Every finding on record at Roselane Health Center by Harborview

Based on observations, interviews, record review, and review of the facility policies titled Abuse, Neglect and Exploitation and Reporting Reasonable Suspicion of a Crime, the facility failed to protect two of 33 sampled residents (R)(R57 and R148) from abuse. Harm was identified to have occurred on 11/14/2025 when R57 sustained bruising and a skin tear after staff grabbed her arm. Findings included:1. A review of the electronic medical record (EMR) revealed resident R57 was admitted to the facility on [DATE] with a diagnosis of, but not limited to, the following: Acute embolism and thrombosis of the right femoral vein, history of pulmonary embolism, fibromyalgia, major depressive disorder, and dementia with agitation.A review of R57's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 10, which indicated R57 had moderate cognitive impairment; that R57 requires setup and cleanup and substantial assistance with toileting hygiene and showering; that R57 requires partial assistance from staff for upper body dressing; that R57 requires substantial assistance for lower body dressing and footwear on and off, and personal hygiene; and that R57 is dependent on the staff for transfer.The review of R57's care plan dated 9/3/2025 indicated a need for activities of daily living (ADL) assistance due to impaired mobility.A review of facility documents revealed that on 11/14/2025, R57 reported that she had asked to be assisted back to bed, and the Certified Nursing Assistant (CNA) AAA, told her she could put herself in bed. The resident further stated that the CNA twisted her arm during the interaction. The nursing supervisor removed the CNA from the floor immediately and did a head-to-toe assessment of R57. R57 had a skin tear to the right arm, where R57 said the CNA twisted her arm. On 11/15/2025, another skin assessment was performed on R57, and bruising in the pattern of fingerprints could be seen around the skin tear on R57's right arm. The responsible party and the police were notified. The CNA AAA immediately submitted a written resignation and left before the police got to the facility.During an observation on 2/15/2026 at 1:56 pm, R57 was observed lying in bed on her left side away from the door. The resident did not answer when questioned about the abuse incident.During an observation on 2/16/2026 at 4:00 pm, R57 was observed lying in bed. The resident would not answer questions related to the incident and asked the surveyor to leave her room.An interview was attempted with R57 on 2/18/2026 at 9:30 am, but the resident refused.2. A review of the EMR revealed that R148 was last admitted to the facility on [DATE] with diagnoses including, but not limited to, essential (primary) hypertension, gastro-esophageal reflux disease, asthma, hemiplegia, and hemiparesis following cerebral infarction affecting the right dominant side. During an interview at 2:30 pm on 2/15/2026 with Social Worker District Coordinator (SDC) revealed that she was told by the staff that CNA BBB verbally abused R148 by yelling at her to shut up, however, she was not present at the time the verbal abuse incident occurred. The SDC stated she spoke with R148 regarding the alleged verbal abuse incident, and that R148 confirmed the allegation of verbal abuse by nodding her head yes. SDC stated she notified the Administrator (ADM) of the alleged verbal abuse incident.During an interview on 2/16/2026 at 2:50 pm, the ADM revealed she was contacted by the SDC on 12/3/2025 regarding the verbal abuse allegation. The ADM stated she interviewed R148 regarding the alleged verbal abuse allegation. She stated R148 is nonverbal but confirmed the verbal abuse allegation by nodding her head up and down to confirm that it occurred. An interview with the Director of Nursing (DON) on 2/18/2026 at 10:30 am revealed that her expectations to prevent abuse are that no physical or verbal abuse is tolerated and will be dealt with swiftly.An interview with the ADM on 2/18/2026 at 3:05 pm revealed that she expects that abuse does not happen at all in the facility.A review of the facility policy titled Abuse, Neglect and Exploitation revised on 7/15/2025, under the section titled Policy, states it is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property.section1a revealed that the policy will prohibit and prevent abuse, neglect, and exploitation of residents. Section 5a Analyzing the occurrence to determine why abuse occurred, and what changes are needed to prevent further occurrences.Further review of the facility policy titled Reporting Reasonable Suspicion of a Crime, revised on 8/1/2024, titled Policy, states it is the policy of this facility pursuant to Section 1150B of the Social Security Act, to report any reasonable suspicion of a crime committed against a resident of this facility.

Based on observations, interviews, and record review, the facility failed to ensure that kitchen staff wore appropriate beard nets. This deficient practice had the potential to contaminate food and cause food-borne illnesses. The facility had a census of 127.Findings included: During an observation on 2/15/2026 at 11:39 am, during the initial kitchen tour, the [NAME] (Cook NN) and the Food Service Director (FSD) were observed to have facial hair with no beard nets. On 2/16/2026 at 10:49 am, during the comprehensive kitchen tour, the [NAME] (Cook OO) and the FSD were observed to have facial hair with no beard nets. On 2/16/2026 at 12:05 pm, during the food temperature observation, [NAME] OO, [NAME] NN, and FSD were observed not to be wearing beard restraints. [NAME] OO took temperature readings for fifteen items. While testing the temperature of the food items, he had to lean over the steam table. His beard came into proximity to hot foods. On 2/16/2026 12:30 pm, the FSD confirmed beard restraints were on order for Dietary staff, and individuals with facial hair should wear restraints to prevent hair coming in contact with food. A review of facility policy titled Dietary Employee Personal Hygiene, dated 3/1/2022 and revised 9/1/2025, revealed that employees should never use bare hand contact with any foods, ready to eat or otherwise, and that all dietary staff must wear hair restraints (e.g., hairnet, hat, and/or beard restraint) to prevent hair from contacting food.

Based on observation, staff interviews, and a review of facility policy titled Puree Food Preparation, it was determined that the facility failed to follow puree preparation guidelines to ensure puree food was prepared in a manner to conserve the nutritive value/appearance, and palatable for eight of eight residents who are on a puree or mechanical diet. This deficient practice places residents at risk for swallowing and choking hazards. Findings included: A review of the facility's policy titled Puree Food Preparation, dated 3/1/2022 and revised 6/1/2024, revealed, It is the policy of this facility to provide puree food that has been prepared in a manner to conserve nutritive value, palatable flavor, and attractive appearance.A review of the Puree Food Preparation Guideline per Serving revealed (more or less may be used depending on the consistency of the cooked food): Meats: Add 1 teaspoon beef broth or beef gravyPoultry: Add 1 teaspoon chicken broth or chicken gravyFish: Add 1 teaspoon of mayonnaiseNoodles: Add 1 teaspoon of margarineVegetables (leaf, stem, or flower) Add 2 teaspoons mashed potato flakesVegetables (root tuber): Add 1 teaspoon of margarineFruits (EXCEPT grapes, oranges, grapefruit, bananas, plums): Remove peels, skins, cores, pits, and or seeds. Add 1 tablespoon of food thickener (most watery fruits require a food thickener).On 2/16/2026 at 10:49 am, [NAME] OO was observed for puree food preparation. [NAME] OO stated that he had worked at the facility for five months and had been a cook for five years. The Food Service Director (FSD) was present during the Puree preparation and confirmed that there were eight residents currently receiving a pureed diet. Three (3) puree items were prepared, including pulled pork, carrots, and baked beans. [NAME] OO did not have all the supplies available before initiating the puree preparation. He stopped production to retrieve beef base and failed to use proper hand hygiene before resuming food preparation; failed to use a recipe and failed to use proper hand hygiene between preparation of each pureed item, observed to use a sink to rinse utensils; and failed to measure ingredients to ensure appropriate consistency for resident consumption. When asked to describe the expected consistency of each puree item, [NAME] OO stated, a peanut butter consistency. He did not follow a puree recipe and acknowledged that he did not know where the recipes were located. The FSD clarified that recipe books were on a shelving unit adjacent to the puree prep area.During an interview with the Administrator on 2/18/2026 at 1:58 pm, it was revealed that pureed foods should be prepared in accordance with recipes to present food integrity and nutritive value.

Based on observations, staff and resident interviews, record review, and review of the facility's policy titled Residents' Rights, the facility failed to allow choice of personal hygiene care, bathing, or showering of one of 33 sampled residents (R) (R112). This deficient practice had the potential to cause loss of dignity and sense of control over life's needs and contributed to depression and poor skin integrity. Findings included: During an observation and interview on 2/15/2026 at 2:30 pm, a malodorous smell was detected in R112's room. During the interview, R112 admitted that when he is offered a bath, it is always a bed bath because he requires a mechanical lift to get out of bed. He stated that he would prefer a shower instead of a bed bath. During a follow-up interview with R112 on 2/16/2026 at 1:30 pm, he stated that he would prefer a shower but said that it is too much work for the staff, so he doesn't push the issue. A review of the electronic medical record (EMR) revealed R112 was admitted to the facility on [DATE] with pertinent diagnoses, including but not limited to morbid obesity, systolic heart failure, atrophic disorder of skin, xerosis cutis, bipolar disorder, and major depressive disorder.A review of R112's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14, which indicated R112 is cognitively intact. The functional status on the assessment revealed R112 required two staff members for care due to morbid obesity. He required a mechanical lift for transfers from bed to chair and back to bed. He is incontinent with his bowels and bladder. A review of R112's care plan dated February 2026 indicated a problem of alteration in elimination of bowel/bladder related to benign prostatic hypertrophy, medication use, decreased mobility, diagnosis of urinary retention, and incontinence. A review of December 2025 and January 2026 shower sheets revealed that there were only five shower sheets for R112 in December 2025 (all documented bed baths) and three shower sheets for January 2026 (all documented bed baths). There was no documentation for refusals, and no documentation that R112 was ever provided with assistance in taking a shower.During an interview on 2/16/2026 at 3:00 pm, Certified Nursing Assistant (CNA) AA revealed that R112 is very particular about who showers him, and this usually occurs during the second shift.During an interview on 2/16/2026 at 3:10 pm, Registered Nurse (RN) BB revealed that she had been working at this facility for three years and was unaware that R112 wanted showers rather than bed baths. She stated that if a resident refuses a bath or shower, the CNA is supposed to complete a shower sheet, document the refusal, and notify the charge nurse on the hall so she/he can ask the resident and confirm the refusal. All residents are to have a shower sheet completed on their shower day, indicating the type of bath or shower, or if they refuse, and the charge nurse signs the sheet.During an interview on 2/18/2026 at 10:26 am, the Director of Nursing (DON) confirmed that every resident should have two shower sheets per week, and that the type of bath, refusals, and any skin issues should be documented. She states that expectations for resident choice include honoring residents' choices and making accommodations for them. During an interview on 2/18/2026 at 11:02 am, the Administrator stated that the expectations are that the resident's baths be a personal choice and that accommodations be made to honor their choices.A review of the facility's policy titled Residents' Rights, with the last revision date of 2/1/2025, revealed the resident has the right to, and the facility must promote and facilitate resident self-determination through support of resident choices, including (a) The resident has the right to choose activities, schedules, and health care, and to make choices about aspects of his or her life in the facility that are significant to the resident.

Based on record review, staff interviews, and review of the facility's policy titled MDS 3.0 Completion, the facility failed to ensure quarterly Minimum Data Set (MDS) assessments were completed within the required regulatory timeframe for two of three sampled residents (R) (R33 and R104). This deficient practice had the potential to delay the development and implementation of an updated comprehensive care plan and impact regulatory compliance.Findings included:A review of the Electronic Health Record (EHR) revealed R33 was admitted on [DATE].A review of the R33's Minimum Data Set (MDS) assessments revealed the following Assessment Reference Dates (ARDs):12/21/2024 - Quarterly Assessment3/25/2025 - Quarterly Assessment3/29/2025 - Quarterly Assessment6/29/2025 - Quarterly Assessment9/21/2025 - Annual Assessment12/22/2025 - Quarterly AssessmentFurther review determined the interval between the 12/21/2024 Quarterly Assessment and the 3/25/2025 Quarterly Assessment was 94 days, exceeding the 92-day regulatory timeframe from the prior Omnibus Budget Reconciliation Act (OBRA) assessment.During an interview on 2/18/2026 at 11:56 am, the Registered Nurse-Vice President of Clinical Reimbursement (RNVPCR) VV, confirmed the assessments were late by two days (94 days between intervals). She stated she expects to monitor the assessment schedule to ensure dates are set according to Resident Assessment Instrument (RAI) guidelines.During an interview on 2/18/2026 at 1:25 pm, the Administrator and National Director of Risk Management (NDRM) WW revealed the expectation is that assessments are completed on time. They identified potential negative outcomes, including failure to meet regulatory requirements and inability to ensure appropriate care planning within required timeframes.A review of the facility policy titled MDS 3.0 Completion, revised on 1/1/2026, revealed that the facility conducts initially and periodically a comprehensive, accurate, and standardized assessment of each resident's functional capacity, using the RAI specified by the State. As stated under the section titled Types of OBRA Assessments. Annual Assessment - a comprehensive assessment completed using an ARD no >366 days from the most recent prior comprehensive assessment and no >92 days from the most recent quarterly assessment (counting ARD to ARD). Quarterly Assessment - completed using an ARD no >92 days from the most recent prior quarterly or comprehensive assessment (counting ARD to ARD).

Based on observations, record review, and resident and staff interviews, the facility failed to ensure that Activities of Daily Living (ADL) care was provided for three of 33 sampled residents (R) (R15, R46, and R125) related to showers and bed baths according to the schedule. Findings included:1. During the initial screening interview on 2/15/2026 at 2:07 pm, R15 shared that she had not had a shower since her admission. She mentioned that she received bed baths; however, she expressed a preference for showers and declined once, when a male provider proposed to assist her with the shower task.A review of the electronic medical record (EMR) for R15 revealed she was admitted to the facility on [DATE] with diagnoses including, but not limited to, orthopedic aftercare following surgical amputation, sepsis, gangrene, atheroembolism of unspecified lower extremity, abscess of left foot, and urinary tract infection.A review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed R15 presented with a Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive impairment, impairment on one side of the lower extremity, and dependent with shower/bathing.A review of the care plan initiated on 1/16/2026, and last revised on 2/17/2026, confirmed focus on ADL care assistance related to decreased/impaired mobility. Goals included that R15 would receive ADL care assistance as recommended through the next review. Interventions included that R15 required assistance of two staff with bath/shower, transfers, and toileting as needed until therapy screen is completed - prefers bed baths.An examination of the bath schedule for the [NAME] Wing indicated that R15's room was allocated a shower on Monday and Thursday from 3:00 pm to 11:00 pm. However, no bath sheet was supplied for the date of 2/2/2026. The records for February bath sheets showed that one shower was administered out of the four scheduled dates.An interview and observation conducted on 2/17/2026, at 10:38 am, with R15 disclosed that her new roommate was given the opportunity to take a shower on the first day; however, no one inquired whether she would like to take a shower.2. Interview and observation on 2/16/2026, at 5:53 pm, R46 was in bed; her hair appeared oily and styled in a single braid at the back. R46 was eating; oral inspection could not be performed; she indicated that she had not had a shower.A review of the clinical record for R46 revealed she was admitted to the facility on [DATE] with diagnoses including, but not limited to, hemiplegia, unspecified affecting the right dominant side, contracture, and right hand.A review of the quarterly MDS assessment dated [DATE] revealed that R46 presented with a BIMS score of 14, indicating no cognitive impairment, and that R46 was dependent on staff for oral hygiene, toileting hygiene, shower/bathe self, lower body dressing, and putting on/taking off footwear.A review of the care plan initiated on 1/21/2025 revealed R46 had an ADL self-care performance deficit related to activity intolerance, impaired balance, and limited mobility related to right-sided hemiplegia. Goals included that R46 will maintain the current level of function in ADL care through the review date. Interventions included checking nail length and trimming and cleaning nails on bath day, to report any changes to the nurse, to provide a sponge bath when a full bath or shower cannot be tolerated, and that R46 requires the assistance of two staff with bathing/showering.An examination of the bath schedule for the East Wing indicated that R46's room was allocated a shower on Tuesday and Thursday from 7:00 am to 3:00 pm. The records for February 2026 bath sheets revealed dates 2/3/2026 and 2/5/2026, with no indication of what bathing was provided.During an interview on 2/15/2026 at 1:04 pm, the family representative for R46 indicated that the resident's hair seemed to have never been shampooed, her teeth appear to be caked with debris and not brushed, and all leadership, particularly the Director of Nursing (DON) and the Social Worker Director, has been informed.During an interview on 2/17/2026 at 3:51 pm, Licensed Practical Nurse (LPN) UU disclosed that there were two shower sheets available for R46 but that a total of six should have been present. Upon examining the shower forms to verify if baths or showers were performed, LPN UU indicated that nothing was recorded. Additionally, LPN UU confirmed that if a resident refused care, it should be documented and confirmed that there have not been any recent reports of such refusals for R46.During an interview on 2/17/2026, at 1:32 pm, the DON indicated that all residents should be provided with a shower on scheduled days. In cases where a resident declines, a nurse's signature must be recorded on the shower sheet, as the nurse is required to return to the resident's room to ask again. If the task cannot be completed, a note should be added to the progress notes, and the care plan must be updated accordingly.3. A review of the EMR revealed resident R125 was admitted to the facility on [DATE] and pertinent diagnoses including but was not limited to rheumatoid arthritis of right shoulder with involvement of other organs, left and right above the knee amputation, diastolic heart failure, atherosclerotic heart disease of native coronary artery, morbid obesity, chronic kidney disease stage 3, pressure ulcer of sacral region unstageable, obstructive sleep apnea, and anxiety disorder.Review of R125's quarterly MDS assessment dated [DATE] revealed a BIMS of 15, which indicated R125 was cognitively intact, that R125 required setup and clean-up assistance for meals, and that R125 was dependent on staff for oral hygiene, toileting, showers, dressing, and personal hygiene.A review of R125's care plan dated 12/22/2025 indicated a behavior problem pertaining to excessive clutter in his room. Interventions included, but were not limited to, the staff assisting R125 in removing unwanted items. Problem-R125 is at risk for falls related to bilateral amputations, morbid obesity, and vertigo. Interventions: Assess that the wheelchair is the appropriate size; assess the need for footrests; assess the need to have the wheelchair locked for safety.A review of the paper shower sheets for December 2025, January 2026, and February 2026 revealed that there were only three bath sheets for December, four for January, and two for February.Observation and interview on 2/15/2026 at 2:26 pm with R125 revealed a very strong body odor upon this surveyor's entry into the resident's room. R125 and his roommate revealed that they do not get baths consistently, less than twice a week, per the facility procedure. R125 will only take bed baths because he stated he has orthostatic hypotension and does not feel comfortable sitting up in a shower or wheelchair. He stated that he does refuse on some occasions when he is not feeling well, but not very often, and now the staff has just quit offering baths altogether.An interview with R125, conducted on 2/1/2026 at 2:18 pm, revealed that he never gets out of bed and is scheduled for baths on Tuesdays and Thursdays.An interview with Certified Nursing Assistant (CNA) AA on 2/16/2026 at 2:40 pm revealed that R125 takes a complete bed bath when he wants to, and that all residents must have a shower sheet completed on their shower day, documenting the type of bath, any skin issues, and whether they refused. So, every resident should have at least two shower sheets documented each week, whether they refused their bath or not.An interview with LPN BB on 2/16/2026 at 3:00 pm revealed that R125 does not feel comfortable getting out of bed, due to being a double above-knee amputee. He feels off balance sitting in a chair, so he will only accept bed baths. She also confirmed that every resident should have a bath sheet for every day they are scheduled for a bath, and if they request an extra bath during the week. If the resident refuses, the bath sheet should reflect that, and the charge nurse must sign it. All residents are scheduled for two baths a week.An interview with the DON on 2/18/2026 at 10:26 am revealed that bath sheets are to be completed for every resident who is offered a bath or shower at least twice a week. If they refuse, that should be reflected on the bath sheet, and the charge nurse should be notified so they can follow up with the residents to ensure that they do not want a bath and if another time would be better. She stated that the expectation is that every resident be offered baths/showers at least twice weekly, and a shower sheet be filled out to document the bath, their skin condition, and refusals. A review of the facility's policy titled Activities of Daily Living (ADLs), revised 7/15/2026, section Policy 1, revealed that care and services will be provided for the following activities of daily living: 1. Bathing, dressing, grooming, and oral care.

Based on observation, record review, staff interviews, and review of the facility's policy titled Oxygen Administration, the facility failed to ensure the oxygen concentrator filter was free of debris for one of 30 residents (R) (R30) receiving oxygen therapy. This deficient practice created the potential for impaired oxygen delivery, inhalation of contaminants, and worsening respiratory symptoms.Findings included:A review of the Electronic Health Record (EHR) revealed R60 was admitted on [DATE] and readmitted on [DATE] with diagnoses including but not limited to chronic obstructive pulmonary disease (COPD), chronic respiratory failure with hypoxia, interstitial pulmonary disease, and paroxysmal atrial fibrillation.A review of the quarterly Minimum Data Set (MDS) dated [DATE] documented that the resident receives oxygen therapy.A review of physician orders dated 2/4/2026 revealed an order to Clean Oxygen (O2) Concentrator Filter once weekly and as needed.A review of the resident's care plan revealed the resident was care planned for COPD and oxygen therapy with interventions including oxygen as ordered and monitoring for signs and symptoms of acute respiratory insufficiency, including anxiety, confusion, restlessness, shortness of breath at rest, cyanosis, and somnolence.Observations conducted on 2/15/2026 at 2:09 pm, 2/16/2026 at 1:30 pm, and 2/16/2026 at 4:20 pm in revealed the oxygen concentrator filter contained gray, fuzzy debris.An interview and observation conducted on 2/17/2026 at 9:53 am with Certified Nursing Assistant (CNA) TT stated that another nurse specializes in oxygen concentrators and changes them, but she was unsure of the schedule. CNA TT confirmed the oxygen concentrator filter contained gray, fuzzy debris.An interview conducted on 2/17/2026 at 10:05 am with Licensed Practical Nurse-Unit Manager (LPN) UU stated that the facility recently transitioned from having a Respiratory Therapist (RT) who previously checked concentrators twice weekly. She stated nursing staff is now responsible for weekly cleaning. She reported checking concentrators on 1/30/2026, but acknowledged she did not turn the concentrator around to inspect the filter. She stated it had likely been over two weeks since the filter had been checked and identified potential negative outcomes, including the resident breathing in bacteria and becoming ill.An interview conducted on 2/18/2026 at 10:26 am with the Director of Nursing (DON) confirmed the facility currently does not have a Respiratory Therapist and that external filters are expected to be cleaned weekly. The DON stated that potential negative outcomes include respiratory symptoms related to a clogged or dirty filter.An interview conducted on 2/18/2026 at 1:25 PM with the Administrator revealed expectations that oxygen concentrators are cleaned weekly, monitored, and audited. She stated that a potential negative outcome could include compromised breathing.A review of the facility policy titled Oxygen Administration, revised on 10/1/2025, revealed under the section titled Policy, Oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident's goals and preferences. As stated under the section titled Policy Explanation and Compliance Guidelines, Follow manufacturer recommendations for the frequency of cleaning equipment filters. Cleaning and care of equipment shall be in accordance with facility policies for such equipment.

Based on record review, staff interviews, and review of the facility's policy titled Antibiotic Stewardship Program, the facility failed to ensure antibiotic medications were not administered unnecessarily for two of five sampled residents (R) (R92 and R10) reviewed for unnecessary medications. This deficient practice had the potential to cause adverse drug reactions, medication interactions, and the development of multidrug-resistant organisms (MDROs).Findings included:1. A review of the Electronic Health Record (EHR) for R92 revealed she was admitted on [DATE] with a most recent readmission date of 4/7/2025 with diagnoses included, but not limited to, vascular dementia with psychotic disturbance, delirium due to a known physiological condition, urinary retention, cerebrovascular disease, metabolic encephalopathy, and major depressive disorder.A review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented that R92 presented with a Brief Interview for Mental Status (BIMS) score of 12, indicating moderate cognitive impairment; and documented active use of antidepressants, anticoagulants, antiplatelet, and anticonvulsant medications.A review of physician orders revealed a urinalysis with culture and sensitivity was ordered on 1/8/2026 due to increased confusion and hallucinations.A practitioner note dated 1/13/2026 documented that the urinalysis results were positive for a urinary tract infection (UTI). The practitioner ordered Nitrofurantoin 100 milligrams (mg) to be administered by mouth two times per day (BID) for seven days.A record review of the January 2026 Medication Administration Record (MAR) revealed R92 was administered Nitrofurantoin Macrocrystal (antibiotic medication) 100 mg by mouth twice daily for seven days from 1/13/2026 through 1/19/2026.A record review of the Antibiotic Stewardship Binder under the document titled Antibiotic Dispensed revealed that R92 was administered Nitrofurantoin Macrocrystal 100 mg BID for seven days with a start date of 1/13/2026. Documentation in the binder indicated R92 did not meet McGeer criteria for antibiotic initiation.A review of the revised McGeer Criteria for Infection Surveillance Checklist provided by the facility, dated 1/8/2026, revealed documentation of increased confusion and visual hallucinations for R92. The checklist indicated that UTI criteria were not met.2. A review of the EHR for R10 revealed he was admitted on [DATE] with diagnoses included, but not limited to, infection and inflammatory reaction due to an indwelling urethral catheter, neuromuscular dysfunction of the bladder, urinary retention, acute cystitis without hematuria, Type 2 diabetes mellitus with hyperglycemia, unspecified psychosis, and major depressive disorder, recurrent, moderate.A review of the Quarterly MDS assessment dated [DATE] documented that R10 presented with a BIMS score of 14, indicating that the resident was cognitively intact; that the resident had an indwelling catheter; and that he was ordered to receive antipsychotic, antidepressant, antibiotic, opioid, antiplatelet, hypoglycemic (including insulin), and anticonvulsant medications.A record review of R10's care plan revealed the resident had an indwelling catheter related to obstructive uropathy and urinary retention, and the care plan directed staff to observe and report signs and symptoms of a UTI, including but not limited to foul-smelling urine, cloudiness, altered mental status, and behavior changes.A record review of progress notes dated 1/13/2026 documented that R10's urine was cloudy with foul smell and sediments, and the practitioner was notified with a request for urine testing.A review of physician orders revealed Ciprofloxacin Hydrochloride 250 milligrams was ordered to be administered by mouth every 12 hours for five days for a UTI, with an order date of 1/20/2026.A review of the January 2026 MAR revealed that R10 was administered Ciprofloxacin HCl Tablet 250 MG every 12 hours for five days from 1/20/2026 through 1/26/2026 for urinary tract infection.A review of the revised McGeer Criteria for Infection Surveillance Checklist for R10, dated 1/13/2026, revealed documentation of foul smell, cloudy urine, and sediments. The checklist indicated urinary tract infection criteria were not met.A review of the Antibiotic Stewardship Binder under the document titled Antibiotic Dispensed revealed R10 was administered Ciprofloxacin Hydrochloride 250 milligrams every 12 hours for five days. Documentation in the binder indicated R10 did not meet McGeer criteria for antibiotic initiation.During an interview on 02/17/2026 at 12:49 pm, the Director of Nursing (DON) revealed that the facility had not been appropriately following antibiotic stewardship practices per their policy and with McGeer criteria. The DON further acknowledged that the facility had not been conducting antibiotic time-outs and that the data tracking tool for stewardship had not been properly implemented. She confirmed the antibiotic stewardship data had been inaccurate due to previous infection prevention oversight. The DON stated that R92 was treated due to increased confusion and hallucinations and positive urine culture with 50-100,000 colony count of Escherichia coli (bacteria), but confirmed treatment was initiated without meeting McGeer criteria. She identified potential negative outcomes, including adverse drug reactions, increased risk of Clostridioides difficile infection, and antibiotic resistance, stating the issue is multifactorial. She stated R92 and R10 did not meet McGeer criteria and confirmed they were administered unnecessary medication.During an interview conducted on 2/18/2026 at 9:12 am, Nurse Practitioner (NP) II revealed she prescribes antibiotics based on the clinical picture and not solely lab results. She stated potential negative outcomes of unnecessary antibiotics include the development of MDROs. She confirmed that inappropriate prescribing can contribute to resistant organisms.During an interview conducted on 2/18/2026 at 1:25 pm, the Administrator and National Director of Risk Management revealed expectations that providers follow McGeer criteria. They stated that if prescribing patterns do not meet protocol, physician privileges can be addressed. They identified potential negative outcomes of unnecessary antibiotics, including MDRO development, inappropriate treatment of organisms, medication interactions, adverse reactions, and potential escalation of the resident's condition requiring a higher level of care.A review of the facility policy titled Antibiotic Stewardship Program reviewed on 6/1/2025 revealed, the facility uses the CDC's (Centers for Disease Control and Prevention) NHSN (National Healthcare Safety Network) Surveillance Definitions and updated McGeer criteria to define infections and determine whether to treat an infection with antibiotics. Under the section titled Monitoring antibiotic use, the policy states, random audits of antibiotic prescriptions shall be performed to verify completeness and appropriateness, and that antibiotic use will be monitored and tracked.

Based on observations, record review, and a review of the facility's policies titled Medication Administration, the facility failed to be free of a medication error rate of 5 percent or less for six of 25 observations (24 percent medication error rate). This deficient practice had the potential to cause serious medication side effects and health issues.Findings included:During an observation of medication administration on 2/17/2026 at 9:12 am, R22 was observed to have a gastrostomy tube (GT) through which all medications were to be administered. Licensed Practical Nurse (LPN) FF crushed R22 medication together in the same envelope, mixed them in water, and administered it through the GT. Per professional standards, the medications should be crushed separately and given separately through the GT. There was also an omission of a Coreg 6/25mg, which was not available on the cart. LPN FF did not call the pharmacy nor check the emergency stock for the medication. A review of the electronic medical record (EMR) revealed that multiple residents had missing documentation in their medication administration records (MARs) on February 9th and 10th. R11 is missing documentation for enoxaparin Sodium Solution 40mg/0.4ml subcutaneously at bedtime dated 2/9, diazepam 10mg 1 po every 12 hours, missing documentation for the 2100 dose 2/9, Micatin Cream 2% 1700 2/10, and albuterol inhalation solution at 0000 and 0600 doses Oxycodone HCL tablet 20mg 1 tab by mouth every 4 hours routine missing documentation at 0000, and 1400 on 2/10/2026. Multiple missing documentations for R22 as follows, 2/10 9:00 am missing blood pressure and amlodipine besylate 10mg tab, change feeding syringe every night shift 2/10, clonidine transdermal patch weekly 0.2mg/24hours 2/10 0900am, MiraLax oral powder 17gm 2/10 9:00 am, Nexium oral packet 40mg 2/10 0600 am, vitamin B1 100mg 2/10 0900 am, Amantadine HCL oral capsule 100mg 2/10 at 0900 am, Coreg oral tab 6.25mg missing blood pressure and medication documentation 2/10 at 0900 am and 1700 pm. Enteral feeding2/10 at 0600 am and 1600 pm. Multiple missing documentations in MAR for R86 for 2/10 @ 0600am Protonix 40mg, 2/10 0600 am Methocarbamol 750mg, 2/10 0600 am acetaminophen 325mg 2 tabs. , 2/10 0400 oxycodone HCl 1 tab by mouth every 4 hours.The average medication error rate is 24%. 25 medications observed, 2 residents had the medication errors. The major cause of the medication errors was that the medications were crushed together and given together in a gastrostomy tube for one of the residents with a gastrostomy tube. An interview with Licensed Practical Nurse (LPN) FF on 2/17/2026 at 9:30 am revealed that she had not handled GT medication administration much, and that she was shown how to administer medication through a GT by another LPN. She confirmed that she was unaware of the proper way to administer medications through a GT and that she is unaware of the potential harm the deficient practice could cause.An interview with the Director of Nursing (DON) on 2/18/2026 at 10:30 am confirmed that mixing medications when crushing and mixing down a GT was a deficient practice, and that she would provide education to the nursing staff. She also confirmed the missing documentation in the MARs of the three residents sampled. She stated her expectations for medication administration were zero errors and to document the medications when given. An interview with the Administrator on 2/18/2026 at 11:10 am States expectations are for medication administration, that medications should be given per the policy and professional standards.

Based on record review, staff interviews, and review of the facility's policy titled Antibiotic Stewardship Program, the facility failed to implement an effective Antibiotic Stewardship Program to ensure antibiotics were initiated in accordance with nationally recognized infection surveillance criteria, specifically the McGeer criteria, for two of five sampled residents (R) (R92 and R10) reviewed. The facility initiated antibiotic therapy for residents who did not meet established McGeer criteria for urinary tract infection. This deficient practice had the potential to result in unnecessary antibiotic exposure, adverse drug reactions, development of multidrug-resistant organisms (MDROs).Findings included:1. A review of the Electronic Health Record (EHR) for R92 revealed she was admitted on [DATE] with a most recent readmission date of 4/7/2025. Diagnoses include but are not limited to vascular dementia with psychotic disturbance, delirium due to a known physiological condition, urinary retention, cerebrovascular disease, metabolic encephalopathy, and major depressive disorder.A record review of the Quarterly Minimum Data Set (MDS) dated [DATE] documented in Section C (Cognitive Patterns) a Brief Interview for Mental Status (BIMS) score of 12, indicating moderate cognitive impairment. Section N (Medications) documented active use of antidepressants, anticoagulants, antiplatelet, and anticonvulsant medications.A record review of physician orders revealed a urinalysis with culture and sensitivity was ordered on 1/08/2026 due to increased confusion and hallucinations.A record review of practitioners note dated 1/13/2026 documented that Urinalysis results were positive for a urinary tract infection. The practitioner ordered Nitrofurantoin 100 milligrams to be administered by mouth two times per day for seven days, UA +UTI, will start nitrofurantoin 100 mg BID x 7 days.A record review of the January 2026 Medication Administration Record (MAR) revealed R92 was administered Nitrofurantoin Macrocrystal (antibiotic medication) 100 mg by mouth twice daily for seven days from 1/13/2026 through 1/19/2026.A record review of the Antibiotic Stewardship Binder under the document titled Antibiotic Dispensed revealed Nitrofurantoin Macrocrystal 100 mg BID x 7 days with a start date of 1/13/2026. Documentation in the binder indicated R92 did not meet McGeer criteria for antibiotic initiation.A record review of the Revised McGeer Criteria for Infection Surveillance Checklist dated 1/8/2026 revealed documentation of increased confusion and visual hallucinations. The checklist indicated that UTI criteria were not met.2. A record review of the EHR for R10 revealed he was admitted on [DATE]. Diagnoses include, but are not limited to, infection and inflammatory reaction due to an indwelling urethral catheter, neuromuscular dysfunction of the bladder, urinary retention, acute cystitis without hematuria, Type 2 diabetes mellitus with hyperglycemia, unspecified psychosis, and major depressive disorder, recurrent, moderate.A record review of the Quarterly MDS dated [DATE] documented in Section C (Cognitive Patterns) a Brief Interview for Mental Status score of 14. The Minimum Data Set documented in Section H (Bladder and Bowel), the resident had an indwelling catheter. As documented in Section N (Medications), the resident received antipsychotic, antidepressant, antibiotic, opioid, antiplatelet, hypoglycemic (including insulin), and anticonvulsant medications.A record review of R10's care plan revealed the resident had an indwelling catheter related to obstructive uropathy and urinary retention, and the care plan directed staff to observe and report signs and symptoms of a urinary tract infection, including but not limited to foul-smelling urine, cloudiness, altered mental status, and behavior changes.A record review of progress notes dated 1/13/2026 documented that the resident's urine was cloudy with foul smell and sediments, and the practitioner was notified with a request for urine testing.A record review of physician orders revealed Ciprofloxacin Hydrochloride 250 milligrams was ordered to be administered by mouth every 12 hours for five days for a urinary tract infection, with an order date of 1/20/2026.A record review of the January 2026 Medication Administration Record (MAR) revealed R10 was administered Ciprofloxacin HCl Tablet 250 MG every 12 hours for five days from 1/20/2026 through 1/15/2026 for urinary tract infection.A record review of the Revised McGeer Criteria for Infection Surveillance Checklist dated 1/13/2026 revealed documentation of foul smell, cloudy urine, and sediments. The checklist indicated urinary tract infection criteria were not met.A record review of the Antibiotic Stewardship Binder under the document titled Antibiotic Dispensed revealed R10 was administered Ciprofloxacin Hydrochloride 250 milligrams every 12 hours for five days. Documentation in the binder indicated R10 did not meet McGeer criteria for antibiotic initiation.An interview conducted on 2/17/2026 at 12:49 pm with the Director of Nursing (DON) revealed the facility had not been appropriately following antibiotic stewardship practices per their policy and had implemented a Performance Improvement Plan (PIP) after identifying noncompliance with McGeer criteria. The DON further acknowledged that the facility had not been conducting antibiotic time-outs and that the data tracking tool for stewardship had not been properly implemented. She confirmed the antibiotic stewardship data had been inaccurate due to previous infection prevention oversight. The DON stated that R92 was treated due to increased confusion and hallucinations and positive urine culture with 50-100,000 colony count of Escherichia coli (bacteria), but confirmed treatment was initiated without meeting McGeer criteria. She identified potential negative outcomes, including adverse drug reactions, increased risk of Clostridioides difficile infection, and antibiotic resistance, stating the issue is multifactorial. She stated R92 and R10 did not meet McGeer criteria and confirmed they were administered unnecessary medication.An interview conducted on 2/18/2026 at 9:12 am with Nurse Practitioner (NP) II revealed that she prescribes antibiotics based on clinical picture and not solely lab results. She stated potential negative outcomes of unnecessary antibiotics include the development of MDROs. She confirmed that inappropriate prescribing can contribute to resistant organisms.An interview conducted on 2/18/2026 at 1:25 pm with the Administrator and National Director of Risk Management revealed expectations that providers follow McGeer criteria. They stated that if prescribing patterns do not meet protocol, physician privileges can be addressed. They identified potential negative outcomes of unnecessary antibiotics, including MDRO development, inappropriate treatment of organisms, medication interactions, adverse reactions, and potential escalation of the resident's condition requiring a higher level of care.A review of the facility policy titled Antibiotic Stewardship Program reviewed on 6/1/2025 revealed, under the section titled Antibiotic use protocols, the policy states the facility uses the CDC's NHSN Surveillance Definitions and updated McGeer criteria to define infections and determine whether to treat an infection with antibiotics. Under the section titled Monitoring antibiotic use, the policy states, random audits of antibiotic prescriptions shall be performed to verify completeness and appropriateness, and that antibiotic use will be monitored and tracked. Also requires monitoring antibiotic use, reviewing laboratory results, conducting antibiotic time-outs within 48-72 hours of initiation, and verifying appropriateness of antibiotic prescriptions.

Based on observation, staff interviews , and review of the facility policy, the facility failed to ensure all food in the freezer, refrigerator, and dry storage was labeled, dated, and not expired. These failures had the potential to affect all 116 residents in the facility who consumed food from the kitchen. Findings include: Review of the facility's policy titled, Date Marking for Food Safety, dated [DATE], revealed The individual opening or preparing a food shall be responsible for date marking the food at the time the food is opened or prepared. The marking system shall consist of a color-coded label, the day/date of opening, and the day/date the item must be consumed or discarded. The discard day or date may not exceed the manufacturer's use-by-date, or four days, whichever is earliest. The date of opening of preparation counts as day one. The head cook, or designee, shall be responsible for checking the refrigerator daily for food items that are expiring, and shall discard accordingly. The dietary manager, or designee, shall spot check refrigerators weekly for compliance . During an observation on [DATE] at 9:43 AM, the following observations in the kitchen were identified and verified by the Dietary Manager (DM). 1. The walk-in freezer contained one bag of turkey that had been opened on [DATE] with no use-by-date. It also contained one bag of hot dogs opened on [DATE] with no use-by-date. 2. The walk-in refrigerator contained one bag of pork that had an expiration date of [DATE]. 3. The dry Storage room contained two bowls of cereal covered with cellophane with no labeling or dating. There was also one bag of cake mix that had been opened with no labeling or dating. An opened bag of Jell-O had an expiration date of [DATE]. During an interview on [DATE] at 9:43 AM, the DM revealed, These things should have been caught. They were just overlooked. During an interview on [DATE] at 10:06 AM, the Administrator revealed, My expectation for the kitchen is that all items in the kitchen need to be labeled and dated and not expired.

Based on observations and staff interview, the facility failed to ensure garbage was properly disposed of for two out of three facility dumpsters. This had the potential for pests and rodents to enter the dumpsters. Findings include: During observation of the dumpster area behind the kitchen with the Dietary Manager (DM) on 12/02/24 at 10:20 AM, a small amount of trash was revealed on the ground by the first of three dumpsters. Dumpster number one's side door was open, and dumpster number two did not have a drain plug to close off the opening. During an interview on 12/02/24 at 10:20 AM, the DM revealed, I did not know that the plug was missing from the dumpster and that the door was open. I understand that pests can get into these dumpsters, and we do not want that.

Based on record review, staff interviews, and review of the Resident Assessment Instrument (RAI) Manual, the facility failed to ensure residents had an accurate Minimum Data Set (MDS) assessment for three of 36 sample residents (Resident (R) 24, R114, and R11) reviewed for MDS. Specifically, R24's Ozempic was coded as insulin, R114's therapy was not coded, and R11's insulin and antidepressant were coded incorrectly. These failures did not accurately represent the resident's health status. Findings include: Review of the RAI Manual, dated 10/01/19 and provided by the facility, indicated, .It is important to note here that information obtained should cover the same observation period as specified by the Minimum Data Set (MDS) items on the assessment and should be validated for accuracy (what the resident's actual status was during that observation period) by the IDT [Interdisciplinary Team] completing the assessment . 1. Review of R24's electronic medical record (EMR) Admission Record under the MDS tab revealed R24 was admitted to the facility on [DATE]. Review of the EMR quarterly MDS with an Assessment Reference Date (ARD) of 09/24/24 indicated R24 received insulin once a week. During an interview on 12/03/24 at 4:50 PM, the MDS Coordinator (MDSC), stated R24's diabetes was controlled by diet and did not receive insulin. The MDSC stated Ozempic should not have been coded as insulin. The MDSC confirmed the R24 did not have orders for insulin. During an interview on 12/04/24 at 2:01 PM, the Director of Nursing (DON) stated her expectation was for the MDS to be accurate. 43050 2. Review of the undated Admission Record located in the Profile tab of the EMR revealed, R114 was admitted to the facility on [DATE] with diagnoses that included a stroke and spondylolisthesis (a condition where a vertebra in the spine slips out of place and onto the bone below it.) Review of the admission MDS located in the MDS tab of the EMR with an ARD of 09/22/24 revealed R114 had a BIMS score of 15 out of 15, which indicated she was cognitively intact. In addition, the assessment revealed R114 had received occupational therapy for only one day and physical therapy for only one day during the seven-day observation period. During an interview on 12/05/24 at 7:36 AM, the Certified Occupational Therapy Assistant (COTA) was asked if R114 had received therapy during the seven-day observation period when she was admitted to the facility. The COTA stated, She received occupational therapy for six out of seven days. During an interview on 12/05/24 at 7:37 AM, the Physical Therapy Assistant (PTA) was asked how many days R114 received physical therapy after admission. The PTA stated, R114 received five days of physical therapy during the seven-day observation period. During an interview on 12/05/24 at 8:38 AM, the MDSC was asked why she coded only one day of occupational therapy and one day of physical therapy for R114 on the admission MDS. The MDSC stated, The therapy notes auto populate into the system daily and I am supposed to update it daily. I coded this section inaccurately as she has more than four days of therapy during the seven-day observation period. 46319 3. Review of R11's quarterly MDS located in the MDS tab of the EMR with an ARD of 10/08/24 revealed an original admitted [DATE] R11 had a BIMS score of 15 out of 15, which indicated she was cognitively intact. In addition, the assessment revealed the resident had diagnoses of anxiety disorder, depression, bipolar disorder, and morbid severe obesity due to excess calories received. The resident received insulin for only one day and antianxiety medication during the seven-day observation period. Review of the physician orders located under the Orders tab of the EMR revealed that R11 received an order for trazodone 50 milligram (mg) by mouth every twelve hours for generalized anxiety disorder, dated 11/22/24 and an order for Ozempic 1mg dose subcutaneous one time a day every Saturday related to severe morbid obesity due to excess calories, dated 03/18/24. During an interview on 12/04/24 at 10:15 AM, the MDSC was asked why she coded trazodone as an antianxiety and the Ozempic as an insulin. The MDSC stated the trazodone was used to help with anxiety and the Ozempic was an antidiabetic medication.

Based on interview, record review, and facility policy review, the facility failed to ensure one of five residents (Resident (R) 70) had an updated Level I Preadmission Admission Screening and Resident Review (PASARR) based on a newly acquired diagnosis of major depression of 36 sample residents. This failure has the potential to cause a negative psychosocial outcome for R70 by not receiving the treatment necessary for an individual with a diagnosis of major depressive disorder. Findings include: Review of facility's policy, titled, Resident Assessment-Coordination with PASARR Program implemented 03/01/22, revealed This facility coordinates assessments with the preadmission screening and resident review (PASARR) program under Medicaid to ensure that individuals with a mental disorder, intellectual disability, or a related condition receives care and services in the most integrated setting appropriate to their needs . The Social Services Director shall be responsible for keeping track of each resident's PASARR screening status. Review of R70's electronic medical record (EMR) Admission Record located under the Profile tab revealed the resident was admitted to the facility on [DATE]. R70 had a diagnosis that included major depressive disorder. Review of R70's EMR quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/21/24 indicated the resident had a Brief Interview for Mental Status (BIMS) score of 14 out of 15, which revealed the resident was cognitively intact. The assessment did not identify the resident with a depression diagnosis. Review of a document provided by the facility titled, Preadmission Screening and Resident Review (PASARR) Level I Assessment (Form: DMA-613), dated 01/08/24, indicated R70 did not have a diagnosis of major depressive disorder. Review of a document provided by the facility titled, Psychiatric Diagnostic Evaluation, dated 01/16/24, indicated the psychiatric provider diagnosed R70 with major depressive disorder. During an interview on 12/05/24 at 3:41 PM, the Social Services Director (SSD) and the Administrator said if a resident had a diagnosis change, the PASARR should be updated. Upon review, the Administrator confirmed the PASARR should have been updated.

Based on interviews, record review, and review of the facility policy titled Comprehensive Care Plan, the facility failed to ensure a comprehensive care plan was developed for two of 36 sampled residents (Resident (R) 65 and R97) reviewed for care plans. The failure had the potential to lead to unmet care needs. Findings include: Review of the facility's policy titled, Comprehensive Care Plan reviewed 01/01/23, revealed It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. 1.Review of R65's electronic medical record (EMR) Admission Record under the Profile tab, revealed R65 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of quadriplegia and type two diabetes mellitus. Review of R65's EMR quarterly Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 08/24/24 revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated that R65 was cognitively intact. The MDS revealed R65 received insulin seven of the last seven days prior to the ARD. Review of R65's EMR Care Plan under the Care Plan tab, revealed the Diabetes Mellitus Management Care Plan had been initiated on 10/20/21 and most recently revised on 02/21/24. There was nothing on the care plan that indicated the doctor should be notified if R65 did not receive his physician ordered insulin or if blood sugars were not obtained. Review of the EMR Medication Administration Record (MAR) under the Orders tab, dated 10/24, revealed R65 was ordered Humalog Solution 100 Unit/mL (insulin Lispro) Injects as per sliding scale if 0-200 = 0 units; 201 - 250 = 4 Units; 251 - 300 = 6 Units; 301 - 350 = 8 Units; 351 - 400 = 10 Units; 401+ = 12 Units, Call MD (Medical Director) . call MD/NP (Medical Doctor/Nurse Practitioner) if BBG (Bedside Blood Glucose) > (greater than) with a start date of 09/26/24. Review of R65's Progress Notes located in the EMR, under the progress notes tab revealed the physician was not notified anytime the facility failed to provide the medication. Review of the EMR MAR under the Orders tab, dated 11/2024, revealed R65 was ordered Humalog Solution 100 Unit/mL (insulin Lispro) Injects as per sliding scale if 0-200 = 0 units; 201 - 250 = 4 Units; 251 - 300 = 6 Units; 301 - 350 = 8 Units; 351 - 400 = 10 Units; 401+ = 12 Units, Call MD, call MD/NP if BBG > (greater than) with a start date of 09/26/24. Review of R65's Progress Notes located in the EMR, under the progress notes tab revealed the physician was not notified anytime the facility failed to provide the medication. During an interview on 12/05/24 at 8:00 AM, the Staff Development Coordinator (SDC) said R65's physician should be notified anytime the resident did not receive their medication or the resident's blood sugars were not obtained. During an interview on 12/05/24 at 1:20 PM, the Director of Nursing (DON) said that notifying the physician should also be included in the resident's care plan. 35690 2. Review of R97's Admission Record located in the Profile tab of the EMR revealed R97 was admitted to the facility on [DATE] with diagnoses that included a stroke and osteoarthritis. Review of the admission MDS located in the MDS tab of the EMR with an ARD of 08/03/24 revealed, R97 had a BIMS score of 15 out 15, which indicated she was cognitively intact. In addition, the assessment revealed R97 required substantial assistance with most activities of daily living (ADLs). Review of Section V Care Area Assessment (CAA) on the admission MDS revealed that Functional Abilities (self-care and mobility) triggered as care area and a care plan would be developed. Review of R97's 07/29/24 ADL Care Plan located in the Care Plan tab of the EMR revealed, ADL assistance r/t [related to] decreased/impaired mobility, new environment. Interventions included the following: Assist with bath/shower as needed; Assist with dressing and choosing appropriate clothes for the season, if needed; Assist with mobility devices as needed; and Enhanced Barrier Precautions as ordered. During an interview on 12/05/24 at 9:52 AM, the MDS Coordinator (MDSC) was asked if she was responsible for developing the Care Plan. The MDSC stated, for R97, the person who developed her 'Care Plan' is no longer here. She does have an ADL Care Plan dated 07/29/24. The MDSC was asked what the interventions listed on the ADL Care Plan were regarding needing assistance and how do staff know how to care for her when it did not list information regarding toileting assistance, transfers etc. The MDSC stated, You will have to ask the DON about that information. During an interview on 12/05/24 at 1:00 PM, the DON stated, When a resident is admitted , the unit manager will do a huddle with staff regarding what they need as far as assistance. The DON further stated, The ADL Care Plan needs to be more specific as to the needs of the residents so staff are aware of transfer status, if the resident is given showers or bed baths and on what days, including how many staff should be assisting her. The DON confirmed R97's ADL Care Plan was not fully developed.

Based on interviews, record review, and review of the facility policy titled, Change in Resident's Condition or Status, the facility failed to identify a resident's need to transfer to the hospital for one of five residents (Residents (R) 171) reviewed of 36 sampled residents, who had experienced a change in condition with altered mental status. This failure placed the residents at risk for increased complications and unmet care needs. Findings include: Review of a facility's policy titled, Change in Resident's Condition or Status, revised May 2022, revealed .The nurse will notify the resident's Attending Physician or physician on call when there has been a(an) accident or incident involving the resident .Significant change in the resident's physical/emotional/mental condition .Need to alter the resident's medical treatment significantly .Need to transfer the resident to a hospital/treatment center . In addition, the facility policy revealed, .A 'significant change' of condition is a major decline or improvement in the resident's status that .Will not normally resolve itself without intervention by staff or by implementing standard disease related clinical interventions . Review of the Admission Record located in the Profile tab of the electronic medical record (EMR) revealed, R171 was originally admitted on [DATE] and readmitted to the facility on [DATE] with diagnoses that included metabolic encephalopathy (a change in how the brain works due to an underlying condition), chronic pain, end-stage renal disease (ESRD), and dependence on hemodialysis. Review of the quarterly Minimum Data Set (MDS) located in the MDS tab of the EMR with an Assessment Reference Date (ARD) of 10/05/24 revealed R171 had a Brief Interview for Mental Status (BIMS) score of six out of 15, which indicated R171 was severely impaired in cognition and received dialysis during the seven-day observation period. Review of the Care Plan, dated 09/11/24 and located in the Care Plan tab of the EMR revealed, Diagnosis of ESRD- receives dialysis and is at risk for complications and potential for occlusion of shunt [a passage that is made to allow blood to move from one part of the body to another.] Signs/Symptoms of complications of renal failure will be identified and appropriate interventions initiated on an ongoing basis. Review of a Nursing Progress Note, dated 10/15/24 at 7:41 PM and located in the Progress Notes tab of the EMR, revealed .[R171] readmitted from [name withheld] hospital. He was admitted to the hospital with AMS [altered mental status.] Review of a Nursing Progress Note, dated 10/16/24 at 3:02 PM and located in the Progress Notes tab of the EMR, revealed Received resident alert and responsive able to make needs known. Resident refused dialysis, stating I am not feeling well. Review of a Medical Practitioner Note, 10/17/24 at 3:12 PM and located in the Progress Notes tab of the EMR, revealed [R171] was seen for routine f/u [follow up] for rehab services 2/2 [secondary to] debility. He is laying in bed at time of rounds. Awake, alert, talkative. He refused HD [hemodialysis] yesterday r/t [related to] 'not feeling well.' He is able to report that he is experiencing pain. He has a h/o [history of] chronic pain, has been followed by physiatry [a medical specialty that deals with the treatment of people who have a disability, chronic pain, or some other physical problem] at the facility .Educated on importance of going to HD. He shares that he will go to his next HD session as scheduled. Support given .Reviewed chronic conditions and POC [plan of care]. No acute issues reported by staff. Review of an eMAR [electronic Medication Administration Record] note, dated 10/18/24 at 5:55 PM and located in the Progress Notes tab of the EMR, revealed R171 went to dialysis. Review of a Medical Practitioner Note, dated 10/19/24 at 10:29 AM and located in the Progress Notes tab of the EMR, revealed .admitted from [name withheld] 2/2 to AMS [altered mental status]. He had initially been hospitalized in August. He had been at HD clinic when he had decreased responsiveness. Upon EMS [emergency medical support] arrival his GCS [Glasgow coma scale-a clinical scale that measures a person's level of consciousness] was 7 [the highest score is 15 and the lowest is 3. A score of 15 means you're fully awake, responsive and have no problems with thinking ability or memory. Having a score of 8 or fewer means you're in a coma] and had a temp of 102.1. At that time, EMS witnessed seizure activity. He was intubated [tube inserted into trachea] for airway protection and hypoxemia [low levels of oxygen in the blood] .He (sic) medically stabilized and transferred . Review of a SBAR (situation, background, assessment, and recommendation) for Providers dated 10/21/24 at 12:00 PM and located in the Progress Notes tab of the EMR, revealed Situation: The Change In Condition/s reported on the CIC [change in condition] evaluation are/were: Altered mental status Edema (swelling) Pain (uncontrolled) .Vital signs at 8:20 AM were: Blood Pressure: 108/62, Pulse 83 regular, Respirations 20, Temperature 97.8 and pulse ox (measure the amount of oxygen in the blood) at 92% on room air. Review of a Nurses Progress Note, dated 10/21/24 at 3:31 PM and located in the Progress Note tab of the EMR, revealed Resident noted with edema and pain to left upper extremity, 3x3 (cm) blister noted. Provider aware, new order confirmed for Xray and venous doppler, both complete. Negative results of Xray. Awaiting on results from doppler. Resident declining, unable to feed self. Unable to verbalize pain scale, however resident was moaning and noted with facial grimacing while being turned and repositioned. Staff will continue to monitor resident for distress and further decline. Provider is aware and will assess. Review of a Nursing Progress Note, dated 10/21/24 at 3:39 PM and located in the Progress Notes tab of the EMR, revealed Resident left facility to attend dialysis. Resident left via stretch accompanied by transport and CNA [Certified Nurse Aide]. Resident alert visibly seen groaning facial grimacing present. Review of a Nursing Progress Note, dated 10/21/24 at 4:01 PM and located in the Progress Notes tab of the EMR, revealed Spoke with [name withheld] and it was reported that resident arrived at the dialysis center unresponsive. [name withheld] explained that she was not going to call 911 for [R171] because that is the way he arrived, and she did not want to assume responsibility. I informed transportation driver to take resident to ER [emergency room ] for eval and treatment .Provider is aware. Review of the discharge MDS located in the MDS tab of the EMR with an ARD of 10/21/24 revealed, R171 had a staff assessed BIMS score of moderately impaired, was on opioid pain medications and had received hemodialysis. During an interview on 12/04/24 at 12:04 PM, Unit Manager (UM) 1 stated, [R171] was responding but he wasn't himself that day. When he arrived at dialysis, they called and told me he was unresponsive. UM1 was asked if the facility had taken vital signs prior to leaving for dialysis. She stated, Yes, they were taken at 1:30 PM. UM1 reviewed the vital signs and stated, His blood pressure was 171/91, temperature was 97.1, pulse was 72, respirations were 20 and his oxygen saturation level was 92%. UM1 was asked if the provider had been made aware of R171's condition prior to leaving the facility. She stated, I did contact the physician, but the Nurse Practitioner (NP) was aware of everything. UM1 further stated, It was [R171's] norm to go in and out of mental status changes and after dialysis he would return to baseline. It was a progressive change in him, but the NP wanted to monitor him. UM1 was asked if she had communicated with dialysis regarding R171's condition when he left the facility to ensure continuity of care. UM1 stated, To be honest with you, there is probably not a note. The van driver did voice concerns about him, and I told him (the driver) that the NP was aware and wanted him to go to dialysis. During an interview on 12/04/24 at 12:39 PM, the NP was asked about R171's change in condition. The NP stated, I saw him last on 10/17/24. At that time, he was awake, alert and talkative. The NP was asked if refusing dialysis was a common issue for R171. She stated, I don't recall. He was not feeling well, he has chronic pain at baseline. The NP further stated, I would have put a note in if I was aware of the situation. The NP was asked, per the Nursing Progress Notes you were notified. The NP stated, They must have notified the physician. During an interview on 12/04/24 at 12:54 PM, the Director of Nursing (DON) stated, The order to go ahead and send R171 to dialysis on 10/12/24 at 3:31 PM was the from the NP. She was here at the facility. The DON further stated, If the NP was in the building and was aware of the situation, then the physician would not have been made aware. During a follow-up interview on 12/04/24 at 1:09 PM, the NP was asked if she had been aware of R171's decline and went ahead and sent him to dialysis. The NP stated, I don't recall this, it was October. During an interview on 12/04/24 at 5:29 PM, the Medical Director was asked if he had been made aware of R171's decline by either the nursing staff or the NP. The Medical Director stated, If anything is going on at the facility before 5:00 PM, then it would have been the NP, during the week. They notify me if after 5:00 PM and on weekends. The Medical Director further stated, The mental status changes are the main concern with him, the nurses were concerned also. I saw him over the weekend, and he was fine. He goes back and forth to the ER. When he showed up his mental status improved, they would send him back. When you see him one time, he is fine and the next time it will change. The Medical Director was given the information regarding the change in condition for R171 from the nurses' notes. The Medical Director stated, I did not know about this issue.

Based on resident and staff interviews, record review, and facility policy review, the facility failed to ensure that narcotics were signed out for one of 36 sampled residents (Resident (R) 99). The deficient practice had the potential for drug diversion. Findings include: Review of the facility's policy titled, Pharmacy Services, reviewed 03/01/24, revealed The facility will provide pharmaceutical services to include procedures that assure the accurate acquiring, receiving, dispensing, and administering of all routine and emergency drugs and biologicals to meet the needs of each resident, are consistent with state and federal requirements . The pharmacist is responsible for helping the facility obtain and maintain timely and appropriate pharmaceutical services that support residents' healthcare needs, goals and quality of life that are consistent with current standards of practice and meet state and federal requirements reflect current standards of practice. Review of the facility's policy titled, Controlled Substance Administration and Accountability, dated 08/01/23 revealed, .The Controlled Drug Record (or other specified form) serves the dual purpose of recording both narcotic disposition and patient administration .The Controlled Drug Record is a permanent medical record document and in conjunction with the MAR [Medication Administration Record] is the source for documenting any patient-specific narcotic dispensed from the pharmacy . During a medication administration observation on 12/04/24 at 7:44 AM LPN1 obtained pregabalin oxycodone (a narcotic pain medication) from the locked controlled substance lock box from the Unit Medication Cart. LPN1 placed the medications in a medication cup with the remainder of R99's scheduled medications. LPN1 then closed the lid on the control substance lock box, locked it, and then proceeded to enter R99's room to administer the medications. LPN1 was not observed to have verified the remaining amount of the pregabalin on the medication card against the controlled substance book or sign the medications out prior to administering the medications to indicate the count was correct and to document she was the nurse who had obtained the controlled medication from the control substance lock box. During an interview on 12/04/24 at 7:44 AM, LPN1 was asked why she did not sign out the narcotic medication she obtained from the controlled substance lock box prior to administering the medication to R99. LPN1 stated, I give the medications first and then come back to the cart and sign them out. I do this because if she refuses them, I can then destroy them. I don't sign them out until after I give the medication. During a medication administration observation on 12/04/24 at 9:34 AM, on the 400 Hall Medication Cart, LPN2 opened the controlled substance lock box and removed pregabalin, oxycodone and trazadone (an antidepressant medication). LPN2 was not observed to have signed out the medications after obtaining them from the controlled substance lock box, nor verified the number of medications left in the medication cards, prior to entering R11's room. During an interview on 10/04/24 at 9:36 AM, LPN2 was asked why she did not sign out the medications at the time she removed them from the medication cart and controlled substance lock box to verify that the count was correct. LPN2 stated, I give the medications first and then come back, so if she refuses, I can destroy them. During an interview on 12/04/24 at 9:56 AM, the DON was asked what her expectation was regarding signing out narcotic and controlled substance medications. The DON stated, They are to look at the MAR and the label to ensure it is the right drug and the right patient. When they punch out the medication, they are to sign the narcotic book [controlled substance logbook], at the same time. This is a standard of nursing practice.

Based on record review, resident and staff interviews, and facility policy review, the facility failed to administer physician ordered insulin for one resident (Resident (R) 65) reviewed for insulin administration of 36 sample residents. This failure had the potential to cause hyperglycemia episodes in insulin dependent residents. Findings include: Review of the facility's policy titled, Medication Administration, reviewed 06/01/24, revealed Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice. Review of the facility's policy titled, Medication Errors, reviewed 03/01/24, revealed Significant medication error means one which causes the resident discomfort or jeopardizes his/her health and safety. Review of R65's electronic medical record (EMR) Admission Record under the Profile tab, revealed R65 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of quadriplegia and type two diabetes mellitus. Review of R65's EMR quarterly Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 08/24/24 revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated that R65 was cognitively intact. The MDS revealed R65 received insulin seven of the last seven days prior to the ARD. Review of R65's EMR Care Plan under the Care Plan tab, revealed the Diabetes Mellitus Management Care Plan had been initiated on 10/20/21 and most recently revised on 02/21/24. The goal for R65 was to not have complications related to diabetes through the review date. Interventions included R65 was to receive diabetes medications as ordered, obtain blood sugar as ordered, and monitor for any signs and symptoms of hyperglycemia and/or hypoglycemia. There was nothing on the care plan that indicated the doctor should be notified if R65 did not receive his physician ordered insulin or if blood sugars were not obtained. Review of the EMR Medication Administration Record (MAR) under the Orders tab, dated 10/24, revealed R65 was ordered Humulin 70/30 Kwik Pen Subcutaneous Suspension Pen-Injector (70-30) 100 Unit/milliliters (mL) Inject 45 Units Subcutaneously two times a day related to Type 2 Diabetes Mellitus with mild Non-proliferative diabetic retinopathy without macular edema, bilateral with a start date of 07/09/24 and discontinued on 10/29/24. Review of the MAR revealed the resident did not receive the 5:00 PM medication on 10/04/24, 10/09/24, 10/22/24, 10/26/24, and 10/28/24. Review of R65's Progress Notes located in the EMR, under the Progress Notes tab revealed the physician was not notified anytime the facility failed to provide the medication. Review of the EMR MAR under the Orders tab, dated 10/24, revealed R65 was ordered Humalog Solution 100 Unit/mL (insulin Lispro) Injects as per sliding scale if 0-200 = 0 units; 201 - 250 = 4 Units; 251 - 300 = 6 Units; 301 - 350 = 8 Units; 351 - 400 = 10 Units; 401+ = 12 Units, Call MD (Medical Director), Subcutaneously before meals and at bedtime related to Type 2 Diabetes Mellitus with mild Non-proliferative diabetic retinopathy without macular edema, bilateral, call MD/NP (nurse practitioner) if BBG (Bedside Blood Glucose) >(greater than) with a start date of 09/26/24. Review of the MAR revealed R65 did not receive the medication on 10/04/24, 10/09/24, 10/22/24, and 10/26/24 at 4:30 PM and his blood sugars were not obtained. Review of R65's Progress Notes located in the EMR, under the Progress Notes tab revealed the physician was not notified anytime the facility failed to provide the medication. Review of R65's EMR MAR under the Orders tab, dated 11/24, revealed R65 was ordered Humulin 70/30 Kwik Pen Subcutaneous Suspension Pen-Injector (70-30) 100 Unit/milliliters (mL) Inject 47 Units Subcutaneously two times a day related to Type 2 Diabetes Mellitus with mile Non-proliferative diabetic retinopathy without macular edema, bilateral with a start date of 11/01/24. Review of the MAR revealed the resident did not receive the medication on 11/15/24 at 9:00 AM or 5:00 PM. Review of R65's Progress Notes located in the EMR, under the Progress Notes tab revealed the physician was not notified anytime the facility failed to provide the medication. Review of the EMR MAR under the Orders tab, dated 11/24, revealed R65 was ordered Humalog Solution 100 Unit/mL (insulin Lispro) Injects as per sliding scale if 0-200 = 0 units; 201 - 250 = 4 Units; 251 - 300 = 6 Units; 301 - 350 = 8 Units; 351 - 400 = 10 Units; 401+ = 12 Units, Call MD (Medical Director), Subcutaneously before meals and at bedtime related to Type 2 Diabetes Mellitus with mild Non-proliferative diabetic retinopathy without macular edema, bilateral, call MD/NP (nurse practitioner) if BBG (Bedside Blood Glucose) >(greater than) with a start date of 09/26/24. Review of the MAR revealed R65 did not receive the medication on 11/13/24 at 9:00 PM, 11/15/24 at 7:40 AM or 4:30 PM, and 11/30/24 at 9:00 PM. Review of R65's Progress Notes located in the EMR, under the Progress Notes tab revealed the physician was not notified anytime the facility failed to provide the medication. During an interview on 12/02/24 08:30 AM, R65 stated the facility ran out of insulin because they don't order meds (medications), and insulin is a problem. He stated the nurses know he used two or three pens a week but no one orders, and no one cares. During an interview on 12/05/24 at 8:00 AM, Licensed Practical Nurse (LPN) 1 and Staff Development Coordinator (SDC) said if the medication the resident needed was not available, they would call the pharmacy to order more. They said that R65 would run out of insulin occasionally because of the amount he received every day. The SDC said that in the insulin pen there was only 100 mL, and he required 47 units twice per day, so it wasn't uncommon to run out.

Based on observations, interviews and review of facility policy, the facility failed to ensure that a glucometer was cleaned properly after blood glucose testing for one of three residents (R) 39) observed for glucometer use of 36 sample residents. This had the potential for cross contamination. Findings include: Review of the facility's policy titled, Blood Glucose Monitoring, dated 11/22/24, revealed Clean and disinfect the glucometer as per manufacturer's instructions . Review of the undated glucometer handbook provided by the facility, revealed .To disinfect your meter, clean the meter surface with one of the approved disinfecting wipes. Other EPA [Environmental Protection Agency] registered wipes may be used for disinfecting the glucometer system, however, these wipes have not been validated and could affect the performance of the meter. Allow the surface of the meter to remain wet at room temperature for the contact time listed on the wipe's directions for use. Review of the facility's germicidal wipes on 12/05/24 at 10:05 AM with the Director of Nursing (DON) revealed the facility used germicidal wipes to disinfect glucometers that met the EPA standards for the glucometer. Observation and interview on 12/02/24 at 4:14 PM revealed R39 receiving blood glucose monitoring by Licensed Practical Nurse (LPN) 4. LPN4 stated, Every diabetic resident has their own glucometer that is kept in the medication cart. After completing the blood glucose monitoring, LPN4 stated, I do not have the wipes on my cart to clean the glucometer and I will use an alcohol wipe. When asked what type of wipe was to be used, LPN4 stated, The purple top, but I would have to go to Central Supply to get them. Review of the electronic medical record (EMR) Admission Record under the Admission Record tab revealed R39 was admitted to the facility on [DATE]. Review of the EMR Orders Record under the Orders Record tab, dated 11/19/24, revealed R39 was to receive Fiasp Flex Touch 100 UNIT/ML (milliliters) Solution pen-injector Insulin per sliding scale subcutaneously before meals and at bedtime related to type two diabetes mellitus without complications. Interview with Unit Manager (UM) 1 on 12/02/24 at 4:25 PM revealed Each diabetic resident has their own glucometer. Alcohol wipes cannot be used. Germicidal wipes (purple top) are to be used according to manufacturer instructions. [LPN4] should have had the wipes on her cart. During an interview on 12/05/24 at 9:54 AM, the DON revealed I heard about the incident, and we educated immediately. All medication carts are to have the proper cleaning supplies. Nurses should notify their managers if they do not have what is needed and carts can be restocked.

Based on interviews, review of facility policy, and record reviews, it was determined the facility failed to provide services as outlined by the comprehensive care plan and that met professional standards of quality for one of 24 sampled residents (R) (R#26) related to thoroughly assessing the resident after a significant change in condition and ensuring pain management. Harm was identified to have occurred on 4/23/23, when staff were returning R#26 to their room after a shower and the resident's right foot hit a door frame. The resident immediately complained of pain and stated the pain radiated from their foot upward to the hip. The resident continued to complain of pain after the incident and requested an x-ray of the leg. Nursing staff assessed the resident's right foot but did not address the resident's continued complaints of pain to the right leg and thigh area or requests for an x-ray until 4/25/23 On 4/24/23 an x-ray was ordered, and R#26 had a fractured femur (bone in the upper part of the leg). This failure resulted in the delay of obtaining an x-ray which was positive for a fractured femur and ultimately resulted in R#26 having uncontrolled pain for approximately two days. Findings included: A review of the facility policy titled Pain Management, with an implementation date of 3/1/23, revealed The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. A review of the facility policy titled, Change in a Resident's Condition or Status, with a revised date of May 2022, indicated, The nurse will notify the resident's Attending Physician or physician on call when there has been a(an): significant change in the resident's physical/emotional/mental condition; specific instruction to notify the Physician of changes in the resident's condition. The policy further indicated The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. A review of the Admission Record indicated the facility admitted R#26 on 3/2/18 with diagnoses that included multiple sclerosis, obesity, depression, hypertension, chronic pain, and diabetes. The Admission Record also indicated on 5/21/23 a diagnosis of fracture of the right femur had been added. A review of the significant change in status Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 5/6/23, indicated R#26 was cognitively intact, with a Brief Interview for Mental Status (BIMS) score of 15. The MDS revealed R#26 required extensive to total assistance for all activities of daily living (ADLs) and required supervision with eating. Active diagnoses included a fracture. The MDS indicated the resident had not had pain in the last five days but had received non-medication interventions for pain. A review of the Care Plan for R#26, initiated on 3/3/18, with a revision date of 5/24/23, indicated R#26 was at risk for pain related to decreased mobility, weakness, and multiple sclerosis. The facility developed interventions that directed staff to administer pain medications per orders, notify the physician if interventions were unsuccessful or if a current complaint was a significant change from the resident's past experience with pain; observe and report changes in usual routine, sleep patterns, decrease in functional abilities, decrease in range of motion, or withdrawal/resistance to care; observe/document side effects of pain medication; report complaints of pain or requests for pain medication to the nurse; provide non-pharmacological interventions. A review of Progress Notes, dated 4/23/23 at 1:05 p.m. and designated as a late entry, indicated the nurse had been notified by the certified nursing assistant (CNA) that R#26 had hit their right foot, and the resident had complained of pain from the right foot radiating upward. The note indicated as needed (PRN) medication was given as ordered. A review of Progress Notes, dated 4/23/23 at 7:21 p.m., indicated R#26 was returning to the resident's room when the resident's foot struck the room door. The note indicated R#26 complained of pain, and a PRN medication was given. The note further indicated the physician was notified and a message was left. The note did not contain documentation that outlined any injury the resident may have sustained and did not include the quality and quantity of pain experienced by R#26. A review of the April 2023 Medication Administration Record (MAR) indicated the nurse gave acetaminophen 500 milligrams (mg), two tablets, on 4/23/23 at 3:00 p.m., or approximately two hours after the incident. There was a U under the time, and the key on the MAR indicated that meant the effectiveness of the medication was unknown. A review of an incident report, initiated on 4/23/23 at 2:16 p.m., indicated R#26 complained of pain to the right leg. The incident report indicated the resident's description of the incident was that the resident's foot dropped and hit the door when returning to their room. Per the resident's description, I felt a lot of pain shooting from the foot up the hip. The nurse documented no injuries were observed at the time of the incident. The incident report indicated the resident's level of pain on a 0-10 scale was a nine at the time of the incident. The incident report further indicated the resident had no observed injuries post incident and the resident's pain was rated as a four on a 0-10 scale. The incident report indicated pain medication was administered. The incident report indicated the physician was notified on 4/23/23 at 4:43 p.m. There was a note on the incident report dated 4/26/23 (no time documented), that indicated the CNA informed the nurse that while taking the resident in the shower chair back to the resident's room after a shower, the resident hit their right foot. The note indicated the nurse assessed the resident, the resident complained of pain to the right foot radiating upward, PRN pain medication was administered as ordered, and the physician was notified. The note further indicated on 4/25/23 the resident voiced that PRN acetaminophen was not relieving the pain and the physician was notified. The physician ordered an x-ray of the right lower extremity. The note indicated the x-ray was positive for a right femur (bone in the upper part of the leg) fracture. The note indicated the resident was transferred to the hospital in stable condition. A review of Progress Notes revealed no assessments were completed to determine any injuries or determine R#26's pain level on Monday, 4/24/23 or Tuesday, 4/25/23. A review of the April 2023 MAR revealed R#26 received no pain medication on 4/24/23, 4/25/23, or 4/26/23. A review of Progress Notes revealed on 4/25/23 at 3:19 p.m., LPN #22 completed a SBAR (an acronym for Situation, Background, Assessment, and Recommendations. The SBAR is a form used to gather data prior to calling a physician for a change in a resident's condition). The SBAR indicated R#26 had uncontrolled pain. On 4/25/22 at 3:50 p.m., the nurse documented R#26 had pain in the right leg from the hip going to the knee and informed the nurse the Tylenol was not relieving the pain. The physician ordered an X-ray of the right leg. A review of a Progress Note, dated 4/25/23 at 7:44 p.m., indicated R#26's physician went to the facility, evaluated R#26, and ordered transfer to the hospital. A review of a radiology report, dated 4/25/23, indicated R#26 had sustained an overlapping, separated fracture through the proximal third of the femur. An interview was held with R#26 on 6/1/23 at 8:30 a.m. R#26 stated that on Sunday, 4/23/23, before lunch, CNA #9 had given the resident a shower. On the way back into the resident's room, R#26's foot struck the door frame. R#26 stated that when the foot struck the door frame, the resident yelled and had immediate pain, described as horrendous, extending from the foot to the thigh. R#26 stated the nurse looked at the foot, and although the resident stated they kept telling the nurse the pain went to the thigh, the nurse only looked at the foot. R#26 stated they asked for an x-ray, and the nurse stated she would recommend an x-ray. R#26 stated that every time the resident was moved, they experienced horrible pain in the thigh. The resident added they did not receive an x-ray on Sunday or Monday and finally, because they continued to ask about an x-ray, the resident stated that on Tuesday, an x-ray was done. R#26 stated that later on Tuesday, 4/25/23, the Director of Nursing (DON) reported the resident had sustained a femur fracture. R#26 stated they had a hard time sleeping after the incident and had to lie very still to avoid pain. R#26 stated they had to keep requesting the x-ray, and they felt that was why it took two days to have the x-ray completed and added they were not sure they would have ever gotten an x-ray if they had not continued to ask staff for an x-ray on a daily basis. R#26 stated that on Monday, 4/24/23, and on Tuesday, 4/25/23, there was no nurse that looked at the resident's leg. R#26 stated the CNA was the only one that seemed to care the resident was in pain. The resident stated the pain was so bad they almost cried and used deep breathing to help control the pain. Resident #26 described the pain as dull pain to sharp, intense pain and added they rated the least amount of pain felt from 4/23/223 to the time of transfer to the hospital on 4/26/23 was an eight on a 0-10 scale. R#26 stated CNA #9 continued to ask about pain and report to the nurses, and the resident felt it was the nurses and the facility that had not followed up as they should have. During an interview with CNA #9 on 6/1/23 at 9:00 a.m., she stated R#26 immediately yelled out when their foot struck the doorway. CNA #9 stated R#26 asked her to report to the nurse that their side was hurting due to the foot striking the doorway, and the CNA confirmed she had reported to LPN #10. The CNA stated LPN #10 went to speak with R#26. CNA #9 stated that by the end of the shift, R#26 stated they felt a little better. The CNA stated she told the nurses the Tylenol was not working for R#26. During an interview with LPN #10 was interviewed on 6/1/23 at 12:19 p.m. she stated CNA #9 reported R#26's incident to her. The LPN stated she had only examined the resident's foot and found no redness or open areas. LPN #10 stated R#26 had complained only of mild pain. LPN #10 stated she reported the incident to the physician, who ordered Tylenol for pain and to continue to monitor the resident. LPN #10 stated the results of the monitoring and assessment should be documented in the progress notes and on the 24-hour report to let the on-coming nurse know. The nurse stated she was unsure if the resident required pain medication on the day of the incident, but if she had given pain medication, it would have been documented. LPN #10 stated she had reported the incident to the nurse supervisor who completed the incident report and stated she had expected the supervisor to write a note in the progress notes. The nurse stated she did not remember receiving a report from the CNA that it was not the resident's foot hurting but the thigh. LPN #10 stated the facility policy for documentation after an incident or change in resident's condition was for nurses to document every shift for 72 hours. During a telephone interview held with LPN #22 on 6/1/23 at 1:12 p.m. she stated that when she came to work for the 7:00 a.m. to 7:00 p.m. shift on Monday, 4/24/23, she had not been informed about R#26's incident by staff and added it was R#26 that told her they had incurred an accident after their shower. LPN #22 stated that on Monday (4/24/23) R#26 described the pain as shooting from knee to hip. The nurse stated she did not ask the resident to rate the pain and just checked the spot to confirm a pain assessment had been completed. The nurse stated she gave the resident Tylenol but returned to R#26 and asked if the pain had been relieved and had no explanation why the Tylenol was not documented as given. LPN #22 confirmed that she was supposed to ask the residents if the Tylenol had been effective. The nurse stated that after an incident or a change in condition, the policy was to assess and document every four hours. She stated she had not assessed the resident on Monday, 4/24/23, and was unable to tell if the resident's leg was swollen or bruised and had no reason for the lack of assessment or documentation. She stated on Tuesday (4/25/23) she had not assessed R#26's leg and hip but knew the resident's pain was uncontrolled. The nurse was unable to give a reason why there was no documentation that the resident was provided acetaminophen as ordered for pain on 4/25/23. During an interview with LPN #17, who was the Unit Manager, on 6/1/23 at 2:57 p.m. they stated that when a resident experienced a change in condition, the expectation was for nurses to document every shift for 72 hours or until resolution of the problem. LPN #17 stated that for the incident involving R#26, the nurses were expected to assess the injured area and assess the resident's pain level every shift. LPN #17 stated it was not the responsibility of the resident to remind staff about the incident and continue to request an x-ray. LPN #17 stated the expectation was for each nurse to document their assessment findings in the progress notes. During an interview with LPN #21, who functioned as the Staff Development Coordinator, on 6/1/23 at 3:24 p.m. she stated that for an incident or a change in condition, nurses were expected to assess the resident and document every shift for 72 hours and added the documentation should be found in the progress notes. LPN #21 stated that for R#26, documentation was expected to include the resident's pain level, signs of redness or bruising to the area that struck the door, or any new complaints the resident had. During an interview with the DON on 6/1/23 at 4:30 p.m., she stated nurses were taught to assess and document every shift for 72 hours for any incident that occurred. The DON stated she had reviewed R#26's medical record and found assessments and documentation were limited after the incident involving R#26 on 4/23/23. She stated she found that nurses had not assessed the resident daily and had not asked the resident about their pain level daily. The DON stated that when the incident occurred, the nurse was expected to complete a head-to-toe assessment for R#26, look for signs and symptoms of pain, ask other staff what had happened, and notify the physician of the incident and assessment findings. The DON stated she expected the nurse to have checked on the resident again before the end of the shift. The DON stated the nurse that had requested the one-time dose of Tylenol on 4/23/23 should have asked for an x-ray at that time, since the Tylenol ordered for the resident had not relieved the pain. The DON stated that from what staff told her, R#26's pain was controlled but added R#26 had told her the pain had not been controlled. The DON stated the nurse that worked Monday from 7:00 a.m. to 7:00 p.m. should have assessed R#26 and should have given the resident acetaminophen, called the physician, reminded the physician about the incident, told the physician about the shooting pain, informed the physician the acetaminophen was not relieving the pain, and requested an x-ray. During an interview with R#26 again on 6/223 at 12:04 p.m., they indicated the pain had decreased their appetite and added that after the incident, they ate almost nothing for lunch and only small amounts for dinner on 4/23/23. R#26 stated they tried to place the bed in a higher position to eat and immediately felt pain and added the focus was on trying to avoid the pain. R#26 added that when staff provided baths or incontinence care, no matter how careful staff tried to be, the pain was a 10 on a 0-10 scale. During an interview with the Administrator on 6/2/23 at 1:47 p.m., she stated that when a resident had an incident, she expected the nurses to assess the resident's condition, including pain, and provide documentation on the resident's condition. During an interview with the physician (MD) for R#26 by telephone on 6/2/23 at 2:35 p.m., she stated staff had called her on Sunday, 4/23/23, and told her R#26 had an incident that involved hitting the resident's foot against the door frame. The MD stated she was not informed R#26's pain extended from the knee to the hip and had not been told the pain was severe. The MD stated she had ordered acetaminophen 1000 mg to be given every eight hours and had ordered that staff monitor the resident. The MD stated had she been made aware of R#26's pain level and the location of the pain, from the knee to the hip, she would have ordered the x-ray before 4/25/23.

Based on interviews, review of facility policy, and record reviews, it was determined the facility failed to provide effective pain management for one of 24 sampled residents (R) (R#26). Harm was identified to have occurred on 4/23/23, when staff were returning R#26 to their room after a shower and the resident's right foot hit a door frame. The resident immediately complained of pain and stated the pain radiated from their foot upward to the hip. The resident continued to complain of pain after the incident and requested an x-ray of the leg. Nursing staff assessed the resident's right foot but did not address the resident's continued complaints of pain to the right leg and thigh area or requests for an x-ray until 4/25/23 On 4/24/23 an x-ray was ordered, and R#26 had a fractured femur (bone in the upper part of the leg). This failure resulted in the delay of obtaining an x-ray which was positive for a fractured femur and ultimately resulted in R#26 having uncontrolled pain for approximately two days. Findings included: A review of the facility policy titled Pain Management, with an implementation date of 3/1/23, revealed The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. A review of the Admission Record indicated the facility admitted R#26 on 3/2/18 with diagnoses that included multiple sclerosis, obesity, depression, hypertension, chronic pain, and diabetes. The Admission Record also indicated on 5/21/23 a diagnosis of fracture of the right femur had been added. A review of the significant change in status Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 5/6/23, indicated R#26 was cognitively intact, with a Brief Interview for Mental Status (BIMS) score of 15. The MDS revealed R#26 required extensive to total assistance for all activities of daily living (ADLs). Active diagnoses included a fracture. A review of the Care Plan for R#26, initiated on 3/3/18, with a revision date of 5/24/23, indicated R#26 was at risk for pain related to decreased mobility, weakness, and multiple sclerosis. The facility developed interventions that directed staff to administer pain medications per orders, notify the physician if interventions were unsuccessful or if a current complaint was a significant change from the resident's past experience with pain; observe and report changes in usual routine, sleep patterns, decrease in functional abilities, decrease in range of motion, or withdrawal/resistance to care; observe/document side effects of pain medication; report complaints of pain or requests for pain medication to the nurse; provide non-pharmacological interventions. A review of Progress Notes, dated 4/23/23 at 1:05 p.m. and designated as a late entry, indicated the nurse had been notified by the certified nursing assistant (CNA) that R#26 had hit their right foot, and the resident had complained of pain from the right foot radiating upward. The note indicated as needed (PRN) medication was given as ordered. A review of Progress Notes, dated 4/23/23 at 7:21 p.m., indicated R#26 was returning to the resident's room when the resident's foot struck the room door. The note indicated R#26 complained of pain, and a PRN medication was given. The note further indicated the physician was notified and a message was left. The note did not contain documentation that outlined any injury the resident may have sustained and did not include the quality and quantity of pain experienced by R#26. A review of the April 2023 Medication Administration Record (MAR) indicated the nurse gave acetaminophen 500 milligrams (mg), two tablets, on 4/23/23 at 3:00 p.m., or approximately two hours after the incident. There was a U under the time, and the key on the MAR indicated that meant the effectiveness of the medication was unknown. A review of an incident report, initiated on 4/23/23 at 2:16 p.m., indicated R#26 complained of pain to the right leg. The incident report indicated the resident's description of the incident was that the resident's foot dropped and hit the door when returning to their room. Per the resident's description, I felt a lot of pain shooting from the foot up the hip. The nurse documented no injuries were observed at the time of the incident. The incident report indicated the resident's level of pain on a 0-10 scale was a nine at the time of the incident. The incident report further indicated the resident had no observed injuries post incident and the resident's pain was rated as a four on a 0-10 scale. The incident report indicated pain medication was administered. The incident report indicated the physician was notified on 4/23/23 at 4:43 p.m. There was a note on the incident report dated 4/26/23 (no time documented), that indicated the CNA informed the nurse that while taking the resident in the shower chair back to the resident's room after a shower, the resident hit their right foot. The note indicated the nurse assessed the resident, the resident complained of pain to the right foot radiating upward, PRN pain medication was administered as ordered, and the physician was notified. The note further indicated on 4/25/23 the resident voiced that PRN acetaminophen was not relieving the pain and the physician was notified. The physician ordered an x-ray of the right lower extremity. The note indicated the x-ray was positive for a right femur (bone in the upper part of the leg) fracture. The note indicated the resident was transferred to the hospital in stable condition. A review of the April 2023 Medication Administration Record (MAR) revealed that on 4/23/23 at 3:00 p.m., R#26 was given acetaminophen 500 mg, two tablets for pain that was rated as three on a 0-10 scale. The MAR further indicated R#26 was given acetaminophen 500 mg, two tablets again at 9:01 p.m. on 4/23/23. The MAR indicated the dose given at 9:01 p.m. on 4/23/23 was a one time dose. The April 2023 MAR indicated there was no further pain-relieving medications provided to R#26 after 4/23/23 at 9:01 p.m. A review of the Progress Notes revealed an SBAR (an acronym that stands for Situation, Background, Assessment, Recommendation. This is a form used to collect data to call the physician and provide a complete recapitulation of a change in condition) was completed on 4/25/23 at 3:19 p.m. The SBAR indicated R#26 had uncontrolled pain. At 3:50 p.m., the resident complained of pain in the right leg from the hip going to the knee and stated Tylenol was not helping. A review of the April 2023 MAR revealed no evidence R#26 was provided pain medication even though documentation in the progress notes indicated the resident had uncontrolled pain. A review of Progress Notes indicated Resident #26 was transferred to the hospital for further evaluation on 04/26/2023. A review of a Discharge Summary from the hospital dated 5/1/23, indicated R#26 was admitted to the hospital on 4/26/23 with a diagnosis of fracture of the shaft of the right femur. The documentation indicated orthopedic surgery, pain control, and supportive care were provided. During an interview with R#26 on 6/1/23 at 8:30 a.m. R#26 stated that on Sunday, 4/23/23, before lunch, CNA #9 had given the resident a shower. On the way back into the resident's room, R#26's foot struck the door frame. R#26 stated that when the foot struck the door frame, the resident yelled and had immediate pain, described as horrendous, extending from the foot to the thigh. R#26 stated the nurse looked at the foot, and although the resident stated they kept telling the nurse the pain went to the thigh, the nurse only looked at the foot. R#26 stated they asked for an x-ray, and the nurse stated she would recommend an x-ray. R#26 stated that every time the resident was moved, they experienced horrible pain in the thigh. The resident added they did not receive an x-ray on Sunday or Monday and finally, because they continued to ask about an x-ray, the resident stated that on Tuesday, an x-ray was done. R#26 stated that later on Tuesday, 4/25/23, the Director of Nursing (DON) reported the resident had sustained a femur fracture. R#26 stated they had a hard time sleeping after the incident and had to lie very still to avoid pain. R#26 stated they had to keep requesting the x-ray, and they felt that was why it took two days to have the x-ray completed and added they were not sure they would have ever gotten an x-ray if they had not continued to ask staff for an x-ray on a daily basis. R#26 stated that on Monday, 4/24/23, and on Tuesday, 4/25/23, there was no nurse that looked at the resident's leg. R#26 stated the CNA was the only one that seemed to care the resident was in pain. The resident stated the pain was so bad they almost cried and used deep breathing to help control the pain. R#26 described the pain as dull pain to sharp, intense pain and added they rated the least amount of pain felt from 4/23/23 to the time of transfer to the hospital on 4/26/23 was an eight on a 0-10 scale. R#26 stated CNA #9 continued to ask about pain and report to the nurses, and the resident felt it was the nurses and the facility that had not followed up as they should have. During an interview with CNA #9 on 6/1/23 at 9:00 a.m., she stated R#26 immediately yelled out when their foot struck the doorway. CNA #9 stated R#26 asked her to report to the nurse that their side was hurting due to the foot striking the doorway, and the CNA confirmed she had reported to LPN #10. The CNA stated LPN #10 went to speak with R#26. The CNA stated she told the nurses the Tylenol was not working for R#26. During an interview with LPN #10 was interviewed on 6/1/23 at 12:19 p.m. she stated CNA #9 reported R#26's incident to her. The LPN stated she had only examined the resident's foot and found no redness or open areas. LPN #10 stated R#26 had complained only of mild pain. LPN #10 stated she reported the incident to the physician, who ordered Tylenol for pain and to continue to monitor the resident. LPN #10 stated the results of the monitoring and assessment should be documented in the progress notes and on the 24-hour report to let the on-coming nurse know. The nurse stated she was unsure if the resident required pain medication on the day of the incident, but if she had given pain medication, it would have been documented. LPN #10 stated she had reported the incident to the nurse supervisor who completed the incident report and stated she had expected the supervisor to write a note in the progress notes. The nurse stated she did not remember receiving a report from the CNA that it was not the resident's foot hurting but the thigh. LPN #10 stated the facility policy for documentation after an incident or change in resident's condition was for nurses to document every shift for 72 hours. During a telephone interview held with LPN #22 on 6/1/23 at 1:12 p.m. she stated that when she came to work for the 7:00 a.m. to 7:00 p.m. shift on Monday, 4/24/23, she had not been informed about R#26's incident by staff and added it was R#26 that told her they had incurred an accident after their shower. LPN #22 stated that on Monday (4/24/23) R#26 described the pain as shooting from knee to hip. The nurse stated she did not ask the resident to rate the pain and just checked the spot to confirm a pain assessment had been completed. The nurse stated she gave the resident Tylenol but returned to R#26 and asked if the pain had been relieved and had no explanation why the Tylenol was not documented as given. LPN #22 confirmed that she was supposed to ask the residents if the Tylenol had been effective. The nurse stated that after an incident or a change in condition, the policy was to assess and document every four hours. She stated she had not assessed the resident on Monday, 4/24/23, and was unable to tell if the resident's leg was swollen or bruised and had no reason for the lack of assessment or documentation. She stated on Tuesday (4/25/23) she had not assessed R#26's leg and hip but knew the resident's pain was uncontrolled. The nurse was unable to give a reason why there was no documentation that the resident was provided acetaminophen as ordered for pain on 4/25/23. During an interview with LPN #17, who was the Unit Manager, on 6/1/23 at 2:57 p.m. they stated that for the incident involving R#26, the nurses were expected to assess the injured area and assess the resident's pain level every shift. LPN #17 stated it was not the responsibility of the resident to remind staff about the incident and continue to request an x-ray. LPN #17 stated the expectation was for each nurse to document their assessment findings in the progress notes. During an interview with LPN #21, who functioned as the Staff Development Coordinator, on 6/1/23 at 3:24 p.m. she stated that for R#26, documentation was expected to include the resident's pain level, signs of redness or bruising to the area that struck the door, or any new complaints the resident had. During an interview with the DON on 6/1/23 at 4:30 p.m., she stated nurses were taught to assess and document every shift for 72 hours for any incident that occurred. The DON stated she had reviewed R#26's medical record and found assessments and documentation were limited after the incident involving R#26 on 4/23/23. She stated she found that nurses had not assessed the resident daily and had not asked the resident about their pain level daily. The DON stated that when the incident occurred, the nurse was expected to complete a head-to-toe assessment for R#26, look for signs and symptoms of pain, ask other staff what had happened, and notify the physician of the incident and assessment findings. The DON stated she expected the nurse to have checked on the resident again before the end of the shift. The DON stated the nurse that had requested the one-time dose of Tylenol on 4/23/23 should have asked for an x-ray at that time, since the Tylenol ordered for the resident had not relieved the pain. The DON stated that from what staff told her, R#26's pain was controlled but added R#26 had told her the pain had not been controlled. The DON stated the nurse that worked Monday from 7:00 a.m. to 7:00 p.m. should have assessed R#26 and should have given the resident acetaminophen, called the physician, reminded the physician about the incident, told the physician about the shooting pain, informed the physician the acetaminophen was not relieving the pain, and requested an x-ray. During an interview with R#26 again on 6/2/23 at 12:04 p.m., they indicated the pain had decreased their appetite and added that after the incident, they ate almost nothing for lunch and only small amounts for dinner on 4/23/23. R#26 stated they tried to place the bed in a higher position to eat and immediately felt pain and added the focus was on trying to avoid the pain. R#26 added that when staff provided baths or incontinence care, no matter how careful staff tried to be, the pain was a 10 on a 0-10 scale. During an interview with the physician (MD) for R#26 by telephone on 6/2/23 at 2:35 p.m., she stated staff had called her on Sunday, 4/23/23, and told her R#26 had an incident that involved hitting the resident's foot against the door frame. The MD stated she was not informed R#26's pain extended from the knee to the hip and had not been told the pain was severe. The MD stated she had ordered acetaminophen 1000 mg to be given every eight hours and had ordered that staff monitor the resident. The MD stated had she been made aware of R#26's pain level and the location of the pain, from the knee to the hip, she would have ordered the x-ray before 4/25/23.

Based on observations, record review, staff interviews, and policy review, the facility failed to follow the care plan for one of 39 residents (R#76), who suffered harm during a fall from the bed when staff failed to provide two-person assistance for care. The facility failed to follow the care plan for one of 39 residents (R#71) by failing to apply a right hand splint. In addition, the facility also failed to develop a care plan for R#76 for the use of a low air loss mattress. Findings include: Review of the policy titled, Comprehensive Care Plan, revised May 2021, revealed the center will develop a comprehensive person-centered care plan that identifies each resident's medical, nursing, mental, and psychosocial needs. The comprehensive care plan must ensure that the resident maintains the highest practical physical, mental, and psychosocial well-being. 1. Review of the clinical record for R#76 revealed she was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's Annual Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was coded as zero, which indicated severe cognitive impairment. Section G revealed R#76 required extensive assistance of two people with bed mobility and transfers. Review of care plan initiated on 4/10/2019 and revised on 10/6/2021 revealed resident was at risk for falls. Interventions for care include provide assistance as required for completion of activities of daily living (ADL) tasks via two-person assistance. Further review of the residents care plans revealed there was no evidence that a care plan was developed for the use of an air mattress. Review of R#76's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview on 1/13/2022 at 10:07 a.m. with Minimum Data Set (MDS) Coordinator SS stated the RCS's utilize the task section on the computer to know what care each resident required. MDS Coordinator SS stated the Unit Managers (UM's) were responsible for ensuring the care plan was followed. Interview on 1/13/2022 at 10:18 a.m. with RCS TT stated the task section on the computer would direct the care the resident required. Interview on 1/13/2022 at 10:31 a.m. with UM FF revealed the charge nurse was responsible for ensuring that care was provided per the care plan. During further interview, she stated the UM had the overall responsibility to ensure the care was provided as care planned. Interview on 1/13/2022 at 1:31 p.m. with the Director of Nursing (DON) confirmed the air mattress was not on R#76 care plan at the time of the October 13, 2021 fall. She further stated the intervention for two staff members to perform ADLs as indicated on the care plan, does not always happen. Interview on 1/14/2022 at 9:56 a.m. with RCS PP stated on the day of the fall she was giving R#76 a bed bath around 4:00 a.m. She stated she put the side rail down and turned the resident towards her. She stated when she went to put the sheet on the bottom of the bed, the resident began to slide down and fell to the floor. During further interview, RCS PP stated prior to this incident, she had not received any training regarding putting the air mattress on hold when providing care. Cross Refer F689 2. Review of the clinical record for R#71 revealed resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's most recent Quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) was coded as eight, which indicated moderate cognitive impairment. Section G revealed the resident had limitation in range of motion (ROM) on one side of the upper extremities and limitation in ROM on both sides of the lower extremity. The resident was not currently receiving therapy services or restorative services. Review of the resident's care plan initiated on 4/23/2020 and revised on 2/11/2021 documented the resident requires assistance with ADL's related to spastic [CONDITION(S)]. Interventions to care include carrot to right hand at all times to prevent further contractures and remove for hygiene, practice passive range of motion (PROM) to right hand and hygiene to both hands during morning care. Apply carrots to right hand. Observation on 1/11/2022 at 9:21 a.m. revealed R#71 was lying in bed and without a splint device in the right hand. Observation on 1/12/2022 at 11:58 a.m. revealed R#71 sitting in her wheelchair and without a splint device in the right hand and the right hand was closed tightly. Observation on 1/13/2022 at 9:17 a.m. revealed R#71 lying in her bed. The resident's right hand was clenched shut and there was no splint device in the right hand. Interview on 1/13/2022 at 9:39 a.m. with the Rehab Director revealed the Resident Care Specialists (RCS's) should put a splint in R#71's hand daily. Cross Refer F688

Based on observations, record review, staff interviews and policy review, the facility failed to provide supervision and care to prevent a fall from the bed for one of one residents (R) R#76 reviewed for falls that had a low air loss mattress in use. Actual harm occurred on October 13, 2021, when R#76 had a fall from the bed during the provision of care that resulted in a laceration to the forehead requiring 11 sutures. Findings include: Review of the facility policy titled, Sava Senior Care Low-Air-Loss Therapy Bed Use date 5/21/2021, documented the low-air-loss therapy bed consists of segmented air-filled cushions that provide surface area for pressure relief. To turn and reposition the resident, use the turn-assist feature or maximum-inflate feature to fully inflate the bed. Review of the facility policy titled, Fall Management dated 7/2017, documented the facility would assist each resident in attaining/maintaining his or her highest practicable level of function by providing the resident adequate supervision, assistive devices and/or functional programs, as appropriate, to minimize the risk for falls. Review of the User-Service Manual Joerns Support Surface DermaFloat LAL (low air loss) Model (mattress in use at time of fall) dated 2015 documented, The Therapy Control Unit Features an autofirm mode which provides maximum air inflation designed to assist both residents and caregivers during resident transfer and treatment. Review of the clinical record for R#76 revealed she was admitted to the facility on [DATE] with diagnoses including but not limited to [CONDITION(S)], hypertension ([CONDITION(S)]), anxiety, agitation, pseudobulbar affect, and dementia. The resident's Annual Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was coded as zero, which indicated severe cognitive impairment. Section G revealed R#76 required extensive assistance of two people with bed mobility and transfers and had decreased range of motion on one side of her upper extremities. Review of care plan initiated on 4/10/2019 and revised on 10/6/2021 revealed resident is at risk for falls. Interventions to care include provide assistance as required for completion of activities of daily living (ADL) tasks via two-person assistance. There was no evidence on the care plan to indicate the use of an air mattress. Review of R#76's Physician Orders revealed an order for an air mattress dated 1/20/2020. Review of the facility's October 2021 Task List Report which directs the Resident Care Specialist (RCS's) care for each resident, did not indicate that R#76 required two staff assistance with ADLs or identify the use of an air mattress. Review of the Fall Risk assessment dated [DATE] revealed the resident to be a high risk for falls. Review of the emergency room (ER) documentation dated 10/13/2021 at 7:25 a.m. revealed patient presents with a fall from the bed this morning while getting a bed bath, hit head and has a 10 centimeter (cm) linear laceration to the right forehead and scalp with placement of 11 sutures. Review of the facility's investigation dated 10/13/2021 at 6:40 a.m. revealed the nurse was called to R#76's room by the Resident Care Specialist (RCS) during morning care to observe the resident on the floor. RCS PP stated the resident flip [sic] out of bed when she turned her over. Resident noted to be lying on her right side on the floor with a head injury with excessive bleeding. The air mattress was not put on hold during care. Review of the Director of Nursing's (DON) summary dated 10/13/2021 documented, per Night Supervisor CC, RCS PP was giving morning care and did not place the air mattress on hold. Upon interviewing RCS PP, she stated the resident was on her side and the weight of the resident along with the movement of the air mattress was forceful enough to cause the resident to roll out of the bed onto the floor causing her to hit her head. Observation on 1/11/2022 at 9:09 a.m. revealed R#76 lying in a low bed and floor mats on both sides of the bed. Further observation revealed air mattress had been removed from the bed. Observation on 1/13/2022 at 9:20 a.m. revealed R#76 lying in a low bed with floor mats on both sides of the bed. One-quarter siderails raised on the top portion of the bed. Interview on 1/12/2022 at 1:35 p.m. with the DON revealed RCS PP was providing morning care to R#76 on the day of the fall. She stated RCS PP turned the resident to her side and the air mattress rolled the resident out of the bed and onto the floor. During further interview, DON stated that the resident was sent to the hospital to get stitches in her head. Interview on 1/13/2022 at 1:31 p.m. with the DON confirmed the air mattress was not on the care plan at the time of the fall. She stated, if staff could have two people to do the turn it would be great but in reality, it does not always happen. During further interview, the DON stated the quarter rails were in the raised position when the resident fell . Interview on 1/13/2022 at 4:10 p.m. with the DON stated there was no policy on how to provide care for a resident lying on an air mattress. Interview on 1/14/2022 at 8:59 a.m. with the DON, stated each unit had the Lippincott Book that the Nurses and RCS's could reference for guidelines to care, including the use of an air mattress. Interview on 1/14/2022 at 9:08 a.m. with Night Supervisor CC, revealed on 10/13/2021 the nurse reported to her that R#76 was on the floor. Night Supervisor CC stated that RCS PP was providing care and the air mattress was not on hold per RCS PP. When RCS PP began to turn R#76, the resident fell to the floor on the window side of the room and received a head laceration. She further stated the siderails were raised but did not remember the height of the bed. During further interview, Night Supervisor CC stated if staff think they need help, they need to get another staff member and always turn the resident towards themselves. Interview with RCS PP on 1/14/2022 at 9:56 a.m. stated on the day of the fall she was giving R#76 a bed bath around 4:00 a.m. RCS PP stated she put the side rail down and turned the resident towards her. When I went to put the sheet on the bottom of the bed the resident began to slide down and fell to the floor. During further interview, she stated after the fall we had an in-service and were told that anybody with an air mattress needs to have two people present for any care and staff should place the air mattress on standby. She further stated prior to this incident she had not received any training about putting the air mattress on hold when providing care.