Every finding on record at Schoenbrunn Healthcare

Based on observation, interview and review of facility policy the facility failed to ensure food was stored, prepared and served under sanitary conditions. This had the potential to affect all 91 residents receiving meals from the kitchen. The facility identified one resident (#9) who did not eat by mouth (NPO). The facility census was 92. Findings include:Observation during the initial tour of the kitchen on 05/21/26 at 8:15 A.M. revealed a 25-pound box of rice was open to air with the rice exposed to the air in the dry storage room. An interview at this time with Manager-in-Training (MIT) #412 verified the rice was open to air and should be in an airtight container. Observation on 05/21/26 at 11:50 A.M. in the facility kitchen revealed the stainless-steel pans stored under the microwave were stored wet. An interview at this time with District Dietary Manager (DDM) #411 verified the pans were wet and should have been air dried prior to storage. Observation on 05/21/26 at 12:20 P.M. in the facility kitchen revealed the plastic warming bases were stacked together wet on a storage rack. An interview at this time with DDM #411 verified the bases were wet and should not have been stored unless air dried. Observation on 05/21/26 at 12:35 PM revealed DDM #425 was making a toasted cheese sandwich with rubber gloves on, and she touched the knob on the stove with her left gloved hand then went over and opened a drawer with her right gloved hand to get a spatula out of the drawer. DDM #425 then touched both of her rear pant pockets so she could get something out of her back pocket for Dietary Aide (DA) #421. Without changing gloves or washing hands, DDM #425 then went back over the stove and picked a piece of bread up with her contaminated gloved hands to continue making the toasted cheese sandwich. An interview at this time with DDM #425 verified the findings and verified she did not change gloves nor wash her hands and put on clean gloves prior to directly touching the bread to make the sandwich. Observation of the kitchenette off of the main dining room on 05/21/26 at 2:13 P.M. revealed the box of iced tea connected to the drink dispensing system had a best by date of 02/05/26. An interview on 05/21/26 at 2:14 P.M. with DA #410 verified the iced tea had a best by date of 02/05/26. Review of the facility policy titled, Food Storage-Dry Goods, dated 02/23 revealed all dry goods would be appropriately stored in accordance with the Food and Drug Administration Food Code. Review of the facility policy titled, Warewashing, dated 12/24 revealed all dishware, service ware and utensils would be cleaned and sanitized after each use. All dishware would be air dried and properly stored. Review of the facility policy titled. Food Preparation, dated 02/26 revealed all staff would practice proper handwashing techniques and glove use.This deficiency represents noncompliance investigated under Complaint Number 2999727.

Based on observation, review of the facility menu and diet spreadsheet, and interviews the facility failed to ensure menus were followed as prepared in advance and failed to ensure residents were notified of substitutions in advance. This affected nine residents (Resident #14, #18, #25, #28, #31, #42, #46, #56, and #73) of 91 residents who received meals from the kitchen. The facility identified one resident (#9) who did not eat by mouth. The facility census was 92.Findings include:Review of the facility menu for week four Thursday (05/21/26) revealed the lunch meal was planned for honey glazed ham, sauteed asparagus cuts, whipped sweet potatoes, dinner roll and butterscotch pudding with the alternate vegetable being zucchini. Review of the Thursday lunch spreadsheet for 05/21/26 revealed residents were to receive either asparagus cuts or zucchini as the vegetables for the meal and three ounces of honey glazed ham. Review of the Resident Council Minutes dated 04/28/26 revealed an unnamed resident complained they did not receive what they ordered for meals.Observation of meal service on 05/21/26 from 11:45 A.M. until 1:25 P.M. revealed at 12:10 P.M. [NAME] #400 had placed a quarter sized slice of ham on a resident plate and handed it to Dietary Aide (DA) #410 to place on the resident tray for meal service. Observation of the pan of honey glazed ham on tray line revealed the pieces of ham were not the size of three-ounce pieces. When questioned by the surveyor on the portion size, [NAME] #400 obtained a scale and weighed the quarter size slice of ham that had been placed on the plate and confirmed it weighed 1.5 ounces which did not meet the three-ounce portion size per the spreadsheet. [NAME] #400 confirmed the 1.5-ounce portions had been prepared as the portion size. Further observation during tray line revealed they had to cook more ham and honey glaze during tray line because they ran out of honey glazed ham halfway through tray line in order to provide the correct three-ounce portion to the residents. Further observation of the lunch tray line meal service revealed at 12:50 P.M. there was no more sauteed asparagus cuts for the last nine trays. District Dietary Manager (DDM) #411 proceeded to open a can of cooked carrots and heat the carrots in the microwave without adding any seasoning to the carrots. The carrots were removed from the microwave and served to the last nine trays which DDM #411 identified were trays for Resident #14, #18, #25, #28, #31, #42, #46, #56, and #73. An interview at this time with DDM #411 verified she had run out the vegetable on the menu and replaced it with unseasoned carrots out of the can and did not notify the nine residents of the substitution. An observation on 05/21/26 at 1:50 P.M. revealed Resident #46 had not eaten his carrots. An interview at this time with Resident #46 revealed he did not really like cooked carrots. On 05/21/26 at 1:55 P.M. an interview with Resident #73 revealed she was tired of carrots because they had them all the time. Resident #73 stated there was no seasoning on the carrots and she did not like the carrots. This deficiency represents noncompliance identified during investigation of Complaint Number 2999727.

Based on personnel record review, observation and interview, the facility failed to employ a qualified director of food and nutrition services (Dietary Manager) and educate dietary aides. This affected all 86 residents in the facility. The facility census was 86.Findings include: Interview on 03/23/26 at 9:43 A.M. with the Administrator revealed they have a company called Health Care Services Group (HCSG) that started as a contract company to run the kitchen. The facility uses their employees and conduct oversight.Review of personnel credentials revealed Dietary Manager #217 did not have the qualifications to be a Dietary Manager. She was not certified and her degrees were not in the areas to qualify her for the position, despite her years of working in a kitchen. Interview on 03/23/26 at 11:02 A.M. with Dietary Manager #217 revealed she had been employed by the facility as a cook. When HSCG was contracted they hired the kitchen employees the facility had employed.Interview on 03/24/26 at 4:13 P.M. with Dietary Manager #217 revealed HCSG took over running the kitchen on 10/20/25. Dietary Manager #217 was promoted to manage the kitchen on 12/01/25. She revealed [NAME] #100 was the credentialed Dietary Manager and stepped down when the contract company took over due to the complexity of the computer system. [NAME] #100 informed HCSG she was stepping down as the Dietary Manager at the beginning of November and recommended Dietary Manager #217, who was a Cook, to take over. She informed HCSG at that time Dietary Manager #217 was not credentialed. They informed the facility they would pay for Dietary Manager #217 to take the classes to receive credentials as a Certified Dietary Manager. Dietary Manager #217 verified she had not started classes. She speculated the new company might be waiting to see if she would be able to handle the position before putting money into her training.This deficiency represents non-compliance investigated under Complaint Number 2701233.

Based on observation, test tray, and interview, the facility failed to ensure food was prepared by methods that conserve nutritive value, flavor, and appearance. This had the potential to affect all 86 residents in the facility.Findings include:1.Observation of the lunch meal on 03/23/26 revealed the Lifebridge Unit was the last hall to be served. The dining cart with trays arrived at 1:15 P.M. Observation and interviews related to the meal appearance and palatability revealed on 03/26/26 at 1:25 P.M. Resident #78 was sitting on the side of the bed eating his lunch. The resident appeared to have two bowls of pasta salad on his tray that he was eating with a fork. The surveyor commented related to the pasta salad and Resident #78 revealed the bowls were chicken noodle soup not pasta salad. There was not any broth in either bowl of chicken noodle soup. The resident was eating it with a spoon. The resident indicated he requested two bowls of chicken noodle soup daily for lunch. When asked if they ever have broth he indicated sometimes, they do but usually he has to eat the soup with a fork. Interview and observations on 03/23/26 at 1:40 P.M. with Certified Nurse Aide (CNA) #111 verified Resident #78 received two bowls of chicken noodle soup that did not contain broth.2.Observation of the dinner tray line on 03/23/26 at 5:28 P.M. revealed broccoli was being served in a bowl. The broccoli appeared to not be holding it's shape. At 5:54 P.M. the broccoli was served into a bowl to be tested. The broccoli did not hold shape. The texture was mushy and watery.Interview on 03/23/26 at 6:04 P.M. with [NAME] #106 verified the broccoli always gets mushy. He indicated he cooks it on the stovetop in a tin on low. 3. Observation on 03/24/26 at 1:16 P.M. of Resident #78's lunch meal revealed he had two bowls of pasta on his tray. He was eating them with a fork. Interview on 03/24/26 at 1:16 P.M. with the resident verified the bowls were supposed to contain his chicken noodle soup. One bowl had no visible broth, and the second bowl had a small amount of liquid on the bottom. Dietary Manager #217 was present during the observation and interview. She asked the resident if he would rather have a flat noodle verses the spring noodle and he said yes. She included the spring noodles must be soaking up the broth. Observation of the tin of soup in the kitchen on 03/24/26 at 1:18 P.M. revealed it was dry at the bottom when the noodles were pushed aside. There was no broth in the soup at all. The tin appeared as a tin of noodles with carrots.Dietary Manager #217 was present during the observation. She verified there was not broth in the tin of soup in the kitchen.This deficiency represents non-compliance investigated under Master Complaint Number 2800638, Complaint Numbers 2701233, 2661187.

Based on menu review and interview, the facility failed to ensure appealing options of similar nutritive value were available to residents who chose not to eat food that was initially served or who requested a different meal choice. This had the potential to affect all 86 residents in the facility. The facility census was 86.Findings include:Interview on 03/23/26 at 11:02 A.M. with Dietary Manager #217 revealed the kitchen needed major plumbing work where the cement floor was removed in areas to access broken pipes in the kitchen and dry storage. They had no use of the kitchen during 19 days of replacing the pipes and re-cementing the floor. An alternative menu was approved by corporate to be able to serve meals from the dining room using roasters, crockpots, microwave, griddle, and a waffle maker. Between 02/26/26 and 03/16/26 meals were made out of the dining room and were not cooked in the kitchen. There was only one choice for each meal. There were no second option and the only substitutes available were a peanut butter and jelly sandwich and a deli sandwich. Interview on 03/23/26 at 1:28 P.M. with Resident #72 revealed there are no second options or substitute items. He does not get to order. They just give him what they want and he doesn't like the peas and carrots and rice he had on his plate.Interview and observation on 03/23/26 at 1:33 P.M. with Resident #78 revealed his meal ticket included he wanted chocolate milk, which was not served on his tray,Interview and observation on 03/23/26 at 1:35 P.M. with Resident #48 revealed she does not order. She is just served whatever they give her. Her preference was to get two percent milk, cranberry juice and fruit punch on her tray. She only was served the fruit punch.Interview and observation on 03/23/26 at 1:42 P.M. with Resident #71 during the lunch meal revealed when the kitchen was down, she was served burnt pizza with no other option. She indicated even when she tells them what she wants she doesn't usually get it. Her ticket indicated she was to receive ice for every meal which was not delivered on her tray. She was also to receive fruit punch per her lunch ticket which was not delivered on her lunch tray.Interview on 03/25/26 at 2:36 P.M. with Dietary Manager #217 verified they did not have a second meal of similar nutritional value available during the kitchen shut down. Further verified, they are training new kitchen dietary aides and with the kitchen in the dining room and just moving back to the kitchen on 03/18/26 she had not given them the time they need for training for their duties including the tray line.This deficiency represents non-compliance investigated under Master Complaint Number 2800638, Complaint Numbers 2789794, 2661187.

Based on observation, interview, record review, and policy review, the facility failed to store, prepare and serve food under sanitary conditions. This had the potential to affect all the residents in the facility. The facility census was 86.Findings include: 1.Observation of the kitchen on 03/23/26 at 2:40 P.M. revealed the large garbage can in the kitchen near the prep table and three compartment sink did not have a lid covering. On 03/23/26 observation at 5:12 P.M. revealed the trash was piled above the top of the large garbage cans. Dietary Aide #105 was placing pineapple in cups and covering them with saran wrap on the prep table by the trash can.Observation of the kitchen on 03/24/26 at 11:08 A.M. revealed the trash can by the prep table did not have a lid. There were large cans piled high over the top of the trash can. At 1:17 P.M. the trash was still over flowing the top of the garbage can without a lid. Interview 03/24/26 at 1:20 P.M. with Dietary Manager #217 verified the garbage can was not covered with a lid.2. Observation of the supper tray line on 03/23/26 at 5:12 P.M. revealed tray line temperatures were taken. There was no observation of the temperature of the milk being obtained. At 5:46 P.M. the surveyor asked for the milk to be tested when placed on a tray. The milk was 40 degrees Fahrenheit.Observation of the kitchen on 03/24/26 at 11:08 A.M. revealed there were five cups of milk poured and dated 03/24/26 on the three compartment sink with the milk gallon next to them. At 11:29 A.M. when the tray line began the glasses of milk were placed on a tray in the milk chest by Dietary Manager #217.At 11:50 A.M. a glass of milk was removed from the milk chest and placed on a tray. The surveyor asked for a temperature reading of the milk. The temperature was 46.9 degrees Fahrenheit. On 03/24/26 at 11:52 A.M. [NAME] # 104 verified the temperature of the milk was not obtained before the tray line started. The milk was above the 41 degree guideline for refrigeration.Review of the food temperature logs for March 2026 revealed there were 71 meals served. There was not a milk temperature reading for 47 of the 71 meals. Interview on 03/24/26 at 1:22 P.M. with Dietary Manager #217 verified the milk temperatures were not consistently monitored.Review of the facility's Record of Food Temperatures policy revised 2022 included potentially hazardous cold food temperatures will be kept at or below 41 degrees Fahrenheit. Food temperatures will be verified using a thermometer which is both clean, sanitized and calibrated to ensure accuracy.3. Observation of the kitchen milk chest on 03/23/26 at 2:53 P.M. revealed the thermometer read 40 degrees. There were eight cartons of 1% milk with a use by date of 03/23/26 in the milk chest.Observation of the milk chest on 03/24/26 at 1:22 P.M. revealed there were six cartons of 1 percent milk in the milk chest.Interview on 03/24/26 at 1:22 P.M. with [NAME] #104 revealed she used two of the milk cartons for trays on 03/24/26 not realizing the use by date was 03/23/26. The milk was served to Resident #21.This deficiency represents non-compliance investigated under Master Complaint Number 2800638, and Complaint Numbers 2789794, 2701233, and 2661187.

Based on review of medical records, review of facility policies and procedures, staff and resident observations and interviews, the facility failed to ensure the privacy of Resident #3 during incontinence care. This affected one resident (#3) of one resident reviewed for incontinence care. The facility census was 86. Findings include:Review of the medical record for Resident #3 revealed admission to the facility on [DATE] with diagnoses including lung disease, heart failure, diabetes, anxiety, gastric reflux, high blood pressure, arthritis, and a bleed of the gastric system. Further review of the medical record revealed a quarterly minimum data set (MDS) assessment was completed on 01/14/26. The MDS assessment revealed Resident #3 was cognitively intact and was dependent on staff with personal hygiene, toileting, bathing, dressing, transfer and mobility. The MDS assessment also indicated Resident #3 was always incontinent of both bowel and bladder.Observation on 03/25/26 at 8:58 A.M. of incontinence care of Resident #3 revealed certified nurse's aide (CNA) #137 gathering appropriate supplies and entering the double occupancy room of Resident #3 and closing the door. Resident #3's roommate was present in the room sitting in his wheelchair. There was an undrawn privacy curtain located in the middle of the room dividing the space. CNA #137 began providing incontinence care of Resident #3 without pulling the privacy curtain to ensure the privacy of Resident #3. Resident #3 was laying in his bed and CNA #137 removed his adult brief exposing his genital area for cleaning then had Resident #3 roll to his left side toward the wall exposing his buttocks to his roommate while she continued to clean Resident #3 buttocks. The privacy curtain was not used at anytime during the care provided by CNA #137.Interview on 03/25/26 at 9:04 A.M. with Resident #3 revealed sometimes the CNAs forget to pull the curtain during incontinence care and it sometimes bothers him that he is exposed to his roommate when he is in the room. CNA #137 was present for interview with Resident #3 and acknowledged she did not pull the privacy curtain for Resident #3 and immediately apologized to him.Review of the facility policy undated and titled Resident Rights, revealed residents have the right to privacy and confidentiality. Further review revealed personal privacy to include personal care.This deficiency represents an incidental finding of non-compliance investigated under Master Complaint Number 2800638.

Based on record review, observation and interview, the facility failed to ensure adaptive equipment was available as ordered. This affected one resident (#49) of six residents reviewed who were ordered adaptive equipment for meals. The facility census was 86.Findings include:Review of Resident #49's medical record revealed a 09/20/23 admission with diagnoses including hypertensive urgency, renal dialysis, glaucoma, and legally blind.Review of the quarterly 01/13/26 Minimum Data Set (MDS) Assessment revealed he was independent for daily decision making and required set up for meals. Physician orders included a renal diet, regular texture, thin consistency, double protein no orange juice, no bananas, no potatoes, 1800 milliliter fluid restriction with blue scoop bowl and plate guard for renal failure.Observation of the supper tray line on 03/23/26 at 5:28 P.M. revealed the meal was cheeseburger on a bun, broccoli, tater tots, and pineapple tidbits.The ticket for Resident #49 included he was to have a blue scoop bowl and a plate guard. The tray only had a plate guard.Interview on 03/23/26 at 5:40 P.M. with Dietary Aide #107 revealed she did not have any blue scoop plates. She included there used to be about 10 and now they can not find any. Dietary Manager #217 included she went to the room and floor and could not find any. She included she is having the Administrator buy some.Observation of the lunch tray line on 03/24/26 revealed the first tray was plated at 11:36 A.M. At 11:58 A.M. it was revealed there were no scoop bowls for Resident #49's meal. The lunch meal was smothered chicken thigh, whole kernel corn, oven brown potatoes, cornbread and sliced pears. Interview on 03/24/26 at 11:58 A.M. with [NAME] #104 revealed they had three of them (scoop bowls) and now they can not find any.Interview on 03/25/26 at 9:35 A.M. with [NAME] #104 revealed they still had not found or obtained any blue scoop bowls.Interview on 03/25/26 at 9:43 A.M. with Dietary Manager #217 revealed scoop bowls were ordered 03/23/26 and were due to be delivered 03/26/26.This deficiency represents an incidental finding of non-compliance investigated under Master Complaint Number 2800638.

Based on observation, staff interview and review of facility policy the facility failed to dispose of expired medications and/or unlabeled medications. The had the potential to affect all 76 residents residing in the facility. Findings include: Observation on 07/30/25 at 7:49 A.M. of the second floor medication storage room revealed the following expired medications:Two Incruse Ellipta inhalers 6.25 micrograms (mcg) in a sealed foil package, removed from box with expiration dates of 10/24 and 02/25. No label attached.Lovenox 100 milligrams/milliliter (mg/ml) injection with an expiration date of 05/25. No label attached Cipro 400 mg 2 mg/ml intravenous (IV) kit with a dispensed date of 03/14/19 and a discard after 04/18/25 date.Acetylcysteine 20% 200 mg/ml 23 vials with an expiration date of 5/2025.Interview on 07/30/25 at 7:55 A.M. with Registered Nurse (RN) #246 verified the medications were expired and stored in the medication room. Review of facility policy titled Medication Storage revealed unused medications: The pharmacy and all medication rooms are routinely inspected by the consultant pharmacist for discontinued, outdated, defective, or deteriorated medications with worn, illegible, or missing labels. These medications are destroyed in accordance with our Destruction of Unused Drugs policy.

Based on observation, interview, review of dishwasher temperature log, review of manufacture guidelines, and policy review the facility failed to ensure the dishwasher and three compartment sink were in proper working order to prevent the potential spread of food borne pathogens. This had the potential to affect all 76 residents residing in the facility. Findings include: Observation on 07/30/25 at 9:34 A.M., of the three compartment sink with Dietary Manger #199 and [NAME] #216 revealed the sink was leaking and water was noted running down the hoses and faucet into the second compartment of the sink (rinse water). There was sediment observed in the water. The Dietary Manger #199 confirmed the sink was used for items that could not be ran through the dishwasher. [NAME] #216 was washing the blender in the sink, preparing for the next pureed food item. The Dietary Manger confirmed findings during observation. Observation on 07/30/25 at 10:14 A.M., of the dishwasher with Dietary Manger #199 revealed the label indicated the dishwasher was a hot temperature dishwasher. The Dietary Manger confirmed the dishwasher was high temperature and the label indicated the wash cycle was 155-160 degrees Fahrenheit and rinse was 180-195 degrees Fahrenheit to disinfect the dishes. The first observation the wash was 110 degrees Fahrenheit and rinse was 186 degrees Fahrenheit. The second and third observation revealed the same temperatures. Review of the daily dishwasher temperature logs dated 07/27/25 to 07/30/25 with the Dietary Manger #199 revealed on 07/27/25 the dishwasher temperature in the A.M. was 183 degrees Fahrenheit for the wash and 132 Fahrenheit for the rinse and P.M. was 178 Fahrenheit Fahrenheit for the wash and 160 Fahrenheit for the rinse. On 07/28/25 the A.M. wash was 132 Fahrenheit, and rinse was 170 Fahrenheit and the P.M. wash was 173 Fahrenheit, and the rinse was 181 Fahrenheit. On 07/29/25 the A.M. wash was 180 Fahrenheit, and the rinse was 130 Fahrenheit and the P.M. the wash was 170 Fahrenheit and the rinse 184 Fahrenheit. On 07/30/25 the A.M. wash 130 Fahrenheit and the rinse was 170 Fahrenheit. The Dietary Manger confirmed findings during the review of the log. Interview on 07/30/25 at 10:14 A.M. and 10:39 A.M., with the Dietary Manger #199 confirmed the wash should be 155-160 degrees F and the rinse should be 180-195. The Dietary Manger confirmed she was not aware the dishwasher temperatures were not meeting recommendations. There had been issues with the water pressure and last night the Maintenance Director had cleaned the filters in the dishwasher and three compartment sinks. The Dietary Manger confirmed staff had been using regular dining ware, however she would have staff use disposable dining ware until the sink and dishwasher were fixed.Interview and observation on 07/30/25 at 10:24 A.M., with Maintenance Director (MD) confirmed she had cleaned the filters in the three compartments sink last night due to there being no water pressure. The MD confirmed the sink was leaking and there was sediment in the rinse water. The MD confirmed she was not aware the dishwasher temperatures were not meeting the recommended temperatures. Review of the facility's policy and procedures manual titled Dishwashing undated revealed the dish machine temperatures are logged at each of meal on the dish machine temperature log. Minimum temperatures, as required by the manufacturer are wash 150-160 F and rinse 180-195. Staff should check the dish machine gauges throughout the cycle to assure properly temperatures for sanitation. A three-compartment sink is set up with wash, rinse, and sanitizing. Employees are trained in proper manual dishwashing procedures. Review of the owner ' s manual for the dishwasher the wash temperature must be 155 minimum. The rinse temp must be 180 minimum. NOTE: Rinse water temperature must be observed during the rinse cycle.

Based on medical record review, observation, interview, and policy review the facility failed to ensure infection control practices were maintained during wound care, dining, incontinence care, and medication administration. This had the potential to affect all 78 resident residing in the facility. Based on medical record review, observation, interview, and policy review the facility failed to ensure infection control practices were maintained during wound care, dining service, incontinence care, and medication administration. This affected Resident #3, #4, #9, #40, #43, #51 and #63 but had the potential to affect all 76 residents residing in the facility. Findings include: 1. Medical record review revealed Resident #4 was admitted to the facility on [DATE] with diagnoses of peripheral vascular disease, above left knee ambulation, heart failure, chronic obstructive pulmonary disease, chronic kidney disease, non-pressure ulcers, neuromuscular dysfunctional bladder, diabetes, legally blind, and chronic pain. Review of Resident #4's orders dated 07/2025 revealed enhanced barrier precautions with high contact resident care activity. Review of Resident #4's wound care orders dated 07/2025 revealed cleanse right lateral foot with normal saline, pat dry, apply medihoney, collagen and calcium alginate, and cover with abdominal pad, and wrap with kerlix Tuesday, Thursday, and Saturday. The right posterior ankle order included to cleanse with normal saline, apply skin prep, cover with abdominal pad and wrap with kerlix Tuesday, Thursday, and Saturday. An. observation and interview on 07/29/25 at 10:00 A.M., revealed Licensed Practical Nurse (LPN) #122 and Wound Nurse Practitioner (WNP) #250 were observed in Resident #4's room without gowns applied while performing wound care and assessing Resident #4's wound on her right foot. LPN #122 removed the old dressing from Resident #4's right foot without evidence of a gown on. The LPN confirmed the old dressing had a scant amount of brown drainage. The WNP measured the resident's wound without a gown and reported the resident had two open areas on her right foot. The outer foot wound measured 3.2 centimeters (cm) by 0.9 cm by 0.2 cm and was treated with medihoney and alginate and the ankle was 1.1 cm by 0.2 and depth was undetermined and treated with skin prep. LPN #122 confirmed Resident #4 was on enhanced barrier precautions (EBP) because the resident had a catheter. The LPN was not aware she was required to wear a gown during wound care. The LPN confirmed the sign on the resident door indicated the resident was on EBP and provider and staff were required to wear gloves and gowns with high contract resident care activities including wound care (any skin opening requiring a dressing). There was no evidence of gowns in the cart outside the door. LPN #122 looked for gowns on the unit and could not find gowns and reported she would have to leave the unit to try to find gowns. Further observation of the room revealed there were clothing and blankets pilled on the two isolation trash bins inside the resident's room and the bins were not located near the exit door. Interview on 07/29/25 at 10:12 A.M., with the Director of Nursing (DON) confirmed Resident #4 was on EBP for wounds and urinary foley catheter. The DON confirmed staff were required to wear gowns and gloves when providing wound care. Observation and interview on 07/29/25 at 11:23 A.M., with Infection Preventionist (IP) #115 of Resident #4's room revealed there were no gowns in the protective personal equipment (PPE) cart outside the room and the isolation trash bins in the resident rooms were not located near the exit door and the bins were covered with clean clothing and blankets. The IP removed the clothing items and opened the bins, and the used PPE was in bins without a biohazard bag in-place. The IP confirmed there were no gowns readily available, the isolation trash bins were not located near the exit door, the isolation trash bins should not be covered with clothing and blankets and the bins should have red biohazard bags inside to contain the used PPE. The IP confirmed the WNP and LPN #122 should have been wearing gowns during wound care. Review of Enhanced Barrier Precautions policy and procedure dated 2025 revealed it was the facility policy to implement enhanced barrier precautions (EBP) for the prevention of transmission of multi-drug-resistant organisms (MDRO). EBP refers to an infection control intervention designed to reduce the transmission of multidrug-resistant organisms that employs targeted gown, and gloves use during high contact resident activities. An order for EBP will be obtained for resident with any of the following: Wounds and/or indwelling medical device even if the resident was not known to be infected or colonized with a MDRO. Implementation of EBP include ensuring gowns and gloves are available immediately near or outside the resident ' s room. Personal protective equipment is only necessary when performing high-contact care activities and may not need to be done prior to entering the resident ' s room. Position the trash cans inside the resident ' s room and near the exit for discarding PPE after removal, prior to exiting the room. The Infection Preventionist will incorporate periodic monitoring and assessment of adherence to determine the need for additional training and education. Provide education to residents and visitors. High-contacts residents ' care activities include wound care (any skin opening requiring a dressing). 2. Review of the medical record revealed Resident #40 was admitted to the facility on [DATE]. Diagnoses included dementia, anxiety disorder, hypertension, glaucoma, major depressive disorder, delusional disorders and bipolar disorder. Review of the Quarterly Minimum Data Set assessment dated [DATE] revealed Resident #40 had severely impaired cognition and was always incontinent of bladder and bowel. Observation of incontinence care for Resident #40 on 07/30/25 at 2:40 P.M. revealed Certified Nursing Assistant (CNA) #105 went into the adjoining bathroom and placed the clean washcloths directly into the sink to get them wet. CNA #105 then proceeded to apply liquid soap on to them, while they were lying in the sink. She took the washcloths out of the sink and began to provide perineal care to Resident #40 with the washcloths she had lying in the sink. An interview on 07/30/25 at 2:55 P.M. with CNA #105 verified she had not sanitized or cleaned the sink prior to placing the clean washcloths for perineal care for Resident #40 directly into the sink. She stated she did not have a basin to place them in. Review of the undated facility policy titled, Perineal Care, revealed it was the practice of the facility to provide perineal care to all incontinent resident during routine bath and as needed in order to promote cleanliness and comfort, prevent infections to the extent possible and to prevent and assess for skin breakdown. Step two indicated for the basin method to gather a basin and fill it no more than three-fourth the way up with warm water and the second method was the disposable cleaning cloth method, which the CNA did not use. 3. Observation on 07/28/25 at 12:35 P.M. revealed Certified Nursing Assistant (CNA) #141 went into the room of Resident #3 to deliver the lunch meal tray. She moved the over-the-bed table in front of the resident after placing the meal tray on to the over-the-bed table. She proceeded to go out into the hallway to the meal cart and get another meal tray off the meal cart for Resident #28 without washing her hands. She placed the meal tray on the over-the-bed table and then picked up his dinner roll with her bare hands and broke it in half and was going to butter it. The surveyor intervened. CNA #141 then went to get another roll off the meal cart and took it back into Resident #28 and butter it without touching it. She placed his over-the-bed table in front of him, went out of the room, retrieved another tray off the meal cart and took it the room of Resident #9 without washing her hands. An interview on 07/28/25 at 12:45 P.M. with CNA #141 verified she had not washed her hands while passing meals trays and touching resident items. 4. Review of medical record for Resident #43 revealed an admission date of 07/26/25 with diagnosis including methicillin resistant staphylococcus aureus infection, type II diabetes, anxiety disorder and hypertension. Observation on 07/28/25 at 8:30 A.M. of Resident #43's room revealed an isolation cart outside of room near the doorway. Upon entering the room, two red isolation bins were observed inside the room near the door. Interview on 07/28/25 at 8:30 A.M. with LPN#209 verified Resident #43 was on contact isolation and no signage was placed at the doorway. Review of facility policy titled Transmission-Based (Isolation) Precautions revealed Signage that includes instructions for use of specific PPE will be placed in a conspicuous location outside of the residents room, wing, or facility-wide. Additionally, either the CDC category of transmission-based precautions (e.g. contact, droplet, or airborne) or instructions to see the nurse before entering will be included in the signage. 5. Medication administration observation was made on 07/29/25 at 8:29 A.M. with RN #246. RN #246 was observed to prepare Resident #51's medications, entered Resident #51's room, administered oral medications and applied gloves. RN #246 then applied a lidocaine topical patch to Resident #51's back. Upon leaving the room, RN #246 removed her gloves and went to the medication cart, signed off the administered medications and prepared oral medications for Resident #63 without performing hand hygiene. RN #246 entered Resident #63's room, administered oral medications, applied new gloves, administered insulin, and applied a lidocaine topical patch to Resident #63's back. Upon leaving the room, RN #246 removed her gloves and went to the medication cart to sign off medications. She did not perform hand hygiene. Interview on 07/29/25 at 8:35 A.M. with RN #246 verified she did not perform hand hygiene between the medication administrations with Resident #51 and resident #63. Review of facility policy titled Medication Administration revealed wash hands using facility protocol and product before and after medication administration with each Resident. Review of the undated facility policy titled, Hand Hygiene, revealed the staff would perform hand hygiene procedures to prevent the spread of infection to other personnel, residents and visitors.

Based on medical record review, interviews, review of information located on Medscape.com, and policy review the facility failed to ensure a resident had an appropriate justification for the use of an antipsychotic medication and also failed to ensure residents had stop dates for antianxiety medications. This affected four (Resident #2, #8, #5 and #35) out of five reviewed for unnecessary medication review. Findings include: 1. Medical record review revealed Resident #2 was admitted to the facility on [DATE] with diagnoses including dementia, anxiety, and depression. Review of Resident #2 's medication administration records (MAR) and orders dated 04/25/25 to 07/22/25 revealed Resident #2 was administered Seroquel (antipsychotic)12.5 milligrams (mg) at bedtime for dementia. Further review of Resident #2's MAR and orders dated 04/24/25 to 07/22/25 revealed no documented evidence the resident was ordered or administered any other medication to treat anxiety, depression, or dementia. Review of Resident #2 ' s psych note dated 05/29/25 revealed the resident was stable with no behaviors noted. The plan was to continue Seroquel 12.5 mg at night for dementia. There was no documented evidence why Seroquel was determined appropriate to treat the resident ' s dementia. Review of Resident #2 ' s pharmacy reviews dated 05/25/25 and 06/22/25 no evidence any irregularities were noted with the Seroquel. Review of Resident #2's quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident was receiving an antipsychotic daily and no gradual reduction was attempted. Review of Medscape information (current) revealed the indication for use was schizophrenia, bipolar, major depression, and off-label use for alcohol dependence and insomnia. There was no evidence Seroquel was indicated to use for dementia. Interview on 07/31/25 at 11:32 A.M., with the Director of Nursing (DON) confirmed the resident returned from a short hospital stay (04/15/25-04/25/25) with an order for Seroquel 12.5 mg. The facility continued the order for Seroquel from 04/25/25 to 07/22/25 for dementia, which the DON confirmed dementia was not an appropriate indication of use for Seroquel. The DON reported psych had discontinued the Seroquel on 07/22/25 due to the resident was not having any behaviors. Review of the facility ' s policy and procedure titled Use of Psychotropic Medication dated 2025 revealed the policy ensures that residents only receive psychotropic medications when other non-pharmacological medication are clinically contraindicated. Additionally, these medication should only be used to treat the resident medical symptoms and not used for the discipline or staff convenience, which would deem a chemical restraint. Adequate for indication for use refers to the identified, documented clinical rationale for administering a medication that is based upon an assessment of the resident ' s condition and therapeutic goals and after any other treatments have been deemed clinically contraindicated. For psychotropic medication, without documentation in the record explaining that the practitioner had determined that other treatments have been deemed clinically contraindicated the indication of use was inadequate. Also, adequate indication for use means that the medication administered is consistent with manufacture ' s recommendation and/or clinical practice guidelines, clinical standards of practice, medication references, clinical studies, or evidence-based review of articles that are published in medical and/or pharmacy journals. The resident medical record shall include evaluation and the rationale for chosen treatment options. This includes any indicated documentation of rationale for prescribing psychotropic medication or switching from one type of psychotropic medication, specifically an antipsychotic medication, to another category of psychotropic medication. 2. Review of the medical record revealed Resident #8 was admitted to the facility on [DATE]. Diagnoses intercranial injury, vascular dementia, pseudobulbar affect, traumatic brain injury, major depression disorder, hypertension, mood disorder, hypothyroidism, right ankle contractures, frontotemporal neurocognitive disorder, generalized anxiety disorder, impulse disorders, hemiplegia and cerebral infarctions affecting the right side. Review of the physician's orders revealed Resident #8 had an order for Ativan 0.5 milligrams (anti-anxiety medication) two times daily for restlessness/anxiety and 0.5 milligrams every 12 hours as needed for restlessness dated 01/20/21. Further review revealed no documentation of a stop dated for the as needed Ativan for Resident #8. Review of the Quarterly Minimum Data Set assessment dated [DATE] revealed Resident #8 had severely impaired cognition and received an antipsychotic and an antianxiety. An interview on 07/29/25 at 2:00 P.M. with the Director of Nursing (DON) revealed all as needed psychotropic were only used for 14 days after being ordered for 14 more days then the order was written to continue. She confirmed there was no stop dated for the as needed Ativan. 3. Review of the medical record revealed Resident #35 was admitted to the facility on [DATE]. Diagnoses included subarachnoid hemorrhage, dementia, protein calorie malnutrition, falls, osteoporosis, neoplasm of the right breast, anxiety disorder, hypertension, head contusion, depression, reduced mobility and weakness. Review of the physician's orders revealed Resident #35 had an order for Ativan 0.5 milligrams (anti-anxiety medication) every four hours as needed for anxiety dated 04/14/25. Further review of the medical record revealed no documentation of a stop dated for the as needed Ativan for Resident #35. Review of the psychiatric progress note dated 06/05/25 revealed the plan was to continue with current psychotropic medication; give Ativan 0.5 milligrams when getting ready for bed and Ativan 0.5 milligrams every four hours as needed for anxiety. The rationale was due to the resident's current psychiatric status and history of instability a gradual dose reduction (GDR) was clinically contraindicated unless otherwise noted. An interview on 07/29/25 at 2:00 P.M. with the Director of Nursing (DON) revealed all as needed psychotropic were only used for 14 days after being ordered for 14 more days then the order was written to continue. She confirmed there was no stop dated for the as needed Ativan. 4. Review of Resident #5's medical record revealed an admission date of 05/15/25 with diagnosis including chronic obstructive pulmonary disease, type 2 diabetes, chronic respiratory failure, anxiety disorder, and major depressive disorder. Review of the 06/06/25 admission Minimum Data Set (MDS) Assessment revealed the resident has intact cognition. Physician orders included: Ativan 0.5 milligrams (mg) every 8 hours as needed for dyspnea or anxiety dated 06/12/25. There was not a 14 day stop for the as needed controlled medication. The medication should have been discontinued 06/28/25. Interview on 07/30/25 at 11:19 A.M. with Director of Nursing (DON) verified the antianxiety medication did not have a 14 day stop as required. Review of the undated facility policy titled, Use of Psychotropic Medications, revealed the policy was to ensure the residents only received psychotropic medications when other nonpharmacological interventions were clinically contraindicated. Additionally, these medications should only be used to treat the resident ' s medical symptoms and not used for discipline or staff convenience. Step 16 indicated psychotropic medications used on an as needed basis must have a diagnosed specific condition and indications for the as needed use documented in the resident ' s medical record and was subject to limitations. As needed orders for psychotropic medication, excluding anti-psychotics should be limited to no more than 14 days, unless the attending physician or prescribing practitioner believed it was appropriate to extend the order beyond the 14 days. The medical record should include documentation from the physician or prescriber for the rational for the extended time period and indicated a specific duration.

Based on observations, review of the medical record, interview with staff and review of facility policy, the facility failed to ensure the call light was within reach of Resident #26. This affected one resident (Resident #26) of one reviewed for accommodation of need. Findings include: Review of the medical record revealed Resident #26 was admitted to the facility on [DATE]. Diagnoses included chronic obstructive pulmonary disease, rhabdomyolysis, paroxysmal tachycardia, anxiety disorders, hypertension, major depressive disorder with psychotic symptoms, and muscle weakness. Review of the plan of care dated 08/18/20 revealed Resident #26 was at a risk for falls related to deconditioning, gait and balance problems, and psychoactive drug use. Interventions included to be sure the call light for Resident #26 was within reach and encourage resident to use it for assistance as needed.Review of the Annual Minimum Data Set assessment dated [DATE] revealed Resident #26 had moderately impaired cognition and was dependent for all Activities of Daily Living. Observation on 07/28/25 at 11:18 A.M. revealed Resident #26 was up in the tilt in space wheelchair by the left side of the bed, however her call light was still attached to the left grab bar out of reach, behind her tilt in space wheelchair. This was verified with Certified Nursing Assistant (CNA) #141 on 07/28/25 at 11:20 A.M.Review of the undated facility policy titled, Call Lights: Accessibility and Timely Response, revealed the purpose of the policy was to assure the facility was adequately equipped with a call light at each resident ' s bedside, toilet, and bathing facility to allow residents to call for assistance. Staff would ensure the call light was within reach of each resident and secured as needed.

Based on observation, review of the medical record, and interview with staff, the facility failed to ensure the responsible party, physician and hospice were notified when Resident #27 spilled soup on herself causing a burn and when Resident #45 received a skin tear. This affected two residents (Resident #27 and #45) of five residents reviewed for accidents. Findings include:1. Review of the medical record revealed Resident #27 was admitted to the facility on [DATE]. Diagnoses included heart failure, atherosclerotic heart disease, dysphagia, extended spectrum beta lactamase resistance, glaucoma, retention of urine, osteoarthritis, hypothyroidism, major depressive disorder, generalized anxiety disorder and hypertension. Review of the Significant Change Minimum Data Set assessment dated [DATE] revealed Resident #27 had moderately impaired cognition.Observation of incontinence care with Certified Nursing Assistant (CNA) #144 and #224 on 07/30/25 at 1:36 P.M. revealed Resident #27 had two large blisters to both her right and left inner thighs. CNA #224 left to get Registered Nurse (RN #183) to look at them. Observation of blisters on 07/30/25 at 1:43 P.M. with RN #183 revealed Resident #27 had large blisters to both of her right and left inner thighs. RN #183 stated she had spilled soup on herself yesterday.Review of the nurse's note dated 07/29/25 at 4:39 P.M. revealed Resident #27 was in the chair for lunch and spilled soup on her lap. The nursing assistant responded, immediately pulled clothing way, and placed cold cloths on the abdominal area. The area was slightly pink. A reassessment was completed and no indications of redness or burning were noted. (There was no documentation the physician, hospice or the responsible party was notified.)Review of the nurse's note dated 07/30/25 at 2: 14 P.M. revealed Resident #27 was noted to have blisters to the bilateral inner thighs from spilling soup on self yesterday. The blisters were intact at this time. Resident was educated the importance of keeping blisters intact to prevent infection (There was no documentation the physician, hospice or the responsible party was notified.)An interview on 07/30/25 at 3:35 P.M. with RN #183 verified the physician, responsible party or hospice were not notified of the burns to the bilateral inner thighs of Resident #27. She stated she would update them.Review of the nurse's note dated 07/30/25 at 3:43 P.M. revealed hospice was notified of burn. The physician was okay with covering blisters with Tegaderm to protect it.Review of the nurse's note dated 07/30/25 at 6:57 P.M. revealed the Power of Attorney was notified on the resident's status.Review of the undated facility policy titled, Notification of Change, revealed the purpose of the policy was to assure the facility promptly informed the resident, consult the resident's physician, and notified the resident's representative when there was a change requiring notification. Circumstances requiring notification included accidents resulting in injury or potential to require a physician's interventions.2. Review of the medical record revealed Resident #45 was admitted to the facility on [DATE]. Diagnoses included pain due to internal orthopedic prosthetic device in the left hip and knee, osteoarthritis, dementia, anxiety disorder, cataracts, and weakness.Review of the Quarterly Minimum Data Set assessment dated [DATE] revealed Resident #45 had moderately impaired cognition.Observation on 07/28/25 at 11:25 A.M. revealed Resident #45 had an undated dressing to her right lower leg. An interview at this time Resident #45 stated the aide threw her into bed after she told her she did not want to go to bed. She stated she hit her shin on the bedrail and got a skin tear. She stated Her Aide came in and asked her what had happened to her leg, she told her what happen then she went and got the nurse. She stated the nurse came back and put a dressing on it. She stated she does not know her name, but it happened couple weeks ago. She stated she did not know anyone's name.Review of the physician's orders revealed Resident #45 had an order to clean the right lower leg with normal saline, apply xeroform, four by four, wrap in Kerlex, change daily every evening shift and as needed dated 07/14/25 at 11:45 A.M. written by Licensed Practical Nurse #122Further review of the medical record revealed no documentation of a skin tear, physician notification, or responsible party notification.An interview on 07/30/25 at 2:00 P.M. with the Assistant Director of Nursing (ADON) revealed the nursing assistant was getting the resident out of bed, bumped her leg on the bed and the resident got a skin tear. She verified there was no investigation, assessment, family or physician notification or documentation of the skin care in the medical record. She stated she did not know who the nursing assistant was who transferred her. She stated she has been having problems getting the nurses to document information in the medical record.An interview on 07/31/25 at 8:15 A.M. with the Director of Nursing (DON) stated she spoke to Resident #45 yesterday and the resident stated she did not believe the nursing assistant had malicious intent, but she transferred her too fast after she told her to go slow and caused a skin tear. The DON stated there were black knobs on the bed and that was what she caught her leg on. She stated Resident #45 thinks the staff were always going too fast with her. She stated the nursing assistant was Certified Nursing Assistant (CNA) #149. She stated the nurse was Registered Nurse (RN) #162. The DON stated the day shift nurse was told by the day shift aide Resident #45 had a dressing to her leg. The day shift nurse had to write an order because there was not one written. She stated she was made aware of the skin tear when she got to work on 07/14/25. She verified the nurse had not written an order, documented, assessed, filled out an incident report or notified the family or physician.An interview on 07/31/25 at 10:25 A.M. with Licensed Practical Nurse (LPN) #122 stated she has been working as the wound nurse while the wound nurse was off on leave. She stated she only worked Monday and Tuesday. She stated she had a message from RN #238 to look at the skin tear of Resident #45, so she looked at it on 07/14/25. She stated it had a dressing on it. She stated she does not know what happened she just wrote an order for a treatment. She verified at this time there was no order written but it did have a dressing on it.Review of the undated facility policy titled, Notification of Change, revealed the purpose of the policy was to assure the facility promptly informed the resident, consult the resident's physician, and notified the resident's representative when there was a change requiring notification. Circumstances requiring notification included accidents resulting in injury or potential to require a physician's interventions.

Based on record review, and interview, the facility failed to ensure a Level II Preadmission Screening and Resident Review (PASARR) was completed with a new psychiatric diagnosis. This affected one (Resident #34) of two residents reviewed for PASARR. The census was 76.Findings include: Review of Resident #34 ' s medical record revealed an admission date of 07/15/22 with diagnosis including vascular dementia, hypertension, anxiety disorder, and paranoid personality disorder. Review revealed the last PASARR submitted for the resident dated 07/08/22 did not indicate Resident #34 had a personality disorder.Record review revealed on 05/30/23 Resident #34 had a diagnosis of paranoid personality disorder added to his list of diagnoses.Review revealed there was no evidence of a subsequent PASARR submission, for a Level II consideration, to the state agency that included the new psychiatric diagnosis.Interview 07/26/25 at 1:10 P.M. with social services #213 verified there was not a PASARR submitted to the state agency for Level II consideration after the addition of the paranoid personality disorder diagnosis.

Based on record review, interview and facility policy review, the facility failed to develop a comprehensive plan of care for pain management. This affected one (Resident #38) of two residents reviewed for pain management. Facility census was 76.Findings include: Review of Resident #38 ' s medical record revealed an admission date of 05/16/25 with diagnosis including chronic systolic heart failure, type 2 diabetes, atrial fibrillation, chronic obstructed pulmonary disease, and hypertension.Review of the 05/28/25 5-day Minimum Data Set (MDS) Assessment revealed the resident received as needed pain medications and had intact cognition.Review of Resident #38 ' s physician orders revealed orders for Norco 5/325 milligrams (mg) every 6 hours as needed and Tylenol 650 mg every 6 hours as needed. Interview on 07/28/25 at 4:08 P.M. with Resident #38 revealed he always has pain and it is somewhat controlled.Further review of the medical record revealed no evidence of a pain care plan.Interview on 07/30/25 at 1:01 P.M. with MDS Nurse #104 verified there was not a comprehensive pain plan of care developed for Resident #38. Review of facility policy titled Comprehensive Care Plans revealed The comprehensive care plan will be developed within 7 days after the completion of the comprehensive MDS assessment.

Based on medical record review, interview, and policy review the facility failed to ensure residents who required staff assistance with activities of daily living received showers per schedule and preferences. This affected two (Resident #4 and #46) of two residents reviewed for shower preferences. Findings include: 1. Medical record review revealed Resident #4 was admitted to the facility on [DATE] with diagnoses of peripheral vascular disease, above left knee ambulation, heart failure, chronic obstructive pulmonary disease, chronic kidney disease, non-pressure ulcers, neuromuscular dysfunctional bladder, diabetes, legally blind, and chronic pain. Review of Resident #4 ' s orders dated 07/2025 revealed on 05/28/25 the resident was ordered showers on Monday, Wednesday, and Fridays per the resident ' s preference. Document refusals in the progress notes. Review of Resident #4 ' s Activity of Daily Living (ADL) care plan dated 05/02/16 and revised on 06/18/2020 revealed the resident required extensive assist of one staff member with bathing/showering three times weekly on Sunday, Tuesday and Thursday dayshift and as necessary. Review of Resident #4 ' s right to make lifestyle changes plan of care dated 05/11/16 and revised 04/23/21 revealed the resident preferred showers. Review of Resident #4 ' s significant change minimum data set (MDS) dated [DATE] revealed it was very important for the resident to choose type important is it to you to choose between a tub bath, shower, bed bath, or sponge bath. Review of Resident #4 ' s quarterly MDS dated [DATE] revealed no evidence the resident had rejected care. Review of the Resident #4 ' s bathing documentation dated 07/01/25 to 07/31/25 revealed no evidence that the resident had received a shower in the last 31 days. There was no documentation the resident had refused a shower. Review of Resident #4 ' s progress notes dated 07/01/25 to 07/31/25 revealed no documented evidence that the resident had refused a shower. Review of Resident #4's hospice note dated 05/02/25 revealed the resident would be seen twice a week for bed baths. The resident was dependent on staff for activities of daily living. Interview on 07/29/25 at 10:20 A.M., with Resident #4 revealed she had only received bed baths lately and she preferred to have a shower. Interview on 07/31/25 at 11:00 A.M., with Medical Record Clerk (MRC) #112 confirmed in the last 30 days Resident #4 was not provided with a shower per the resident's preference, orders and plan of care. The MRC reported currently she had Resident #4 on the shower schedule for Monday and Fridays, due to the resident being under hospice services and the hospice aides only come twice a week on Monday and Fridays. The MRC reported she would talk to the resident and hospice to work out a schedule to meet the resident preference for showers. 2. Medical record review revealed Resident #46 was admitted to the facility on [DATE] with diagnoses including ends stage renal disease, diabetes, legally blind, difficulty walking, weakness, and history of falls. Review of the annual modification MDS dated [DATE] revealed it was very important important is it to you to choose between a tub bath, shower, bed bath, or sponge bath. Review of quarterly MDS dated [DATE] revealed no evidence of the refusal of care and the resident required partial to moderate assistance with showering. Review of Resident #46's activity of daily living plan of care initiated 01/20/25 and revised 02/26/25 revealed the resident required partial/moderate assistance with bathing. Review of Resident #46's preference plan of care dated 01/04/23 revealed the resident would participate in choosing a bathing schedule that meets my preference and needs. Review of progress notes dated 07/01/25 to 07/31/25 revealed no evidence the resident refused showers. Review of resident's shower documentation (paper and electronic medical records) dated 07/2025 revealed the resident did not get a shower on 07/06/35, 07/20/25 and 07/27/25 Interview on 07/28/2025 at 2:53 P.M. with Resident #46 revealed his shower days were Tuesday, Thursday, and Sundays, however the doesn't get them three times a week and the staff forgets about him. Interview on 08/04/25 at 8:26 A.M., with MRC #112 confirmed it may have been her fault the resident didn't receive showers on Sundays in July 2025 because she only had the resident on the shower schedule for Tuesday and Thursday. MRC #112 confirmed there was no documented evidence the resident had received a shower on Sunday in July on 07/06/25, 07/20/25 and 07/27/25. The MRC confirmed she did not have access to the plan of care to update the resident's shower preferences. Review of the facility's policy and procedure dated 2024 revealed it was the facility's practice of this facility to assist residents with bathing to maintain proper hygiene, stimulate circulation and help prevent skin issues as per current standards of practice. Resident would be provided showers as per request or as per facility schedule protocols and based up resident safety.

Based on observations, review of the medical record, interviews with staff, review of the facility policy, the facility failed to ensure treatment orders were received for burns to Resident #27's thighs and failed to comprehensively assess a skin tear to Resident #45's leg. This affected two residents (Resident #27 and #45) of five residents reviewed for accidents.Findings include: 1. Review of the medical record revealed Resident #27 was admitted to the facility on [DATE]. Diagnoses included heart failure, atherosclerotic heart disease, dysphagia, extended spectrum beta lactamase resistance, glaucoma, retention of urine, osteoarthritis, hypothyroidism, major depressive disorder, generalized anxiety disorder and hypertension. Review of the Significant Change Minimum Data Set assessment dated [DATE] revealed Resident #27 had moderately impaired cognition.Observation of incontinence care with Certified Nursing Assistant (CNA) #144 and 224 on 07/30/25 at 1:36 P.M. revealed Resident #27 had two large blisters to both her right and left inner thighs. CNA #224 left the room to get Registered Nurse (RN #183) to look at them.Observation of the blisters on 07/30/25 at 1:43 P.M. with RN #183 revealed Resident #27 had large blisters to both of her right and left inner thighs. RN #183 stated she had spilled soup on herself yesterday.Review of the nurse's note dated 07/29/25 at 4:39 P.M. revealed Resident #27 was in the chair for lunch and spilled soup on her lap. The nursing assistant responded, immediately pulled clothing way, and placed cold cloths on the abdominal area. The area was slightly pink. A reassessment was completed and no indications of redness or burning were noted. There was no documentation the physician, hospice or the responsible party was notified.Review of the nurse's note dated 07/30/25 at 2:14 P.M. revealed Resident #27 was noted to have blisters to the bilateral inner thighs from spilling soup on self yesterday. The blisters were intact at this time. Resident #27 was educated on the importance of keeping blisters intact to prevent infection. An interview on 07/30/25 at 3:35 P.M. with RN #183 verified no treatment order was written for the blisters to both inner thighs of Resident #27.Review of the nurse ' s note dated 07/30/25 at 3:43 P.M. revealed hospice was notified of the burn. The physician was okay with covering the blisters with Tegaderm (clear protective film) to protect it.Review of the physician ' s orders revealed Resident #27 had an order to apply Tegaderm to the left and right thigh burn sites, leave in place for seven days then remove or remove if no longer clean or intact, and check site every shift dated 07/30/25.2. Review of the medical record revealed Resident #45 was admitted to the facility on [DATE]. Diagnoses included pain due to internal orthopedic prosthetic device in the left hip and knee, osteoarthritis, dementia, anxiety disorder, cataracts, and weakness.Review of the Quarterly Minimum Data Set assessment dated [DATE] revealed Resident #45 had moderately impaired cognition.Observation on 07/28/25 at 11:25 A.M. revealed Resident #45 had an undated dressing to her right lower leg. An interview at this time Resident #45 stated the aide threw her into bed after she told her she did not want to go to bed. She stated she hit her shin on the bedrail and got a skin tear. She stated Her Aide came in and asked her what had happened to her leg, she told her what happen then she went and got the nurse. She stated the nurse came back and put a dressing on it. She stated she does not know her name, but it happened couple weeks ago. She stated she did not know anyone ' s name.Review of the physician ' s orders revealed Resident #45 had an order to clean the right lower leg with normal saline, apply xeroform, four by four, wrap in Kerlix (medical cling wrap), change daily every evening shift and as needed dated 07/14/25 at 11:45 A.M. written by Licensed Practical Nurse (LPN) #122.Review of the nurse ' s notes revealed no documentation of a skin tear, physician notification, or responsible party notification.An interview on 07/30/25 at 2:00 P.M. with the Assistant Director of Nursing (ADON) revealed the nursing assistant was getting the resident out of bed, bumped her leg on the bed and the resident got a skin tear. She verified there was no investigation, assessment, family or physician notification or documentation of the skin care in the medical record. She stated she did not know who the nursing assistant was who transferred her. She stated she has been having problems getting the nurses to document information in the medical record. An interview on 07/31/25 at 8:15 A.M. with the Director of Nursing (DON) stated she spoke to Resident #45 yesterday and the resident stated she did not believe the nursing assistant had malicious intent, but she transferred her too fast after she told her to go slow and caused a skin tear. The DON stated there were black knobs on the bed and that was what she caught her leg on. She stated Resident #45 thinks the staff were always going too fast with her. She stated the nursing assistant was Certified Nursing Assistant (CNA) #149. She stated the nurse was Registered Nurse (RN) #162. The DON stated the day shift nurse was told by the day shift aide Resident #45 had a dressing to her leg. The day shift nurse had to write an order because there was not one written. She stated she was made aware of the skin tear when she got to work on 07/14/25. She stated they did not do an investigation because Resident #45 never said the nursing assistant threw her in bed she just said she went too fast. She verified the nurse had not written an order, documented, assessed, filled out an incident report or notified the family or physician.An interview on 07/31/25 at 10:25 A.M. with LPN #122 stated she has been working as the wound nurse while the wound nurse was off on medical leave. She stated she only worked Monday and Tuesday. She stated she had a message from RN #238 to look at the skin tear of Resident #45, so she looked at it on 07/14/25. She stated it had a dressing on it. She stated she does not know what happen she just wrote an order for a treatment. She verified at this time there was no order written but it did have a dressing on it.

Based on observation, record review and interview, the facility failed to ensure residents had a comprehensive treatment plan in place for the use of hand splints to improve or maintain mobility. This affected one (Resident #60) of one residents reviewed for mobility. The census was 76. Findings include: Review of Resident #60 ' s medical record revealed the resident was admitted on [DATE] with diagnosis including multiple sclerosis, marasmic kwashiorkor, hypertension, major depressive disorder, and obstructive and reflux uropathy. Review of Resident #60 ' s Annual Minimum Data Set (MDS) dated [DATE] revealed no restorative days or minutes for splint or brace assistance, no impairment to the resident's upper extremities.Review of Resident #60 ' s physician orders revealed a resting wrist/hand splint to the left hand once daily for up to four hours on dayshift dated 04/25/25. Review of Resident#60 ' s care plans did not identify a resting hand splint.Review of Review of Resident #60's medication administration records and treatment administration records from July 2025 revealed no documentation the left resting hand splint was applied as ordered.Interview on 07/31/25 at 2:15 P.M. with Director of Nursing (DON) verified the resting hand splint is a nursing order and staff should be putting it on and verified staff has not been signing off on administration.Observation on 07/31/25 at 2:34 P.M. with therapy #152 revealed Resident #60's left wrist was contracted with no resting hand splint in place. Therapy stated they initiate the splint and then nursing takes over after that.

Based on observation, review of the medical record, interview with staff and policy review, the facility failed to ensure fall interventions were in place for Resident #12. This affected one resident (Resident #12) of five reviewed for accidents.Findings include: Review of the medical record revealed Resident #12 was admitted to the facility on [DATE]. Diagnoses included atherosclerotic heart disease, severe protein calorie malnutrition, malignant neoplasm of the prostate, depression, peripheral vascular disease, adult failure to thrive, history of falling, transient ischemic attack, fracture of the fifth metatarsal of the left hand, emphysema, dementia, and hypertension.Review of the plan of care dated 11/01/24 revealed Resident #12 had a potential for falls related to history of falls, cachexia, and unsteady gait. Interventions did not include wearing hipsters. Review of the Quarterly Minimum Data Set assessment dated [DATE] revealed Resident #12 had moderately impaired cognition and had one fall with injury. Review of the physician ' s orders revealed Resident #12 had an order for hipsters (protective hip pads) on at all times, remove every shift to check skin integrity dated 07/02/25. Observation on 07/28/25 at 9:15 A.M. and 10:58 A.M. revealed Resident #12 was in bed on his back with the sheet pulled down to expose his incontinence brief. He did not have his ordered hipsters on while in bed. An interview on 07/28/25 at 11:11 A.M. with Certified Nursing Assistant (CNA) #223 verified Resident #12 did not have his ordered hipsters on in bed. Review of the undated facility policy titled, Fall Management, revealed the facility would identify each resident who was at risk for falls and would develop a plan of are and implement interventions to manage falls, The facility would provide an environment that was free from potential hazards.

Based on medical record review, review of a facility self-reported incident (SRI) and investigation, review of a personnel records, review of staff schedules and time punches, facility policy review and interviews, the facility failed to ensure Resident #03 was free from an incident of staff to resident abuse which included intimidation, verbal and emotional abuse. Actual psychosocial harm occurred on 09/30/24 to Resident #03 when State tested Nursing Assistant (STNA) #174, while providing care for the resident, yelled, used profanity and punched/hit the wall above the resident's bed. Resident #03 believed STNA #174's actions were directed toward her. Following the incident, STNA #174 worked additional shifts, providing care for Resident #03, before he was suspended on 10/06/24, and subsequently terminated. Resident #03 reported being fearful, afraid of retaliation and not wanting to eat or do anything as a result of the incident. This affected one resident (#03) of three residents reviewed for abuse. The facility census was 65. Findings include: Review of Resident #03's medical record revealed an admitted [DATE]. Diagnoses included acute and chronic respiratory failure with hypoxia, myocardial infarction, anxiety disorder and major depressive disorder. Review of the quarterly Minimum Data Set (MDS) assessment, dated 10/09/24, revealed Resident #3 was cognitively intact. Review of the facility SRI, tracking number 252690 dated 10/06/24, revealed on 09/30/24 Resident #03 alleged that a staff person (STNA #174) was angry and punched a nearby wall. On Sunday, 10/06/24, at approximately 6:13 A.M., the Administrator was notified by a facility nurse that STNA #174 became frustrated in Resident #03's room and punched/hit the wall. Although this incident took place on 09/30/24 at 10:10 A.M. it was not reported to facility management until 10/06/24. Review of a facility investigation written statement, completed by STNA #100 and dated 10/09/24, revealed around 09/30/24, STNA #174 and STNA #100 were putting Resident #03 to bed. STNA #174 was frustrated about something and punched the wall in Resident #03's room. STNA #174 had been getting frustrated easily lately. At times, the nurses would get STNA #100 when they needed something so STNA #174 did not get upset. STNA #100 asked STNA #174 if he had been going to counseling lately and taking antianxiety medications. STNA #100 stated STNA #174's actions startled her and Resident #03. Three or five days later, Resident #64 (Resident #03's spouse) asked STNA #100 if she heard about the incident with STNA #174. Resident #64 stated Resident #03 was fearful because of the incident. Review of a facility investigation written statements, completed by STNA #114 and STNA #152, revealed they had witnessed STNA #174 express frustration and anger in front of residents and staff. Review of an undated written statement, completed by STNA #181, revealed on 09/27/24, STNA #181 asked STNA #174 to help put a resident in bed using a mechanical lift. STNA #174 got angry and started punching the shower book and throwing things. Review of an undated written statement, completed by STNA #174, revealed on 09/30/24 it was a rough day and due to last minute appointments, therapy, call lights going off and demands, STNA #174 got frustrated and snapped. STNA #174 slapped the wall and yelled out comments, which STNA #174 realized scared Resident #03. Interview on 10/18/24 at 10:44 A.M. with Resident #03 revealed on 09/30/24, she had her call light on and STNA #174 came in the room. Resident #03 stated STNA #174 hit the wall above her head and stated, you [explicative] people. Resident #03 stated STNA #100 reported the incident to a nurse and stated the nurse would talk to STNA #174. During the interview with Resident #03, her husband, Resident #64, entered the room. Resident #64 stated he resided in another room and was not aware of the incident with STNA #174 until STNA #181 told him about it. Resident #64 stated he went to the nurse to make sure it was reported, and the nurse stated the incident could not be reported until Monday because the Administrator was not in the facility on the weekend. Resident #03 and Resident #64 stated STNA #174 continued to work after the incident. Resident #03 confirmed STNA #174 was assigned to provide care for her following the incident and stated he kept telling her it was okay; he had just been frustrated with her. Resident #03 stated she told LPN #202 she was afraid of retaliation by STNA #174. Additionally, Resident #03 stated she was upset and did not want to eat or do anything for three days following the incident. Resident #03 revealed none of the nurses came to ask her about what happened with STNA #174. Interview on 10/18/24 at 10:48 A.M. with STNA #181 revealed she did not witness the incident with STNA #174 (and Resident #03) but had heard about it. STNA #181 stated STNA #174 was upset prior to going to Resident #03's room and had been throwing binders at the nurse's station. STNA #181 stated LPN #214 witnessed STNA #174 getting upset. STNA #181 stated she thought STNA #100 reported witnessing STNA #174 punch the wall in Resident #03's room. Interview on 10/18/24 at 11:06 A.M. with LPN #214 verified she witnessed STNA #174 upset at the nurse's station on 09/30/24. LPN #214 stated STNA #174 got frustrated when there was any change or if a lot of residents needed assistance. LPN #214 denied STNA #100 reported any concerns with STNA #174 and Resident #03 until the end of the week. Interview on 10/18/24 at 11:20 A.M. with the Administrator verified he was not notified about the incident with STNA #174 and Resident #03 until the morning of 10/06/24. The Administrator stated STNA #100 wrote a statement that it was not reported because she did not feel abuse occurred. Review of STNA #174's personnel file revealed a hire date of 02/27/19. STNA #174 was terminated on 10/10/24 due to creating a hostile work environment for co-workers on numerous occasions and had been witnessed expressing frustrations with aggressive, and at times, threatening behavior. On or around 09/30/24, STNA #174 punched/slapped a wall in a resident's room. As a result of the seriousness and frequency of his actions, termination was deemed appropriate and necessary. Review of the staff schedule and time punches revealed STNA #174 worked on 09/30/24 from 5:53 A.M. to 2:05 P.M., 10/01/24 from 5:53 A.M. to 2:00 P.M., 10/02/24 from 5:53 A.M. to 2:10 P.M., 10/03/24 from 5:53 A.M. to 2:02 P.M., 10/05/24 from 5:53 A.M. to 2:09 P.M. and 10/06/24 from 5:53 A.M. to 6:33 A.M. Review of the undated facility policy titled Abuse, Neglect and Exploitation revealed abuse was defined as willful infliction of injury, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Possible indicators of abuse included, but were not limited to, resident, staff, or family report of abuse, psychological abuse of a resident observed and sudden or unexplained changes in behaviors and/or activities such as fear of a person or place, or feelings of guilt or shame. The facility would make efforts to ensure all residents were protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation. Examples included, but were not limited to, responding immediately to protect the alleged victim and integrity of the investigation and providing emotional support and counseling to the resident during and after the investigation as needed. This was an incidental finding discovered during the complaint investigation.

Based on interview and record review the facility failed to ensure interventions were followed to prevent a fall for Resident #6. Harm occurred when Resident #6 fell and sustained a fractured femur during transfer from the bed to a chair by one State tested Nurse Aide, instead of two STNAs as was indicated in the plan of care. This affected one of three residents (Resident #6) reviewed relative to falls. Findings include: On 08/18/15 at 11:30 A.M., interview with Resident #6 revealed the resident had a fall on 08/04/15. The resident explained a State tested Nurse Aide (STNA) came into her room to get her into her wheelchair as she was leaving for an appointment with her foot doctor. The STNA brought a sit to stand mechanical lift to the bedside. A sit to stand lift had handles that the resident held on to. It then, raised the resident up to a standing position, the resident was turned and then lowered again. Resident #6 said she told the STNA twice that she could not use that kind of lift because she could not stand. The STNA insisted she could do it. Resident #6 said she sat at the bedside and held onto the lift, but as soon as she was pulled to her feet, her arms and legs gave out and she started to slide downward. The STNA held onto her and lowered her to the floor. Resident #6 said they got her back into bed and then into her wheelchair and she had some pain in her leg but did not want to cancel her appointment so she went to the foot doctor. After returning to the facility, she had some pain in her left leg so they sent her to the hospital and had X-rays that showed a fractured hip. The doctor said surgery wasn't recommended and she came back to the facility on [DATE]. Resident #6 explained that prior to the fall on 08/04/15 the STNAs had not used the sit to stand mechanical lift to transfer her. Per the resident, normally two STNAs would get on each side of her and lift her up then turn and lower her into her wheel chair. Review of the open medical record for Resident #6 revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An annual Minimum Data Set (MDS) assessment completed on 07/01/15 revealed Resident #6 was alert and oriented and required extensive assistance of two or more persons for transferring between surfaces such as from the bed to the wheelchair. A care plan relative to falls initiated on admission and last revised on 01/14/14 revealed the resident was at risk for a fall relative to deconditioning and gait problems and the facility fall protocol should be followed. A care plan relative to a [DIAGNOSES REDACTED]. Interventions indicated a Hoyer lift (mechanical Lift) should be used for extensive assistance. A care plan relative to activities of daily living (ADL) initiated on admission and last revised on 08/18/15 revealed the resident required extensive assistance of two persons and the use of a Hoyer lift for transfers. At the time of the fall on 08/04/15 the ADL care plan indicated the resident required the extensive assistance of two persons for transfers. Nurses notes dated 08/04/15 and fall investigation documentation revealed Resident #6 was lowered to the floor by the State tested Nurse Aide during a transfer using a mechanical sit to stand lift device. The physician was notified of the fall, the resident complained of some pain in the left leg and the resident wanted to keep her appointment with the foot doctor. Resident #6 was sent to the appointment with the foot doctor at 10:15 A.M. and upon return at 1:00 P.M. an X-ray revealed a fracture of the left femur. The resident was sent to the hospital and admitted . The physician and resident's daughter were kept informed of the events. On 08/05/15 Resident #6's daughter contacted the facility and informed them surgical repair was not recommended and the resident would be returning to the facility. On 08/07/15 Resident #6 was readmitted to the facility from the hospital. On 08/18/15 at 4:00 P.M., interview with the Administrator and review of documentation relative to details of Resident #6's fall on 08/04/15 and associated care plans, the Administrator verifed Resident #6 was assessed to be at risk for a fall and for fractures related to a [DIAGNOSES REDACTED].#6. This certification deficiency substantiates Complaint Control Number OH 353

Based on medical record review, pain management policy review, facility investigation review, staff statement review, and staff interview, the facility failed to ensure a resident received prompt treatment and pain management for a left femoral neck fracture that resulted in harm. This affected one of three Stage 2 sampled residents reviewed for accidents (Resident #31). Eighty-one residents resided in the facility. Harm occurred to Resident #31 when the resident alleged a doctor broke the resident's leg, and Resident #31 continued to complain of severe pain without adequate assessment and treatment of [REDACTED]. Findings include: Medical record review revealed Resident #31 was admitted to the facility on [DATE]. The minimum data set (MDS) assessment (reference date of 09/03/10) revealed the resident's daily decision-making was moderately impaired with memory problems and required extensive assist of two staff for bed mobility and transfers. Resident #31 was repositioned and toileted every two hours. Review of the nurse progress note (dated 01/11/11 at 8:15 A.M.) revealed the resident left the facility for a doctor's appointment and returned at 11:45 A.M. Review of Licensed Practical Nurse (LPN) #65's written statement (dated 01/11/11 at 11:45 A.M.) revealed when the resident returned from the doctor's appointment, the resident stated the doctor had broken his leg, and the resident complained of pain. Review of the pain management flow record (dated 01/11/11 at 12:30 P.M.) revealed the resident's pain was rated 10 of 10 (very severe, horrible pain), and he was given Tylenol. Medical record review revealed no documented evidence the physician was notified the resident stated his leg was broken or of the resident's severity of pain. Review of State-tested Nurse Aide (STNA) #17's written statement (dated 01/11/11) revealed when getting the resident up for dinner, the resident complained of pain and was holding his leg, stating it was broken. Nurse progress note (dated 01/11/11 at 10:00 P.M.) revealed STNA #14 reported to LPN #15 an 11 centimeter (cm) x 2 cm bruise to the resident's left hip and Tylenol was administered for complaints of pain when the resident's hip or leg were touched. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED].M. on 01/12/11. Nurse progress note (dated 01/12/11 at 5:00 P.M.) revealed the doctor was notified of the bruise, and the family requested stronger pain medication. There was no documented evidence the physician was notified the resident stated his leg was broken, and no new pain medications or interventions were ordered. Nurse progress note (dated 01/12/11 at 10:00 P.M.) revealed the resident was angry when attempting to roll over for care and was administered Tylenol for pain. On 01/12/11 at 11:00 P.M., LPN #16 documented the Tylenol was ineffective. The medical record revealed no evidence of pain management strategies attempted or physician notification of ineffectiveness of pain medication with Resident #31's continued complaints of pain stating his leg was broken. Review of nurse progress note (dated 01/13/11 at 4:00 A.M.) revealed Tylenol was administered for non-verbal symptoms of pain, moaning and fist clenching during incontinence care. On 01/13/11 at 5:00 A.M., LPN #16 documented the Tylenol with little effect. The medical record revealed no evidence of pain management strategies attempted or physician notification of ineffectiveness of pain medication and Resident #31's continued complaints of pain stating his leg was broken. Review of the pain management flow sheet (dated 01/13/11 at 1:00 P.M.) revealed the resident's pain was rated 10 of 10 (very severe, horrible pain) and nursing observations included complaining of left leg pain, fidgeting, restlessness, and guarding. On 01/13/11 at 1:00 P.M., the physician was updated, and a new order for a topical [MEDICATION NAME] was received. Medical record review revealed no evidence the physician was notified of the resident's continued complaints of pain rated 10 of 10 (very severe, horrible pain) and stating his leg was broken. On 01/14/11 at 8:00 A.M., Resident #31 complained of left leg pain 10 of 10, with documented nursing observations that included complaining of pain, restlessness, and guarding. Tylenol was given but no effectiveness of medication was documented. Review of STNA #66's written statement dated 01/14/11 revealed the resident was "screaming in pain." On 01/14/11 at 7:50 P.M., the resident's physician was called and updated on the resident's complaints of pain in left thigh/hip area. A new order was received for an X-ray of the leg and hip. On 01/14/11 at 9:20 P.M., an x-ray was obtained. At 11:20 P.M., the x-ray revealed subcapital fracture of left femoral neck of the left hip. At 11:30 P.M., the resident's physician was notified of the X-ray results and ordered the resident sent to the emergency room . Review of Resident #31's As Needed [MEDICATION NAME] Pain Management flow record revealed no documented assessment of the effectiveness of Tylenol on 01/11/11, 01/12/11 and 01/14/11. Medical record review of Resident #31's nurse progress notes revealed no documented evidence the physician was notified of ineffective pain management on 01/12/11 at 11:00 P.M. and 01/13/11 at 5:00 A.M. On 01/28/11 at 9:15 A.M., interview with the director of nursing (DON) verified the medical record did not contain documentation of physician notification of the ineffectiveness of pain medications for Resident #31. The DON verified LPN #16 and #65 did not notify the physician or the administrator of the resident's statement that his leg was broken. This resulted in delay of treatment and ineffective pain management for Resident #31.