Every finding on record at Sierra Basin Post Acute

Based on interview, clinical record review, and document review, the facility failed to report an allegation of staff-to-resident physical abuse for 1 of 18 sampled residents (Resident #24). This deficient practice could allow allegations of abuse to occur and not be reported for investigation resulting in continued or worsening abuse of vulnerable residents throughout the facility.Findings include:Resident #24Resident #24 was admitted to the facility on [DATE], with diagnoses including fracture of left femur, fracture around internal prosthetic left hip joint, and chronic obstructive pulmonary disease.On 03/09/2026 at 12:00 PM, Resident #24 verbalized a Certified Nursing Assistant (CNA) had handled the resident roughly and the resident was concerned the CNA would cause further injury to an existing fracture in the resident's hip. Resident #24 had requested the Physical Therapy Assistant (PTA) to remove the CNA from the resident's care due to the CNA handling the resident roughly when providing care. The resident verbalized feeling unsafe as the CNA continued to enter the resident's room to provide care to the resident's roommate.A Physical Therapy Treatment Encounter Note dated 03/08/2026 at 6:26 PM, documented Resident #24 requested to speak with a supervisor and verbalized a CNA had been rough with the resident. A Registered Nurse (RN)/Weekend Nurse Manager (WNM) was notified.On 03/11/2026 at 1:33 PM, the Physical Therapy Director (PT Director) defined abuse as being physically or verbally harmful and withholding care needed to meet basic human rights. Any willful and harmful emotional, physical, or sexual act would constitute abuse. The PT Director confirmed treating a resident roughly could be considered abuse. The PT Director recalled the PT Director had been notified on 03/08/2026, Resident #24 had informed the PTA a CNA was rough with the resident. The PT Director notified the Director of Nursing (DON) of the incident via text message between the PT Director and the DON's personal cellular phones. The DON responded and directed the PT Director to notify the WNM on staff and to educate the resident on how to file a grievance. The PT Director notified the WNM of the resident's allegation.The PT Director was unwilling to provide the documentation of correspondence with the DON of the reporting of the allegation due to its location being on a personal cell phone device. On 03/11/2026 at 2:44 PM, the Resident Care Manager (RCM) defined physical abuse as kicking, hitting, pulling, and providing care in a rough manner. The RCM verbalized the PT Director notified the RCM of the physical abuse allegation on 03/11/2026 and the RCM had been previously unaware. The RCM indicated the CNA providing care for Resident #24 on 03/08/2026 was still working in the facility and was providing care to residents on 03/11/2026.On 03/11/2026 at 2:57 PM, the CNA verbalized on the morning of 03/08/2026, the CNA entered Resident #24's room to provide care and the resident refused. After assisting three other residents the CNA noticed Resident #24's call light was on. The resident was upset with the CNA, and the CNA notified the WNM. The CNA requested to be removed from the resident's care but continued to provide care to the roommate. The CNA was not aware of any allegation of treating the resident roughly until the afternoon of 03/11/2026.On 03/11/2026 at 3:31 PM, the DON verbalized the DON had been notified of the allegation by the PT Director on 03/08/2026 at 12:08 PM and requested the WNM to obtain a statement from the resident. The DON verbalized the WNM had informed the DON the resident had alleged the CNA providing care to Resident #24 moved too quickly when transferring the resident and the resident did not believe the CNA understood proper care for a fractured hip. The DON verbalized the only statement collected was a verbal statement from the WNM. The DON explained having difficulty locating the verbal statement as the DON preferred to document on the DON's personal laptop. Upon retrieval of the WNM's statement, the DON confirmed the statement was not signed or dated by the WNM. The DON confirmed lack of reporting to the resident's family, or the required State agencies.On 03/12/2026 at 8:51 AM, the WNM defined abuse as causing harm to an individual through physical, verbal, mental, or sexual abuse. The WNM gave the examples of name calling, being too rough, behaving aggressively, or anything causing a resident to feel unsafe. The WNM stated Resident #24 had a fracture in the resident's left femur and required assistance with transfers. The WNM conducted a full conversation with the resident, and the resident had felt the CNA was rough and transferred the resident too quickly. The CNA was removed from the resident's care but was allowed to continue to care for the resident's roommate. The WNM verbalized the CNA should have been removed from the resident's area. The WNM verbalized an allegation of physical abuse constituted temporary suspension of the alleged perpetrator until the conclusion of an investigation. The WNM verbalized the WNM should have included the Abuse Coordinator in reporting the allegation, but this had not been completed. The WNM stated statements should have been collected from all parties involved, but this had not been completed.On 03/12/2026 at 2:49 PM, the Abuse Coordinator/Administrator verbalized when the Abuse Coordinator was not available the DON acted as the designee. When an allegation of abuse was reported the suspected staff member would be suspended immediately until reporting was concluded. Written statements would be collected from all parties involved. The Administrator verbalized, If an allegation appears to be unfounded, I am not sure a preliminary investigation needs to be provided or recorded. The Administrator confirmed the allegation of abuse was not reported to the required State agencies.A facility policy titled, Resident Rights, revised December 2016, documented employees shall treat all residents with kindness, respect, and dignity. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to a dignified existence, be treated with respect, kindness, and dignity. Be free from abuse, neglect, misappropriation of property, and exploitation.A facility policy titled, Abuse, Neglect, Exploitation, and Misappropriation, Prevention Program, revised April 2021, documented residents had the right to be free from abuse, neglect, misappropriation, of resident property and exploitation. This included but was not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual, or physical abuse. The facility would investigate and report any allegations within the timeframe required by federal requirements.A facility policy titled, Abuse, Neglect, Exploitation, and Misappropriation, Reporting and Investigating, revised April 2021, documented all reports of resident abuse, neglect, exploitation were reported to local, state, and federal agencies as required by current regulations and thoroughly investigated by facility management. Findings of all investigations were documented and reported. If a resident abuse, neglect exploitation, or injury was suspected, the suspicion must be reported immediately to the Administrator and to other officials according to state law. The Administrator of the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: The state licensing/certification agency responsible for surveying/licensing the facility, the local state ombudsman, the resident's representative, and adult protective services. Immediately it was defined as within two hours of an allegation involving abuse, within 24 hours of an allegation that does not involve abuse. Cross reference with F610, and F842

Based on interview, clinical record review, and document review, the facility failed to ensure 2 of 18 sampled residents (Residents #6 and #14) had an appropriate diagnosis to support the use of an antipsychotic medication. This deficient practice had the potential to result in the use of an unnecessary psychotropic medication and to restrict a resident's ability to function.Findings include:Resident #6 Resident #6 was admitted to the facility on [DATE], with a diagnosis of unspecified dementia unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety. A physician's order dated 02/16/2026, documented Quetiapine Fumarate oral tablet 50 milligrams (mg). Give 50 mg by mouth at bedtime for behaviors. A progress note dated 02/18/2026 at 12:00 AM, documented Quetiapine Fumarate oral tablet 50 mg. Give 50 mg by mouth at bedtime for dementia. A medication regimen review form dated 02/18/2026, documented Resident #6 received the antipsychotic Quetiapine Fumarate for behaviors. An antipsychotic medication should be used only for an appropriate diagnosis as determined by the Centers for Medicare and Medicaid Services (CMS) guidelines. The physician used the medication for an alternate diagnosis, unspecified, and behavioral symptoms presented a danger to the resident or to others. On 03/12/2026 at 11:10 AM, a Certified Nursing Assistant (CNA) verbalized the CNA was assigned to Resident #6 and was familiar with the resident's care. The CNA verbalized being unaware of any behaviors to include hallucinations, delusions, yelling out, or any other physically or verbally aggressive behavior. On 03/12/2026 at 11:20 AM, a Licensed Practical Nurse (LPN) verbalized the LPN was familiar with Resident #6's care needs. The LPN explained resident #6 had a diagnosis of dementia and sometimes exhibited signs of hallucinations such as preparing to make children breakfast. The LPN verbalized the LPN was unaware of any physically or verbally aggressive behavior by Resident #6. The LPN confirmed Resident #6's clinical record included a physician's order for Quetiapine Fumarate at bedtime for behaviors. On 03/12/2026 at 1:04 PM, the Director of Nursing (DON) verbalized the facility ensured pharmacy interventions were used only when clinically indicated through medication regimen reviews. The DON reviewed Resident #6's clinical record and explained Quetiapine Fumarate, an antipsychotic, was ordered for behaviors. The DON was unable to specify what behaviors were being targeted. The DON verbalized expecting a diagnosis associated with psychotropic medication. The DON verbalized a progress note dated 02/18/2026, documented the Quetiapine Fumarate was ordered for dementia. The DON explained neither behaviors nor a diagnosis of dementia would be appropriate indications of use for an antipsychotic medication. Resident #14 Resident #14 was admitted to the facility on [DATE], with diagnoses including dementia in other diseases classified elsewhere, moderate, without behavioral disturbance, psychotic disturbance, mood disturbance, or anxiety, and Alzheimer's disease, unspecified. On 03/09/2026 at 11:00 AM, Resident #14 was sleeping in bed at the lowest position. A physician order dated 02/05/2026, documented Risperidone 0.25 mg, one tablet by mouth two times a day, for a diagnosis of dementia. A medication regimen review form dated 02/18/2026, documented this resident is receiving the antipsychotic for Risperdal. An antipsychotic medication should be used only for an appropriate diagnosis as determined by CMS regulations. The physician selected a diagnosis of schizoaffective disorder for the resident's use of Risperidone. On 03/11/2026 at 2:09 PM, the DON explained Risperidone was an antipsychotic medication and would not be used solely for a diagnosis of dementia. The DON verbalized the pharmacy review was reviewed by the physician and documented schizoaffective disorder as the diagnosis for the resident receiving risperidone; however, the facility was unable to determine where the physician obtained the diagnosis and could not determine the clinical rationale for the order. On 03/12/2026 at 8:16 AM, the Physician verbalized when residents were admitted with antipsychotic medications, the Physician evaluated whether the medication was prescribed in the hospital or brought from home. The Physician stated if the medication was brought from home, the resident's primary care provider continued the evaluation; however, if the medication was prescribed in the hospital, the Physician reviewed the necessity of the medication. The Physician confirmed risperidone was prescribed for dementia and confirmed Resident #14 did not have a diagnosis of schizoaffective disorder. The facility policy titled Psychotropic Medication Use, undated, documented psychotropic medication management was an interdisciplinary process involving the resident, family, and or the representative and included determining adequate indication of usage. Adequate indication for uses referred to the identified documented clinical rationale for administering the medication. A diagnosis alone did not necessarily warrant the use of psychotropic medications.

Based on interview, clinical record review, and document review, the facility failed to investigate an allegation of staff-to-resident physical abuse for 1 of 18 sampled residents (Resident #24). This deficient practice could allow allegations of abuse to occur and result in continued or worsening abuse of vulnerable residents throughout the facility.Findings include:Resident #24Resident #24 was admitted to the facility on [DATE], with diagnoses including fracture of left femur, fracture around internal prosthetic left hip joint, and chronic obstructive pulmonary disease.On 03/09/2026 at 12:00 PM, Resident #24 verbalized a Certified Nursing Assistant (CNA) had handled the resident roughly and the resident was concerned the CNA would cause further injury to an existing fracture in the resident's hip. Resident #24 had requested the Physical Therapy Assistant (PTA) remove the CNA from the resident's care due to the CNA handling the resident roughly when providing care. The resident verbalized feeling unsafe as the CNA continued to enter the resident's room to provide care to the resident's roommate.A Physical Therapy Treatment Encounter Note dated 03/08/2026 at 06:26 PM, documented Resident #24 requested to speak with a supervisor and verbalized a CNA had been rough with the resident. A Registered Nurse (RN)/Weekend Nurse Manager (WNM) was notified.On 03/11/2026 at 1:33 PM, the Physical Therapy Director (PT Director) defined abuse as being physically or verbally harmful and withholding care needed to meet basic human rights. Any willful and harmful emotional, physical, or sexual act would constitute abuse. The PT Director confirmed treating a resident roughly could be considered abuse. The PT Director recalled the PT Director had been notified on 03/08/2026, Resident #24 had informed the PTA a CNA was rough with the resident. The PT Director notified the Director of Nursing (DON) of the incident via text message between the PT Director and the DON's personal cellular phones. The DON responded and directed the PT Director to notify the WNM on staff and educate the resident on how to file a grievance. The PT Director notified the WNM of the resident's allegation.The PT Director was unwilling to provide the documentation of correspondence with the DON of the reporting of the allegation due to its location being on a personal cell phone device. On 03/11/2026 at 2:44 PM, the Resident Care Manager (RCM) defined physical abuse as kicking, hitting, pulling, and providing care in a rough manner. The RCM verbalized the PT Director notified the RCM of the physical abuse allegation on 03/11/2026 and the RCM had been previously unaware. The RCM indicated the CNA providing care for Resident #24 on 03/08/2026 was still working in the facility and was providing care to residents on 03/11/2026. The RCM was unable to review the allegations with the CNA.On 03/11/2026 at 2:57 PM, the CNA verbalized on the morning of 03/08/2026, the CNA entered Resident #24's room to provide care and the resident refused. After assisting three other residents the CNA noticed Resident #24's call light was on. The resident was upset with the CNA, and the CNA notified the WNM. The CNA requested to be removed from the resident's care but continued to provide care to the roommate. The CNA was not aware of any allegation of treating the resident roughly until the afternoon of 03/11/2026.On 03/11/2026 at 3:31 PM, the DON verbalized the DON had been notified of the allegation by the PT Director on 03/08/2026 at 12:08 PM and requested the WNM to obtain a statement from the resident. The DON verbalized the WNM had informed the DON the resident had alleged the CNA providing care to Resident #24 moved too quickly when transferring the resident and the resident did not believe the CNA understood proper care for a fractured hip. The DON verbalized the only statement collected was a verbal statement from the WNM. The DON explained having difficulty locating the verbal statement as the DON preferred to document on the DON's personal laptop. Upon retrieval of the WNM's statement, the DON confirmed the statement was not signed or dated by the WNM. The DON confirmed lack of notification to the resident's family, or the required State agencies.On 03/12/2026 at 8:51 AM, the WNM defined abuse as causing harm to an individual through physical, verbal, mental, or sexual abuse. The WNM gave the examples of name calling, being too rough, behaving aggressively, or anything causing a resident to feel unsafe. The WNM stated Resident #24 had a fracture in the resident's left femur and required assistance with transfers. The WNM conducted a full conversation with the resident, and the resident had felt the CNA was rough and transferred the resident too quickly. The CNA was removed from the resident's care but was allowed to continue to care for the resident's roommate. The WNM verbalized the CNA should have been removed from the resident's area. The WNM verbalized an allegation of physical abuse constituted temporary suspension of the alleged perpetrator until the conclusion of the investigation. The WNM verbalized the WNM should have included the Abuse Coordinator in the investigation, but it had not been completed. The WNM stated statements should have been collected from all parties involved, but this had not been completed.On 03/12/2026 at 2:49 PM, the Abuse Coordinator/Administrator verbalized when the Abuse Coordinator was not available the DON acted as the designee. When an allegation of abuse was reported the suspected staff member would be suspended immediately until the investigation was concluded. Written statements would be collected from all parties involved. The Administrator verbalized, If an allegation appears to be unfounded, I am not sure a preliminary investigation needs to be provided or recorded.A facility policy titled, Resident Rights, revised December 2016, documented employees shall treat all residents with kindness, respect, and dignity. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to a dignified existence, be treated with respect, kindness, and dignity. be free from abuse, neglect, misappropriation of property, and exploitation. A facility policy titled, Abuse, Neglect, Exploitation, and Misappropriation, Prevention Program, revised April 2021, documented residents had the right to be free from abuse, neglect, misappropriation, of resident property and exploitation. This included but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual, or physical abuse. The facility would investigate and report any allegations within the timeframe required by federal requirements.A facility policy titled, Abuse, Neglect, Exploitation, and Misappropriation, Reporting and Investigating, revised April 2021, documented all reports of resident abuse, neglect, exploitation are reported to local, state, and federal agencies as required by current regulations and thoroughly investigated by facility management. Findings of all investigations are documented and reported. Investigating Allegations: All allegations are thoroughly investigated. The Administrator initiates investigations. Investigations may be assigned to an individual trained in reviewing, investigating, and reporting such allegations. The individual conducting the investigation must at minimum: review documentation and evidence, review resident medical record to determine cognitive and medical status, observe alleged victim, interview persons reporting the incident, interview any witnesses, interview staff members who had contact with resident during incident, interview the resident roommate, review all events leading up to the incident, and document the investigation completely and thoroughly. Witness statements are obtained in writing, signed and dated. The witness may write his/her statement, or the investigator may obtain a statement. Cross reference with F609, and F842.

Based on interview, clinical record review, and document review, the facility failed to ensure a resident was provided with written notice of the facility bed-hold policy when 1 of 3 residents sampled for closed records (Resident #78) was transferred to a hospital. This deficient practice had the potential to result in an unsafe discharge and prevent the resident from being informed of the resident's rights related to returning to the facility.Findings include:Resident #78 Resident #78 was admitted to the facility on [DATE], and readmitted on [DATE], with a primary diagnosis of idiopathic chronic gout, multiple sites, without tophus. A physician's progress note dated 02/18/2026 at 12:00 AM, documented Resident #78 was seen in bed and very confused. A smell of strong urine was present. A urinalysis was ordered and medications were adjusted due to concern for worsening confusion. The provider would send the resident to acute for concern of worsening infection.Resident #78's Discharge Minimum Data Set 3.0 (MDS) assessment dated [DATE], section A0310 (Identification Information - Optional Resident Items) documented discharge to a short-term general hospital with a discharge date of 02/18/2026.Resident #78's clinical record lacked documented evidence of a bed-hold notification.On 03/12/2026 at 11:01 AM, the Resident Care Manager Registered Nurse (RCM) verbalized administration would be responsible for completed documentation related to a resident's discharge. The RCM was familiar with Resident #78, however could not recall the specifics of the resident's discharge. On 03/12/2026 at 1:40 PM, the Director of Nursing (DON) explained the direct care nurse present during transfer and the RCM were responsible to educate the resident on the facility's bed-hold policy. This education would include written documentation of bed-hold notification. Bed-hold notifications would be scanned into the resident's electronic record or stored in the medical records office. The DON recalled Resident #78 was sent to the hospital on [DATE] due to altered mental status. The DON believed the facility expected Resident #78 to return to the facility after being stabilized; however, the resident did not return and was discharged from the facility. The DON verbalized the DON was unable to locate a bed-hold notification within Resident #78's clinical record or in the medical records office. The DON explained the facility previously collected verbal consents which may explain the lack of bed-hold notification documentation. The DON explained it was important to provide bed-hold notifications to ensure transferring residents were aware of the right to return to the facility. The facility policy titled Bed Hold Policy, undated, documented a bed-hold would be initiated when a resident was transferred to an acute hospital for medical purposes. The bed hold policy differed depending on the source of pay.

Based on observation, interview, and record review, the facility failed to revise the comprehensive person centered care plan to address changes in the resident's condition after experiencing two falls for 1 of 18 sampled residents (Resident #34). This deficient practice had the potential to result in unmet care needs, continued fall risk, and preventable injury.Findings included:Resident #34Resident #34 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including muscle weakness and difficulty in walking.Resident #34's initial care plan for falls dated 12/19/2025 identified the resident as being at risk for falls and included baseline fall prevention interventions.Resident #34's clinical record showed the resident sustained two falls in the facility on 12/24/2025 and 01/08/2026. These falls represented a change in the residents' condition requiring reassessment and revision of the care plan.Resident #34's clinical record lacked documented evidence the care plan was revised following either fall. No new fall prevention interventions were added, and no modifications were made to existing interventions to address the residents' repeated falls. The care plan remained unchanged from the 12/19/2025 version.On 03/11/2026 at 10:12 AM, a Licensed Practical Nurse (LPN) explained the care plan would be reviewed and updated following a resident's fall by the Resident Care Manager (RCM). The LPN confirmed no revisions were completed to Resident #34's care plan following the resident's falls.On 03/11/2026 at 10:17 AM, the RCM Registered Nurse explained care plans were initiated and updated as needed. The RCM verbalized care plans would be updated post fall to include new fall prevention interventions, and mobility and transfers would be evaluated by physical therapy. The RCM confirmed Resident #34's care plan was initiated in December and was not updated after the resident sustained falls in the facility.On 03/11/2026 at 2:34 PM, the Director of Nursing (DON) explained when a resident experienced falls, an assessment was completed to determine the root cause and update the care plan with new interventions. The DON verbalized care plans were updated to ensure resident safety and to identify interventions to meet the resident's needs. The DON confirmed Resident #34's care plan had not been updated to include the facility falls, revised interventions, or a documented root cause assessment.The facility policy titled Care Plans, Comprehensive Person-Centered, revised March 2022, documented care plan interventions were chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes and the relevant clinical decision making. When possible, interventions address the underlying sources of the problem areas, not just symptoms or triggers. Assessments of the residents were ongoing, and care plans were revised as information about the residents and the residents' conditions changed. Cross reference with F689

Based on interview, clinical record review, and document review, the facility failed to ensure a resident received treatment and care in accordance with professional standards of practice when 1 of 18 sampled residents (Resident #55) was not assisted with transportation to an orthopedics appointment outside the facility. This deficient practice had the potential to result in a delay in required services and hindered wound recovery.Findings include:Resident #55 Resident #55 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including acquired absence of right leg below knee and encounter for orthopedic aftercare following surgical amputation. A provider consultation form dated 02/12/2026, documented the resident was seen for orthopedic services to include range of motion knee extension and splint care. A follow-up appointment was made for 02/26/2026 at 3:00 PM. A provider consultation form dated 02/19/2026, documented the resident was seen for orthopedic services to include suture removal and dressing change. Follow-up was recommended for one week. A follow-up appointment was kept for 02/26/2026. The appointment calendar for 02/26/2026 documented Resident #55 had an orthopedics appointment at 3:00 PM, no transport. On 03/09/2026 at 4:07 PM, Resident #55 verbalized the facility lacked appropriate communication with residents regarding transportation to outside services. Resident #55 recalled approximately two weeks prior; the resident had an orthopedics appointment to receive care after a recent surgery. The resident recalled on the day of the appointment, the resident approached the nursing station and asked about the plan for transportation. A Registered Nurse (RN) referred to a communication slip indicating family would assist with transportation. The resident verbalized the resident did not have family available to assist with transportation. The resident explained the resident missed the orthopedics appointment because the facility did not have accurate information. On 03/12/2026 at 9:04 AM, the RN explained staff were made aware of resident appointments through the appointment calendar. Transportation would discuss with the resident the transportation plan and would populate the appointment calendar with the outside entity, the time and the transportation plan. Night shift nurses were responsible for preparing the transportation packet to include a face sheet, medication summary, provider notes, and a blank provider consultation form. The RN explained Resident #55 recently had surgery and was scheduled for follow-up orthopedic appointments to monitor the resident's amputation site. The RN recalled approximately two weeks prior; there was miscommunication between the resident and the facility regarding transportation. The RN was present on the day of the appointment but did and believed the appointment calendar and provider consultation form indicated family would assist the resident to the orthopedics appointment. The RN had not spoken with the resident regarding the transportation plan. At around noon on the day of the appointment, the RN asked the resident why the resident was still present in the facility and the resident explained the resident was under the impression the facility would be assisting with transportation. The resident informed the RN the resident did not have family to assist with transportation. The resident missed the appointment, Transportation was informed, and a new appointment was scheduled for the following week. On 03/12/2026 at 9:15 AM, the Transportation Certified Nursing Assistant (CNA) verbalized either the direct care nurse present on the day of transport, or the Transportation CNA would collaborate with the resident prior to a scheduled appointment to determine what type of transportation assistance was required. There would be no documentation of the discussion with the resident. The Transportation CNA would then update the appointment calendar to include the date, time and location of the appointment along with the transportation type. The facility had access to two vehicles for transportation to outside services. If both vehicles were unavailable, the facility would organize external transportation. The Transportation CNA explained Resident #55 received weekly orthopedic services because of the need for extensive wound care related to a recent surgery. The Transportation CNA explained on 02/26/2026, the appointment calendar documented Resident #55 was to receive family transport to an orthopedic appointment; however, the resident required transportation assistance provided by the facility. The resident missed the appointment due to a lack of transportation assistance, and the appointment was rescheduled for 03/05/2026. The Transportation CNA could not recall who discussed the transportation plan with the resident and when the calendar was updated. The facility policy, titled Transportation, Social Services, revised 12/2008, documented residents would be assisted as needed to obtain transportation.

Based on observation, interview, and record review, the facility failed to ensure supervision and assistive devices were provided to prevent accidents by failing to revise the comprehensive person centered care plan after the resident experienced two falls for 1 of 18 sampled residents (Resident #34). This deficient practice had the potential to result in unmet care needs, continued fall risk, and preventable injury.Findings included:Resident #34Resident #34 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including muscle weakness and difficulty in walking.On 03/09/2026 at 11:12 AM, Resident #34 verbalized having two falls while in the facility. The first fall happened when attempting to transfer to the wheelchair and the wheelchair breaks were not set. The second fall happened when attempting to use the toilet. Resident #34 explained having been in pain after the second fall and required x-rays for the hip and hand.Resident #34's clinical record showed the resident sustained two falls in the facility on 12/24/2025 and 01/08/2026. These falls represented a change in the residents' condition requiring reassessment and revision of the care plan.A progress note dated 12/29/2025 documented Resident #34 had a fall and to begin neuro checks.A post fall review was completed on 12/29/2025; however, the resident's care plan was not updated to reflect updated interventions.A progress note dated 01/13/2026 documented Resident #34 had fallen in the bathroom in the therapy gym. The resident explained was transferring from the wheelchair to the toilet. A nurse assessed the resident and assisted the resident back in the wheelchair.A post fall review was completed on 01/14/2026; however, the resident's care plan was not updated to reflect updated interventions.The resident's initial care plan for falls dated 12/19/2025 identified the resident as being at risk for falls and included baseline fall prevention interventions.Resident #34's clinical record lacked documented evidence the care plan was revised following either fall. No new fall prevention interventions were added, and no modifications were made to existing interventions to address the residents' repeated falls. The care plan remained unchanged from the 12/19/2025 version.On 03/11/2026 at 10:12 AM, a Licensed Practical Nurse (LPN) explained the care plan would be reviewed and updated following a resident fall by the Resident Care Manager (RCM). The LPN confirmed no revisions were completed to Resident #34's care plan following the resident's falls.On 03/11/2026 at 10:17 AM, the RCM Registered Nurse explained care plans were initiated and updated as needed. The RCM stated care plans would be updated after a fall to include new fall prevention interventions, and mobility and transfers would be evaluated by physical therapy. The RCM confirmed Resident #34's care plan was initiated in December and was not updated after the resident sustained falls in the facility.On 03/11/2026 at 2:34 PM, the Director of Nursing (DON) explained when a resident experienced falls, an assessment was completed to determine the root cause and update the care plan with new interventions. The DON verbalized care plans were updated to ensure resident safety and identify interventions to meet the resident's needs. The DON confirmed Resident #34's care plan had not been updated to include the facility falls, revised interventions, or a documented root cause assessment.The facility policy titled Care Plans, Comprehensive Person-Centered, revised March 2022, documented care plan interventions were chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes and the relevant clinical decision making. When possible, interventions address the underlying sources of the problem areas, not just symptoms or triggers. Assessments of the residents were ongoing, and care plans were revised as information about the residents and the residents' conditions changed.The facility policy titled Falls and Fall Risk, Managing, revised March 2018, documented based on previous evaluation and current data, the stall would identify intervention related the resident's specific risks and causes to try to prevent the resident from falling and try to minimize complications from falling. The staff would monitor and document each resident's response to interventions intended to reduce falling or the risks of falling. Cross reference with F657

Based on observation, interview, and document review, the facility failed to ensure the treatment/wound cart containing resident medications was secured. This deficient practice had the potential to result in unauthorized access to medications.Findings include:On 03/12/2026 at 11:36 AM, a treatment/wound cart was observed unlocked in the resident care area. There was no nursing staff present in the area at the time of the observation. The following medications were noted inside drawers one and two of the cart: one tube of lidocaine cream one tube of triamcinolone (TAC) cream three bottles of nystatin powderOn 03/12/2026 at 11:40 AM, the Resident Care Manager (RCM) Registered Nurse confirmed the treatment cart had been left unlocked and explained it should not be left unlocked. The RCM Registered Nurse verbalized it was important to keep the cart locked to keep residents, and visitors from getting in the cart and to keep everyone safe.On 03/12/2026 at 1:59 PM, the Director of Nursing verbalized the expectation was for staff to ensure the treatment cart was locked before walking away.The facility policy titled Storage of Medications, undated, documented drugs and biologicals used in the facility were stored in locked compartments under proper temperature, light and humidity controls. Only persons authorized to prepare and administer medications had access to locked medications.

Based on interview, clinical record review, and document review, the facility failed to ensure a resident's medical record was complete for 1 of 18 sampled residents (Resident #24). The deficient practice had the potential for staff to be unaware of resident needs resulting in further harm.Findings include:Resident #24Resident #24 was admitted to the facility on [DATE], with diagnoses including fracture of left femur, fracture around internal prosthetic left hip joint, and chronic obstructive pulmonary disease.On 03/09/2026 at 12:00 PM, Resident #24 verbalized a Certified Nursing Assistant (CNA) had handled the resident roughly and the resident was concerned the CNA would cause further injury to an existing fracture in the resident's hip. Resident #24 had requested the Physical Therapy Assistant (PTA) remove the CNA from the resident's care due to the CNA handling the resident roughly when providing care. The resident verbalized feeling unsafe as the CNA continued to enter the resident's room to provide care to the resident's roommate.A Physical Therapy Treatment Encounter Note dated 03/08/2026 at 06:26 PM, documented Resident #24 requested to speak with a supervisor and verbalized a CNA had been rough with the resident. A Registered Nurse (RN)/Weekend Nurse Manager (WNM) was notified.On 03/11/2026 at 1:33 PM, the Physical Therapy Director (PT Director) defined abuse as being physically or verbally harmful and withholding care needed to meet basic human rights. Any willful and harmful emotional, physical, or sexual act would constitute abuse. The PT Director confirmed treating a resident roughly could be considered abuse. The PT Director recalled the PT Director had been notified on 03/08/2026, Resident #24 had informed the PTA a CNA was rough with the resident. The PT Director notified the Director of Nursing (DON) of the incident via text message between the PT Director and the DON's personal cellular phones. The DON responded and directed the PT Director to notify the WNM on staff and educate the resident on how to file a grievance. The PT Director notified the WNM of the resident's allegation.The PT Director was unwilling to provide the documentation of correspondence with the DON due to the communication was maintained on the PT Director's personal cell phone and had not been documented in the resident record or maintained in facility files as required. The facility was unable to produce documentation verifying when the allegation was reported to the DON, the content of the communication, or any actions taken in response. The lack of available documentation prevented the facility to ensure the required records were complete, accurate, and readily accessible.On 03/11/2026 at 2:44 PM, the Resident Care Manager (RCM) defined physical abuse as kicking, hitting, pulling, and providing care in a rough manner. The RCM verbalized the PT Director notified the RCM of the physical abuse allegation on 03/11/2026 and the RCM had been previously unaware. The RCM indicated the CNA providing care for Resident #24 on 03/08/2026 was still working in the facility and was providing care to residents on 03/11/2026. The RCM was unable to review the allegations with the CNA.On 03/11/2026 at 2:57 PM, the CNA verbalized on the morning of 03/08/2026, the CNA entered Resident #24's room to provide care and the resident refused. After assisting three other residents the CNA noticed Resident #24's call light was on. The resident was upset with the CNA, and the CNA notified the WNM. The CNA requested to be removed from the resident's care but continued to provide care to the roommate. The CNA was not aware of any allegation of treating the resident roughly until the afternoon of 03/11/2026.On 03/11/2026 at 3:31 PM, the DON verbalized the DON had been notified of the allegation by the PT Director on 03/08/2026 at 12:08 PM and requested the WNM to obtain a statement from the resident. The DON verbalized the WNM had informed the DON the resident had alleged the CNA providing care to Resident #24 moved too quickly when transferring the resident and the resident did not believe the CNA understood proper care for a fractured hip. The DON verbalized the only statement collected was a verbal statement from the WNM. The DON explained having difficulty locating the verbal statement as the DON preferred to document on the DON's personal laptop. Upon retrieval of the WNM's statement, the DON confirmed the statement was not signed or dated by the WNM. The DON confirmed lack of notification to the resident's family, or the required State agencies.On 03/12/2026 at 8:51 AM, the WNM defined abuse as causing harm to an individual through physical, verbal, mental, or sexual abuse. The WNM gave the examples of name calling, being too rough, behaving aggressively, or anything causing a resident to feel unsafe. The WNM stated Resident #24 had a fracture in the resident's left femur and required assistance with transfers. The WNM conducted a full conversation with the resident, and the resident had felt the CNA was rough and transferred the resident too quickly. The CNA was removed from the resident's care but was allowed to continue to care for the resident's roommate. The WNM verbalized the CNA should have been removed from the resident's area. The WNM verbalized an allegation of physical abuse constituted temporary suspension of the alleged perpetrator until the conclusion of the investigation. The WNM verbalized the WNM should have included the Abuse Coordinator in the investigation but had not been completed. The WNM stated the WNM should have collected statements from all parties involved but had not been completed.On 03/12/2026 at 2:49 PM, the Abuse Coordinator/Administrator verbalized when the Abuse Coordinator was not available the DON acted as the designee. When an allegation of abuse was reported the suspected staff member would be suspended immediately until the investigation was concluded. Written statements would be collected from all parties involved. The Administrator verbalized, If an allegation appears to be unfounded, I am not sure a preliminary investigation needs to be provided or recorded.A facility policy titled, Resident Rights, revised December 2016, documented employees shall treat all residents with kindness, respect, and dignity. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to a dignified existence, be treated with respect, kindness, and dignity. be free from abuse, neglect, misappropriation of property, and exploitation. The facility was unable to provide a completed abuse investigation, abuse report, and updated administration and clinical resident record reflecting any changes made to the resident's care. A facility policy titled, Abuse, Neglect, Exploitation, and Misappropriation, Prevention Program, revised April 2021, documented residents had the right to be free from abuse, neglect, misappropriation, of resident property and exploitation. This included but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual, or physical abuse. The facility would investigate and report any allegations within the timeframe required by federal requirements.A facility policy titled, Abuse, Neglect, Exploitation, and Misappropriation, Reporting and Investigating, revised April 2021, documented all reports of resident abuse, neglect, exploitation are reported to local, state, and federal agencies as required by current regulations and thoroughly investigated by facility management. Findings of all investigations are documented and reported. Investigating Allegations: All allegations are thoroughly investigated. The Administrator initiates investigations. Investigations may be assigned to an individual trained in reviewing, investigating, and reporting such allegations. The individual conducting the investigation must at minimum: review documentation and evidence, review resident medical record to determine cognitive and medical status, observe alleged victim, interview persons reporting the incident, interview any witnesses, interview staff members who had contact with resident during incident, interview the resident roommate, review all events leading up to the incident, and document the investigation completely and thoroughly.Cross reference with F609, and F842.

Based on observation, interview, and document review, the facility failed to ensure a staff member performed hand hygiene when assisting residents in the dining room for 4 of 4 observed opportunities to perform hand hygiene. This deficient practice had the potential to result in the spread of bacteria and viruses, including multi drug resistant organisms, to the residents in the facility.Findings include:On 03/09/2026 at 12:14 PM, a staff member was assisting residents in the dining room. The staff member performed the following activities without performing hand hygiene:delivered coffee to a resident.touched the back of a resident's chair.touched the table in front of a resident and then touched the resident's chair.assisted a resident with opening a container of salad dressing and then poured the dressing over the resident's salad.The staff member confirmed the staff member had not performed hand hygiene in between touching residents or before assisting a resident with the resident's salad dressing. The staff member verbalized the staff member should have washed their hands or performed hand hygiene in between contact with residents.On 03/12/2026 at 1:33 PM, the Infection Preventionist verbalized staff should have performed hand hygiene or washed their hands in between touching residents or anytime a staff member touched a surface.The facility policy titled Handwashing/Hand Hygiene, revised 08/2019, documented the facility considered hand hygiene the primary means to prevent the spread of infections. Hand hygiene would be performed before and after direct contact with residents, after contact with objects in the immediate vicinity of the residents, and before and after assisting a resident with meals.

Based on interview, personnel record review and document review, the facility failed to ensure staff were trained on the prevention of elder abuse prior to engaging with residents for 8 of 20 sampled personnel records reviewed (Employee #1, #10, #13, #14, #15, #16, #19, and #20). Findings include: On 01/15/2025 at 11:40 AM, the Business Office Coordinator (BOC) and the Administrator participated in an interview to confirm the accuracy of the Personnel Records Checklist completed by the facility for 20 employees. On 01/15/2025 at 11:40 AM, the BOC and the Administrator verbalized elder abuse training was required upon hire, annually, and as needed (PRN). Employee #1 Employee #1 was hired as the Administrator with a start date of 05/28/2024. The Administrator's elder abuse training was completed on 06/26/2024. Employee #10 Employee #10 was hired as the Director of Rehabilitation (PT) with a start date of 08/01/2024. The PT's elder abuse training was completed on 12/18/2024. Employee #13 Employee #13 was hired as a Registered Nurse (RN) with a start date of 11/11/2024. The RN's elder abuse training was completed on 12/18/2024. Employee #14 Employee #14 was hired as a License Practical Nurse (LPN) with a start date of 09/16/2024. The LPN's elder abuse training was completed on 12/18/2024. Employee #15 Employee #15 was hired as an LPN with a start date of 11/26/2024. The LPN's elder abuse training was completed on 12/18/2024. Employee #16 Employee #16 was hired as a Certified Nursing Assistant (CNA) with a start date of 09/27/2024. The CNA's elder abuse training was completed on 12/18/2024. Employee #19 Employee #19 was hired as a Dietary Aide with a start date of 12/12/2024. The Dietary Aide's elder abuse training was completed on 12/18/2024. Employee #20 Employee #20 was hired as a Housekeeper with a start date of 08/01/2024. The Housekeeper's elder abuse training was completed on 12/18/2024. On 01/15/2025 at 3:03 PM, the Administrator confirmed the aforementioned elder abuse training dates for Employee #1, #10, #13, #14, #15, #16, #19, and #20, and confirmed the employee's initial elder abuse training was not completed prior to working with residents. The facility policy titled Abuse Neglect, Exploitation and Misappropriation Prevention Program, revised April 2021, documented the facility would provide staff orientation and training/orientation programs to include topics such as abuse prevention, identification and reporting of abuse.

Based on observation, clinical record review, interview, and document review the facility failed to ensure 1 of 17 sampled residents (Resident #2) and the Resident's Representative received written notification of transfer or discharge. This deficient practice had the potential to cause confusion and prevent the Resident Representative from being informed of the reason for transfer. Findings include: Resident #2 Resident #2 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including hypertensive heart disease with heart failure, acute and chronic respiratory failure with hypoxia, and acute on chronic systolic (congestive) heart failure. Resident #2's Minimum Data Set 3.0 (MDS) assessments, Section A, documented Resident #2 was admitted to the facility on [DATE], and discharged on [DATE] to a short term general hospital. A Health Status Note dated 11/29/2024, documented Resident #2 was sent to the emergency room (ER) at an acute care hospital due to difficulty breathing and acute hypoxia. A Health Status Note dated 11/29/2024, documented Resident #2 was admitted to the hospital. Resident #2's clinical record lacked documented evidence written notification of the reason for transfer/discharge was provided to Resident #2 and/or the Resident's Representative when the resident was transferred to an acute care ER and admitted to the hospital on 11/29/2024. On 01/16/2025 at 3:17 PM , the Director of Nursing (DON) verbalized notification of transfer to a hospital was no longer required and had been removed from the facility's transfer check list used to guide the transfer process. On 01/16/2025 at 4:10 PM, the DON confirmed when Resident #2 was transferred and subsequently admitted to an acute care hospital on 11/29/2024, the facility did not provide written notification of the reason for transfer to the resident or the Resident Representative. On 01/16/2025, at 4:12 PM, the facility did not to provide a policy related to facility transfers, as requested by the surveyor.

Based on observation, interview, clinical record review, and document review, the facility failed to provide a bed hold policy notification to 1 of 17 residents (Resident #2) and/or the Resident's Representative upon transfer to an acute care hospital. This deficient practice had the potential to cause confusion and prevent the Resident Representative from being informed of the right to exercise the bed hold provisions and any associated fees. Findings include: Resident #2 Resident #2 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including hypertensive heart disease with heart failure, acute and chronic respiratory failure with hypoxia, and acute on chronic systolic (congestive) heart failure. Resident #2's Minimum Data Set 3.0 (MDS) assessments, Section A, documented Resident #2 was admitted to the facility on [DATE], and discharged on [DATE] to a short term general hospital. A Health Status Note dated 11/29/2024, documented Resident #2 was sent to the emergency room (ER) at an acute care hospital due to difficulty breathing and acute hypoxia. A Health Status Note dated 11/29/2024, documented Resident #2 was admitted to the hospital. Resident #2's clinical record lacked documented evidence written notification of the right to exercise a bed hold provision was provided to Resident #2 and/or the Resident's Representative, when the resident was discharged to an acute care hospital on 11/29/2024. On 01/16/2025 at 3:17 PM, the Director of Nursing (DON) verbalized notification of the bed hold policy was no longer required and had been removed from the facility's transfer check list used to guide the transfer process. On 01/16/2025 at 4:10 PM, the DON confirmed when Resident #2 was transferred and subsequently admitted to an acute care hospital, the facility did not provide written notification of the facility's bed hold policy to the resident and/or the Resident Representative. A facility policy titled Bed-Holds and Returns revised on 10/2022, documented the facility informed residents and/or the resident's representative in writing of the right to exercise a bed hold provision upon admission. A second notice was provided before transfer to a general acute care (short term general) hospital. In the event of an emergency transfer, the second notice was provided within 24 hours.

Based on observation, interview, and document review, the facility failed to ensure a fire alarm sounded in the front of the facility, including the therapy gym and resident dining hall, during a fire drill. This deficient practice had the potential to affect resident, visitor, and staff safety in the event of an actual fire. Findings include: On 01/14/2025 at 1:28 PM the fire alarm was pulled at a nurse's station in the facility. Emergency strobe lights activated throughout the facility, however the alarm did not sound in the front part of the facility, to include the front lobby, staff administrative offices, resident therapy gym, private dining room, and the resident dining room. On 01/15/2025 at 9:20 AM, the Maintenance Director verbalized the expectation was when the fire alarm was pulled, the alarm would sound throughout the building. The Maintenance Director was unaware the alarm did not sound in the front part of the building. On 01/15/2025 at 9:24 AM, a Certified Occupational Therapist Assistant (COTA) verbalized at approximately 1:30 on 01/14/2025, the COTA did not hear the fire alarm sound. The COTA explained the COTA was in the therapy gym restroom with a resident when the emergency strobe lights began flashing. The COTA confirmed the fire alarm did not sound in the therapy gym area. On 01/15/2025 at 9:29 AM, the Dietary Director verbalized the Dietary Director did not hear the fire alarm during the fire drill on 01/14/2025. The Dietary Director explained they knew there was a fire alarm because the emergency strobe lights began flashing. The Dietary Director confirmed the fire alarm did not sound in the resident dining room, where residents frequented. On 01/15/2025 at 3:51 PM, the Director of Rehabilitation verbalized during the fire alarm drill on 01/14/2025 at approximately 1:30 PM, there were five residents in the therapy gym receiving services. The facility policy titled Fire Indicated by Alarm Panel, revised 07/19/2021, documented the center attempted to extinguish fires and keep residents/staff/visitors safe as they occur.

Based on observation, interview, clinical record review, and document review the facility failed to ensure physical therapy (PT) frequency of treatment was provided per the physician's order for 1 of 3 sampled residents (Resident #1). Findings include: Resident #1 Resident #1 was admitted to the facility on [DATE], with a diagnosis of fracture of superior rim of left pubis, subsequent encounter for fracture with routine healing. Resident #1's Physician Order dated 02/13/24, documented PT to evaluate and treat as indicated. Resident #1's Therapy Dashboard documented PT, start date 02/14/24, five times a week, signed by the facility Physician. Resident #1's PT Evaluation and Plan of Treatment dated 02/14/24, documented PT five times a week for eight weeks. Resident #1's Comprehensive Care Plan lacked evidence of the frequency of treatments per the physician order. On 03/08/24 at 11:00 AM, Resident #1 verbalized the resident admitted to the facility for therapy to learn to walk again. The resident explained the resident was concerned about their upcoming discharge because they did not receive physical therapy (PT) for a few days due to a lack of PT staff. On 03/08/24 at 11:54 AM, a Registered Nurse (RN) verbalized Resident #1 was admitted to the facility for PT rehabilitation. The RN explained the facility recently began using a new company to provide PT services and the resident did not receive PT services for a few days due to lack of physical therapy personnel. On 03/08/24 at 1:38 PM, a Physical Therapist verbalized Resident #1 was to receive PT five times a week. The Physical Therapist confirmed Resident #1 did not receive PT five times a week due to staffing issues with the physical therapy company. Resident #1's PT Treatment Encounter Notes documented the resident received physical therapy services on 02/26/24, 02/28/24, 02/29/24, and 03/01/24 or a total of four PT sessions (treatment) for the week of 02/25/24 to 03/02/24. Resident #1's PT Treatment Encounter Notes documented the resident received physical therapy on 03/06/24 or a total of one PT session for the week of 03/03/24 to 03/09/24. On 03/08/24 at 1:46 PM, the Director of Nursing (DON) verbalized PT Director took a leave of absence. The DON explained the PT Director was a treating therapist and the facility was having a hard time finding coverage for therapy with the PT company. The DON confirmed Resident #1 did not receive PT five times a week during that time frame. The DON confirmed the discrepancy was due to staffing issues.

Based on interview, observation, clinical record review, and document review the facility failed to ensure a process was developed and implemented to assess/screen residents for participation in a bowel and bladder retraining program with the potential to affect the facility's entire resident census of 48 and 1 of 12 sampled residents (Resident #9) was assessed to determine if the resident was a candidate for a bowel and bladder retraining program. Findings include: Bowel and Bladder Program 01/09/24 at 12:03 PM, the Director of Nursing Services (DNS) explained the initial resident assessment drove a resident's plan of care. A bowel and bladder assessment were done upon admission as part of the required Minimum Data Set 3.0 (MDS) assessment. A resident's bowel and bladder continence status were documented in the resident's progress notes. The DNS verbalized the facility did not have a formal screening process to determine if a resident was a candidate for a bowel and bladder retraining program. On 01/09/24 at 4:36 PM, the DNS confirmed the facility did not have worksheets, policies, or any other material specific to a Bowel and Bladder Retraining Program. The DNS was not able to explain how the facility ensured the components of the facility's Bladder Incontinence policy were being implemented. On 01/10/24 at 10:04 AM, a Licensed Practical Nurse (LPN) verbalized a resident's continence status was discussed during a verbal report from the sending facility and the Residential Care Manager (RCM) asked cognitively intact residents about their continence status during the admission process. On 01/10/24 at 10:16 AM, the LPN verbalized incontinent residents requiring more than minimum assistance for transfers were either changed in bed or assisted to the bathroom to be changed as needed. On 01/10/24 at 10:18 AM, the RCM explained the expectation was incontinent residents would be encouraged to use the bathroom regardless of the amount of assistance required, including upon waking for the day, before mealtimes, and at bedtime. The RCM explained the facility did not have a formal bowel and bladder retraining program and the RCM was not aware of any facility forms related to bowel and bladder management. On 01/10/24 at 1:56 PM, the DNS provided a blank copy of a 72-hour voiding diary and explained the expectation was the form would be used when a trend of incontinence was noticed, such as during a certain time of the day. The DNS confirmed the facility was not currently using the 72-hour voiding diary form and confirmed the form had not been used in recent memory. On 01/10/24 at 1:58 PM, the DNS confirmed the facility was not able to locate any additional forms related to screening, assessing, or implementing a bowel and bladder retraining program. On 01/10/24 at 2:12 PM, the DNS explained residents were ambulated and taken to the bathroom which helped to retrain the bladder. The DNS confirmed the facility did not have a policy or program in place related to a bowel and bladder retraining program. The facility policy titled Bladder Incontinence, last revised 02/2019, documented the facility ensured residents incontinent of bladder received appropriate treatment and services to restore as much normal bladder function as possible. The policy included definitions of a bladder retraining program, a scheduled toileting plan, a 72-hour voiding diary, and incontinence management but did not include a process or instructions on how to implement a bowel and bladder retraining program. Resident #9 Resident #9 was admitted to the facility on [DATE], with diagnoses including chronic obstructive pulmonary disease, unspecified, and systolic (congestive) heart failure. Resident #9's MDS assessment dated [DATE], section GG0100 (Prior functioning: everyday activities) documented prior to admission to the facility Resident #9 needed partial assistance from another person to complete self-care activities including toileting. Section GG0130 (functional abilities and goals - admission) documented the resident required partial/moderate assistance for toileting including perineal hygiene and adjusting clothes before and after voiding or having a bowel movement. Section GG0170 (Mobility- first three days of the resident's stay) documented the resident needed substantial/maximum assistance for toilet transfers, the ability to get on and off a toilet or commode. Section H0200 (Urinary toileting program) documented Resident #9 did not have a trial of a toileting program including scheduled toileting, prompted voiding, or bladder training attempted upon admission/entry, reentry, or since urinary incontinence was identified by the facility. Section H0300 documented the resident was occasionally incontinent of urine. Section H0400 documented the resident was frequently incontinent of bowel. Section H0500 documented a toileting program was not being used to manage the resident's bowel incontinence. On 01/09/24 at 4:32 PM, the DNS verbalized Resident #9 did not qualify for a bowel and bladder retraining program, a scheduled toileting plan, or a 72-hour voiding diary as defined in the facility's policy titled Bladder Incontinence, due to the resident being incontinent. The DNS explained the policy indicated a resident had to be aware of the urge to void and be either independent or need limited assistance with toileting. The DNS confirmed Resident #9 was not on a bowel and bladder retraining program. The facility policy titled Bladder Incontinence, last revised 02/2019, documented the facility ensured residents incontinent of bladder received appropriate treatment and services to restore as much normal bladder function as possible. The policy included definitions of a bladder retraining program, a scheduled toileting plan, a 72-hour voiding diary, and incontinence management. Cross reference with F658

Based on interview and clinical record review, the facility failed to ensure a resident's discharge status was accurately documented on a Minimum Data Set 3.0 (MDS) assessment for 1 of 5 closed resident records (Resident #40). Findings include: Resident #40 Resident #40 was admitted to the facility on [DATE], with diagnoses including encounter for surgical aftercare following surgery on the circulatory system, presence of cardiac pacemaker and paroxysmal atrial fibrillation. The resident was discharged on [DATE]. A Progress Note dated 11/03/23, documented Resident #40 was discharging home with all personal belongings. Resident #40's clinical record documented the MDS assessment dated [DATE], section A2105, indicated Resident #40 was discharged to the hospital. On 01/09/24 at 10:56 AM, the MDS Coordinator confirmed the MDS assessment dated [DATE], section A2105 was not completed accurately for Resident #40. The MDS Coordinator verbalized the MDS assessment should have indicated Resident #40 discharged home and not to the hospital. On 01/09/24 at 11:02 AM, the Director of Nursing Services (DNS) explained the DNS worked closely with the MDS Coordinator to ensure assessments were correct and accurate prior to submission. The DNS confirmed Resident #40 was discharged to the community and was not discharged to the hospital.

Based on interview, clinical record review, and document review, the facility failed to ensure 1) a care plan for administering a resident's as needed (PRN) heart medication was developed for 1 of 12 sampled residents (Resident #5). Findings include: Resident #5 Resident #5 was admitted to the facility on [DATE], with diagnoses including NON-ST elevation myocardial infarction (NSTEMI), other pericardial effusion (non-inflammatory), cardiac tamponade, presence of coronary angioplasty implant and graft, and atherosclerotic heart disease of native coronary artery without angina pectoris. On 01/08/24 at 11:30 AM, Resident #5 verbalized the resident had nitroglycerin prescribed for chest pain. The resident explained the staff needed to know what to do prior to and after administration. The resident stated vitals needed to be monitored prior to and after administration. Resident #5's physician's order dated 12/11/23, documented Nitrostat sublingual tablet 0.4 milligram (mg). Give 0.4 mg sublingually every five minutes as needed for chest pain. If chest pain persists after the second dose, give one more dose and call Emergency Management Services (EMS). On 01/08/24 at 2:27 PM, a Registered Nurse (RN) verbalized when a resident had chest pain, the RN would check for a physician order for the medication, Nitrostat, check the resident's vitals, administer Nitrostat, check the resident's vitals after administration, and monitor the resident for any adverse reactions or further chest pain. On 01/09/24 at 3:58 PM, a Licensed Practical Nurse (LPN) verbalized when a resident had chest pain and a physician order for Nitrostat, the nursing staff would check the resident's vitals, administer the medication, and assess for pain. The LPN confirmed Resident #5 had a cardiac care plan, however the cardiac care plan had not been updated to include the medication Nitrostat and interventions including taking vitals, assessing for pain, and monitoring vitals after administration. Resident #5's Comprehensive Care Plan initiated 12/01/23, documented the resident had altered cardiovascular status related to NSTEMI resulting in stenting of (Left Anterior Descending Artery) LAD with subsequent cardiac tamponade since resolved. The care plan lacked intervention specific to the administration and monitoring of the medication Nitrostat. On 01/10/24 at 4:04 PM, the Director of Nursing Services (DNS) verbalized the expectation was medications requiring monitoring, such as a resident's cardiac medication, should be care planned. The facility policy titled Medication Administration General Guidelines, revised 01/2023, documented medications were administered in accordance with physician orders, obtain and record any vital signs as necessary prior to administration. The facility policy titled Care Plan - Kardex/Baseline Care Plan, revised 12/2019, documented direct care givers would have accurate information available to them to properly care for residents. Information would be updated as changes occurred. Problem areas and interventions, including special instructions, would be provided on the Kardex. Cross reference with F689, F761

Based on observation, clinical record review, interview, and document review the facility failed to ensure professional standards of practice were followed by failing to develop and implement a bowel and bladder retraining program ensuring residents were provided the appropriate treatment and services needed to restore as much bowel and bladder function as possible. The failure had the potential to affect the facilities entire resident census of 48. Findings include: Bowel and Bladder Program On 01/09/24 at 12:03 PM, the Director of Nursing Services (DNS) explained the initial resident assessment drove a resident's plan of care. A bowel and bladder assessment were done upon admission as part of the required Minimum Data Set 3.0 (MDS) assessment. A resident's bowel and bladder continence status were documented in the resident's progress notes. The DNS verbalized the facility did not have a formal screening process related to bowel and bladder continence and did not have a bowel and bladder training program. On 01/10/24 at 1:56 PM, the DNS provided a blank copy of a 72-hour voiding diary and explained the expectation was the form would be used when a trend of incontinence was noticed, such as during a certain time of the day. The DNS confirmed the facility was not currently using the 72-hour voiding diary form and confirmed the form had not been used in recent memory. On 01/10/24 at 1:58 PM, the DNS confirmed the facility was not able to locate any additional forms related to screening, assessing, or implementing a bowel and bladder training program. On 01/10/24 at 2:12 PM, the DNS explained residents were ambulated and taken to the bathroom which helped to retrain the bladder. The DNS confirmed the facility did not have a policy related to a bowel and bladder program and confirmed the facility did not have a formal bowel and bladder program. The facility policy titled Bladder Incontinence, last revised 02/2019, documented the facility ensured residents incontinent of bladder received appropriate treatment and services to restore as much normal bladder function as possible. The policy included definitions of a bladder retraining program, a scheduled toileting plan, a 72-hour voiding diary, and incontinence management. Residents displaying incontinence were assessed as part of the Admission Resident Assessment Instrument (RAI) process and an individualized care plan based directly on the conclusion of the comprehensive assessment was developed. The policy did not include bowel incontinence. Cross reference with F690.

Based on observation, interview, clinical record review, and document review the facility failed to ensure medications were not left unsecured in a resident's room with the potential for accidental ingestion of the medication for 1 of 12 sampled residents (Resident #5). Findings include: Resident #5 Resident #5 was admitted to the facility on [DATE], with diagnoses including NON-ST elevation myocardial infarction (NSTEMI), other pericardial effusion (non-inflammatory), cardiac tamponade, presence of coronary angioplasty implant and graft, and atherosclerotic heart disease of native coronary artery without angina pectoris. Resident #5's Minimum Data Set 3.0 assessment dated [DATE], documented the resident had a Brief Interview for Mental Status Score (BIMS) of 14, indicating the resident was cognitively intact. On 01/08/24 at 11:30 AM, Resident #5 verbalized the resident had nitroglycerin prescribed for chest pain and the resident opened an unlocked drawer next to the bed and pulled out a pill sandwiched between two stacked clear medication cups. On 01/08/24 at 11:32 AM, Resident #5 verbalized the resident had chest pain on 12/11/23 and requested a nitroglycerin pill. The resident recalled the nurse brought two pills in a medication cup to the resident and touched the pills with their hands while attempting to administer the medication to the resident. The resident recalled the resident told the nurse they could not take the medication because it had been touched by the nurse. The nurse responded to the refusal by giving the resident another medication cup to cover the pills and left the pills with the resident. The resident confirmed the resident did not take the medication. Resident #5's physician's order dated 12/11/23, documented Nitrostat sublingual tablet 0.4 milligram (mg). Give 0.4 mg sublingually every five minutes as needed for chest pain. If chest pain persists after the second dose, give one more dose and call Emergency Management Services (EMS). A drug formulary document, printed from epocrates.com, on 01/18/24, documented Nitrostat, serious adverse reactions such as severe hypotension, syncope, anaphylactoid reaction, exfoliative dermatitis, methemoglobinemia, and nitrate tolerance. On 01/08/24 at 2:27 PM, a Registered Nurse (RN) verbalized the process when administering a medication was to verify the resident, the medication, administer the medication and watch the resident take the medication. When a resident refused to take a medication, the RN would educate the resident, honor the resident's choice, notify the provider, and document the refusal on the Medication Administration Record (MAR). The RN explained a medication should never be left with a resident. When a medication was refused or unable to be administered, the medication would be discarded per the facility process. The RN verbalized medications needed to be secured to avoid another resident accidentally ingesting the medication. On 01/08/24 at 2:33 PM, the RN confirmed there was a pill sandwiched between two clear medication cups in an unlocked drawer in Resident #5's room. The RN compared the pill found in the drawer with the Nitrostat medication prescribed to Resident #5, located in the unit medication cart. The RN verbalized the pill was stored improperly and was unsecured. On 01/09/24 at 2:41 PM, the Director of Nursing Services (DNS) verbalized it was not acceptable to have unsecured medications in a resident's room. The expectation when administering medications was nursing staff would watch the resident take the medication, or if the resident refused, the nursing staff would take the medication back, discard the medication per the facility process, and document the refusal on the MAR. On 01/09/24 at 3:58 PM, a Licensed Practical Nurse (LPN) verbalized the Medication Administration Record lacked documentation the medication was requested, administration was attempted, and the medication was refused by the resident. The facility policy titled Self Administration of Medication, revised 03/2020, documented medication at bedside was stored in closed, locked cupboards, or drawers. The facility policy titled Medication Administration General Guidelines, revised 01/2023, documented medications were administered in accordance with physician orders, obtain and record any vital signs as necessary prior to administration. Medications were to be administered at the time they were prepared. Residents were allowed to self administer medications when specifically authorized by the prescriber, the Interdisciplinary Team (IDT), and residents were always observed after administration to ensure the dose was completely ingested. If a dose was withheld, refused, or given other than the scheduled time, the space provided on the front of the MAR for that dosage administration was initialed and circled. Cross Reference F761, F656