Every finding on record at Senior Village Nursing & Rehabilitation Center

Based on record review and interview, the facility failed to ensure the physician documented a Gradual Dose Reduction (GDR) was attempted or a clinical rationale for not reducing psychotropic medication recommended for GDR for 1 (#2) out of 5 (#1, #2, #4, #7, and #99) residents sampled for unnecessary medication review.Findings: A review of Resident #2's Electronic Health Record (EHR) revealed the resident was admitted to the facility on [DATE] with diagnoses which included in part, generalized anxiety disorder, bipolar disorder, and depression.A review of Resident #2's Pharmaceutical Consultant Report dated 10/24/2025 and signed by S2DON (Director of Nursing) read in part, Please evaluate the routine use of the following psychoactive medications and consider a dose reduction. If a dose reduction is not desired, please indicate below a rationale for the continued use. This resident is prescribed the following psychoactive medications:Benadryl 25 mg (milligrams) q6hrs prn itching (every 6 hours as needed)Divalproex DR (delayed release) 250 mg hs (hour of sleep)Meclizine 12.5 mg q12hrs prn dizziness (every 12 hours as needed)Rexulti 0.5mg qd (every day)Further review of the report revealed that the physician failed to indicate if a dose reduction was indicated or not. Further review of the report also revealed that, according to CMS (Center for Medicare and Medicaid Services) Interpretive Guidelines for Long Term Care Facilities, justification for not reducing a psychoactive must be documented (either on this form or within the clinical record) as to why a dose reduction is clinically contraindicated and not currently desired. Review of Resident #2's EHR revealed a psychiatric progress note for 11/03/2025 which read in part, Treatment plan: routine follow-up and med (medication) management. Current medications: reviewed. Patient's current medications were obtained, updated, and/or reviewed: yes. Further review of Resident #2's EHR failed to reveal evidence that a GDR was attempted or a clinical rationale as to why a dose reduction was contraindicated.On 12/03/2025 at 1:39 p.m., a review of Resident #2's EHR was conducted with S2DON. S2DON confirmed the Pharmaceutical Consultant Report dated 10/24/2025 was not completed by the physician. S2DON stated the physician had addressed the client's medication in the physician's progress notes. The physician's progress notes were reviewed with S2DON. S2DON neither agreed nor denied that the physician completed and documented that a dose reduction was attempted or a rationalization for continued use of medication.

Based on record reviews and interviews, the facility failed to notify the State's Long-Term Care Ombudsman of emergency transfers in writing for 1 (#7) out of 4 (#7, #62, #89, #105) residents reviewed for accidents. Findings:Review of Resident #7's Electronic Medical Record (EMR) revealed, in part, Resident #7 was admitted to the facility on [DATE]. Further review of the EMR revealed Resident #7 had an emergency transfer to a local hospital on [DATE].Review of the facility's Ombudsman notification lists of emergency transfers dated July 2025 and August 2025, failed to reveal Resident #7's transfer on 08/20/2025 and there was no further evidence the Ombudsman had been notified of the transfer. On 12/03/2025 at 12:45 p.m., a concurrent record review and interview was conducted with S1AADM (Assistant Administrator). S1AADM stated that she was partially responsible for the accuracy of the State's Long-Term Care Ombudsman list of emergency transfers. S1AADM reviewed the emergency transfer forms and confirmed they failed to identify Resident #7's emergency transfer on 08/20/2025.On 12/03/2025 at 1:00 p.m., a concurrent records review and interview was conducted with S2DON (Director of Nursing). S2DON stated S1AADM was solely responsible for the accuracy of the State's Long-Term Care Ombudsman list of emergency transfers. S2DON confirmed Resident #7 had an emergency transfer on 08/20/2025 that was not listed on the State's Long-Term Care Ombudsman list and should have been as required.

Based on interviews and record reviews, the facility failed to ensure the assessment accurately reflected the resident's status for 2 (Resident #1, and Resident #43) residents out of 41 sampled residents. Findings: Resident #1 Review of Resident #1's EMR (Electronic Medical Record) revealed an admission date to facility on 05/28/2025 with diagnoses including major depressive disorder, recurrent, severe with psychotic symptoms; and bipolar disorder, severe, with psychotic features. Review of Resident #1's Form 142 dated 05/08/2025 and 08/16/2025 revealed the resident was approved for admission by Level II authority. Review of Resident #1's admission MDS (Minimum Data Set) with an ARD (Assessment Reference Date) 06/05/2025 revealed: Section A1500 PASARR: the answer was no to the question, Is the resident currently considered by the state level II PASRR process to have a serious mental illness and/or intellectual disability or related condition? Review of Resident #1's Significant Change MDS with an ARD 08/08/2025 revealed: Section A1500 PASARR: the answer was no to the question, Is the resident currently considered by the state level II PASRR process to have a serious mental illness and/or intellectual disability or related condition? On 12/03/2025 at 8:30 a.m., an interview was conducted with S4SSD (Social Service Director), she reviewed Resident #1's Form 142 dated 05/08/2025 and 08/16/2025 and confirmed the resident did have a Level II PASARR. On 12/03/2025 at 8:49 a.m., a record review and subsequent interview was conducted with S3MDS (Minimum Data Set). S3MDS reviewed Resident #1's admission MDS dated [DATE] and significant change MDS dated [DATE]. She confirmed that Section A1500 for preadmission screening and resident review (PASRR) on each assessment was answered no. She confirmed the assessments were incorrectly coded. Resident #43A review of Resident #43's Electronic Health Record (EHR) revealed the resident was admitted to the facility on [DATE] with diagnoses which included in part, cerebral infarction and atrial fibrillation. A review of Resident #43's Quarterly MDS with an Assessment Reference Date (ARD) of 10/02/2025 revealed Section N0415 N0415 - Medications, High Risk Drug Classes, Use and Indication (I) Antiplatelet was coded No, which indicated the resident did not receive an antiplatelet during the 7- day lookback period. A review of Resident #43's Medication Administration Records (MAR) revealed the resident was administered aspirin (antiplatelet) during the 7- day lookback period from 09/26/2025 through 10/02/2025. On 12/03/2025 at 9:35 a.m., a review of Resident #43's Quarterly MDS with an ARD of 10/2/2025 was conducted with S3MDS. She confirmed antiplatelet was coded No and should have been coded Yes.

Based on record review and interviews, the facility failed to develop and implement a comprehensive careplan for 2 (Resident #4 and Resident #62) of 41 sampled residents as evidenced by failing to: 1. ensure physician orders were implemented for wound care for Resident #4 and 2. develop a careplan for bed rails for Resident #62Findings:Review of Resident #4's electronic health record revealed an admission date of 06/24/2021 with diagnoses that included but were not limited to, age-related osteoporosis, cognitive communication deficit, and hereditary and idiopathic neuropathy. Review of Resident #4's TAR (Treatment Administration Record) for September 2025, October 2025, and November 2025 revealed an order dated 09/07/2025 for Cleanse excoriated area to left buttock with normal saline, and apply zinc oxide bid (twice a day) until resolved. Further review of Resident #4's TARs failed to reveal nurses initials or evidence that treatments were performed on the following dates: 1. September 2025 a. AM- 09/10/2025 and 09/15/2025 b. HS (at bedtime) - 09/07/2025, 09/18/2025, 09/21/2025, 09/23/2025, 09/24/2025, 09/26/2025, 09/27/2025, 09/29/2025, and 09/30/20252. October 2025 a. AM- 10/07/2025, 10/12/2025 b. HS- 10/01/2025, 10/04/2025, 10/06/2025, 10/12/2025, 10/13/2025, 10/14/2025, 10/15/2025, 10/17/2025, 10/18/2025, 10/19/2025, 10/21/2025, 10/22/2025, 10/24/2025, 10/27/2025, 10/30/2025, and 10/31/20253. November 2025 a. AM- 11/24/2025, 11/25/2025, 11/26/2025, 11/27/2025, and 11/30/2025 b. HS- 11/01/2025, 11/02/2025, 11/04/2025, 11/06/2025, 11/07/2025, 11/10/2025, 11/11/2025, 11/29/2025, and 11/30/2025 On 12/03/2025 at 03:00 p.m., a review of Resident #4's September 2025, October 2025, and November 2025 TARs and subsequent interview was conducted with S2DON (Director of Nursing). Resident #4's TARs revealed the respective missing signatures for the above dates for wound care. S2DON confirmed that the nurses' initials on the above respective dates were missing, and agreed that the nurses should have initialed Resident #4's TAR in order to provide evidence that the wound care was completed as ordered. Resident #62Review of Resident #62's electronic health record revealed and admission date of 02/07/2025 with diagnoses that included but were not limited to, chronic kidney disease and acute diastolic (congestive) heart failure. Review of Resident #62's medical record revealed no careplan for the use of bed rails. On 12/01/2025 at 9:53 a.m., an observation was made of Resident #62's bed with top quarter bed rails.On 12/02/2025 at 12:36 p.m., an interview was conducted with S6CNA (Certified Nursing Assistant). She stated that she had been caring for Resident #62 and that she had bed rails on her bed for months.On 12/02/2025 at 1:22 p.m., an interview was conducted with S7CNA. She stated that she had been caring for the Resident #62 and that she had bed rails for at least a month.On 12/03/2025 at 1:48 p.m., an observation was made of Resident #62 in bed with upper quarter bed rails up on both sides. On 12/03/2025 at 2:54 p.m., an interview was conducted with S2DON (Director of Nursing). She stated that Resident #62 had utilized bed rails since her admit on 02/07/2025. She confirmed that Resident #62's careplan had no mention of bed rails.

Based on record review and interviews the facility failed to develop a person-centered comprehensive care plan within 7 days after completion of the comprehensive assessment for 1 (Resident #16) out of 41 sampled residents. Findings:Review of the facility's policy titled, Care Plan Process, with a last reviewed dated of 12/2024, revealed in part, Regulations require facilities to complete, at a minimum and at regular intervals, a comprehensive, standardized assessment of each resident's functional capacity and needs, in relation to a number of specified areas (e.g., customary routine, vision and continence). The results of the assessment, which must accurately reflect the resident's status and needs, are to be used to develop, review, and revise each resident's comprehensive person-centered plan of care. The RAI (Resident Assessment Instrument) will be used to determine guidelines for revisions and completion dates for the Comprehensive Care Plan.Review of the CMS (Centers for Medicare and Medicaid Services) RAI Version 3.0 Manual revealed in part, Assessment Type: admission (Comprehensive).CAA (Care Area Assessment) completion date: no later than the 14th calendar day of the resident's admission (admission date + 13 calendar days).Care Plan Completion Date: no later than CAAs completion date +7 calendar days.Review of Resident #16's admission Record revealed the resident was admitted to the facility on [DATE] with diagnoses that included in part, acute respiratory failure with hypoxia, type 2 diabetes mellitus and essential hypertension.Review of Resident #16's admission MDS (Minimum Data Set) assessment revealed an ARD (Assessment Reference Date) of 10/08/2025 and CAA completion date of 10/09/2025.A review of Resident #16's Care Plan was conducted. The review revealed 3 focused areas with interventions which were initiated on 10/02/2025 which included: Full Code, Resident Lifting Plan, LA bed hold notice upon transfer/leave. Further review of Resident #16's Care Plan failed to include focused areas with interventions regarding the resident's medical conditions.On 12/02/2025 at 2:08 p.m., an interview was conducted with S3MDS (Minimum Data Set Nurse). S3MDS failed to provide evidence that a comprehensive person-centered care plan was completed for Resident #16 within 7 calendar days of the CAA completion.On 12/02/2025 at 4:10 p.m., an interview was conducted with S2DON (Director of Nursing). S2DON confirmed that the MDS nurses were responsible for creating care plans for the residents. S2DON could not provide evidence that a comprehensive person-centered care plan was completed for Resident #16 within 7 calendar days of the CAA completion.

Based on observations, interviews, and record review, the facility failed to ensure accurate administration of all drugs by failing to administer the correct dose of Zinc for 1 (Resident #79) out of 4 residents observed form medication administration. Findings: A review of the facility's policy titled Administration of Medications which was last reviewed on 03/2025, read in part, Oral Medication Administration Procedure, 3. Verify the physicians order, comparing the medication label to the MAR (Medication Administration Record) to verify the following, b. right dosage. Review of Resident #79's health record revealed he was admitted to the facility on [DATE] diagnoses which included, but were not limited to chronic kidney disease and atherosclerotic heart disease of native coronary artery without angina pectoris. Review of Nursing Home Progress Note on 11/17/2025 for Resident #79 revealed a physician order for Zinc Sulfate 220 mg (milligrams) one by mouth once a day.Review of Resident #79's MAR (Medication Administration Record) for December 2025 revealed an order dated 11/18/2025 for Zinc oral tablet, Give 1 tablet by mouth one time a day for wound healing. There was no dosage on the order for this medication in the MAR.On 12/02/2025 at 8:44 a.m., S5LPN was observed administering medications to Resident #79. S5LPN was observed administering Zinc 50mg to Resident #79. A review of Resident #79's MAR was conducted with S5LPN. S5LPN confirmed that there was no dosage on the order for Zinc in the MAR, and that she should have known the correct dose for Zinc before administering the medication to the resident. On 12/03/2025 at 3:55 p.m., and interview and review of Resident #79's Nursing Home Progress Note dated 11/17/2025 was conducted with S2DON. SDON confirmed that Zinc 220mg was the current order. She further confirmed that Zinc 220mg should have been administered to Resident #79.

Based on record review and interviews, the facility failed to follow physician's orders for 1 (Resident #3) of 3 (Residents #1, #2, #3) sampled residents. The deficient practice had the potential to affect a census of 126. Findings: Resident #3 was admitted to the facility on [DATE] with diagnoses included but not limited to Unspecified Severe Protein-Calorie Malnutrition, Anorexia, Aphasia and Cognitive Communication Deficit. Review of Resident #3's Significant Change MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 05/20/2025 revealed he had a BIMS (Brief Interview for Mental Status) of 03, indicating he was severely, cognitively impaired. Review of Resident #3's current active physician's orders revealed an order with a start date of 05/19/2025 that read in part, Check oxygen saturation every shift. If less than 92% administer as needed oxygen at 2 liters per minute via nasal cannula. Review of Resident #3's MAR (medication administration record) for May 2025 and June 2025 revealed no evidence that an oxygen saturation was done for Resident #3. On 06/18/2025 at 12:27 p.m., an interview and record review was conducted with S3LPN (Licensed Practical Nurse). She stated that she was the nurse responsible for Resident #3. S3LPN confirmed after review of the physicians orders that Resident #3 had a current order to check oxygen saturations every shift. She confirmed that there was no evidence that oxygen saturations had been done for Resident #3 per physician orders every shift on the task documentation, in the nurse's notes or on the MAR. On 06/18/2025 at 1:00 p.m., an interview and record review was conducted with S2DON (Director of Nursing). She confirmed that Resident #3 had a physician order for oxygen saturation check every shift and if saturation is less than 92% to give oxygen at 2 liters per nasal cannula as needed. She stated that she could not find the documentation of the oxygen saturation.

Based on record review and interviews, the facility failed to ensure that an injury of unknown origin was reported immediately, but not later than two (2) hours to State Survey Agency after discovering or learning of the injury for 1 (Resident #1) of 3 (Residents #1, #2, #3) sampled residents. The deficient practice had the potential to affect a total census of 126 residents. Findings: Review of the facility's policy with a review date of 05/24 titled Incident Investigation and Reporting, read in part; Injury of Unknown Origin: When all criteria are met: Source of injury was not observed by any person and the source of injury could not be explained by the resident, and the injury is suspicious due to the extent or location of the injury 3. The administrator shall report to the State Survey Agency and local law enforcement entities in which the facility is located, any allegation or reasonable suspicion of a crime against any resident. The administrator shall report no later than 2 hours after forming the suspicion, if the events that cause the suspicion involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the suspicion do not involve abuse or result in serious bodily injury Review of Resident #1 electronic medical records revealed he was admitted to the facility on [DATE] with diagnoses that included but were not limited to Other Sequelae Following Unspecified Cerebrovascular Disease, Muscle Weakness, Generalized and Dysphagia, Oropharyngeal Phase. Resident #1 was discharged from the facility on 06/09/2025. Review of Resident #1's Significant Change MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 04/23/2025 revealed in Section C1000 that his cognitive skills for daily decision making was severely impaired. Review of Client #1's facility's incident report read in part, Resident's sister came to desk and stated that Client's right shoulder, hand and arm had swelling. Entered the room with RN (registered nurse). Resident assessed, slight edema to right shoulder 2.5 cm (centimeter) by 2.5 cm. No redness, discoloration, tears or bruises/abrasion noted. Resident denied pain when asked. Palpated right shoulder, arm and hand. Transferred resident per [NAME] lifter (mechanical lifter) times 3 staff to bed. Resident unable to give description. The incident was not witnessed. Immediate action taken: Assessed, called doctor. Resident transferred to hospital for evaluation. Review of nurse's notes revealed in part, on 05/31/2025 at 4:15 p.m., call placed to hospital for update on Client #1's condition. Was told by ER (emergency room) nurse that resident's right shoulder was dislocated and will be set by the doctor in the emergency room. Review of Client #1's hospital records revealed an X-RAY of the right shoulder done on 05/31/2025 at 1:04 p.m. with the final impression of anterior shoulder dislocation. On 06/18/2025 at 1:12 p.m., an interview was conducted with S2DON (Director of Nursing). She stated that she was made aware of the dislocation of Client #1's dislocated right shoulder on 05/31/2025. S2DON also confirmed that the facility was unsure of how or when the incident occurred. She stated that this was not reported to state office survey because it was not a fracture. On 06/18/2025 at 1:38 p.m., an interview was conducted with S1ADM (Administrator). He stated that he was not aware that a dislocated shoulder should have been reported to the state survey agency. He stated that they were told to report fractures. He confirmed that this had not been reported to stated survey agency and the facility did not know how it occurred.

Based on record review and interviews, the facility failed to electronically submit accurate payroll information for direct care staffing as required. Finding: Review of the PBJ (Payroll Based Journal) Staffing Data Report for FY (Fiscal Year) Quarter 3 2024 (April 1- June 30) revealed triggers for Excessively Low Weekend Staffing. Review of the facility's Staff Reporting Forms provided from April to June 2024, revealed in part: Weekdays (Monday-Friday) were noted to have between 3 -6 RN's (Registered Nurses), and 7-9 LPN's (Licensed Practical Nurses), whereas the weekends (Saturday-Sunday) had 1 RN and 4 LPN's for the Day shifts. On 09/10/2024 at 10:00 a.m., an interview was conducted with S3DON (Director of Nursing), with S10ADM (Administrator) present. S3DON reported that PBJ staffing was done between S9AA (Administrative Assistant) and Corporate Human Resources. S3DON and S10ADM denied knowledge of any low staffing on weekends and stated the state requirements for staffing ratios were met. S10ADM reported S9AA was having issues with the imputing contract/agency staff in the PBJ system during Quarter 3. On 09/10/2024 at 12:00 p.m., an interview was conducted with S3DON. She stated that on the weekdays, the facility had Administrative staff nurses on duty for the roles of Director of Nursing, Assistant Director of Nursing, Registered Nurse Supervisor, Nurse Aide Training Instructor and Assessment (Minimum Data Set-MDS) Nurses. There were no administrative nursing staff on duty for the weekends, other than a weekend supervisor. She confirmed they are counting these nursing roles in the staffing hours for the weekdays, but was unsure of how they were imputed in the PBJ system. She reviewed the staff report forms and confirmed that the nurse staffing hours during the weekday included the administrative nurses, whereas the weekend staffing hours did not include those administrative nurses. On 09/10/2024 at 12:30 p.m., an interview was conducted with S9AA. She confirmed that she must manually input contract/agency staffing hours into the PBJ system. She stated that other nurse staffing hours were put into the PBJ system via the employee clock in system. She confirmed they did not utilize the role of Nurse with Administrative Duties for calculation of Registered Nurse or Licensed Practical Nurse performing those administrative duties. She stated they were in the PBJ system as Registered Nurse or Licensed Practical nurse, which was considered direct care staffing. She denied knowledge that Administrative duties were not considered direct care staffing.

Based on record reviews and interviews, the facility failed to ensure the resident's Minimum Data Set (MDS) assessments were transmitted within 14 days after completion for 8 (# 8, #10, #23, #45, #67, #105, #112, and #122) out of 9 ( (# 8, #9, #10, #23, #45, #67, #105, #112, and #122) residents reviewed for resident assessments submission activities. Findings: Resident # 45 Review of Resident #45's Quarterly MDS, with ARD (Assessment Reference Date) of 07/25/2024, revealed it was completed on 08/08/2024, and transmitted on 09/09/2024. Resident # 10 Review of Resident #10's Quarterly MDS, with ARD of 08/06/2024, revealed it was completed on 08/20/2024, and transmitted on 09/06/2024. On 09/10/24 at 8:30 a.m., an interview and review of Resident #45 and #10's Quarterly MDS was conducted with S7MDS. She verified Resident #45's and #10's Quarterly MDS completion date and transmission date. She confirmed that the Quarterly MDS assessments were not transmitted within the required timeframe of 14 days after completion. Resident # 8 Review of Resident #8's Discharge -return not anticipated MDS, with ARD of 4/5/2024, revealed it was completed on 04/19/2024, and transmitted on 09/10/2024. Resident # 23 Review of Resident #23's Discharge- return not anticipated MDS, with ARD of 03/27/2024, revealed it was completed on 04/10/2024, and transmitted on 09/10/2024. Resident #122 Review of Resident #122's Discharge- return not anticipated MDS, with ARD of 05/10/2024, revealed it was completed on 05/24/2024, and transmitted on 09/10/2024. Resident # 67 Review of Resident #67's Discharge- return not anticipated MDS, with ARD of 05/16/2024, revealed it was completed on 05/16/2024, and transmitted on 09/10/2024. Resident # 105 Review of Resident #105's Discharge- return not anticipated MDS, with ARD of 04/15/2024, revealed it was completed on 04/15/1024, and transmitted on 09/10/2024. Resident # 112 Review of Resident #112's Discharge-return not anticipated MDS with ARD of 04/08/2024, revealed it was completed on 04/22/2024, and transmitted on 9/10/2024. On 09/10/24 at 11:10 a.m., an interview was conducted with S7MDS. She confirmed that the above resident's Discharge- not anticipated MDS assessments were completed, but she had sent them in for transmission on today, 09/10/2024. She confirmed the assessments were not transmitted within the required timeframe of 14 days after completion.

Based on policy review, observation, record review and interview, the facility failed to store food in accordance with professional standards for food service safety by the dietary staff failing to ensure that all foods on the steam table maintained adequate holding temperature prior to being served. This deficient practice had the potential to affect 111 residents that received food from the kitchen. Total facility census was 118. Findings: A review of the facility's Monitoring Temperatures of Cooked Foods policy was conducted on 09/09/2024 at 1:30 p.m. The policy read in part . Policy: The temperature of potentially hazardous cooked foods will be monitored to insure that the foods are not in the danger zone (above 41 degrees Fahrenheit and below 135 degrees Fahrenheit) for more than six hours. Procedure: Potentially hazardous cooked foods, after being cooked to the required minimum internal temperature, will be held on hot holding equipment that will keep the food at a minimum 135 degrees Fahrenheit or higher. On 09/09/2024 at 10:50 a.m., S13Cook was observed checking the food temperatures on the steam table. She was informed that she would need to allow this surveyor to see the thermometer and verify the readings on the thermometer. During the process, S13Cook was again reminded to allow the surveyor to make an observation of the thermometer and verify the temperatures reading. After checking and recording the temperature of the rice, beans, a regular vegetables and a pureed vegetables on the daily food temperature monitoring log, S13Cook began placing a thermometer in five different pans of foods. She quickly pulled the thermometers out without verifying or recording the temperatures on the daily food temperature monitoring log. S13Cook also failed to check the temperature of the pureed beans, gravy, and cold food and liquids. The following abnormal temperatures were observed: pureed sausage-120 degrees, pureed vegetable-124 degrees. At 11:00 a.m., S13Cook placed the serving utensils in the food pans and began preparing meal trays for the residents. S13Cook was asked what the temperature of food where the thermometers were removed, she replied, All of them were above 140 degrees. When asked how she knew the food was at the right temperature to serve since she did not verify or record most of the food temperatures, she began pulling food pans off the food line and placing them back in the steamer. On 09/09/2024 at 11:10 a.m., an interview was conducted with S5RD (Registered Dietician). She stated that the holding temperature for food on the steam table should be 130 degrees Fahrenheit or above. On 09/09/2024 at 11:25 a.m., a review of the Daily Food Temperature Monitoring Log for 09/09/2024 was conducted with S11DM (Dietary Manager). It read the following: Temperatures at the start of service--Required Temp (temperature): Hot--135 degrees Fahrenheit or greater. Cold--41 degrees Fahrenheit or less. Further review revealed that S13Cook only recorded four food temperatures. S11DM stated S13Cook should have verified the temperature of the foods and recorded them on the Daily Food Temperature Monitoring Log as she took the temperatures and not wait until after all food temperatures were taken. She confirmed S13Cook did not conducted the food temperature checks correctly.

Based on observations and interviews, the facility failed to maintain a clean and sanitary environment by failing to ensure the Resident's personal equipment in the resident's room were free of dust and lint for 1 (#231) of 48 sampled residents. Findings: Review of Resident #231's electronic health record revealed Resident #231 was admitted to the facility on [DATE] with diagnoses that included Sleep Apnea and Insomnia. On 09/09/2024 at 1:03 p.m., an observation revealed Resident #231's CPAP (Continuous Positive Airway Pressure) Machine, Mask Sanitizer device, a small fan on the end table, and a multi-plug extension cord on the floor were all observed to be covered with dust and lint. On 09/10/2024 at 9:15 a.m., an observation was made with S7LPN (Licensed Practical Nurse) of Resident #231's room. S7LPN confirmed Resident #231's CPAP Machine and Mask Sanitizer device, a small fan on the end table, and a multi-plug extension cord on the floor were all covered with dust and lint. She stated Housekeeping was to ensure the room and resident's personal equipment were clean and sanitary. On 09/10/2024 at 9:19 a.m., an observation was made with S8HK (House Keeper) of Resident #231's CPAP Machine and Mask Sanitizer device, a small fan on the end table, and a multi-plug extension cord on the floor. S8HK confirmed they were covered with dust and lint. She stated it was her job to clean the resident's equipment and ensure the resident's room was clean and sanitary. On 09/10/24 at 9:25 a.m., an interview with S3DON (Director of Nursing) confirmed the facility's housekeeping staff should have ensured Resident #231's personal equipment and room were clean and sanitary.

Based on record review and interview, the facility failed to ensure the resident's Minimum Data Set (MDS) assessment was completed accurately for 1 (#9) out of 48 sampled residents. Findings: Review of Resident #9's Quarterly MDS assessment dated [DATE], indicated that the resident was coded for the use of an anticoagulant under Section N, Medications. Review of the resident's MAR (Medication Administration Record) for May 2024 revealed there was no order for an anticoagulant. Review of the resident's physician orders for May 2024 revealed no order for an anticoagulant. On 09/10/2024 at 2:33 p.m., an interview and review of Resident #9's Quarterly MDS assessment dated [DATE] was conducted with S1MDS. She stated that Resident #9 was not on an anticoagulant. S1MDS confirmed that it was incorrectly coded for the use of anticoagulant.

Based on observations, record reviews, and interviews, the facility failed to develop and implement a person-centered care plan that addressed catheter care for 1 (#63) out of a total sample of 48 residents. Findings: A review of the facility's policy on 09/10/2024 titled Indwelling Catheterization with a latest revision date of 11/2017 read in part, Catheter care with soap and water each shift and PRN (As Needed) unless otherwise indicated by physician. Review of Resident #63's record revealed an admitted [DATE] with diagnoses that included Benign Prostatic Hyperplasia with Lower Urinary Tract Symptoms and Urinary Retention. Review of Resident #63's Minimum Data Set (MDS) Admission assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 14, which indicated the resident's cognition was intact. Review of Resident #63's physician orders revealed an order dated 08/09/2024 for Catheter-Type (Foley); 16 French, 10cc (cubic centimeter) bulb. On 09/10/24 at 02:07 p.m., a record review and interview was conducted with S1MDS (Minimum Data Set) and S2MDS. S2MDS stated that catheter care should be performed every shift by the nurses on the hall and should be present on the careplan as well as on the MAR (Medication Administration Record) or TAR (Treatment Administration Record). S1MDS confirmed that catheter care was not present on the careplan, MAR or TAR for resident #63, and it should have been. On 09/10/24 at 02:57 p.m., an interview was conducted with Resident #63. Resident #63 stated that staff have only cleaned around his catheter site when he has had a bowel movement, and that has not been every day. Resident #63 stated that he has cleaned the area around the catheter site himself when he takes a shower every couple of days. He stated that staff had not offered to perform catheter care other than at those times, but that he would have allowed them if they had offered. On 09/10/24 03:32 p.m. a record review and interview was conducted with S3DON. S3DON stated that the nurses on the halls should have conducted catheter care every shift for Resident #63. S3DON confirmed that catheter care was not present on the Careplan, MAR, or TAR, and it should have been.

Based on record review and interview, the facility failed to maintain acceptable parameters of nutritional status, by failing to address a recommendation from the RD (Registered Dietician) for 1 (resident #127) out of 7 residents (#47, #58, #100, #102, #109, #124, #127) investigated for nutrition out of a total sample of 48 residents. Findings: Resident #127. Review of the resident's electronic clinical record revealed the resident was admitted to the facility on [DATE]. The resident's admitting diagnoses included End Stage Renal Disease, Dependence on Dialysis, and Infection and Inflammatory Reaction due to Internal Left Knee Prosthesis. Review of the resident's weight log revealed the resident weighed 175.6 pounds on 06/14/2024 and weighed 133 pounds on 08/09/2024 for a 24.26 % weight loss in 2 months, which was a significant weight loss. Review of RD Nutrition assessment dated [DATE] at 6:30 a.m. revealed, -10% sig (significant) wt (weight) loss in 1 month. ESRD (End Stage Renal Disease) with HD (Hemodialysis) 3x/wk (three times a week). Poor intake per staff, 25% of most meals, occasionally 75%. Can feed self and is verbal of needs . Wt: 154.0 May benefit from supplementation. 1) Recommend add 4oz (ounces) house supplement qid (four times a day) with meds . Review of the resident's clinical record revealed no evidence the RD's recommendation was addressed. Review of RD Nutrition assessment dated [DATE] at 7:34 a.m. revealed, Wt change. -9.5% sig wt loss in 1 month. Wt: 133.0 . 25-50% intake of meals. Diet order: Liberal Renal, Mech Soft, honey thick liquids. ESRD with HD. Can feed self and is verbal of needs. Continue with current nutritional plan of care . Recommend add 4oz honey thick house supplement bid with meds . Review of the resident's clinical record revealed no evidence the resident was receiving 4 oz house supplement for the months of July 2024 and August 2024. Further review of the resident's clinical record revealed no evidence for a physician's order for the house supplement. On 09/10/2024 at 12:00 p.m., an interview was conducted with S4LPN (Licensed Practical Nurse). S4LPN confirmed the resident had weight loss. S4LPN stated she was not aware of the recommendations for the resident to receive 4 ounces of house supplement with meds. S4LPN confirmed there was no order for the house supplement. On 09/10/2024 at 12:15 p.m., an interview was conducted with S5RD. She confirmed the resident had a significant weight loss. S5RD stated she made recommendations for Resident #127 to receive the house supplement. S5RD stated she did not know where the staff documented the information that the supplements were given and that the DON (Director of Nursing) would know. S5RD stated that she made the recommendations to the staff and the staff would then send the recommendations to the physician. On 09/10/2024 at 12:40 p.m., an interview was conducted with S3DON. She confirmed that if the RD made recommendations that they should be sent to the physician for an order. S3DON confirmed there was no evidence Resident #127 received the recommended house supplement and confirmed there was no order for the recommended house supplement.

Based on policy review, observation and interview, the facility failed to ensure the resident's food was palatable and attractive by the dietary staff failing to prepare foods according to the recipe. This deficient practice had the potential to affect 111 residents that received food from the kitchen. Total facility census was 118. Findings: A review of the facility's Standardized Recipes policy was conducted on 09/09/2024 at 1:30 p.m. The policy read in part, Policy: Standardized recipes are used in preparation of food for control of quality, quantity, and uniformity of product. Procedure: .5. The Director of Food and Nutrition Services requires the food and nutrition service staff to follow the standardized recipes . On 09/09/2024 at 1:55 p.m., an observation was made of S12DM/Cook (Dietary Manager/Cook) prepare nectar thickened milk without the use of a recipe. She was observed adding an undetermined amount of milk in a plastic container. S12DM/Cook then poured an undetermined amount of powdered thickener in the container and stirred. She checked the consistency of the liquid in the container and added another undetermined amount of food thickener. When asked how she knew how much food thickener she needed to add to the milk, S12DM/Cook replied, I just add the food thickener according to the consistency I think is needed. On 09/09/2024 at 2:10 p.m., an observation of the milk was made with S11DM (Dietary Manager). The liquid in the plastic container was observed to be very thick and hard to pour in a glass. A review of the food thickener container was made with S11DM. The preparation instructions on the back of the container read, To thicken liquid by the glass, add level measured amount of thickener to the liquid and stir for 10-20 seconds. Allow 4 minutes to reach desired thickness. S11DM stated that the milk should have been prepared by the glass and not in a large quantity to get the right consistency. On 09/09/2024 at 2:30 p.m., an observation was conducted with one of the dietary cooks and S12DM/Cook of an okra and tomatoes dish. They both were asked what ingredients were used to prepare the dish. S12DM/Cook stated, one can of tomato sauce, one can of diced tomatoes, one- 30 lb (pound) box of okra, one onion, one bell pepper and seasoning. The recipe for the okra and tomatoes was reviewed with S11DM/Cook. The recipe's largest serving amount (125 servings) required to use 12 pounds and 8 ounces of okra. Further review of the recipe revealed that recipe didn't indicate to use tomato sauce. S12DM/Cook confirmed that tomato sauce was not one of the ingredients in the recipe. She stated that she liked to prepare the okra and tomato the way she prepared it at her house. S12DM/Cook was asked if they used a recipe to prepare the dish, she replied, No. On 09/09/2024 at 2:45 p.m., an interview was conducted with S11DM (Dietary Manager) who stated that all food recipes for the weekly menus were kept in a binder. She confirmed that the dietary staff should use the recipes when preparing the menu.

Based on observations and interview, the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition by having an air conditioner that was leaking a liquid substance for 1 (Resident #48) out of a finalized sample of 48 residents. Findings: On 09/09/2024 at 10:41 a.m., an observation of resident #48's room revealed an air conditioner attached to the wall that was leaking a liquid substance. Multiple towels were observed under the unit, all of which were wet. On 09/10/2024 at 11:21 a.m., a second observation of resident #48's room revealed an air conditioner attached to the wall that was leaking a liquid substance. Multiple towels were observed under the unit, all of which were wet. On 09/10/2024 at 4:04 p.m., an interview and observation was conducted with S6MAINT (Maintenance), he stated he was unaware of an air conditioner leaking in Resident #48's room. Upon inspection, he observed the wet towels under the air conditioner and confirmed that the unit was leaking and not in safe operating condition.

Based on records reviewed and interviews, the facility failed to ensure their grievance policy and procedure was followed. The facility failed to initiate grievances that were voiced for 1 (#3) out of 4 (#1-#4) residents investigated for grievances out of a sample of 6 (#1-#4, R1 and R2) residents. Findings: Review of the facility's policy and procedure titled, Grievances-Residents, revealed in part: The following outlines the process: Family members may also present grievances on behalf of residents . The Administrator or Designee is responsible for overseeing the grievance process, receiving and tracking grievances through to their conclusion, leading any necessary investigations by the facility . The Social Service Designee has been appointed by the Administrator . -upon receipt of a grievance/complaint, the staff receiving the complaint will initiate the Grievance/Complaint Form . Review of Resident #3's medical record revealed the resident was admitted to the facility on [DATE]. Review of facility's Grievance Logs from August 10, 2023 to October 09, 2023 did not reveal a grievance initiated on 09/29/2023 for Resident #3. On 10/09/2023 at 8:27 a.m., a phone interview was conducted with Resident #3's family member. Resident #3's family member stated she spoke with S4SSD (Social Services Department) about Resident #3's left hearing aid being missing on 09/29/2023. On 10/10/2023 at 2:35 p.m., an interview was conducted with S4SSD who stated Resident #3's family member voiced concerns about the resident's left hearing aid being missing on 09/29/2023. S4SSD confirmed she had not initiated a grievance form. On 10/10/2023 at 4:54 p.m., an interview was conducted with S1ADM who confirmed he was not aware Resident #3's left hearing aid was missing and denied S4SSD informing him of Resident #3's family member voicing concerns about the resident's left hearing aid being missing on 09/29/2023.

Based on record review and interviews, the facility failed to ensure an alleged violation of physical abuse involving staff to resident was reported immediately, but not later than 2 hours after the allegation was made to the State Survey Agency for 1 (#4) of 1 resident investigated for abuse out of a total of 6 (#1-#4, R1 and R2) sampled residents. Findings: Review of the facility's policy and procedure titled, Incident Investigation and Reporting (LA ONLY), revealed in part: Purpose: To provide guidance to the facility for investigation and reporting incidents of abuse, neglect, .and/or other reportable incidents to state department, local law enforcement and others as required by state and federal requirements. To ensure reporting reasonable suspicion of crimes against a resident within prescribed timeframes. .3 .In the event of any incident involving an allegation or suspicion of .abuse .will be reported immediately to the Administrator of the facility. The administrator shall report to the State Survey Agency and local law enforcement entities in which the facility is located, any allegation or reasonable suspicion of a crime against any resident. The administrator shall report not later than 2 hours after forming the suspicion, if the events that cause the suspicion involve abuse . Review of the facility's incident/accident log dated 08/10/2023 thru 10/09/2023 included Resident #4 with date of 08/15/2023 with type of incident= Other Review of the facility's State Survey Agency Incident Report dated 08/15/2023 revealed the event was discovered on 08/15/2023 at 2:10 p.m. and was entered on 08/15/2023 at 5:11 p.m. The date and time the incident occurred was left blank. Further review of the facility's incident report revealed the resident victim was Resident #4 with an allegation of physical abuse. On 10/10/2023 at 4:49 p.m., an interview was conducted with S1ADM (Administrator). He stated Resident #4's family met with him on 08/15/2023 to discuss concerns including allegations of physical abuse. S1ADM stated during the meeting, one of the family members, informed him that Resident #4 informed her family that a CNA (Certified Nursing Assistant) was rough with her during a bath, and in a separate incident a CNA slapped her on her belly. S1ADM confirmed he was made aware of the allegations on 08/15/2023 at 2:10 pm and entered the incident report on 08/15/2023 at 5:11 p.m. S1ADM stated that any allegation of physical abuse was to be reported to the State Agency within 2 hours. He confirmed he reported Resident #4's allegation of abuse 3 hours after he was made aware of the incident.

Based on observation, record review and interview, the facility failed to ensure the resident's Minimum Data Set (MDS) assessments were completed accurately for 2 (#2 and #4) out of 6 (#1-#4, R1 and R2) sampled residents. Findings: Resident #2 Review of Resident #2's SM5 (5 Day admission) MDS assessment dated [DATE] revealed the resident was admitted to the facility on [DATE] and was coded under section B titled, Hearing, Vision and Speech as having adequate hearing and no hearing aid. Review of Resident #2's current care plan revealed a problem onset dated 03/14/2023, for Resident #2 being at risk for impaired communication, with an intervention to assist resident with hearing aids. On 10/10/2023 at 8:34 a.m., a phone interview was conducted with Resident #2's family member who stated the resident has had hearing aids for approximately one year. Resident #2's family member stated she visited the resident last week and confirmed the resident was wearing her hearing aids. On 10/10/2023 at 11:26 a.m., an interview was conducted with S3CNA (Certified Nursing Assistant). She stated daily morning duties for Resident #2 consisted of making sure her hearing aids were in use. On 10/10/2023 at 1:40 p.m., Resident #2 was observed sitting in her wheelchair in her room, awake and alert with hearing aids in place to both ears. Resident #2 stated she had been having her hearing aids for about one year and that sometimes she needed assistance from facility staff to apply her hearing aids. On 10/10/2023 at 3:16 p.m., an interview was conducted with S2MDS (Minimum Data Set Nurse) who confirmed Resident #2 was coded as not having hearing aid(s) or other hearing appliance used and then reviewed the resident's current care plan that included the resident required assistance by facility staff with her hearing aids. S2MDS confirmed Resident #2's SM5 MDS assessment dated [DATE] was inaccurate and failed to reflect the resident's use of hearing aids. Resident #4 Review of Resident #4's significant change MDS assessment dated [DATE] revealed the resident was admitted to the facility on [DATE]. Further review of Resident #4's significant change MDS assessment dated [DATE] revealed section J titled, Health Conditions, that the resident had a prognosis of life expectancy of less than six months and section O titled, Special Treatments, Procedures, and Programs, revealed under K. Hospice Care was coded without a check mark. Review of Resident #4's October 2023 physician's orders revealed an order entry dated, 07/14/2023 to Admit to Hospice and palliative care with a diagnosis of Hypertensive Heart Disease with Heart Failure. On 10/10/2023 at 3:16 p.m., an interview was conducted with S2MDS who reviewed Resident #4's significant change MDS assessment dated [DATE] and confirmed the resident was coded as having a life expectancy of less than six months, but was not coded for receiving hospice care. S2MDS then reviewed the resident's current orders and confirmed an order entry dated 07/14/2023 to admit to Hospice services with a diagnosis of Hypertensive Heart Disease with Heart Failure; she then confirmed the MDS assessment dated [DATE] was not coded accurately under section O to reflect Resident #4 receiving hospice services.

Based on interview and record review, the facility failed to identify and provide the needed care and services in accordance with professional standards of practice to meet the highest practicable physical well-being of residents for 1 (#2) out of 5 (#1, #2, #3, #4 and #5) sample residents: 1. staff failing to assess Resident #2's glucose when the resident had symptoms of hyperglycemia; and by 2. staff failing to follow up with the physician after notifying the physician of a change in the resident's #2's condition: This failure resulted in a harm on 04/27/2023 at 4:10 p.m., for Resident #2, who was admitted with Type 2 Diabetes Mellitus with Hyperglycemia 9 days prior, when he had a change of condition/decrease, in level of consciousness. S3LPN failed to obtain a Capillary Blood Glucose (CBG) with these symptoms of altered glucose. S3LPN further failed to follow up with Resident #2's physician after notifying the physician of a change in Resident #2's level of consciousness, which resulted in a delay of treatment. As a result, when Resident #2 was assessed by S4LPN at 9:00 p.m., he was hard to arouse, his blood pressure was 89/45 and his CBG reading was HI. He was transferred to a local hospital at 10:40 p.m. and presented in the emergency room (ER) with decreased level of consciousness, low blood pressure (77/37), dehydration, and an elevated blood glucose (599). He was treated in the ER with 3 liters of Intravenous (IV) fluids, IV antibiotics, 10 Units of Insulin and an Insulin drip. The resident was admitted to the hospital with diagnoses of Urinary Tract Infection, Dehydration, Hypernatremia, Uncontrolled Diabetes with Hyperglycemia and Acute Kidney Injury. He returned to the facility on hospice services on 05/15/2023. Findings: Resident #2 was admitted from the hospital to the facility on [DATE] with an admitting diagnosis of Type 2 Diabetes Mellitus with Hyperglycemia. His other diagnoses included in part, Parkinson's Disease, Dysphagia, Gastro-esophageal Reflux, Anxiety Disorder and Generalized Muscle Weakness. The facility policy titled, Change In Resident Medical Status read in part, a change in medical status is defined as any physical, psychological and/or medical deviation as compared to the resident's status as noted in the initial assessment .a facility must immediately .consult with the resident's physician . Review of Resident #2's Baseline Care Plan and Summary, dated 04/21/2023, revealed problems and intervention including in part, Diabetes with hyperglycemia. Intervention- observe for s/s of hypo/hyperglycemia .Dehydration/Fluid Maintenance. Intervention-monitor for s/s of dehydration. Review of Resident #2's April physician's orders, dated 04/19/2023, revealed an order that read, CBG PRN (as needed) AC (before meals) & HS (at hour of sleep): insulin regular 100 units/ml SQ (subcutaneous) per sliding scale. 61-200 (glucose reading): 0 units (insulin), 201-250: 2 units, 251-300: 4 units, 301-350: 6 units, 351-400: 8 units, >400 Call MD. Review of the resident's April MAR (Medication Administration Record) revealed no documentation that CBGs were conducted from 04/19/2023 to 04/27/2023. Further review of the MAR revealed an order for Lantus U-100 Insulin Glargine (injectable medication used to lower blood sugar) 100 unit/ml subcutaneous (under the skin) solution 20 units SQ (subcutaneous) HS 8 (at bedtime at 8 p .m); and Jardiance (oral medication used to lower blood sugar) 25mg tablet by mouth daily. Start date: 04/20/2023. Review of the nurse's note dated 04/27/2023 at 4:13 p.m. written by S3LPN read in part, keeps eyes closed but attempts to speak. Speech is low tone as to whisper . Vital signs: BP 119/76, P 71, R 19, T 98.6 .Dr. (doctor) (S5MD) made aware of resident increase sleepiness. Med list faxed and awaiting response. Further review revealed no CBG check by the nurse. Review of the nurse's note date 04/27/2023 at 10:22 p.m. read in part, Note reflecting 9 p.m.hard to arouse verbally . BP (Blood Pressure) 89/45, P (Pulse) 104, R (Respirations) 18, T (Temperature) 97.2, O2 Sat (Oxygen Saturation) 96% RA (room air), CBG reading HI.new order to transfer to hospital emergency room for evaluation due to elevated CBG and low BP. Review of the nurse's note date 04/27/2023 at 10:40 p.m. read in part, Note reflecting 9:35 p.m. Resident CBG rechecked -result-HI . Review of the nurse's note date 04/27/2023 at 10:43 p.m. read in part, Note reflecting 9:39 p.m. Resident transferred to hospital .condition unchanged . Review of the hospital emergency department note dated 04/27/2023 at 10:22 p.m. read in part, .patient presents per EMS (Emergency Medical Service) from the nursing home with report of an altered mental status and elevated glucose on examination he appears to be dehydrated with rather dry oral mucosa, his exam is otherwise remarkable for hypotension with a pressure of 77/37. The patient was given 2L (liters) of fluids .he still not arousable .work-up (labs) .he has got marked hypernatremia with a sodium of 160 (high) and a chloride of 123 (high). His BUN (blood urea nitrogen)/creatinine (kidney function test) is 98 and 4.03 (high) with a glucose of 599 (high) .It appears that he has severe dehydration with acute kidney injury . will go ahead and give him some further fluid resuscitation to get his pressure up .will give him some IV (intravenous) insulin .will speak with hospitalist service regarding admission for hydration and glucose control. Review of the hospital discharge summary dated 05/15/2023, Resident #2 was treated with IV Rocephin (antibiotic), 10 units of insulin and 3 liters of normal saline in the emergency room . He was admitted to the hospital inpatient unit with the following diagnoses: Non-ketotic Hyperosmolar Syndrome (life-threatening complication of uncontrolled diabetes mellitus), which was treated with IV fluids and IV insulin drip; Pneumonia and Urinary Tract Infection, which was treated with IV antibiotics. After 18 days of hospitalization , he was accepted by hospice. He remained in the hospital for 19 days and transferred to the nursing home on 05/15/2023 with hospice services. Resident #2 no longer resided in the facility during the survey therefore observation and interview was not conducted. On 06/19/2023 at 4:30 p.m., an interview with S1DON was conducted. S2ADON was present during the interview. S1DON stated that when the glucometer indicated a HI reading, it meant the glucose level was above 500. They both agreed that the glucose should be rechecked to ensure that the reading is correct. On 06/20/2023 at 12:10 p.m., an interview with S3LPN was conducted. She confirmed that the resident was a diabetic but could not remember if the resident was getting blood sugar checks. A review of the resident April physician orders was conducted with S3LPN and she confirmed that at that time the resident's CBGs were only on if needed. S3LPN agreed that a CBG would be done if the resident shows signs and symptoms of hypo/hyperglycemia. A review of the nurse's note dated 4/27/2023 at 4:13 p.m. was conducted with S3LPN. She stated that she notified the doctor because she noticed that the resident was sleeping more than usual that day and his speech was very low. S3LPN agreed that increased drowsiness and slurred speech could be symptoms of hypo/hyperglycemia. S3LPN confirmed that she did not check the resident's blood sugar at that time. S3LPN stated that S5MD didn't call her back before her shift ended at 6 p.m. She stated that she didn't not call to follow up with S5MD before she left at the end of her shift. She stated that she informed the oncoming nurse that she had been waiting on a call from S5MD regarding the resident's increased sleepiness. On 06/20/2023 at 3:25 p.m., a phone interview was conducted with S5MD. She stated that when a resident was admitted from the hospital to the nursing home, she does not see that resident right away after they are admitted to the home. She stated that she relied on the nurse's assessment of the resident during that time to keep her informed of the resident's status. She stated she was unaware that Resident #2's blood sugar had not been checked since he was admitted on [DATE] until he was transferred to the hospital on 04/27/2023. She agreed that a resident who was taking an injectable insulin should have their blood glucose monitored. She stated that the resident's blood glucose should have been checked at least when he was admitted to the nursing home to see if the prn CBG order need to be changed. On 06/21/2023 at 1:52 p.m., a phone interview was conducted with SL4PN. She stated that on 04/27/2023 at 9 p.m., she went in the resident's room, the resident was unable to keep his eyes open. He was hard to arouse when she called his name but did respond to physical and tactile stimuli. She stated that the signs that the resident was exhibiting prompted her to check the resident's vital signs and blood glucose. She confirmed that when the glucometer indicated a reading of HI, she knew this meant that the resident's blood glucose was above 500mg/dl and she need to notify the MD immediately. She stated that S3LPN, who was the day nurse on 04/27/2023, did not inform her during shift change report at 6 p.m. of the change in the resident's condition during her shift. S4LPN stated that S3LPN also did not inform her that she had notified the physician and the physician had not called back. On 06/21/2023 at 2:45 p.m., an interview was conducted with S1DON. She agreed that on 04/27/2023, S3LPN should have followed up with the physician after she had notified the physician of the change in Resident #2's condition.

Based on record review and interview, the facility failed to notify the resident's physician of a significant change in the resident's physical status regarding the new onset of pain, which resulted in a delay in treatment for 1 of 5 sampled residents (Resident #2). Resident #2 fell on [DATE] at 7:30 p.m., which resulted in a " quarter size hematoma " to the right side of her head, a small abrasion on her right forearm, and she denied complaints of pain. At 8:30 p.m., the physician was notified of the fall and that neuro checks were in progress. At 10:30 p.m., Resident #2 complained of pain to her right wrist when it was moved, however the physician was not notified of the new complaint of pain. On 10/1/11, Resident #2 was sent to the emergency room for evaluation of pain, and was diagnosed with [REDACTED]. Failure to notify the physician of the resident 's complaint of pain resulted in delay of evaluation and treatment for 10 ? hours of a wrist fracture, and the resident experiencing untreated pain in her wrist for that amount of time. Resident #2 had a history of [REDACTED]. This deficiency has the potential to affect 35 other residents that were identified by the facility for having falls. FINDINGS: A review of a Resident Incident Report dated 9/30/11 at 7:30 p.m. revealed that Resident #2 sustained a fall with a head injury. Further review of the narrative of the incident report revealed that Resident #2 was found lying on the floor on her right side in her room. A small abrasion which measured 1 cm (centimeter) by 1 cm was noted to her right forearm, a " quarter size " hematoma was noted to the right side of her head, and she denied pain at that time. Further review of the incident report revealed that the doctor was notified of the fall at 8:30 p.m., on 9/30/11. A review of the facility ' s Incident Logs from 9/1/2011 through 2/29/2012 was conducted and revealed that Resident #2 had the following falls: 9/30/2011, 10/29/2011, 1/20/2012, and 1/23/2012. A review of Resident #2 ' s care plan was conducted and revealed that she had been care planned for falls. A fall had been documented on 9/30/11 as follows: Hematoma to head, abrasion to Rt (right) wrist, 10/1/11 transferred to hosp ER and admitted . A fall had been documented on 10/29/11 with no injuries, and on 1/23/2012 with a laceration above an eye (side not specified) and an abrasion to the right knee. A review of Resident #2 ' s medical record was conducted and revealed that the resident was admitted to the facility on [DATE]. Resident #2 had [DIAGNOSES REDACTED]. A review of the Nurses Notes in Resident #2 ' s record was conducted and revealed an entry dated 9/30/11 at 7:30 p.m. Resident #2 was found lying on the floor on her right side. The assessment of injuries for Resident #2 was documented as follows: " quarter size " hematoma to right side of head, small abrasion (1 cm x 1 cm) on right forearm, alert, denies pain, MAE (moves all extremities) without difficulty. Further review of this entry revealed that a call was made to the physician on call, and the nurse was awaiting a return call from him. A review of the Nurses Notes dated 9/30/11 at 8:30 p.m., revealed that a call was received from the physician on call, and he stated to continue Neuro (Neurological) checks and notify Resident #2 ' s doctor on Monday (10/3/2012). Continued review of the Nurses Notes revealed that on 9/30/11 at 10:30 p.m., the nurse documented the " Res did c/o (complain of) pain in right wrist when wrist is moved, states happened in fall. MD aware of abrasion. Will continue to monitor c/o wrist pain with movement. " The entry was signed by S6 LPN. Further review of the Nurses Notes failed to reveal that the physician was made aware of the new complaints of pain with right arm movement. A review of the Nurses Notes dated 10/1/11 at 8:30 a.m., revealed an entry which stated that new orders had been received to send Resident #2 to the emergency room . A review of the Physician ' s Telephone Orders in Resident #2 ' s record revealed an order dated 10/1/11 at 9:00 a.m., to transfer the resident to the emergency for evaluation of c/o pain to the right wrist, to r/o (rule out) a fracture. Further review of Resident #2 ' s chart revealed a document dated 10/7/11 and titled " Transfer Summary/Orders: Return to Nursing Home with a [DIAGNOSES REDACTED]. " On 3/9/12 at 11:40 a.m., an interview was conducted with S6 LPN. She was questioned about the entry in the Nurses Notes on 9/30/11 at 10:30 p.m., where she had documented that Resident #2 complained of pain with movement of her right wrist. S6 LPN confirmed that she had documented that Resident #2 had pain when she moved her right wrist but stated that it was a mistake and that the resident had not complained that she had wrist pain. Further review of Resident #2 ' s record failed to reveal an addendum stating that Resident #2 had not complained of pain on 9/30/11 at 10:30 p.m., after sustaining a fall, as documented in the Nurses Notes entry made by S6 LPN. A review of S6 LPN ' s personnel file was conducted and revealed a document titled Employee Warning Report dated 10/3/2011. Review of the document revealed a Supervisor ' s/Employer ' s Statement with the following information: Type of Violation: Substandard Work Quality, Violation of Company Policies or Procedures. Date of Violation 9/30/11 Time 10:30 pm. No MD notification of change in condition. The document was signed by S6 LPN and dated 10/4/11 and a box indicating " I have read this Employee Notice and understand it " , was checked.

Based on record review and staff interview, the facility failed to ensure that each resident receives the necessary care and services to attain and maintain the highest practicable physical well-being for 1 of 5 sampled residents (Resident #2), by: 1. failing to consult with the physician for Resident #2 ' s new complaints of pain after sustaining a fall 2 hours earlier, and 2. failing to reassess Resident #2 during the shift after she had complained of pain with movement to her right wrist, and 3. failing to administer pain medication to Resident #2 when she complained of pain. Resident #2 sustained a fall on 9/30/11 at 7:30 p.m., and had no complaints of pain. The physician was notified at 8:30 p.m. of the fall. At 10:30 p.m., Resident #2 complained of pain to her right wrist with movement. The physician was not notified, the resident was not reassessed, and pain medication was not administered. On 10/1/11 at 9:00 a.m., orders were received to send Resident #2 to the hospital to evaluate complaints of pain to her right wrist. Resident #2 was diagnosed with [REDACTED]. Failure to notifythe physician of the resident 's complaint of pain resulted in a delay of evaluation and treatment for 10 ? hours of a wrist fracture, and the resident experiencing untreated pain in her wrist for that amount of time. FINDINGS: A review of Resident #2 ' s medical record was conducted and revealed that the resident was admitted to the facility on [DATE]. Resident #2 had [DIAGNOSES REDACTED]. On 11/3/2011, Resident #2 ' s cognitive status was documented as moderately impaired - decisions poor. A review of a Resident Incident Report dated 9/30/11 at 7:30 p.m., revealed that Resident #2 had sustained a fall with a head injury. Further review of the incident report revealed that Resident #2 was found lying on the floor, on her right side in her room. A small abrasion which measured 1 cm (centimeter) by 1 cm was noted to her right forearm, a " quarter size " hematoma was noted to the right side of her head, and she had no pain at present. Further review of the incident report revealed that the doctor was notified of the fall at 8:30 p.m., on 9/30/11. A review of the Nurses Notes in Resident #2 ' s record was conducted and revealed an entry dated 9/30/11 at 7:30 p.m. Resident #2 was found lying on the floor on her right side; she was able to move all extremities and denied pain. Further review of this entry revealed that a call was made to the physician on call, and the nurse was awaiting a return call from him. Further review of the Nurses Notes revealed an entry dated 9/30/11 at 7:40 p.m., documenting that Resident #2 ' s curator, her daughter, had been notified of the fall. Further review of the Nurses Notes dated 9/30/11 at 8:30 p.m., revealed that a call was received from the physician on call, and he was notified of the fall. The physician on call stated to continue neuro checks, and to notify Resident #2 ' s physician on Monday (10/3/2011). No further orders were noted. Further review of the Nurses Notes revealed that on 9/30/11 at 10:30 p.m., Resident #2 complained of pain to her right wrist with movement, and she stated that it happened in the fall. The Nurses Notes continued " MD aware of abrasion. Will continue to monitor c/o wrist pain with movement. " The entry was signed by S6 LPN. Further review of the Nurses Notes revealed that the next entry was dated 10/1/11 at 8:00 a.m., and revealed that treatment to a right wrist skin tear had been initiated. This entry was not completed by S6 LPN. Further review of the Nurses Notes dated 10/1/11 at 8:30 a.m., revealed that orders had been received to send Resident #2 to the emergency room . Further review of the Nurses Notes, and other documents in Resident #2 ' s record failed to reveal any reassessments of Resident #2, after sustaining a fall with an abrasion to her right wrist on 9/30/11 at 7:30 p.m., and complaining of pain at 10:30 p.m. This review also failed to reveal that the physician was made aware of Resident #2 ' s complaints of pain, which began on 9/30/11 at 10:30 p.m. A review of the Physician ' s Telephone Orders in Resident #2 ' s record revealed an order dated 10/1/11 at 9:00 a.m., to transfer the resident to the emergency room for evaluation of complaints of pain to the right wrist and to rule out a fracture. A review of Resident #2 ' s Physician order [REDACTED].>100. The order was dated 8/23/2010. No other medications for pain were noted in the physician's order [REDACTED]. A review of Resident #2 ' s September 2011 medications administration record was reviewed. An area for the administration of Tylenol 650 mg by mouth every 4 hours as needed for pain or temp > 100 was noted. Further review of the record revealed that no Tylenol 650 mg was administered on 9/30/11 for complaints of pain. A review of the back of the administration record revealed that no documentation of pain assessment or medication was noted. Further review of the medication administration record revealed no other medication for pain was administered to Resident #2. A review of Resident #2 ' s October 2011 medications administration record was reviewed. An area for the administration of Tylenol 650 mg by mouth every 4 hours as needed for pain or temp > 100 was noted. Further review of the record revealed that no Tylenol 650 mg was administered on 10/1/11 for complaints of pain. A review of the back of the administration record revealed that no documentation of pain assessment or medication was noted. Further review of the medication administration record revealed no other medication for pain was administered to Resident #2. Further review of Resident #2 ' s chart revealed a document dated 10/7/11 titled Transfer Summary/Orders: Return to Nursing Home with a [DIAGNOSES REDACTED]. " A review of a document titled Physicians Orders Admits/readmits dated 10/7/11 was conducted and revealed that Resident #2 was readmitted to the facility with a [DIAGNOSES REDACTED]. On 3/8/12 at 11:00 a.m., an interview conducted with S3 Corporate Nurse and S2 ADON. A request for the facility ' s policy and procedure for assessment documentation was requested. S3 Corporate Nurse stated that the facility had no policy or protocol which the facility nurses were expected to follow for assessment documentation. S3 Corporate Nurse and S2 ADON both stated that a nurse only documents negative assessments in the nurses notes. S3 Corporate Nurse stated the nurse who made the entry into Resident #2 ' s Nurses Notes on 9/30/11 at 10:30 p.m., was S6 LPN. S3 Corporate Nurse stated that she had spoken to S6 LPN regarding the entry in the Nurses Notes dated 9/30/11 at 10:30 p.m., and that S6 LPN had told her that she had reassessed Resident #2's pain during the night, and that the resident had not complained of pain. S3 Corporate Nurse confirmed that there was no documentation of pain reassessment in Resident #2 ' s record and again stated that a nurse would only document an assessment of pain if a resident complained of pain. S3 Corporate Nurse confirmed documentation from the 9/30/11, 10:30 p.m. Nurses Note entry which stated " Res did c/o (complain of) pain in Rt (right) wrist when wrist is moved, states happened in fall. Will continue to monitor c/o wrist pain with movement." S3 Corporate Nurse stated that S6 LPN told her that she meant to document that Resident #2 ' s daughter complained of pain on behalf of her mother, but that the resident denied pain when asked. Both S3 Corporate Nurse and S2 ADON stated that the documentation by S6 LPN stated that Resident #2 did complain of pain and that S6 LPN would continue to monitor the pain. Both S3 Corporate Nurse and S2 ADON stated that there was no documentation of further assessments of Resident #2 after complained of pain on 9/30/11 at 10:30 p.m. On 3/9/12 at 11:40 a.m., an interview was conducted with S6 LPN. S6 LPN stated that she would have documented the monitoring of pain assessments in the Nurses Notes. S6 LPN further stated that if Resident #2 did complain of pain, medication would have been documented on the MAR (medication administration record) and further stated that she did not administer any medications because Resident #2 did not have complaints of pain on 9/30/11 at 10:30 p.m. She stated that Resident #2 ' s daughter actually complained of pain for her mother. S6 LPN further stated that it was her mistake documenting that the resident complained of pain. A review of S6 LPN ' s personnel file was conducted and revealed a document titled Employee Warning Report dated 10/3/2011. Review of the document revealed a Supervisor ' s/Employer ' s Statement with the following information: Type of Violation: Substandard Work Quality, Violation of Company Policies or Procedures. Date of Violation: 9/30/11 Time 10:30 p.m. Lack of Assessment on _ (Resident #2) _ with c/o pain upon movement of wrist after sustaining a fall at 7:30 p.m. No further assessment remainder of shift. Further review of the document revealed an area titled Explanation of Statement, with a handwritten description of violation by the employee which read: " I realize the error made in not assessing resident properly " and " Will make an effort to better assess res ' s in future and be more attentive " was noted. The document was signed by S6 LPN and dated 10/4/11 and a box indicating " I have read this Employee Notice and understand it " , was checked.