the header of the EMR. She further confirmed that a Full Code Advance Directive was signed on [DATE] by the resident and would have rendered the previous Advance Directive of DNR, signed on [DATE], null and void. The SSA AA stated that the current Advance Directive should have been updated in the EMR, but it was not. She further stated that she did not have a chance to update it in the EMR, and that a negative outcome, if it was not updated, would be that the residents' wishes would not be fulfilled based on what he signed to be put in place. The SSA AA further stated that when the staff sees the DNR order, they would not resuscitate the resident during an emergency; therefore, the staff would go against the resident's wishes.In an interview on [DATE] at 3:26 pm, the Interim Director of Nursing confirmed the Advance Directive in the EMR for R71 was a DNR order, and the DNR was the status in the header of the EMR. She further confirmed that a current Full Code Advance Directive, signed on [DATE], was on file in the EMR for the resident. She stated that she placed the DNR order in the EMR and that it was a human error. She stated she inadvertently discontinued the wrong Advance Directive, and she should have placed the Full Code Advance Directive in the EMR instead. She stated that in an emergency, the staff would first look at the orders and the dashboard/header in the EMR for the resident's Advance Directive, and if the incorrect Advance Directive of DNR was in the orders and on the EMR dashboard, a negative outcome could be that the staff would not commence resuscitation for the resident.In an interview on [DATE] at 3:32 pm, the Unit Manager (UM) of the 200 Hall stated that the staff would first look in the EMR system for a resident's Advance Directive, and the staff would look for the order in the banner/dashboard. The UM stated that the staff would see a DNR order and a DNR Advance Directive status in the banner in the EMR for R71. She stated that if R71 had a DNR order and DNR banner/header in the EMR when R71's current Advance Directive status was Full Code, a negative outcome would be that in an emergency, the staff would not attempt to resuscitate R71.

Based on interview, record review, and review of the facility's policy, the facility failed to ensure the residents were allowed to receive mail/packages without staff opening and obtaining copies of the documents without the resident's/resident's representative's permission for one of 14 Residents (R) (R3) interviewed about receiving mail unopened.Findings include:Review of the facility's policy titled, Mail, dated 11/2017, revealed, . residents are allowed to communicate privately with the persons of their choice and may send and receive their personal mail unopened unless otherwise advised by the attending physician or resident and documented in the residents' medical records . Review of R3's admission Packet, signed by the resident on 2/6/2024, revealed under the section titled Mail that the resident shall be afforded reasonable privacy in communications, including the timely sending and receiving of mail and electronic communications.Review of R3's Diag (Diagnosis) tab of the EMR revealed R3 had diagnoses which included cerebral infarction and slurred speech.Review of R3's quarterly Minimum Data Set (MDS), with an assessment reference date (ARD) of 4/4/2025 and located under the MDS tab of the electronic medical record (EMR), revealed R3 had a Brief Interview for Mental Status (BIMS) score of 12 out of 15, which indicated she was moderately cognitively impaired.During an interview on 6/30/2025 at 1:02 pm, R3 and her daughter were interviewed. During the interview they stated the Sherrif had delivered copies of private documents on two occasions, and on each occasion the Social Worker (SW) took the documents and made copies of them without the resident's permission. The resident and the resident's daughter stated the SW told them they needed to keep copies in the resident's file just in case something comes up.Review of R3's power of attorney (POA) documents, located in the Misc section of the EMR, revealed the daughter who had been interviewed on 6/30/2025 at 1:02 pm along with the resident was the designated POA.During an interview on 6/30/2025 at 3:08 pm, the Administrator stated a police officer brought the papers to his office, and the social worker made copies of the papers and then walked the police officer to the resident's room and delivered the paper to the resident. The Administrator stated he did not remember the date of the incident; however, he did provide a folder with a copy of the documents. Review of the documents revealed they were dated 11/25/2024 and 1/28/2025.During an interview on 7/2/2025 at 10:50 am, the SW stated the police met with the Administrator and then she walked the officer to the resident's room, and he gave R3 the papers. She stated the resident told her she was expecting the documents. The SW confirmed she did copy the documents prior to obtaining the resident's permission.

Based on record review, staff interview and review of the facility's policy titled, Discharging/Transferring the Resident, the facility failed to notify the resident's responsible party on the day the resident was discharged and transported out of the facility for one of three Residents (R) (R7) reviewed for discharge out of a total sample of 20.Findings include:Review of the facility's policy titled, Discharging/Transferring the Resident, dated 6/2025, revealed it was the facility's policy to notify the responsible party of the transfer or discharge.Review of R7's admission Minimum Data Set (MDS), with an assessment reference date (ARD) of 2/19/2025 and located in the Aspen MDS Viewer, revealed R7 was admitted to the facility on [DATE] with diagnoses that included coronary artery disease, dementia, and aphasia.Review of R7's Progress Note, dated 6/10/2025 at 4:39 pm and located under the Progress Notes tab of the electronic medical record (EMR), revealed a progress note written by the previous Social Worker (SW) that recorded the SW had spoken to the family member about R7's transfer. It was recorded the family agreed to the transfer and did not voice any concern. The note was silent about why, where, or when R7 was being transferred.Review of a Nurse's Note, written by the Infection Preventionist Nurse, dated 6/11/2025 at 11:41 am, and located under the Progress Notes tab of the EMR, revealed R7 was discharged to (Name of Nursing Home) via non-emergency transport. It was recorded that the report was called into the nurse at (Name of Nursing Home), and all medications had been sent with the resident. The note did not indicate the family member was notified of the discharge/transfer.During an interview on 7/1/2025 at 10:55 am, Resident Representative (RR) 7 stated she was confused about why they discharged R7 and moved her to a sister facility. She stated she was called on 6/10/2025 by the Social Worker and was told R7 would have to be transferred to a different facility on 6/13/2025, and she was not offered the option to keep R7 at her current facility. RR7 stated that when she arrived at the facility on 6/11/2025, R7 was not in the facility and had already been moved to a different facility, and no one had called/notified her the resident was being transferred on 6/11/2025.During an interview on 7/1/2025 at 11:43 am, the Infection Preventionist Nurse stated she was shocked when a private transport arrived to pick up R7 because she was not aware R7 was being discharged /transferred to another nursing facility. She stated she stopped by the SW's office and asked her about it, and the SW told her she had contacted the resident's representative, and the representative was aware of the transfer. She stated she stopped by the SW's office a second time as R7 was being transported out, and the SW again stated the representative was notified of the discharge/transfer.During an interview on 7/3/2025 at 11:10 am, the Administrator verified RR7 had not been contacted on the day R7 was discharged and transferred to a different facility.

Based on record review, interview, and review of the facility's policy titled, Prevention of Resident Abuse, Neglect, Misappropriation or Misappropriation of Property, the facility failed to ensure the resident's right to be free from verbal/mental abuse for one of eight Residents (R) (R) (R11) reviewed for abuse out of a total sample of 20.Findings include:Review of the facility's policy titled, Prevention of Resident Abuse, Neglect, Misappropriation or Misappropriation of Property, dated 8/22/2022, revealed it was the policy of the facility that each resident be free from verbal, sexual, physical, and mental abuse, and mistreatment of any kind. Under the Definitions section of the policy, it defined mental abuse as the use of verbal or nonverbal conduct which causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation, or degradation.Review of R11's quarterly Minimum Data Set (MDS), with an assessment reference date (ARD) of 4/7/2025 and located in the ASPEN MDS Viewer, revealed R11 was readmitted to the facility on [DATE]. It was recorded R11 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident was cognitively intact.Review of R11's Diag (Diagnosis) tab of the electronic medical record (EMR) revealed R11 had diagnoses which included depression, dementia, psychotic disturbance, mood disorder, and anxiety.Review of R11's Care Plan, revised 1/7/2025 and located under the Care Plan tab of the EMR, revealed focus areas of expressing mood problems/symptoms, tearfulness, and a history of depression. It was recorded that the resident received psychoactive medications due to a mood disorder.During an interview on 6/30/2025 at 3:08 pm, the Administrator stated the facility did not have a social worker (SW) because she was terminated for a violation of resident's rights.During an interview on 7/1/2025 at 1:37 pm, R11 stated one day a lady came into her room and told her she had to move because she was a hoarder and did not keep her room clean. She stated she was very upset and worried about it. R11stated she was happy they let her stay because she liked living in the facility and did not want to move.On 7/1/2025 the Administrator provided a copy of the SW's termination documents which included the following:a. An Employee Status Change Form and a State of Georgia Department of Labor Separation Notice, each signed by the Administrator and dated 6/12/2025, recorded the SW was terminated for Questionable behavior practices, violating resident rights.b. A printed email from the Administrator to the facility's Regional Human Resources Director, dated 6/12/2025 and with a subject line of Permission to Terminate, revealed he recommended the termination of the SW. The report recorded that on 6/10/2025 they received a compliance call stating the SW had told R11 that she would be moved to another facility in the morning because she was a hoarder and kept her room dirty. The resident was crying and upset, and the resident and the family called the compliance line because of this. He wrote This is considered improper Transfer and/or Discharge.c. An undated written statement, completed by the Administrator, detailing his conversation with R11 on Wednesday 6/11/2025 at 9:55 am. He asked R11 what happened last night, and she told him a lady came in her room and told her she was being transferred/moved to another facility because her room was dirty and she was a hoarder. The resident stated she told the lady No, I don't want to go, and the lady told her she would be moving to (Name of the sister facility) in the morning. In the statement the Administrator wrote, Just an FYI . [R11] was admitted to the facility on [DATE] and has a BIMS of 15. He stated he interviewed Registered Nurse (RN) 1, Licensed Practical Nurse (LPN) 1 and Certified Nursing Assistant (CNA) 1, and all their stories of what happened were the same.d. Review of a written statement, dated 6/11/2025 and signed by RN1 (the 3:00 pm to 11:00PM Supervisor) who recorded that on 6/10/2025, she was approached by a CNA and an LPN who told her that R11 was in her room crying and upset, telling them that she had been told that she had to leave the facility in the morning. RN1 wrote she immediately went to the resident's room and upon entering the room the resident was crying and told her that the social worker told her she had to leave the facility in the morning because she was nasty. She wrote that the resident was upset because she was not given any type of notice to prepare for the leave. When asked if she wanted to go, R11 replied No and stated she was told she was being transferred to (Name of the sister facility). RN1 wrote that R11stated she was not given a choice. RN1 wrote R11 was crying unconsolably and had to be reassured that she would not be forced to go anywhere without her consent. She wrote the resident kept saying this is not right, this is not right. She wrote she had seen the social worker go into the resident's room around supper time and this was reported to her later in the evening. She wrote she reported it to the Director of Nursing who said she would follow up in the morning and instructed her to tell R11 to calm down because she did not have to go anywhere.During an interview on 7/1/2025 at 4:38 pm, RN1 confirmed what she wrote in her written statement. She stated that R11 was very upset that the SW had told her she had to leave in the morning, and she told her she did not have to go anywhere she could stay in the facility. She stated she felt it was abuse and should have been investigated.During an interview on 7/2/2025 at 10:19 am, the Administrator stated he did not report this treatment of R11 to the State Survey Agency because he did not consider it to be abuse. He confirmed R11 was told she had to leave in the morning, and she was very upset.During an interview on 7/2/2025 at 11:50 am, the DON stated that she did consider SW telling R11 she had to be discharged because she was nasty a form of verbal abuse. She stated this incident was not reported as abuse to the State Agency.

Based on interview, record review, and facility's policy titled, Prevention of Resident Abuse, Neglect, Misappropriation or Misappropriation of Property, the facility failed to report an allegation of verbal/mental abuse to the State Survey Agency within two hours after the allegation was made for one of eight Residents (R) (R11) reviewed for abuse out of a total sample of 20.Findings include:Review of the facility's policy titled, Prevention of Resident Abuse, Neglect, Misappropriation or Misappropriation of Property, dated 8/22/2022, revealed it was the policy of the facility that each resident be free from verbal, sexual, physical, and mental abuse, and mistreatment of any kind. The policy indicated abuse is to be reported to the Administrator and the State Survey Agency within two hours of the allegation being made.Review of R11's quarterly Minimum Data Set (MDS), with an assessment reference date (ARD) of 4/7/2025 and located in the ASPEN MDS Viewer, revealed R11 was readmitted to the facility on [DATE]. It was recorded R11 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident was cognitively intact.During an interview on 6/30/2025 at 3:08 pm, the Administrator stated the facility did not have a social worker (SW) because she was terminated for a violation of resident's rights.During an interview on 7/1/2025 at 1:37 pm, R11 stated one day a lady came into her room and told her she had to move because she was a hoarder and did not keep her room clean. She stated she was very upset and worried about it. R11 stated she was happy they let her stay because she liked living in the facility and did not want to move.On 7/1/2025 the Administrator provided a copy of the SW's termination documents which included the following:a. An Employee Status Change Form and a State of Georgia Department of Labor Separation Notice, each signed by the Administrator and dated 6/12/2025, recorded the SW was terminated for Questionable behavior practices, violating resident rights.b. A printed email from the Administrator to the facility's Regional Human Resources Director, dated 6/12/2025 and with a subject line of Permission to Terminate, revealed he recommended the termination of the SW. The report recorded that on 6/10/2025, they received a compliance call stating the SW had told R11 that she would be moved to another facility in the morning because she was a hoarder and kept her room dirty. The resident was crying and upset, and the resident and the family called the compliance line because of this. He wrote This is considered improper Transfer and/or Discharge.c. An undated written statement, completed by the Administrator, detailing his conversation with R11 on Wednesday 6/11/2025 at 9:55 am. He asked R11 what happened last night, and she told him a lady came in her room and told her she was being transferred/moved to another facility because her room was dirty and she was a hoarder. The resident stated she told the lady No, I don't want to go, and the lady told her she would be moving to (Name of the sister facility) in the morning. In the statement the Administrator wrote, Just an FYI . [R11] was admitted to the facility on [DATE] and has a BIMS of 15. He stated he interviewed Registered Nurse (RN) 1, Licensed Practical Nurse (LPN) 1 and Certified Nursing Assistant (CNA) 1, and all their stories of what happened were the same.d. Review of a written statement, dated 6/11/2025 and signed by RN1 (the 3:00 pm to 11:00 pm Supervisor) who recorded that on 6/10/2025, she was approached by a CNA and an LPN who told her that R11 was in her room crying and upset, telling them that she had been told that she had to leave the facility in the morning. RN1 wrote she immediately went to the resident's room and upon entering the room the resident was crying and told her that the social worker told her she had to leave the facility in the morning because she was nasty. She wrote that the resident was upset because she was not given any type of notice to prepare for the leave. When asked if she wanted to go, R11 replied No and stated she was told she was being transferred to (Name of the sister facility) RN1 wrote that R11stated she was not given a choice. RN1 wrote R11 was crying unconsolably and had to be reassured that she would not be forced to go anywhere without her consent. She wrote the resident kept saying this is not right, this is not right. She wrote she had seen the social worker go into the resident's room around supper time and this was reported to her later in the evening. She wrote she reported it to the Director of Nursing who said she would follow up in the morning and instructed her to tell R11 to calm down because she did not have to go anywhere.During an interview on 7/1/2025 at 4:38 pm, RN1 confirmed what she wrote in her written statement. She stated that the resident was very upset that the SW had told her she had to leave in the morning, and she told her she did not have to go anywhere she could stay in the facility. She stated she felt it was abuse and should have been investigated.During an interview on 7/2/2025 at 10:19 am, the Administrator stated he did not report this treatment of R11 to the State Survey Agency because he did not consider it to be abuse. He confirmed she was told she had to leave in the morning, and she was very upset.During an interview on 7/2/2025 at 11:50 am, the DON stated that she did consider SW telling R11 she had to be discharged because she was nasty was a form of verbal abuse. She stated this incident was not reported as abuse to the State Agency.

Based on record review, staff interviews, review of the facility's policy titled, Prevention of Resident Abuse, Neglect, Mistreatment, or Misappropriation of Property, the facility failed to ensure allegations of abuse were thoroughly investigated for two of eight Residents (R) (R1 and R14) reviewed for a total sample of 20. Findings include: Review of the facility's policy titled, Prevention of Resident Abuse, Neglect, Mistreatment, or Misappropriation of Property, dated 8/22/2022, revealed it was the policy of the facility to ensure all suspected cases of abuse be fully investigated by the Administrator, Abuse Coordinator, or designee. Under the investigation section of the policy, it stated to . Interview all associates, residents, and family members involved . 1. Review of R1's admission tab in the electronic medical record (EMR) revealed she was admitted to the facility with diagnoses that included dementia, psychotic disturbance, mood disturbance, anxiety, mental disorder, depression, muscle weakness, difficulty in walking, and adult failure to thrive. It was recorded R1 discharged to the hospital on [DATE]. Review of R1's Progress Note, dated 11/24/2024 at 12:05 am and located in the Progress Notes tab of the EMR, revealed the resident was alert and oriented to person, place, and time, communicated verbally, had clear speech and was able to understand and to be understood. Review of R1's Physical Therapy notes, dated 11/20/2024 and provided by the Director of Nursing (DON), revealed the resident was dependent on one staff for bed mobility. Review of a Facility Incident Report Form, dated 11/22/2024 and completed by the Administrator, revealed on 11/22/2024 at 5:45 pm, R1 alleged Certified Nurse Aide (CNA) 2, who worked the day shift, was mean to her. She alleged CNA2 was rough while changing her brief. CNA2 was suspended pending the investigation. Review of a right wrist x-ray completed on 11/23/2024 revealed she had a nondisplaced oblique fracture through the fourth metacarpal with no abnormal soft tissue swelling. Review of a letter with the letter head of (Name of Facility) dated 12/02/2024 and addressed to the Georgia Department of Community Health, Long Term Care Section and signed by the Administrator, confirmed the resident had a fractured fourth metacarpal and recorded the resident's family member stated the finger had been broken previously and the rough handling could have reaggravated the old injury. The investigation summary stated the resident complained of right arm pain and had bruising on her right arm and hand upon admission. The report stated CNA2 had been employed by the facility for 11 years and there had been no past accusations or allegations of abuse. The report concluded that the allegation of abuse was unsubstantiated. The report stated the staff was reeducated on abuse, kinds of abuse and preventing abuse and dealing with residents with dementia. Review of the investigation revealed the only witness statements were from the alleged perpetrator (CNA2) dated 11/25/2024, from Registered Nurse (RN) 1, and from Licensed Practical Nurse (LPN) 5. Review of the schedule and interview with RN1 revealed both of the nurses worked the 3:00 pm to the 11:00 pm shift and were not working at the time the alleged abuse occurred. According to the statement written by LPN5 and dated 11/22/2024, R1's family member reported to her that around noon today (11/22/2024) someone taking care of R1 was rough with her. According to the family member, someone snatched a cup from her and popped her on the arm. The statement from RN1, dated 11/22/2024, revealed RN1 stated R1 reported CNA2 was rough today during incontinence care. She wrote R1 was asking CNA2 to be gentle because she was rubbing her too hard and then the CNA grabbed her right hand and held it tight and then hit her several times on the left hand. The resident told her CNA2 threw a box of tissues at her and tossed a teddy bear as well. During an interview on 7/10/2025 at 4:38 pm, RN1 stated she was the RN supervisor on the 3:00 pm to 11:00 pm shift, and she was not working at the time of the alleged incident. She stated LPN 5 was also working on the 3:00 pm to 11:00 pm shift and had not worked the day shift. RN1 stated LPN5 had informed her of the alleged abuse after R1 had reported it to LPN5. Review of the staffing schedule for the date and time of the alleged incident was reviewed and revealed there were no witness statements from any of the staff that was working on the shift of the alleged abuse, and no resident statements were included. During an interview on 7/3/2025 at 11:10 am, the Administrator was asked if he had any additional witness statements related to this alleged abuse, and he stated the did not. He stated they did not get statements from the residents CNA2 had cared for that evening, and they did not obtain any from the staff working with CNA2 on the day of the alleged incident. He stated it was his expectation that the staff on duty at the time of the alleged abuse should have given a witness statement for the day and residents should have been interviewed. 2. Review of R14's admission Record, located in the EMR under the admission tab, revealed she was admitted to the facility with diagnoses that included muscle weakness, difficulty in walking, and cognitive communication deficit. Review of R14's annual Minimum Data Set (MDS), with an assessment reference date (ARD) of 6/5/2025 and located under the MDS tab of the EMR, revealed R14 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident was cognitively intact. Review of a Facility Incident Report Form, dated 4/8/2025 and completed by the Director of Nursing (DON), revealed that the Administrator was informed on 4/8/2025 that R14's assigned CNA3 had been talking negatively to her while administering care. According to the report, CNA3 was sent home immediately, and the resident's family member, the police, and the Medical Director were notified. Review of the investigation revealed the only statements in the investigation were from CNA3, the alleged perpetrator, and from the Infection Control LPN. The statement from the Infection Control LPN was not dated and stated on 4/1/2025, she was working on the 200 hall and she was in the room with R14 when she asked to get up earlier than she normally does. She wrote she told CNA3 while in the hall, and CNA3 began complaining in a loud voice about the resident asking to get up early. There was no documentation in her statement about CNA speaking negatively to R14 while providing care. During an interview on 7/3/2025 at 11:10 am, the Administrator was asked if he had any additional witness statements related to this alleged abuse, and he stated he did not. He stated they did not get statements from the residents that CNA3 had cared for, and they did not obtain any from the staff working with CNA3 on the day of the alleged incident. He stated it was his expectation that the staff on duty at the time of the alleged abuse should have given a witness statement for the day and residents should have been interviewed. Review of the staffing schedule for the date and time of the alleged incident was reviewed and revealed there were no witness statements from any of the staff that was working on the shift of the alleged abuse, and no resident statements were included. During an interview on 07/03/25 at 11:10 AM, the Administrator was asked if he had any additional witness statements related to this alleged abuse, and he stated the did not. He stated they did not get statements from the residents CNA2 had cared for that evening, and they did not obtain any from the staff working with CNA2 on the day of the alleged incident. He stated it was his expectation that the staff on duty at the time of the alleged abuse should have given a witness statement for the day and residents should have been interviewed. 2. Review of R14's admission Record, located in the EMR under the admission tab, revealed she was admitted to the facility on [DATE] with diagnoses that included muscle weakness, difficulty in walking, and cognitive communication deficit. Review of R14's annual Minimum Data Set (MDS), with an assessment reference date (ARD) of 06/05/25 and located under the MDS tab of the EMR, revealed R14 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident was cognitively intact. Review of a Facility Incident Report Form, dated 04/08/25 and completed by the Director of Nursing (DON), revealed that the Administrator was informed on 04/08/25 that R14's assigned CNA3 had been talking negatively to her while administering care. According to the report, CNA3 was sent home immediately, and the resident's family member, the police, and the Medical Director were notified. Review of the investigation revealed the only statements in the investigation were from CNA3, the alleged perpetrator, and from the Infection Control LPN. The statement from the Infection Control LPN was not dated and stated on 04/01/25, she was working on the 200 hall and she was in the room with R14 when she asked to get up earlier than she normally does. She wrote she told CNA3 while in the hall, and CNA3 began complaining in a loud voice about the resident asking to get up early. There was no documentation in her statement about CNA speaking negatively to R14 while providing care. During an interview on 07/03/25 at 11:10 AM, the Administrator was asked if he had any additional witness statements related to this alleged abuse, and he stated he did not. He stated they did not get statements from the residents that CNA3 had cared for, and they did not obtain any from the staff working with CNA3 on the day of the alleged incident. He stated it was his expectation that the staff on duty at the time of the alleged abuse should have given a witness statement for the day and residents should have been interviewed.

Based on interview, record review, and review of the facility's policy and procedure titled, Documentation of Transfers/Discharges, the facility failed to ensure residents were not inappropriately transferred or discharged against the resident's/residents' representatives wishes for two of three Residents (R) (R7 and R4) reviewed for discharge out of a total sample of 20.Findings include:Review of the facility's policy and procedure titled, Documentation of Transfers/Discharges, dated 6/2025, revealed, . when a resident is transferred or discharged , his or her medical records shall be documented as to the reasons why such action was taken . The policy indicated should the resident be transferred or discharged because the safety of individuals in the facility would be endangered the basis of the discharge . must be documented in the resident's clinical record by a physician . The policy indicated the documentation must include at minimum: the reason for the discharge, that an appropriate notice be provided to the resident/representative; the resident/representative participate in a pre-discharge orientation program; the date and time of the discharge; and the new location of the resident.Review of the facility's policy titled, Notice of Transfer/Discharge, dated 6/2025, revealed, . The facility shall provide a resident/resident's representative with a thirty (30)-day written notice of an impending transfer or discharge . with an exception being if the safety of the individuals in the center was endangered. The policy was silent as to what notice would be given if the resident was transferred or discharged as a result of the residents in the facility being endangered.1. Review of R7's admission Record, located in the admission tab of the electronic medical record (EMR), revealed R7 was admitted to the facility with diagnoses that included cerebrovascular disease, traumatic hemorrhage of right cerebrum, dementia, psychotic disturbance, mood disturbance, and anxiety. It was recorded R7 was discharged on 6/11/2025.Review of R7's significant change of condition Minimum Data Set (MDS), with an assessment reference date (ARD) of 4/9/2025 and located under the MDS tab of the EMR, revealed R7 had a Brief Interview for Mental Status (BIMS) score of three out of 15, which indicated the resident was severely cognitively impaired. It was recorded R7 was dependent on staff for all her activities of daily living.Review of R7's Progress Note, dated 6/10/2025 at 4:39 pm, written by the previous Social Worker (SW), and located under the Progress Notes tab of the EMR, revealed the SW had spoken with the resident's family member about transferring R7. It was recorded the family member had agreed to the transfer and did not voice any concern. The note did not indicate why or where R7 was being transferred.Review of R7's Nurse's Note, written by the Infection Preventionist (IP) Nurse, dated 6/11/2025 at 11:41 am, and located under the Progress Notes tab of the EMR, revealed R7 was discharged to (Name of Nursing Home) via non-emergency transport. It was recorded report was called to the nurse at (Name of Nursing Home), and all medications had been sent with non-emergent transport.During an interview on 6/30/2025 at 3:08 pm, the Administrator stated they did not have a social worker because she was terminated for a violation of a resident's rights.Review of an email from the Administrator to the Regional Human Resource Director, dated 6/12/2025 at 3:24 pm and provided by the Administrator, revealed the Administrator was asking for the termination of the SW's employment. One reason listed for her termination was that on 6/11/2025, the facility received a compliance call stating the SW told R7's family member that they would be moving R7 to (Name of Nursing Home) on Friday 6/13/2025, and the resident was moved on Wednesday 6/11/2025. The Administrator wrote that the family member had stated that she was not given an option to decline the offer of transfer. The Administrator wrote, . This is considered improper Transfer and/or Discharge .During an interview on 7/1/2025 at 10:55 am, Resident Representative (RR) 7, the family member of R7, stated she was confused about why they discharged R7 and moved her to a sister facility. She stated she was called on 6/10/2025 by the Social Worker and was told R7 would have to be transferred to a different facility on 6/13/2025. RR7 stated she was not offered the option to keep R7 at her current facility. RR7 stated when she arrived at the facility on 6/11/2025, R7 was not in the facility and had already been moved to a different facility, and no one had called/notified her about the move that had occurred earlier that day.During an interview on 7/1/2025 at 11:05 am, the facility's former SW stated she did call R7's family member (RR7) on 6/10/2025 and told her R7 had to be transferred to a sister facility on Friday 6/13/2025 because she was in a short-term bed, and they needed it to admit a short-term resident into. She stated R7 was transferred on 6/11/2025 while she was off, and the nurse should have contacted RR7. She stated she did not document the reason for the discharge in the medical record because she was too busy and did not have time.During an interview on 7/1/2025 at 11:27 am, the Administrator stated they were trying to have more short-term beds available, and the social worker did tell R7's responsible party (RR7) that R7 would be discharged on Friday 6/13/2025 and she did not offer RR7 an option for R7 to stay in the facility, and that was one reason why the SW was terminated.During an interview on 7/1/2025 at 11:43 am, the IP Nurse stated she was shocked when a private transport arrived to pick up R7 on 6/11/2025 because she was not aware R7 was being discharged /transferred to another nursing facility. She stated she stopped by the SW's office and asked her about it, and the SW stated she contacted the resident's family member, and the family member was aware of the transfer. The IP stated she and Licensed Practical Nurse (LPN) 11 stopped by the SW's office a second time as R7 was being transported out of the facility, and the SW again stated the family member was notified of the discharge/transfer. The IP stated she also asked the SW if she needed a discharge summary, and the SW told them no. The IP stated the SW was working on the day R7 was transferred out of the facility.During an interview on 7/1/2025 at 2:00 pm, LPN11 stated she did not know R7 was leaving until transport came to pick her up the morning of 6/11/2025. She stated the SW was in the facility in her office, and she asked her twice if she had contacted R7's responsible party. LPN11 stated the SW said she had contacted the responsible party on the previous day, and the responsible party knew R7 was being transferred to another nursing facility. LPN11 stated R7's hospice aide came in as the transport company was transporting R7 out of the facility, and they gathered up all of the resident's personal belongings and sent them with her in the transport van. LPN11 stated she completed the discharge instructions and medications and called the receiving facility and gave them report. Review of R7's admission agreement, located in the Misc (miscellaneous) section of the EMR and signed by RR7 on 2/20/2025 at 11:36 am, revealed on page 16 of 22 of the agreement that the facility agreed not to discharge the resident from the facility solely as a result of the resident changing his or her source of payment for services (e.g. private pay, Medicare, Medicaid or private insurance) or because of a change in resident care needs. 2. Review of R4's admission Record, located under the admission tab of the EMR, revealed R4 was admitted to the facility on [DATE] with diagnoses that included pain, muscle weakness, aftercare following joint replacement surgery, arthritis, artificial hip joint, nondisplaced fracture of medial malleolus of right tibia, orthopedic aftercare, and difficulty walking. It was recorded R4 was discharged from the facility on 3/21/2025. Review of the R4's quarterly MDS, with an ARD of 2/16/2025 and located in the MDS tab of the EMR, revealed R4 had a BIMS score of 15 out of 15, which indicated the resident was cognitively intact. It was recorded R4 required maximal assistance with toilet hygiene, dressing, and bed mobility and was dependent on staff for bathing. She required a wheelchair for mobility. Review of R4's Progress Note, dated 3/20/2025 at 8:05 pm and located in the Progress Notes tab EMR, revealed a note by the SW that recorded the resident had a disagreement with a nurse, which led to R4 contacting her family members for support. As a result of the situation, the police were called, and a report was made. The note stated the incident was documented, and the necessary steps were being taken to address the situation appropriately. The note stated the facility was committed to ensuring R4's care and the care of the other residents continued in a safe and respectful environment.Review of R4's Physician's Orders, dated 3/20/2025 at 9:07 pm and located in the Orders tab of the EMR, revealed, . discharge home with home health services for nursing for medication and disease management, home health aide., PT/OT [physical therapy/occupational therapy], DME [Durable Medical Equipment] Wheelchair, hospital bed, and 3 in 1 shower chair . Review of R4's Progress Note, dated 3/21/2025 at 3:17 pm and located under the Progress Notes tab of the EMR, revealed R4 was discharged and had been picked up by non-emergent transport. It was recorded family came and got the rest of R4's belongings. The EMR was reviewed in its entirety and there was no documentation related to why the resident was discharged , whether the resident was given other options, or any physician documentation related to the reason for the discharge. Review of a facility abuse investigation, conducted in relation to the disagreement between the nurse and the resident as documented in the 3/20/2025 8:05 pm nursing progress note, revealed a document titled Facility Incident Report Form, dated 3/20/2025, which recorded the resident came back after therapy asking for pain medications, and the nurse was pulling the medications for another resident and told R4 she would come to her room to give her medications as soon as she finished with the resident she was giving medications to. The report recorded R4 became irate and began to yell at the charge nurse. It was recorded R4 then called her family, and her family came into the building. It was recorded once the family entered the building, they were loud and threatening the nurse. Several nursing staff witnessed the family threatening to shoot up the building. The police were called. A report was filed. The two family members were asked to leave by the police, and restraining orders were filed. There were two residents who witnessed the incident. These residents currently feel safe at the facility. The medical director was notified. There was no change in any of the residents' psychosocial disposition. A follow up letter, written by the Director of Nursing to the Long Term Care Section, Complaint Unit and dated 3/27/2025, recorded it was a follow-up report to the threat to the facility reported on 3/20/2025. According to the report, the resident was discharged home on 3/21/2025. Review of R4's entire EMR revealed no documented evidence R4 or the family members were notified of the restraining order or that the family members did not abide by the restraining order. There was no documented evidence that the facility completed the appropriate assessments to determine if care plan revisions would allow the resident to remain in the facility while protecting the health and safety of others. During an interview on 7/1/2025 at 4:06 pm, the DON stated she was at the facility when the incident occurred. She stated some residents who heard this were crying and the nurse called 911 because she was afraid. She stated the resident was planning to discharge home after her rehabilitation anyway, so they called the Regional Office, and they were told they had to discharge her.During an interview on 7/2/2025 at 3:36 pm, the Administrator was asked for a copy of a discharge notice for R4, and he stated they did not have one. He stated the regional office told him they had to discharge her and no discharge notice was issued to the resident or resident's representative.During an interview on 7/2/2025 at 3:49 pm, R4's daughter was called (not the one who threatened the facility). She stated the Administration at the facility wanted them to take R4 home the night of 3/20/2025; however, they could not transport her in their car because she was wheelchair bound so they transported her via private transport on 03/21/2025. She stated they were not given an option for her to stay at the facility, and she asked them if she could stay until they found an alternative placement and they told her no.During an interview on 7/3/2025 at 11:10 am, the Administrator verified that R4/R4's responsible party was not given a choice to remain in the facility, the reason for the discharge was not documented in the resident's clinical record, and there was no documentation from a physician about the reason for the discharge.

Based on interview, record review, and review of the facility's policy and procedure titled, Documentation of Transfers/Discharges, the facility failed to notify the resident and the resident's representative of the reasons for a discharge/transfer, failed to notify the Office of State Long-Term Care Ombudsman of the discharge/transfer, and failed to record the reasons for the transfer/discharge in the resident's medical record for two of three Resident (R) (R7 and R4) reviewed for discharge out of a total sample of 20.Findings include:Review of the facility's policy and procedure titled, Documentation of Transfers/Discharges, dated 6/202025, revealed, . when a resident is transferred or discharged , his or her medical records shall be documented as to the reasons why such action was taken . The policy recorded should the resident be transferred or discharged because the safety of individuals in the facility would be endangered the basis of the discharge . must be documented in the resident's clinical record by a physician . The policy stated the documentation must include at minimum: the reason for the discharge, that an appropriate notice was provided to the resident/representative; the resident/representative participated in a pre-discharge orientation program; the date and time of the discharge; and the new location of the resident.Review of the facility's policy titled, Notice of Transfer/Discharge, dated 6/2025, revealed, . The facility shall provide a resident/resident's representative with a thirty (30)-day written notice of an impending transfer or discharge . The policy recorded an exception would be if the safety of the individuals in the center were endangered. The policy was silent about what notice would be given if the resident was transferred or discharged as a result of the residents in the facility being endangered.1. Review of R7's admission Record, located in the admission tab of the electronic medical record (EMR), revealed R7 was admitted to the facility with diagnoses that included cerebrovascular disease, traumatic hemorrhage of right cerebrum, dementia, psychotic disturbance, mood disturbance, and anxiety. It was recorded R7 discharged on 6/11/2025.Review of R7's significant change of condition Minimum Data Set (MDS), with an assessment reference date (ARD) of 4/9/2025 and located under the MDS tab of the EMR, revealed R7 had a Brief Interview for Mental Status (BIMS) score of three out of 15, which indicated the resident was severely cognitively impaired. It was recorded R7 was dependent on staff for all her activities of daily living.Review of R7's Progress Note, dated 6/10/2025 at 4:39 pm, written by the previous Social Worker (SW), and located under the Progress Notes tab of the EMR, revealed the SW had spoken with the resident's family member about transferring R7. It was recorded the family member had agreed to the transfer and did not voice any concern. The note did not indicate why or where R7 was being transferred.Review of R7's Nurse's Note, written by the Infection Preventionist (IP) Nurse, dated 6/11/2025 at11:41 am, and located under the Progress Notes tab of the EMR, revealed R7 was discharged to (Name of the Facility) via non-emergency transport. It was recorded report was called to the nurse at (Name of the Facility), and all medications had been sent with non-emergent transport.The EMR was reviewed in its' entirety, and this was the only documentation related to the resident's discharge/transfer. The EMR was silent for the reason the resident was being transferred/ discharged and was silent for physician documentation of the transfer/discharge.During an interview on 6/30/2025 at 3:08 pm, the Administrator stated they did not have a social worker because she was terminated for a violation of a resident's rights.Review of an email from the Administrator to the Regional Human Resource Director, dated 6/12/2025 at 3:24 pm and provided by the Administrator, revealed the Administrator was asking for the termination of the SW's employment. One reason listed for her termination was that on 6/11/2025, the facility received a compliance call stating the SW told R7's family member that they would be moving R7 to (Name of the Facility) on Friday 6/13/2025, and the resident was moved on Wednesday 6/11/2025. The Administrator wrote that the family member had stated that she was not given an option to decline the offer of transfer. The Administrator wrote, . This is considered improper Transfer and/or Discharge .During an interview on 7/1/2025 at 10:55 am, Resident Representative (RR) 7, the family member of R7, stated she was confused about why they discharged R7 and moved her to a sister facility. She stated she was called on 6/10/2025 by the Social Worker and was told R7 would have to be transferred to a different facility on 6/13/2025. RR7 stated she was not offered the option to keep R7 at her current facility. RR7 stated when she arrived at the facility on 6/11/2025, R7 was not in the facility and had already been moved to a different facility and no one had called/notified her about the move that had occurred earlier that day.During an interview on 7/1/2025 at 11:05 am, the facility's former SW stated she did call R7's family member (RR7) on 6/10/2025 and told her R7 had to be transferred to a sister facility on Friday 6/13/2025 because she was in a short-term bed, and they needed it to admit a short-term resident into. She stated R7 was transferred on 6/11/2025 while she was off, and the nurse should have contacted RR7. She stated she did not document the reason for the discharge in the medical record because she was too busy and did not have time.During an interview on 7/1/2025 at 11:27 am, the Administrator stated they were trying to have more short-term beds available, and the social worker did tell R7's responsible party (RR7) that R7 would be discharged on Friday 6/13/2025 and she did not offer R7's responsible party an option to stay in the facility. The Administrator verified that the reason for R7's discharge was not documented in her medical record.During an interview on 7/1/2025 at 11:43 am, the Infection Preventionist (IP) Nurse stated on the day R7 was transferred out of the facility, the SW was working at the facility, and she asked the SW twice if R7's responsible party had been notified of the transfer and she was told each time that the responsible party was aware. The IP stated she asked the SW if a discharge summary needed to be completed, and the SW told her no.During an interview on 7/3/2025 at 11:10 am, the Administrator confirmed the reason for the discharge was not documented in R7's medical record, that the facility did not issue a discharge notice to R7/R7's responsible party, and the facility did not notify the Ombudsman of the discharge.2. Review of R4's admission Record, located under the admission tab of the EMR, revealed R4 was admitted to the facility with diagnoses that included pain, muscle weakness, aftercare following joint replacement surgery, arthritis, artificial hip joint, nondisplaced fracture of medial malleolus of right tibia, orthopedic aftercare, and difficulty walking. It was recorded R4 was discharged from the facility on 3/21/2025. Review of the R4's quarterly MDS, with an ARD of 2/16/2025 and located in the MDS tab of the EMR, revealed R4 had a BIMS score of 15 out of 15, which indicated the resident was cognitively intact. It was recorded R4 required maximal assistance with toilet hygiene, dressing, and bed mobility and was dependent on staff for bathing. It was recorded R4 required a wheelchair for mobility. Review of R4's Progress Note, dated 3/20/2025 at 8:05 pm and located in the Progress Notes tab of the EMR, revealed a note by the SW that recorded the resident had a disagreement with a nurse, which led to R4 contacting her family members for support. As a result of the situation, the police were called, and a report was made. The note recorded that the incident was documented and the necessary steps were being taken to address the situation appropriately. The note recorded the facility was committed to ensuring R4's care and the care of the other residents continued in a safe and respectful environment.Review of R4's Physician's Orders, dated 3/20/2025 at 9:07 pm and located in the Orders tab of the EMR, revealed . discharge home with home health services for nursing for medication and disease management, home health aide., PT/OT [physical therapy/occupational therapy], DME [Durable Medical Equipment] Wheelchair, hospital bed, and 3 in 1 shower chair . Review of R4's Progress Note dated 3/21/2025 at 3:17 pm and located under the Progress Notes tab of the EMR, revealed R4 was discharged and had been picked up by non-emergent transport. It was recorded family came and got the rest of R4's belongings.The EMR was reviewed in its entirety and was silent for documentation related to why the resident was discharged , whether the resident was given other options, and any physician documentation related to the reason for the discharge. Review of a facility abuse investigation, conducted in relation to the disagreement between the nurse and the resident as documented in the 3/20/2025 8:05 pm nursing progress note, revealed a document titled Facility Incident Report Form, dated 3/20/2025, which recorded the resident came back after therapy asking for pain medications, and the nurse was pulling the medications for another resident and told R4 she would come to her room to give her medications as soon as she finished with the resident she was giving medications to. The report recorded R4 became irate and began to yell at the charge nurse. It was recorded R4 then called her family, and her family came into the building. It was recorded once the family entered the building, they were loud and threatening the nurse. Several nursing staff witnessed the family threatening to shoot up the building. The police were called. A report was filed. The two family members were asked to leave by the police and restraining orders were filed. The medical director was notified.During an interview on 7/2/2025 at 3:36 pm, the Administrator was asked for a copy of a discharge notice for R4, and he stated they did not have one. He stated the regional office told him they had to discharge her.During an interview on 7/2/2025 at 3:49 pm, R4's daughter was called (not the one who threatened the facility). She stated the Administration at the facility wanted them to take R4 home the night of 3/20/2025; however, they could not transport her in their car because she was wheelchair bound so they transported her via private transport on 3/21/2025. She stated they were not given an option for her to stay at the facility, and she asked them if she could stay until they found an alternative placement and they told her no.During an interview on 7/3/2025 at 11:10 am, the Administrator verified the reason for the discharge was not documented in R4's medical record, that no discharge notice was issued to R4/R4's responsible party, and the facility did not notify the Ombudsman of the discharge.

Based on staff interviews and record review, the facility failed to ensure notifications of discontinuation of Medicare Part A benefits were issued in a timely manner for three of three residents (R) (R36, R81, and R605) reviewed for beneficiary notification. This failure had the potential to result in a lack of understanding of appeal rights and/or the termination of the current level of care against the resident's/representative's wishes. Findings include: 1. Review of R36's Part A Discharge Minimum Data Set (MDS) assessment dated [DATE] revealed section A (Identification Information) documented the Medicare stay had a start date of 7/1/2024 and an end date of 8/17/2024. Review of R36's Occupational Therapy Discharge Summary dated 5/11/2024 to 8/16/2024 revealed R36 had reached her maximal potential and was discharged to long-term care at this facility. The Occupational Therapist (OT) signed the note on 8/21/2024. Review of R36's medical record revealed no evidence that a (Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage) SNF-ABN form or a (Notice of Medicare Non-Coverage) NOMNC form was provided before discharge from Medicare Part A on 8/16/2024. The facility provided a NOMNC form that was signed and dated 6/13/2024. 2. Review of R81's Part A Discharge MDS assessment dated [DATE] revealed section A (Identification Information) documented the Medicare stay had a start date of 6/1/2024 and an end date of 8/6/2024. Review of R81's Occupational Therapy Discharge Summary dated 4/30/2024 to 8/6/2024 revealed R81 was discharged from therapy on 8/6/2024. The document was signed by the OT on 8/7/2024. Review of R81's medical record revealed no evidence that an SNF-ABN form or a NOMNC form was provided before discharge from Medicare Part A on 8/6/2024. The facility provided a NOMNC form that was signed and dated 5/30/2024. 3. Review of R605's Discharge MDS assessment dated [DATE] revealed Section A (Identification Information) documented discharge from the facility on 6/1/2024, return not anticipated, planned discharge, and the end of the most recent Medicare stay was 6/1/2024. Review of R605's Occupational Therapy Discharge Summary dated 5/15/2024 to 5/31/2024 revealed R605 had reached his maximum potential with skilled services. The document was signed by the OT on 5/31/2024. Review of R605's medical record revealed no evidence that a NOMNC form was provided before discharge from Medicare Part A on 5/31/2024. The facility provided a NOMNC form that documented services ended on 3/17/2024. In an interview on 10/31/2024 at 9:34 am, the Business Office Manager (BOM) confirmed R36 was discharged from Medicare Part A Services on 8/18/2024, R81 was discharged from Medicare Part A services on 8/7/2024, and they remained in the facility after discharge from Medicare Part A services. She further confirmed R605 was discharged from Medicare Part A services on 6/1/2024 and discharged to home on 6/1/2024. She stated she does not issue NOMNC or SNF-ABN forms to residents. In an interview on 10/31/2024 at 9:45 am, the Social Services Director (SSD) confirmed R605, R81, and R36 were discharged from Medicare Part A due to meeting their individual therapy goals. She stated Medicare Part A residents should receive both a NOMNC and SNF-ABN notification approximately three days prior to discharge from Medicare Part A services. She confirmed R605 should have received a NOMNC three days prior to his discharge on 6/1/2024. She confirmed the facility did not provide a NOMNC prior to his discharge on 6/1/2024, and the only NOMNC he received was dated 3/15/2024. She further confirmed the NOMNC and SNF-ABN forms should have been completed and provided to R36 and R81 two to three days prior to their most recent discharge from Medicare Part A services. In an interview on 10/31/2024 at 10:20 am, the Administrator revealed the team was new, and his expectation was the SSD should be providing the NOMNC and SNF-ABN to residents prior to their discharge from Medicare Part A services. He further stated possible outcomes of not providing the notifications were that the residents could possibly be billed for services not covered during that time. He stated he expected staff should make sure everything was provided, signed, and dated appropriately.

Based on observation, staff interviews, and review of the facility's policy titled, Food Service Director, the facility failed to maintain sanitary practices in the kitchen in regard to food handling and hair coverings. The deficient practice had the potential to affect 101 of 103 residents receiving an oral diet from the kitchen. Findings include: Review of the facility's policy titled Food Service Director revealed under Procedure: 6. Food is prepared in a manner that prevents food borne illness. Staff follow proper sanitation and food handling practices. Food is served as soon as possible after it has been prepared, and at the proper safe temperature. Observation on 10/29/2024 at 9:30 am revealed [NAME] NN without a beard net in the kitchen food preparation area. Observation on 10/29/2024 at 9:35 am revealed a fan blowing debris that was accumulated on the fan blades and wire cage towards the food preparation area. Observation on 10/29/2024 at 9:40 am in the dry storage room revealed an unsealed bag of instant food thickener. The bag was left open in the box with the top of the box open as well. The Dietary Manager (DM) was observed tying the bag back up and closing the box. Observation of soy sauce left in the dry storage area with over half of the product used with a label reading, Refrigerate after opening. The DM was observed throwing the product away. Interview on 10/29/2024 at 9:50 am with the DM revealed staff should always have on hair nets at all times as long as they are in the kitchen. She mentioned that they are currently out of beard nets, and she has ordered some and are waiting for them to arrive. However, in the meantime, staff can wear a mask. She also mentioned that the fan should not be blowing towards the food prep area.

Based on observations, staff and interviews, record review, and review of the facility's policies titled Activities of Daily Living (ADLs)/Maintain Abilities, and Care of Fingernails, the facility failed to ensure that Activities of Daily Living (ADL) was provided for two of three residents (R) R72 and R83 reviewed for ADL. Findings include: Review of the facility's undated policy titled Activities of Daily Living (ADLs)/Maintain Abilities under the section titled Intent revealed, It is the facility's responsibility to ensure all staff understand the principles of quality of life and honor and support these principles for each resident; and that the care and services provided are person-centered. Under the section titled Procedure revealed, 3. The facility will provide care and services for the following activities of daily living, hygiene which is bathing dressing, grooming and oral care. 4. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming and personal hygiene Review of the facility's policy titled Care of Fingernails, dated April 2022 under the section titled Steps in the Procedure revealed, 7. Gently, remove the dirt from around and under each nail with an appropriate device; 8. Trim fingernails in an oval shape straight across; 9. Smooth the nails with a nail file or emery board, if necessary. Apply lotion if requested; 10. Repeat the procedure for the second hand. Review of the Electronic Medical Record (EMR) for R72 revealed he was with diagnoses that included but not limited to aphasia, cognitive social deficit following intracerebral hemorrhage, type 2 diabetes mellitus and dementia. 1. Review of R72's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed, Section C (Cognitive Pattern) a Brief Interview for Mental Status (BIMS) of three, which indicated severe cognitive impairment; Section GG (Functional Status) revealed, R72 was dependent for ADLs with one or more-person assistance. Observation on 10/29/2024 at 11:04 am revealed, R72 fingernails were dirty with dark debris underneath them. Observation on 10/30/2024 at 1:20 pm revealed R72 was feeding himself with his hands and his fingernails remained dirty with dark debris underneath them. Interview with R72's family on 10/30/2024 at 1:22 pm revealed his nails were usually dirty. R72 family revealed, that she would wash his hands when she came to visit but did not have anything to clean his nails and that she expected staff to provide nail care. Interview on 10/30/2024 at 1:50 pm with Certified Nursing Assistant (CNA) GG revealed residents were bathed three times per week which included hair care, face care and nail care that should be completed during this time. Interview on 10/30/2024 at 1:50 pm with CNA HH revealed residents are bathed three times per week which includes hair care, face care, foot care and nail care that should be completed during this time. Interview on 10/30/2024 at 2:01 pm with Licensed Practical Nurse (LPN) BB confirmed all residents should be provided with nail care during every bath time except for diabetic residents. Interview on 10/30/2024 at 2:05 pm with the Director of Nursing (DON) confirmed expectations for every resident to receive nail care with each bath as per policy. 37650 2. Review of EMR for R83 revealed, he was admitted to the facility with diagnoses that included but not limited to hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, and muscle weakness. Review of R83's MDS assessment dated [DATE] revealed Section C (Cognitive Pattern) a Brief Interview for Mental Status (BIMS) of 14, which indicated little to no cognitive impairment; Section GG (Functional Status) revealed, R83 had impairment on one side and was dependent for ADLs with one or more-person assistance. Observation and interview on 10/29/2024 at 1:04 pm revealed, R83 sitting up in bed preparing to eat lunch. R83's fingernails were long and dirty with dark debris underneath them. He revealed, staff did not offer R83 a wipe, washcloth or hand sanitizer before eating. Interview on 10/29/2024 at 1:04 pm with R83 revealed, he was not aware that staff could trim his nails and clean underneath them. R83 reported his family member provided his nail care. During an interview on 10/31/2024 at 3:52 pm the Director of Nursing (DON) revealed that the nursing staff was responsible for making sure R83s nails were clean and free of debris. DON revealed nail care was a part of ADL care and should be completed.

Based on observations, resident and staff interviews, record review, and review of the facility policy titled Self-Administration of Medication, the facility failed to adequately assess one of 50 sampled residents (R) (R24) for self-administration of medication. This failure placed R24 at risk for inappropriate and unsafe medication use. Findings Include: A review of the facility policy titled Self-Administration of Medication, dated 4/2022, revealed the Policy was, The purpose of this procedure is to establish uniform guidelines concerning the self-administration of drugs. The General Guidelines section included 1. A resident may not be permitted to administer or retain any medication in his/her room unless so ordered, in writing, by the attending physician and approved by the Interdisciplinary Care Plan Team. A review of R24's electronic medical record (EMR) revealed diagnoses including, but not limited to, cognitive-communication deficit, dementia, major depressive disorder, mild cognitive impairment, psychotic disturbance, mood disturbance, and anxiety. A review of R24's Quarterly Minimum Data Set (MDS) dated [DATE] revealed section C (Cognitive Patterns) documented a Brief Interview for Mental Status (BIMS) of 9 (indicating moderate cognitive impairment). A review of R24's care plan dated 9/21/2024 for R24 revealed a care plan area for knowledge deficit, impaired cognitive function, and some short-term memory deficits. Further review revealed there was no care plan area for self-administration of medication. A review of R24's active Physicians Orders revealed no orders were found for the medication zinc oxide ointment (a topical medication used for skin protection). Observation on 10/29/2024 at 10:59 am in R24's room revealed two boxes of zinc oxide ointment on the resident's bedside table. During an interview on 10/30/2024 at 10:22 am, Registered Nurse/Unit Manager (RN/UM) VV stated residents were not permitted to have medications at their bedside. RN/UM VV explained that, typically, if staff found medication at the bedside, it would be removed and given to the nurse. RN/UM VV further stated when self-administration of medications was considered, the resident had to be assessed for cognitive ability, complete a return demonstration, and obtain approval from the doctor. RN/UM VV stated when a physician's order was updated, the physician could specify which residents were allowed to self-administer medications, and this information would be reflected on the MAR (Medication Administration Record). RN/UM VV further stated that Certified Nursing Assistants (CNAs) were expected to routinely check for medications at the bedside daily, although they didn't typically conduct formal sweeps. She further stated if medication was found at the bedside, it should be reported to the charge nurse or unit manager. RN/UM VV also stated that leaving medication at the bedside could lead to potential risks such as contraindications with other medications, overdose, or various adverse side effects, depending on the medication. During an interview on 10/31/2024 at 10:58 am, the Director of Nursing (DON) confirmed that a physician's order must be in place before allowing medications at the bedside. Additionally, the DON stated a self-administration for medication assessment must be conducted, and the medication must be stored in a locked box. The DON further explained that one of the potential negative outcomes of allowing medications at the bedside was the risk of a roommate accessing the medication or improperly applying it, such as with topical creams. During an interview on 10/31/2024 at 11:00 am, the Administrator confirmed that a self-administration of medication assessment and a physician's order was required for a resident to keep medication at the bedside. The Administrator emphasized that, to his knowledge, no residents were currently authorized to self-administer medications. The Administrator stated that it was the expectation of the nursing staff to check for medications at the bedside daily and if any are found, they are to be removed immediately.

Based on observations, staff interviews, record review, review of the facility policy titled Environmental Services, and review of the manufacturer recommendations titled Monthly Maintenance Front Filters, the facility failed to maintain a clean, homelike environment by not ensuring that packaged terminal air conditioner (PTAC) filters were free of debris in 2 of 42 resident rooms. This failure had the potential to compromise the hygiene and safety of the room environments, increasing the risk of infection and negatively impacting the health and well-being of the residents residing in the rooms.The census was 103 residents. Findings Include: Review of the facility policy titled Environmental Services, dated 4/2022, revealed the Policy stated, It is the primary responsibility of the Housekeeping, Laundry and Maintenance Departments to ensure a safe, sanitary, orderly and comfortable environment. The Policy Interpretation and Implementation section included . 2. Preventative maintenance will be conducted. 7. A safe, clean, comfortable, and homelike environment will be provided. Review of the facility-provided manufacturer recommendations titled Monthly Maintenance Front Filters documented, One of the most important things you can do to maintain your PTAC units is clean the air filters at least once a month, or more often in a new facility or one with new carpeting. Observation on 10/29/2024 at 10:30 am in room [ROOM NUMBER] revealed the PTAC filters to have a thick layer of white, fuzzy substance. Observation on 10/29/2024 at 1:28 pm in room [ROOM NUMBER] revealed the PTAC filters to have a thick layer of white, fuzzy substance. During an interview on 10/31/2024 at 9:36 am, Housekeeper UU revealed maintenance was responsible for cleaning the air filters, and she was unsure how often they were cleaned. During an observation on 10/31/2024 at 9:39 am, the Maintenance Director (MD) confirmed the PTAC filters in room [ROOM NUMBER] had a thick layer of white, fuzzy substance. During an interview on 10/31/2024 at 11:02 am, the Administrator stated that the PTAC filters should be checked monthly. The Administrator emphasized that the expectation was for the filters to be cleaned regularly to ensure good air quality. Furthermore, the Administrator noted that poor air quality could result in negative outcomes, such as respiratory issues for residents. 50272

Based on observations, interviews, record review, and review of facility's policy titled Resident Assessment, the facility failed to ensure that all high-risk medications were coded on the admission assessment for one of 50 sampled residents (R) R309. This deficient practice had the potential to cause resident not to receive person centered care. Findings include: Review of the undated facility's policy titled Resident Assessment, under the section titled Intent revealed, It is the policy of the facility to provide, and services related to Resident Assessment/Instrument and process in accordance with State and Federal regulation. Under the section titled Procedure revealed, This policy will include: 1. Admission Physician orders for Immediate care .7. Accuracy of Assessments. Review of the Electronic Medical Record (EMR) for R309 revealed, she was admitted with diagnoses that included but were not limited to acute respiratory failure, acute embolism and thrombosis of deep veins or right lower extremity, sepsis due to streptococcus pneumoniae, chronic combined systolic and diastolic heart failure. Review of physician orders revealed R309 had orders that included vancomycin intravenous solution (IV antibiotic) with start date of 10/28/2024, furosemide (diuretic) with start date of 10/18/2024, oxycodone-acetaminophen (pain medication) with start date of 10/7/2024, and apixaban (anticoagulant) with start date of 10/7/2024. Review of the 5 (five)-day admission Minimum Data Set (MDS) dated [DATE] for Section N (Medications) revealed that the resident was taking high risk medications that included diuretic, opioid, and a hypoglycemic medication as a resident. There was no indication that the resident was taking an anticoagulant. Interview on 10/31/2024 at 5:55 pm with MDS Director BBB revealed, care plans are updated and reviewed quarterly with assessments, and during Intradisciplinary Team (IDT), Patients at Risk (PAR) and clinical meetings. She also revealed, that the MDS assessment information is received from the resident's profile, clinical and PAR meeting, Patient-Drive Payment Model (PDPM) meeting, nurses' notes, medication administration record (MAR), therapy notes, hospital records, and documentation. The 5-day assessment is to be completed by day 8 from admission and transmitted by day 14. They will have until Day 20 if it includes the admission.

Based on observations, staff interviews, record review, and review of the facility policy titled Care Plan -Comprehensive, the facility failed to develop a comprehensive person-centered care plan that addressed all high-risk medications for two of 50 sampled residents (R) (R309 and R83). This failure had the potential for residents to not receive treatment and/or care according to their needs. Findings include: Review of the facility policy titled Care Plan-Comprehensive, dated January 2023, revealed the Policy stated, A comprehensive care plan that includes measuring objectives and timetables to meet the residents medical, nursing, mental and psychological needs shall be developed for each resident. The Policy Interpretation and Implementation section included 2. The Comprehensive Care Plan has been designed to do the following but was not limited to b. Incorporate risk factors associated with identified problems; d. Reflect treatment goals and objectives in measurable outcomes. 4. Care plans are revised as changes in the resident's condition dictate. Reviews are made at least quarterly. 1.Review of the Electronic Medical Record (EMR) for R309 revealed, that she was admitted to the facility with diagnoses that included but were not limited to acute respiratory failure, acute embolism and thrombosis of deep veins or right lower extremity, sepsis due to streptococcus pneumoniae, chronic combined systolic and diastolic heart failure. Review of physician orders revealed R309 had orders that included but not limited to (diuretic) with start date of 10/18/2024, oxycodone-acetaminophen (pain medication) with start date of 10/7/2024, and apixaban (anticoagulant) with start date of 10/7/2024 and O2 (oxygen) 2L (two liters) NC (nasal cannula) continuous. Review of R309's care plan dated 10/8/2024 revealed, there were no care plans with interventions that addressed the risk for diuretic and anticoagulant medications or the use of oxygen. Interview on 10/31/2024 at 5:35 pm with Infection Preventionist (IP) TT revealed, that any nurse can update the care plan. Interview on 10/31/2024 at 5:55 pm with Minimum Data Set (MDS) Director BBB revealed, care plans are updated and reviewed quarterly with assessments, and during Intradisciplinary Team (IDT), Patients at Risk (PAR) and clinical meetings. 37650 2. Review of EMR for R83 revealed, he was admitted to the facility with diagnoses that included but not limited to hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, and muscle weakness. Review of R83's MDS assessment dated [DATE] revealed Section C (Cognitive Pattern) a Brief Interview for Mental Status (BIMS) of 14, which indicated little to no cognitive impairment. Review of EMR for R83 revealed physician's orders that included but not limited to, valsartan oral tablet 80 mg (milligram), melatonin oral tablet, buspirone hcl oral tablet 15 mg, and duloxetine hcl (hydrochlorothiazide) oral capsule delayed release sprinkle 60 mg. Review of R83's care plan dated 9/14/2024 revealed there was no care plans that addressed psychotropic medication usage. During an interview on 10/31/2024 at 3:46 pm the Director of Nursing (DON) confirmed there was no comprehensive care plan for R83s psychotropic medications. The DON revealed she was not aware there was no care plan for R83s psychotropic medications and that the MDS and Social service department was responsible for ensuring the care plans were developed and updated.

Based on observations, resident, resident family and staff interviews, record review, and review of the facility's policies titled, Medication Administration and Activities of Daily Living (ADLs)/Maintain Abilities, the facility failed to give ordered medications that were readily available for one of 50 sampled residents (R) (R553) and failed to implement resident-directed care and treatment consistent with the resident's orders as directed by podiatrist and professional standards of practice for one of 50 sampled R (R50). The deficient practices had the potential to cause R553 to be at risk for medical complications, unmet needs, and a diminished quality of life and cause pain and possible open skin which can lead to infection for R50. Findings include: Review of the facility policy titled Medical Administration dated April 2022 revealed under Policy Interpretation and Implementation: 8. Unless otherwise specified by the resident's attending physician, routine drugs should be administered as scheduled. Review of the facility policy titled Activities of Daily Living (ADLs)/Maintain Abilities not dated, revealed under Intent: It is the facility's responsibility to ensure all staff understand the principles of quality of life and honor and support these principles for each resident; and that the care and services provided are person-centered. Under Procedure revealed: 3. The facility will provide care and services for the following activities of daily living, hygiene which is bathing dressing, grooming and oral care. 4. Residents who are unable to carry out activities of daily living will receive the necessary services to maintain good grooming and personal hygiene. 1. Review of the electronic medical record (EMR) for R553 revealed that she was admitted with diagnoses that included but were not limited to chronic obstruction pulmonary disease (COPD), and chronic respiratory failure with hypoxia. R553 requires 3 liters per minute (LPM) of oxygen, related to diagnoses. Review of the admission Minimum Data Set (MDS) for dated 11/1/2024 for R553 revealed a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. Interview on October 29, 2024, at 3:59 pm with R553, her son, and her Homecare Aide revealed that the resident had not received her medications. It was revealed that she had not received her night and the following morning medications. The son showed that he brought R553's home medications in hopes that the staff would administer her medications. The son and the Homecare Aide stated that they did inform Registered Nurse (RN) RR. Review of the physician's orders revealed that R553 medications included: albuterol sulfate, atorvastatin, Eliquis, furosemide, levothyroxine, lorazepam, losartan, and Spiriva. An interview on 10/30/2024 at 10:29 am with RN RR confirmed and verified that R553 did not receive night and morning medications. She explained that because the resident arrived late in the afternoon that the pharmacy could not dispense the medication as ordered. Also, she would need the Director of Nursing's (DON) approval for the resident to be given home medications. An interview on 10/30/2024 at 11:41 am with the DON revealed that the facility does have an emergency medication machine. Home medications, if brought to her attention, could be administered after she received an order from the provider. The DON stated that she did not know about the home medication being available or that the ordered medications were not given. 50526 2. Review of the EMR revealed R50 was admitted to the facility with diagnoses including but not limited to malignant neoplasm of colon, hypertension, schizophrenia, and dementia without behavioral disturbance. Review of R50s quarterly MDS assessment dated [DATE] revealed a BIMS score of 00, which indicates R50 was identified to have severe cognitive impairment. Section GG (Functional Status) revealed R50 required maximum assistance for ADLs with two or more-person assistance. Section M (Skin Conditions) did not identify dry scaly skin on both feet. Review of R50s care plan dated 10/7/2024 indicated a problem of potential impairment to skin integrity related to fragile skin, incontinence of bowel and bladder, impaired mobility, history of pressure ulcers. Goals included but not limited to: resident will be free from injury through the review date. Interventions included but not limited to avoid scratching and keep hands and body parts from excessive moisture. Keep fingernails short. Educate resident/family/caregivers of causative factors and measures to prevent skin injury. Encourage good nutrition and hydration in order to promote healthier skin. Keep skin clean and dry. Use lotion on dry skin. Additional problem identified ADL Self Care Performance Deficit r/t (related to) dementia, limited mobility and limited range of motion. Goals included but not limited to improve current level of function in bed mobility, transfers, eating, dressing, toilet use and personal hygiene, ADL through the review date. Interventions included but not limited to explain all procedures/tasks before starting. Skin inspection: R50 requires skin inspection. Observe for redness, open areas, scratches, cuts, bruises, and report changes to the Nurse. Check nail length and clean on bath day and as necessary. Report any changes or necessity for trimming to the nurse. Review of the Physician's Orders for R50 included but was not limited to: Order dated 1/24/2024- podiatry to evaluate and treat mycotic nails, ingrown nails, calluses, abscesses, xerosis, cellulitis, toe contusion, granuloma and foot deformities. Order dated 10/16/2024- amlodipine oral tablet two and a half milligrams (mg) daily for high blood pressure. Order dated 10/17/2024- pepcid oral tablet 20 mg at bedtime for gastric reflux. Order dated 6/21/2023- quetiapine fumarate oral tablet 25 mg at bedtime related to schizophrenia. Order dated 12/27/2023- seroquel oral tablet 25 mg tablet in the morning for schizophrenia and behavioral outbursts. Order dated 12/17/2023- vitamin D3 one and one quarter mg oral tablet weekly. Review of Podiatry Consultation Note dated 10/18/2022 revealed routine nail care visit for thickened toenails and recommendation for moisturizer to lower limbs every week. Review of Podiatry Consultation Note dated 8/17/2023 revealed routine nail care and foot scrub once a week with warm, soapy wash cloth to remove dead skin throughout the feet and then moisturizer to lower limbs every week. Review of Podiatry Consultation Note dated 5/15/2024 revealed routine nail care and foot scrub once a week with warm, soapy wash cloth to remove dead skin throughout the feet and then moisturizer to lower limbs every week. Review of Podiatry Consultation Note dated 8/1/2024 revealed routine nail care and foot scrub once a week with warm, soapy wash cloth to remove dead skin throughout the feet and then moisturizer to lower limbs every week. Observation and interview on 10/29/2024 at 9:48 am with R50 revealed a frail gentleman lying in bed on back with the head of the bed slightly elevated. He was verbally responsive repeatedly saying my legs and pointing. R50 then reached down and pulled the covers away from his feet and lower legs revealing thin legs with shiny, reddened and dry skin, both feet very dry with large, thick, flaking skin. R50 did not add any information regarding pain as he was difficult to communicate with and unable to answer specific questions. Observation and interview conducted on 10/31/2024 at 9:35 am of R50 revealed staff member at bedside speaking with him. He responded when spoken to and was smiling. Staff member pulled the covers back and R50s feet were both nearly free of skin flaking and when R50 was asked if he felt better, he nodded his head repeatedly. Interview on 10/29/2024 at 2:33 pm with R50's family representative revealed he had asked for a podiatrist to come see R50 numerous times and had never heard back about it. He also stated R50 had not been out of bed for about one- and one-half years, he can move but his hands are crumpled, so when he visits, he tries to work with his hands to keep them moving. It was also revealed that R50 did have therapy but not in a long time. An interview on 10/30/2024 at 11:05 am with Licensed Practical Nurse (LPN) II revealed R50 had been treated by the wound treatment team for pressure ulcers before, but only had some redness and the team was not treating any other conditions. An interview on 10/30/2024 at 11:12 am with Certified Nursing Assistant (CNA) JJ revealed she does care for R50, and he received bed baths. Her process was to tell him what she would be helping with, started with washing the face and moved down, she saved his feet for last, washing them off carefully and puts on skin protection cream. CNA JJ further revealed R50's feet had been like this for a long time, and they were not getting better, and she has reported to the nurses a long time ago, unable to remember dates or exactly who she told. An interview on 10/30/2024 at 11:18 am with LPN KK revealed she was a regular nurse on tR50's unit for more than one year and she had not been notified of any orders for skin care for his feet and she was aware they were very dry and flaky. She also confirmed this should be addressed. LPN KK viewed Podiatry Notes in the EMR and confirmed these recommendations should have been put into place and would have been if she had seen them. She then revealed the podiatrist did not provide any information for the care plan when visits at facility were completed and notes were sent later, but the nurses did not get them to review. Interview on 10/30/2024 at 12:25 pm with the Social Service Director (SSD) revealed she did assist with podiatry scheduling and received progress/visit notes back from the provider's office. The SSD further stated if there were orders, these were given to the nursing staff to initiate. If no orders were present, documents were sent to be scanned into the resident chart. The SSD viewed podiatry notes in the EMR and did not see any physician orders but did acknowledge there were treatment orders the nurses should be seeing. The SSD also added if she gave them to the nurse to review, she documented a communication stating this was done. An interview on 10/30/2024 at 2:07 pm with the Director of Nursing (DON) revealed expectations for the process when residents have been seen in house by a provider was that progress/consult notes come back to the SSD and then placed in her in-box so they could be reviewed. The DON would then pass these to the Unit Managers for review and ensure information was shared with the Nurses. The DON also shared any item in the plan of care was to be considered an order without exception and should be carried out by the nursing staff.

Based on record review, interviews, and review of the policy titled Care Plan Policy, the facility failed to update and revise the comprehensive person-centered care plan related to unwitnessed falls for one resident (R) (R#306). The sample size was 35 residents. Findings include: Review of the Care Plan Policy reviewed October 25, 2022, revealed each resident will have a plan of care to identify problems, needs, and strengths that will identify how the facility staff will provide services to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Standard of Practice: Number 1: Each resident will be assessed by the interdisciplinary team on admission, quarterly, annually, and with a significant change in status. Number 12. The plan of care is to be reviewed and updated as necessary at the completion of every assessment by the interdisciplinary team and resident representatives party if so desired. Review of the Admission Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status Score (BIMS) of nine, indicating moderate cognitive impairment. Section E revealed no behaviors exhibited. Section G revealed resident required extensive assistance of two persons with bed mobility, transfers, toilet use, walking in corridor, locomotion on the unit, locomotion off unit, dressing, eating, and personal hygiene. Care Area Assessment (CAA) triggered for Falls. Review of the care plan dated 1/13/2023 revealed resident is at risk for falls related to deconditioning, gait/balance problems, vision (blindness left eye), hearing (hard of hearing) problems. Interventions include anticipate resident's needs, call light within reach, prompt response to all requests for assistance, educate the resident/family/caregivers about safety reminders and what to do if a fall occurs, keep furniture in locked position, keep needed items, water, etc., in reach, maintain a clear pathway, free of obstacles, and provide visual prompts to ask for help. Interview on 6/24/2023 at 8:40 a.m. with Licensed Practical Nurse (LPN) II, indicated when a resident has a fall the Unit Manager (UM) is responsible for updating the residents care plans. Interview on 6/24/2023 at 8:50 a.m. with the Director of Nursing (DON) stated changes to care plans are done by the Unit Manager (UM), care plan team, or the DON. She stated information needed to update resident care plan is provided through Communication in Point Click Care (PCC) or discussed in the morning meeting. During further interview, residents fall risk care plan was reviewed with the DON and she confirmed R#306 had two unwitnessed falls, and there has been no revision or update to the fall risk care plan related to the unwitnessed falls. Interview on 6/24/2023 at 10:05 a.m. with residents Medical Doctor (MD), revealed his expectation when a resident has a fall, an update should be done to their care plan.

Based on record review, interviews, and review of facility policies, the facility failed to ensure proper assessment and followup for one resident (R) (R#306) post fall on 1/20/2023. Specifically, facility failed to complete a fall assessment after an unwitnessed fall, failed to complete neuro-checks on 1/20/2023, and failed to provide Radiology services in a timely manner. Actual harm was identified on 1/23/2023 when resident was transferred to the hospital with continued pain. Computerized tomography (CT) of the head indicated chronic right posterior parietal lobe subdural hematoma. The sample size was 35 residents. Findings include: 1. Review of the policy titled Fall Prevention Protocol Policy revised 10/18/2021 revealed Action number 4. After an incident of a fall: a. Complete the Post Fall Risk Assessment (electronic medical record-EMR); b. Notify Medical Doctor (MD) and Resident Representative. c. Start Neuro check if there is a suspected head injury or for an unwitnessed fall as per facility protocol. d. Complete pain assessment after the fall (EMR). e. Fall placed on the 24-hour report. (EMR). f. Refer to therapy or restorative nursing as deemed appropriate. g. Referrals, Interventions, care plan updates completed in the clinical meeting. h. Review fall incident during the clinical meeting with a root-cause analysis. 2. Review of the policy titled Neurological Assessment Procedure revised 1/17/2022 revealed it is the policy of this facility to perform a neurological vital sign assessment: Upon a physician or health care provider's order, when following an unwitnessed fall protocol, subsequent to a fall or post trauma event with a suspected head injury, when indicated by resident condition. Procedure number 4. perform neurological examination with the ordered frequency. Document on the flow record. Standard of practice sequence for Vital Signs and Neuro Checks: every 15 minutes X one hour, every 30 minutes X one hour, every one-hour X four hours, then every four hours X 24 hours. 3. Review of the policy titled Laboratory, Radiology and Other Diagnostic Services reviewed November 2022, revealed facility will provide laboratory and diagnostic services to meet the needs of the residents in a timely manner. Standard of Practice Radiology or Other Diagnostic Services revealed results from radiology or other diagnostic services will be obtained and acted upon in a timely manner by the physician, physician assistant, nurse practitioner or clinical nurse specialist or the facility staff as ordered. Review of the clinical record revealed resident was admitted to the facility on [DATE] with diagnoses including acute kidney failure, dysphagia, diabetes, hypertension (HTN), and gastroesophageal reflux disease (GERD). Review of the Admission Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status Score (BIMS) of nine, indicating moderate cognitive impairment. Section E revealed no behaviors exhibited. Section G revealed resident required extensive assistance of two persons with bed mobility, transfers, toilet use, walking in corridor, locomotion on the unit, locomotion off unit, dressing, eating, and personal hygiene. Review of the care plan dated 1/13/2023 revealed resident is at risk for falls related to deconditioning, gait/balance problems, vision (blindness left eye), hearing (hard of hearing) problems. Interventions include anticipate resident's needs, call light within reach, prompt response to all requests for assistance, educate the resident/family/caregivers about safety reminders and what to do if a fall occurs, keep furniture in locked position, keep needed items, water, etc., in reach, maintain a clear pathway, free of obstacles, and provide visual prompts to ask for help. Review of the medical record with the DON revealed the resident had unwitnessed falls on 1/19/2023 at 8:35 a.m. and on 1/20/2023 at 10:00 p.m. She confirmed the fall on 1/20/2023 occurred over 24 hours after the fall on 1/19/2023 and stated that neuro checks were initiated but were not complete and there was no fall assessment done for the unwitnessed fall on 1/19/2023. During this time, she confirmed the Physician ordered an x-ray for bilateral hips on 1/20/2023. During further interview, she stated the Unit Managers (UM) are responsible to follow-up on delays with the mobile x-ray. The DON confirmed there is no documentation in the medical record to indicate the UM called to inquire about the delay on x-ray for R#306. DON revealed the online portal for the mobile x-ray shows the request was put in the system on 1/20/2023 as first priority. The DON confirmed there was no fall assessment done for the fall on 1/19/2023 and that the 24 hours for neuro checks was up at 8:45 a.m. on 1/20/2023. She confirmed the staff should have started neuro checks again after the fall on 1/20/2023 at 10:00 p.m. but there was only one done on 1/20/2023 and two on 1/21/2023. Review of the incident report dated 1/20/2023 at 10:00 p.m. revealed R#306 was observed laying on the floor with no clothing on. Staff assisted resident into the wheelchair and performed assessment. Resident complained of pain to bilateral hips and lower back. Medical Doctor (MD) was notified and ordered to give resident 1000 milligrams (mg) of Tylenol at the time and order x-ray of bilateral hips and lower back. Resident was not taken to the hospital. No injuries observed at the time of the incident. Review of the Nurse Note dated 1/21/2023 at 12:06 a.m. revealed (in part) wife called regarding fall, Medical Doctor (MD) was informed of fall and complaints of pain after this afternoon's fall. X-Ray was called and will occur in the morning. Resident has neuro checks on-going right now. Review of the Incident Note dated 1/22/2023 at 9:52 p.m. revealed resident has had two falls this week getting out of bed without assistance. Resident has problems sleeping. Spouse, spent last night with him, and is again tonight to be sure resident does not get out of bed and fall again. Complaints of back pain, x-rays ordered, have not been completed. Show as first priority on mobile x-ray portal. Review of the Nurse Note dated 1/23/2023 at 10:49 a.m. revealed nurse and unit manager spoke with resident's wife who explained she has been waiting for x-rays for her husband, since Friday 1/20/2023 evening around 11:00 p.m. Resident's wife asked to have resident sent to the emergency room to have x-rays done. MD notified of situation. Review of the Physician Order Note dated 1/23/2023 at 10:30 a.m. revealed wife at bedside requesting for resident to be sent to emergency room (E.R.). Patient has had several falls, most recent was Friday 1/20/2023. Patient had consistent pain to bilateral hips with no relief, x-ray was ordered Friday and mobile x-ray has not come to perform test. Resident was sent to ER per resident and wife's request. Phone interview on 6/23/2023 at 12:30 a.m. with family member of R#306 revealed the resident is at home, bedridden and lays in a fetal position. She stated resident is only able to communicate at times, but for the most part is not able to do so. She stated when he does talk, he is confused. She revealed when he fell on [DATE], his wife went to the nursing home to stay with him to ensure the resident did not fall again. Interview on 6/24/2023 at 8:36 a.m. with Licensed Practical Nurse (LPN) EE, revealed when a resident has an unwitnessed fall, she assesses them for injury and if there is no injury, she assists the resident to a chair or the bed. She stated if the resident can say if they hit their head, then she would start neuro checks, call the Physician, the family, or the responsible party. She stated with unwitnessed falls, neuro checks must be done. LPN EE revealed there is no specific orders from the Physician for how often neuro checks should be done, but they follow the facility protocol. She revealed the neuro checks are every 15 minutes for an hour, then every 30 minutes for an hour, then every hour for four hours, and every four hours for 24 hours. During further interview, she stated when a resident has another fall the next day, staff should start the neuro checks over from the beginning starting with every 15-minute neuro checks for the first hour. LPN EE stated a fall assessment is to be completed after each fall a resident has. Interview on 6/24/2023 at 8:40 a.m. LPN II stated when a resident has an unwitnessed fall she assesses the resident for injury, obtains their vital signs, and begins Neuro checks. She stated she calls the Physician and the family. She revealed neuro checks are every 15 minutes for the first hour, every 30 minutes for the second hour, every hour for 4 hours, then every 4 hours for 24 hours. She confirmed when there is a new unwitnessed fall the neuro checks should begin all over again and a fall assessment should be done. Interview on 6/24/2023 at 8:50 a.m. Director of Nursing (DON) revealed it is her expectation that the nurse asses the resident for injury and notify the Physician and family after each fall. She stated neuro checks should be initiated immediately if the fall is unwitnessed or if the resident stated they hit their head or there are signs they hit their head and are completed in a 24-hour period. DON revealed if a resident has two unwitnessed falls occurring within 24 hours of one another, she expects staff to continue the neuro checks from the first fall and not start them over unless the second fall occurred after 24 hours of the first fall.

Based on record review, staff and family interview, and review of the policy titled Pain Management - Acute and Chronic, the facility failed to manage pain for one resident (R) (R#306) after a fall. Actual harm occurred on 1/20/2023 when R#306 had an unwitnessed fall, hitting his head, with complaints of pain in bilateral hips and back. Resident was transferred to hospital on 1/23/2023 with continued pain. Computerized tomography (CT) of the head without contrast indicated chronic right posterior parietal lobe subdural hematoma. The sample size was 35 Residents. Findings include: Review of the facility policy Pain Management - Acute and Chronic reviewed November 2022 revealed the facility will have an effective pain recognition and management that is on-going and committed to resident's comfort, identifying, and addressing barriers to managing pain and addressing any misconceptions that the residents, family, and staff may have about managing pain. Review of the clinical record revealed resident was admitted to the facility on [DATE] with diagnoses including acute kidney failure, dysphagia, diabetes, hypertension (HTN), and gastroesophageal reflux disease (GERD). Review of the Admission Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status Score (BIMS) of nine, indicating moderate cognitive impairment. Section E revealed no behaviors exhibited. Section G revealed resident required extensive assistance of two persons with bed mobility, transfers, toilet use, walking in corridor, locomotion on the unit, locomotion off unit, dressing, eating, and personal hygiene. Section J revealed no pain medications in the past five days. Care Area Assessment (CAA) triggered for Falls. Review of the care plan dated 1/13/2023 revealed resident is at risk for pain related to cervical stenosis. Interventions to care include administer medication as ordered, ask physician to review medication if side effects persist, monitor for increased risk for falls. For respiratory depression: monitor respiratory rate, depth, and effort after administration of pain medications. Review of incident report dated 1/20/2023 at 10:00 p.m. related to a fall revealed R#306 complained of pain to bilateral hips and lower back. Medical Doctor (MD) notified and gave orders to give resident 1000 milligrams (mg) of Tylenol at the time and order x-ray of bilateral hips and lower back. R#306's spouse notified of incident and new orders. Resident was not taken to the hospital. No injuries observed at the time of the incident. Review of Physician order dated 1/20/2023 revealed to ensure fall precautions as per facility protocol, x-ray of bilateral hip and spine related to fall with pain, and Tylenol 1000mg by mouth times one dose now. Review of January 2023 Medication Administrative Record (MAR) revealed on 1/21/2023 the resident was offered Tylenol Extra Strength 500 milligrams (mg) two tablets by mouth at 4:04 a.m. and 9:32 p.m. and facility documented he refused. Further review of the January 2023 MAR indicated staff to assess and document pain. There was no pain documented apart from 1/21/2023 when resident refused the Tylenol. There were no pain medication orders for residents stay in the facility apart from a one-time order of Tylenol. However, there is documentation in the progress notes by staff and the Physician the resident was in pain, consistently, for three days after the fall on 1/20/2023. Review of the Nurse's Note dated 1/21/2023 at 12:06 a.m. revealed (in part) wife called regarding fall, MD was informed of fall and complaints of pain after this afternoon's fall. X-Ray was called and will occur in the morning. Resident has neuro checks on-going right now. Review of the Nurse's Note dated 1/21/2023 at 11:17 p.m. revealed therapy working with resident. When toileting him, resident stood and transferred him off toilet without problem, but when resident stood up with walker, his knees gave way, and resident complained of pain to back. Resident had fall yesterday on 3:00 p.m. - 11:00 p.m. shift, x-ray has been ordered of hips and lumbar spine. Spouse is present in room with resident. Review of Incident Note dated 1/22/2023 at 9:52 p.m. revealed resident has had two falls this week getting out of bed without assistance. Resident has problems sleeping. Spouse spent last night with him and is again tonight to be sure resident does not get out of bed and fall again. Complaints of back pain, x-rays ordered, have not been completed. Show as first priority on mobile x-ray portal. Review of the Skilled Evaluation dated 1/22/2023 at 10:45 p.m. revealed (in part) that R#306 verbalizes pain in back and reports that the pain is constant. Resident gets up without assist and has fallen two times since admission. Resident's wife has started spending the night with him to prevent falls from happening. Review of the Nurse's Note dated 1/23/2023 at 10:49 a.m. revealed at 9:00 a.m. nurse and unit manager spoke with resident's wife, who explained she has been waiting for x-rays for her husband, since Friday 1/20/2023 evening around 11:00 p.m. Resident's wife asked to have resident sent to the emergency room to have x-rays done at a faster pace. Medical Doctor (MD) notified of situation. Review of Physician Electronic Communication dated 1/23/2023 at 10:30 a.m. revealed wife at bedside requesting for resident to be sent to emergency room (E.R.). Patient has had several falls, most recent was Friday 1/20/2023. Patient had consistent pain to bilateral hips with no relief, x-ray was ordered Friday and X-ray has not come to perform test. Resident was sent to ER per resident and wife's request. Phone interview on 6/23/2023 at 12:30 p.m. spouse of R#306 stated resident fell on [DATE], and he complained of pain for three days. She stated his pain became worse after the fall and no one came to do the x-ray that was ordered, so she asked that he be sent to the hospital to have the x-ray done and to address his pain. Interview on 6/24/2023 at 9:00 a.m. Director of Nursing (DON) and Licensed Practical Nurse (LPN) EE provided surveyor a paper titled Incident Packet. The DON revealed the document is kept in at the nurse's station and is what the nurses are to follow when there is a fall. The document revealed all charting must be completed, please do not leave blanks, failure to complete will result in returning to facility the same day to complete. It indicated new onset of pain, send to emergency room (ER) for evaluation and notify DON. Interview on 6/24/2023 at 10:05 a.m. residents' Medical Doctor (MD) stated when resident fell , there would have been someone in the facility to assess him and determine if there was a need to send him out. He stated it is not always necessary to send a resident out for pain. He stated after a fall, the facility monitors vital signs, assesses their movement, mental status, and pupil reaction. He stated pain medications have to be utilized very carefully due to the potential to cause falls and addiction. Review of the ER records dated 1/23/2023 revealed (in part) under Chief Complaint on page 5 the resident informed the ER Physician the condition started three days ago when he had a ground level fall from a height of one - two feet, landing on a hard floor. Resident revealed he had no blood loss, and the point of impact was the head and back and the pain is moderate. On page eight of the ER records indicated the ER Physician documented resident had midline tenderness to palpitation in the lumbar spine and left leg tenderness to palpitation of the left lower extremity, neurovascular intact. On page nine of the ER records, it is documented that resident received fentanyl 75 micrograms (mcg) Intravenously (IV) at 12:41 p.m. and Tylenol 1000 mg by mouth. Page 10 of the ER records revealed x-ray femur left two- views indicating: 1. No acute osseous abnormality identified. 2. Diffuse superficial soft tissue edema, and a computerized tomography (CT) head without contrast indicating: 1. Mild to moderate cortical atrophy and chronic periventricular white matter ischemic changes. 2. Chronic right posterior parietal lobe subdural hematoma, new since last CT study. On page 15 of the ER report at 3:29 p.m. it is documented that the flight crew is leaving with patient.