Every finding on record at Spring Lake Skilled Nursing and Rehabilitation

Based on record review and interview, the facility failed to develop and implement a comprehensive person-centered care plan that includes measurable objectives and timeframes to meet the resident's medical, nursing, mental, and psychosocial needs for 2 (#10, #86) of 40 sampled residents reviewed. The facility failed to follow physician's orders for Resident #10 and Resident #86. Findings:Review of Resident #10's medical records revealed an admit date of 10/21/2025 including the following diagnoses, in part: type 2 diabetes mellitus with diabetic polyneuropathy, chronic respiratory failure with hypoxia, and enterocolitis due to clostridium difficile recurrent (11/01/2025).Review of Resident #10's Physician's orders revealed an order dated 11/10/2025 for Fluconozole 50mg (milligram) by mouth once daily for 7 days.Review of Resident #10's November medication administration record failed to reveal Fluconazole 50mg once daily x 7 days was administered for the full 7 days. Further review revealed the first dose of the medication was not administered until 11/15/2025 and resident only received 3 out of 7 days ordered.Review of Resident #10's Antibiotic Time Out form dated 11/15/2025 revealed: Initial treatment - Fluconazole oral tablet 50mg by mouth one time a day for fungal infection.Review of Resident #10's Nurse Practitioner notes dated 11/05/2025 revealed, in part: Chief Complaint / Nature of Presenting Problem: status post hospitalization from 11/05/2025 through 11/10/2025 from dialysis center for increased confusion now with continued weakness and debility . computed tomography head without contrast: .bilateral sinus disease with complete maxillary sinus opacification with hyperdense material suggesting fungal rhinosinusitis versus inspissated secretions (less likely hemorrhage or calcification) . Review of Resident #10's progress notes revealed the following entry dated 11/15/2025 at 4:47 p.m. revealed, in part: Fluconazole oral tab 50mg for fungus initial start date was 11/11/2025 through 11/18/2025 resident didn't receive med until 11/14/2025 after hours . During an interview on 12/03/2025 at 8:45 a.m. S2 Director of Nursing confirmed Resident #10 was ordered Fluconazole 50mg by mouth daily for 7 days to start on 11/11/2025, received the first dose on 11/15/2025 and only received 3 out of 7 days of medication. S2 DON further acknowledged Resident #10 did not receive the medication for 7 days and should have.Resident #86Review of the facility's Central Venous Catheter Dressing Changes policy revised 04/2016 revealed in part:PurposeThe purpose of this procedure is to prevent catheter-related infections that are associated with contaminated, loosened, soiled, or wet dressings.General Guidelines5. Change transparent semi-permeable membrane (TSM) dressings at least every 5-7 days and as needed (when wet, soiled, or not intact).Review of Resident #86's medical record revealed an admission date of 07/02/2025, with a recent readmission on [DATE]. Further review revealed the following diagnoses, in part: Parkinson's disease, dysphagia, and need for assistance with personal care.Review of Resident #86's physician orders revealed an order dated 11/13/2025: Change PICC (Peripherally Inserted Central Catheter) dressing every seven days or as indicated for soiled or damaged dressing. Notify MD (Medical Doctor) of negative findings. Change stabilization device and injection caps with each dressing change; every day shift every 7 day(s) and every 1 hours as needed for soiled or damaged dressing.An observation on 12/01/2025 at 6:40 a.m. revealed Resident #86 had a PICC line with a dressing dated 11/13/2025. Further observation revealed PICC line dressing was loose and discolored. An observation on 12/01/2025 at 1:13 p.m. with S5LPN (Licensed Practical Nurse) revealed Resident #86 had a PICC line with a dressing dated 11/13/2025. Further observation revealed PICC line dressing was loose and discolored. During an interview on 12/01/2025 at 1:13 p.m. S5LPN confirmed Resident #86's PICC line dressing was dated 11/13/2025, was loose and discolored, and the dressing should have been changed. Review of Resident #10's medical records revealed an admit date of 10/21/2025 including the following diagnoses, in part: type 2 diabetes mellitus with diabetic polyneuropathy, chronic respiratory failure with hypoxia, and enterocolitis due to clostridium difficile recurrent (11/01/2025).Review of Resident #10's Physician's orders revealed an order dated 11/10/2025 for Fluconozole 50mg (milligram) by mouth once daily for 7 days.Review of Resident #10's November medication administration record failed to reveal Fluconazole 50mg once daily x 7 days was administered for the full 7 days. Further review revealed the first dose of the medication was not administered until 11/15/2025 and resident only received 3 out of 7 days ordered.Review of Resident #10's Antibiotic Time Out form dated 11/15/2025 revealed: Initial treatment - Fluconazole oral tablet 50mg by mouth one time a day for fungal infection.Review of Resident #10's Nurse Practitioner notes dated 11/05/2025 revealed, in part: Chief Complaint / Nature of Presenting Problem: status post hospitalization from 11/05/2025 through 11/10/2025 from dialysis center for increased confusion now with continued weakness and debility . computed tomography head without contrast: .bilateral sinus disease with complete maxillary sinus opacification with hyperdense material suggesting fungal rhinosinusitis versus inspissated secretions (less likely hemorrhage or calcification) . Review of Resident #10's progress notes revealed the following entry dated 11/15/2025 at 4:47 p.m. revealed, in part: Fluconazole oral tab 50mg for fungus initial start date was 11/11/2025 through 11/18/2025 resident didn't receive med until 11/14/2025 after hours . During an interview on 12/03/2025 at 8:45 a.m. S2 Director of Nursing confirmed Resident #10 was ordered Fluconazole 50mg by mouth daily for 7 days to start on 11/11/2025, received the first dose on 11/15/2025 and only received 3 out of 7 days of medication. S2 DON further acknowledged Resident #10 did not receive the medication for 7 days and should have.

Based on record reviews, observations and interviews, the facility failed to provide services that met professional standards for 1 (#113) of 40 residents in the sample. The facility failed to ensure safe medication administration practices by leaving medications at the bedside.Findings:Review of facility's Self-Administration of Medications policy with a Revision date of December 2016 revealed in part:Policy StatementResidents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so.Policy Interpretation and Implementation1. As part of their overall evaluation, the staff with the assistance from the practitioner will assess each resident's mental and physical abilities to determine whether self-administering medications is clinically appropriate for the resident.2. In addition to general evaluation of decision-making capacity, the interdisciplinary team will perform an assessment of Self Administration of Medications Form, or equivalent including (but not limited to) the resident's:a. Ability to read and understand medication labels,b. Comprehension of the purpose and proper dosage and administration time for his or her medications;c. Ability to remove medications from a container and to ingest and swallow (or otherwise administer) the medication; andd. Ability to recognize risks and major adverse consequences of his or her medications.3. If the team determines that a resident cannot safely self-administer medications, the nursing staff will administer the resident's medications.4. If the resident is determined to self-administer, then he/she will be capable and willing to assume control and responsibility for his/her medication. The resident must sign the Consent for Administration of Medication Form regarding and agree to abide by the restrictions for handling and storage of medication according to one of the following plans.5. Any bedside medications will meet all the required labeling specifications and guidelines required of any medications in the facility.7. Staff shall identify and give to the Charge Nurse any medications found at the bedside that are not authorized for self-administration, for return to the family or resident representative.11. The staff will evaluate the resident who wishes to self-administer medications upon request or admission, readmission, routine quarterly, significant change MDS and PRN in order to reevaluate a resident's ability to continue to self-administer medications. Review of Resident #113's Medical Diagnoses revealed the following but not limited to disorders of peripheral nervous system, reduced mobility, and fibromyalgia. Review of Resident #113's December 2025 Physician Orders revealed an order for Fluticasone Propionate Suspension 50 MCG (micrograms)/ACT (actuation); 1 spray in each nostril one time a day for seasonal allergies with a start date 09/17/2025 with a revision date 10/25/2025. Further review of Resident #113's December 2025 Physician Orders failed to reveal an order for eye drops (Xaditor). Review of Resident #113's Quarterly MDS (minimum data sets) dated 08/01/2025 revealed a BIMS (Brief Interview of Mental Status) of 15 indicating cognitively intact. Review of Resident #113's Care Plan revealed seasonal allergies/sinus allergies with interventions to give meds as ordered and identify causative factors making allergies worse and report to medical doctor and treat as ordered. Further review of Care Plan failed to reveal Resident #113 was care planned for self-administration. Observation on 12/01/2025 at 6:00 a.m. revealed Resident #113 had 4 eye drops (Xaditor) and 1 nose spray (Fluticasone) at the bedside. Observation on 12/01/2025 at 9:10 a.m. revealed Resident #113 had 4 eye drops (Xaditor) and 1 nose spray (Fluticasone) at the bedside. Observation on 12/01/2025 at 1:50 p.m. with S2 DON (Director of Nursing) revealed Resident #113 had 4 bottles of eye drops (Xaditor) and 1 bottle of nose spray (Fluticasone) at the bedside. During an interview on 12/01/2025 at 6:00 a.m. Resident #113 reported the eye drops and nose spray are kept at the bedside. Resident #113 reported self-administering the eye drops for allergy, itchy eyes twice a day, in the morning and at night and the nose spray at night only. Resident #113 reported a family member brought the four bottles of eye drops (Xaditor) and the nose spray (Fluticasone) was from the facility. During an interview on 12/01/2025 at 1:50 p.m. S2 DON reported Resident #113 had not completed a self-administration evaluation and Resident #113's medications should not have been at the bedside.

Based on record reviews and interviews, the facility failed to provide ADL (activities of daily living) for 2 (#17, #131) of 3 (#17, #31, #131) residents reviewed for ADL care of dependent residents. The facility failed to trim and clean Resident #17's fingernails and bathe/shower Resident #131. Findings: Review of the facility's Care of Fingernails/Toenails policy revised 10/2010 included in part:PurposeThe purposes of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infectionsGeneral Guidelines1. Nail care includes daily cleaning and regular trimming.4. Trimmed and smooth nails prevent the resident from accidentally scratching and injuring his or her skin. Review of Facility's Shower/Tub Bath policy and procedure revised October 2010 revealed in part: Documentation - The following information should be recorded on the resident's ADL record and/or in the resident's medical record: 1. The date and time the shower/tub bath was performed. 5. If the resident refused the shower/tub bath, the reason (s) why and the intervention taken. 6. The signature and the title of the person recording the data. Resident #17Review of Resident #17's medical record revealed an admission date of 09/22/2025 with diagnoses that included hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, muscle weakness (generalized), and muscle wasting and atrophy left upper arm and right upper arm. Further review of Resident #17's medical record revealed Resident #17 was dependent for oral hygiene, toileting hygiene, and personal hygiene.Review of the Resident #17's admission MDS (Minimum Data Set) dated 09/26/2025 revealed a BIMS (Brief Interview of Mental Status) score of 12, indicating moderately impaired cognition.An observation on 12/01/2025 at 9:01 a.m. revealed Resident #17's fingernails were untrimmed, jagged and had grown over the tip of the fingers on both hands with brown residue under fingernails. During an interview on 12/01/2025 at 9:01 a.m., Resident #17 reported she had requested to have her fingernails trimmed yesterday. An observation on 12/02/2025 at 11:55 a.m. revealed Resident #17's fingernails were untrimmed, jagged and had grown over the tip of the fingers on both hands with brown residue under fingernails. During an interview on 12/02/2025 at 11:56 a.m. Resident #17 reported she requested again to have her fingernails trimmed this morning.An observation on 12/02/2025 at 4:05 p.m. with S2 DON revealed Resident #17's fingernails were untrimmed, jagged and had grown over the tip of the fingers on both hands with brown residue under fingernails. During an interview on 12/02/2025 at 4:05 p.m. S2 DON confirmed Resident #17's fingernails on both hands were untrimmed, jagged and had grown over the tip of the finger with brown residue under fingernails.Resident #131Review of Resident #131's medical records revealed an admit date of 11/25/2025 with diagnosis of, in part: hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, muscle weakness (generalized), need for assistance with personal care and other reduced mobility.Review of Resident #131's Baseline Care Plan revealed in part: daily preferences that resident prefers - receiving shower; shower/bathe self: the ability to bathe self, including washing, rinsing, and drying substantial/maximal assistance; and cognitive status a. cognitively intact.Review of Resident #131's tasks in medical records failed to reveal bathing was documented since admission.Review of Resident #131's hall shower log failed to reveal a shower/bath for November and December.During an interview on 12/01/2025 at 7:20 a.m. Resident #131 reported he had not received a bath since he was admitted .During an interview on 12/02/2025 at 2:30 p.m. Resident #131 reported he had not received a bath.During an interview on 12/02/2025 at 4:20 p.m. S2 DON (Director of Nursing) reported she was unable to find documentation Resident #131 received since a shower/bath since admission.

Based on record review and interviews, the facility failed to maintain acceptable parameters of nutritional status by failing to follow up with the physician in a timely manner to implement the registered dieticians (RD) recommendation for 1 (#99) of 6 (#1, #16, #25, #86, #99 and #132) residents reviewed for nutrition. Findings:Review of Resident #99's medical record revealed an admission date of 08/28/2025 with the following diagnoses, not limited to, muscle wasting and atrophy, type 2 diabetes mellitus without complications, mild protein-calorie malnutrition, muscle weakness (generalized) and need for assistance with personal care.Review of Resident #99's weights revealed a significant 17.93% (33 pounds) weight loss in 73 days from dates 08/29/2025 (184 pounds) and 11/10/2025 (151 pounds).Review of Resident #99's physician orders for dates 09/01/2025 through 12/03/2025 failed to reveal recommendations from S7RD and S8RD were implemented:On 09/16/2025 S8 RD recommended: three times a day house shake supplements for 90 days.On 11/20/2025 S7RD recommended: two times a day house shake supplement to aid with oral intake.During an interview on 12/03/2025 at 11:02 a.m., S2DON (Director of Nursing) reported the recommendations by S7RD and S8RD for Resident #99 were not sent to S6NP (Nurse Practitioner).During an interview on 12/03/2025 1:22 p.m., S6NP reported she was not notified of Resident #99's weight loss or recommendations from S7RD and S8RD.

Based on record reviews, observations, and interview, the facility failed to provide specialized care needs for the provision of respiratory care including tracheostomy care and tracheal suctioning, in accordance with professional standards of practice for 1 (#117) of 1 (#117) resident reviewed for respiratory care. The facility failed to date and store hand held nebulizer mask and tubing in a covered bag. Findings: Review of Facility's policy and procedure for oxygen administration revised February 2025 revealed in part: 6. Nebulizer tubing will be changed within 7-10 days, or if visibly soiled. 6. Store nebulizer equipment in a covered device (i.e. plastic bag, kangaroo pouch) between uses.Review of Resident #117's medical records revealed an admit date of 11/05/2025 with the following diagnoses, in part: severe persistent asthma uncomplicated and chronic systolic (congestive) heart failure. Review of Resident #117's physician's orders revealed an order dated 11/25/2025 for Budesonide-Formoterol Fumarate Inhalation Aerosol 160-4.5 mcg(microgram)/Act(actuation) (Budesonide-Formoterol Fumarate Dihydrate) 2 puffs inhale orally two times a day related to severe persistent asthma uncomplicated. Review of Resident #117's November 2025 medication administration record failed to reveal documentation respiratory mask and tubing were changed per policy. Observation on 12/02/2025 at 7:00 a.m. revealed Resident #117's hand held nebulizer mask and tubing sitting on bedside table, undated and not stored in a covered bag. Observation on 12/03/2025 at 7:50 a.m. revealed Resident #117's hand held nebulizer mask and tubing sitting on bedside table, undated and not stored in a covered bag. During an interview on 12/02/2025 at 7:50 a.m. S3 LPN (Licensed Practical Nurse) acknowledged Resident #117's hand held nebulizer mask and tubing was undated and not stored in a covered bag.

Based on record review, observation and interviews the facility failed to ensure residents who were unable to complete their ADL (Activities of Daily Living) received the necessary services to maintain proper grooming for 1 (#48) of 3 (#2, #34, #48) residents reviewed for ADL. The facility failed to ensure Resident #48 received nail care. Findings: Review of Resident #48's medical diagnoses revealed the following, but not limited to cerebral infarction, type 2 diabetes mellitus with diabetic neuropathy, and systemic lupus erythematosus. Review of Resident #48's September 2024 physician orders dated 05/08/2024 revealed: Activity as tolerated. Licensed nurse may clip and trim diabetic finger and toenails as indicated. Review of Resident #48's quarterly MDS (Minimum Data Sets) dated 07/08/2024 revealed a BIMS (Brief Interview of Mental Status) was 15 out of 15 indicating cognitively intact. Review of Resident #48's care plan revealed resident has an ADL self-care performance deficit and requires assistance with ADL. Observation on 09/23/2024 at 11:03 A.M. revealed Resident #48 sitting up in wheel chair wearing sandals. Further observation revealed Resident #48's toe nails were long, thick and yellow. During an interview on 09/23/2024 at 11:03 A.M. Resident #48 confirmed her toe nails were long and she was unable to recall the last time her toe nails were trimmed. During an interview on 09/25/2024 at 1:00 P.M. S2 DON (Director of Nursing) reported S3 NP (Nurse Practitioner), from a local foot care group, performs nail care on residents every 60 days. S2 DON confirmed S3 NP's last service date, at the facility, was 08/19/2024 and reported Resident #48 did not receive services on 08/19/2024. S2 DON confirmed Resident #48 was a diabetic and should have received nail care by a podiatrist or NP.

Based on record review and interviews the facility failed to accurately submit mandatory direct care staffing information to Centers for Medicare and Medicaid Services (CMS) for the Fiscal Year (FY) Quarter 3 2024 (April 1-June 31). Findings: Review of the facility's Payroll Based Journal (PBJ) Staffing Data Report for FY Quarter 3 2024 (April 1-June 31) revealed triggers for the following: One Star Staffing Rating and Excessively Low Weekend Staffing. During an interview on 09/25/2024 at 12:30 p.m. S1 Administrator reported he did not understand why the facility triggered for low staffing. S1 Administrator reported he is the only person at the facility that submits agency invoices to the corporate office. S1 Administrator further reported the corporate office submits the PBJ data to the CMS system.

Based on record reviews and interviews, the facility failed to ensure residents with pressure ulcers receive necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 1 (#1) out of 4 (#1, #2, #3, #4) sampled residents reviewed for pressure ulcers and skin conditions. The facility failed to perform a skin and wound evaluation upon admission and weekly for Resident #1. Findings: Review of medical records revealed Resident #1 with an admitted [DATE] with the following diagnosis, in part: muscle wasting and atrophy, not elsewhere classified/multiples sites, primary generalized (osteo) arthritis, mild protein-calorie malnutrition, Chronic Obstructive Pulmonary Disease/unspecified, muscle weakness (generalized), difficulty walking/not elsewhere classified, unsteadiness on feet, Peripheral Vascular Disease/unspecified, and cellulitis of right lower limb. Review of Resident #1's MDS (Minimum Data Set) assessment dated of 04/21/2024 revealed Section M: venous and arterial ulcers - 1. Review of Resident #1's Baseline Care Plan dated 04/19/2024 revealed skin risk - current skin integrity issue - RLE (right lower extremity) cellulitis with ulceration. Review of Resident #1's Skin & Wound Total Body Skin assessment dated [DATE] revealed 1 new wound upon admission. Review of Resident #1's Skin & Wound Evaluations revealed the initial evaluation was completed on 05/01/2024 - wound bed eschar 100%; no exudate; surrounding tissues fragile/intact; treatment: betadine/no dressing; no infection; 9 x 5.5cm (centimeter) intact eschar Education: Keep clean-dry. CV (cardiovascular) consult ordered .Further review revealed Skin & Wound Evaluation was not completed upon admission. Review of Resident #1's Nurse Practitioner (NP) Progress Note dated 04/19/2024 revealed - Chief complaint: Status post hospitalization . RLE (right lower extremity) arterial ulcer. Review of Facility's Pressure Ulcers/Skin Breakdown Policy (revised April 2018) revealed: - Assessment and Recognition: 3. In addition, the nurse shall describe and document/report the following wound conditions when identified within the EMR (electronic medical record): a. full assessment of pressure sore including location, stage, length, width and depth, presence of exudates or necrotic tissue. 4. The DON (Director of Nursing) or designee will examine the skin of newly admitted /readmitted residents for evidence of existing pressure ulcers or other skin conditions; reporting any abnormalities to the physician. - Documentation: Newly identified skin concerns will be added to the Wound Assessment Manager and EMR upon identification and updated weekly with assessments recording the progress of the skin concern. During an interview on 06/04/2024 at 3:40 p.m. S2 Corporate Nurse reported Skin & Wound Evaluations should be completed every 7 days. During an interview on 06/05/2024 at 8:50 a.m. S2 DON acknowledged Resident #1 did not have a Skin & Wound Evaluation completed upon admission and every 7 days and should have.

Based on record review and interview, the facility failed to develop and implement a comprehensive care plan for 1 (#1) out of 4 (#1, #2, #3, #4) sampled residents plan of care reviewed. Findings: Review of medical records revealed Resident #1 with an admitted [DATE] and discharge date of [DATE] with the following diagnosis, in part: muscle wasting and atrophy, not elsewhere classified/multiples sites, primary generalized (osteo) arthritis, mild protein-calorie malnutrition, Chronic Obstructive Pulmonary Disease/unspecified, muscle weakness (generalized), difficulty walking/not elsewhere classified, unsteadiness on feet, Peripheral Vascular Disease/unspecified, and cellulitis of right lower limb. Review of Resident #1's MDS (Minimum Data Set) Admission Assessment revealed a date of 04/21/2024. The comprehensive care plan was initiated on 04/19/2024 with only one problem and approach - activities of daily living (ADL) self-care performance deficit. During an interview on 06/04/2023 at 8:25 a.m. S4 MDS Nurse acknowledged Resident #1's care plan included one problem and approach for ADL care. S4 MDS Nurse further acknowledged the care plan was incomplete.

Based on record reviews and interview, the facility failed to ensure pain management was provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. The facility failed to administer pain medication for 1 (#1) out of 3 (#1, #2, #3) sampled residents receiving pain medication. Findings: Review of medical records revealed Resident #1 with an admitted [DATE] with the following diagnosis, in part: muscle wasting and atrophy, not elsewhere classified/multiples sites, primary generalized (osteo) arthritis, mild protein-calorie malnutrition, Chronic Obstructive Pulmonary Disease/unspecified, muscle weakness (generalized), difficulty walking/not elsewhere classified, unsteadiness on feet, Peripheral Vascular Disease/unspecified, and cellulitis of right lower limb. Review of Resident #1's Physician's Orders revealed the following orders: - 05/09/24 - hydrocodone-acetaminophen oral tablet 7.5-325mg (milligram) give 1 tablet by mouth every 6 hours as needed for moderate pain - 05/09/24 - Diclofenac Sodium tablet delayed release 50mg give 50mg by mouth every 12 hours as needed for pain - 04/29/24 - Acetaminophen tablet 325mg give 2 tablet by mouth six times a day for pain every 4 hours - 04/18/24 - assess pain using verbal/non-verbal scale every shift - 04/18/24 - Diclofenac Sodium delayed release 50mg give 50mg by mouth every 24 hours as needed for inflammation Review of Resident #1's May 2024 Medication Administration Record revealed pain was assessed on 05/06/2024 during day shift with a pain level of 7. Further review revealed pain was assessed on 05/09/2024 during day shift with a pain level of 7. Further review revealed Resident #1 was not administered prn (when necessary) Diclofenac Sodium tablet delayed release 50mg give 50mg by mouth every 12 hours as needed for pain as ordered on 05/06/2024 during day shift and on 05/09/2024 during day shift. During an interview on 06/04/2024 at 2:10 p.m. S3 LPN (licensed practical nurse) reported did not know why Resident #1 did not receive prn Diclofenac Sodium tablet delayed release 50mg on May 6th (pain score of 7) and May 9th (pain score of 7) during the day shifts she worked. During an interview on 06/04/2024 at 3:30 p.m. S1 DON acknowledged Resident #1 did not receive prn Diclofenac Sodium tablet delayed release 50mg pain medication on May 6th and May 9th for a pain level of 7 after reviewing the May MAR.

Based on interviews and record reviews, the facility failed to treat each resident with respect, dignity and care in a manner that promotes maintenance of his or her quality of life, recognizing each resident's individuality for 1 resident (#102) of 3 residents (#62, #102, #106) residents investigated for dignity. Findings: Review of Resident #102's Quarterly MDS (Minimum Data Sets) assessment dated [DATE] revealed a BIMS (Brief Interview of Mental Status) score of 13 which indicated the resident was cognitively intact. Review of Resident #102's clinical record revealed an admitted [DATE] with the following diagnoses in part: aphasia, hemiplegia affecting the left side, muscle wasting and atrophy, cognitive communication deficit. Review of Occupational Therapy Notes dated 06/30/2023 revealed Resident #102 was feeling mistreated at the facility due to CNAs (Certified Nursing Assistant) not answering the call light. During an interview on 08/07/2023 at 1:49 a.m. Resident #102 reported every time S6CNA changes her brief, his hands hurt her bottom because he pushes her over in the bed forcefully. Resident #102 reported S6CNA was rough and tried to tell her when she needed to go to bed. Resident #102 indicated S7Therapy and S1Administrator were aware of S6CNA's rough treatment. During an interview on 08/07/2023 at 4:25 p.m. S6CNA confirmed he changed briefs of female residents without another female in the room. S6CNA reported he will ask the female resident if it is okay for him to change their brief. S6CNA report if the residents are okay with him changing their brief, he will change the brief. During an interview on 08/08/2023 at 3:40 p.m. S7Therapy reported on 06/30/2023 Resident #102 was crying and upset when in therapy and reported S6CNA was rough with her when changing her brief and when she asked him to stop being rough, he ignored her and kept going. S7Therapy reported they sent S8Therapy to get S1Administrator and they both reported what Resident #102 told them regarding S6CNA to S1Administrator. S7Therapy further reported Resident #102 was completely aware and in a clear state of mind when she reported S6CNA was being rough with her. S7Therapy indicated they were under the impression S1Administrator handled the situation. During an interview on 08/08/2023 at 4:00 p.m. S1Administrator confirmed having a meeting on 06/30/2023 with therapy about the care Resident #102 received from S6CNA. During an interview on 08/09/2023 at 7:45 a.m. S9PTA (Physical Therapy Assistant) recalled a day around 06/30/2023 when Resident #102 was in the therapy room and was visibly upset, tearful and frustrated with the care S6CNA was giving her. S9PTA reported remembering S1Administrator being aware of the situation and that S1Administrator was going to handle it but nothing was done. During an interview on 08/09/2023 at 8:30 a.m. Resident #102 reported when she sees S6CNA, he makes her a little nervous. Resident #102 reported preferring a female CNA when her brief gets changed. During an interview on 08/09/23 at 10:06 a.m. S8Therapy reported on 6/30/23 Resident #102 was visibly upset and crying. S8Therapy reported leaving to get S1Administrator and S1Administrator came to the gym with Resident #102. During a phone interview on 08/09/2023 at 2:26 p.m. Resident #102's RP (Responsible Party) reported S6CNA was the only staff they noticed Resident #102 did not care for. RP reported Resident #102 would roll her eyes when S6CNA entered the room. During an interview on 08/09/2023 at 3:15 p.m. S10COTA (Certified Occupational Therapist Assistant) reported on 6/30/23 S7Therapy was working with Resident #102 and S10COTA recalled Resident #102 felt like she had been mistreated by a male CNA. S10COTA reported knowing about S6CNA being rough with her during a transfer or rolling in bed. S10COTA reported S1Administrator had knowledge S6CNA had been rough with Resident #102 while transferring or rolling Resident #102 in the bed. S10COTA reported Resident #102 seemed to have a clear mind on 6/30/23. During an interview on 08/09/2023 at 4:10 p.m. S11ADON (Assistant Director of Nursing) reported she was told S6CNA needed to be retrained in patient care, transfers, and customer service. S11ADON reported did not have knowledge of Resident #102 being handled roughly and no one reported Resident #102 being handled roughly to S11ADON. S11ADON reported she just knew what areas S6CNA needed to be retrained. S11ADON could not recall who told her to retrain S6CNA. During an interview on 08/09/2023 at 4:25 p.m. S2DON (Director of Nursing) reported the facility did not offer another CNA to care for Resident #102 and S6CNA continued to work with Resident #102 after 06/30/2023. The facility did not ask or let the residents know they may have a male CNA changing their brief. S2DON reported no knowledge of S6CNA handling Resident #102 roughly when changing her brief.

Based on record reviews and interview, the facility failed to ensure there was a sufficient number of skilled licensed nurses, nurse aides, and other nursing personnel to provide care and respond to each Resident's basic needs. The facility failed to provide the minimum required staffing hours for 8 of 25 weekend days reviewed. Findings: Review on the facility's PBJ (Payroll Based Journal) Staffing Data Report for FY (Fiscal Year) Quarter 2 2023 (January 1 to March 31) revealed the submitted weekend staffing data was excessively low. Review of the facility's staffing pattern reports for weekends from FY Quarter 2 2023 revealed the facility provided 238 hours on 01/08/2023 and were required to provide 268 hours. Further review revealed the facility provided 267 hours on 01/14/2023 and were required to provide 277 hours, provided 249 hours on 01/22/2023 and were required to provide 280 hours, provided 260 hours on 01/29/2023 and were required to provide 261 hours, provided 247 hours on 02/19/2023 and were required to provide 260 hours, provided 214 hours on 02/26/2023 and were required to provide 265 hours, provided 226 hours on 03/4/2023 and were required to provide 277 hours, and provided 230 hours on 03/19/2023 and were required to provide 275 hours. During an interview on 08/09/2023 at 4:20 p.m. S1 Administrator reviewed the facility's staffing pattern reports for weekends from FY Quarter 2 2023, and acknowledged the facility did not provide the minimum hours required on 01/08/2023, 01/14/2023, 01/22/2023, 01/29/2023, 02/19/2023, 02/26/2023, 03/4/2023, 03/19/2023, and should have.

Based record reviews and interviews, the facility failed to ensure nursing staff demonstrated competencies to provide care, assure residents' safety, and maintain the residents' highest practicable physical well-being. The facility failed to ensure nursing staff assessed a resident for injury in a timely manner and before the resident was moved following a witnessed fall for 1 (#16) of 3 (#2, #16, #77) residents reviewed for falls. Findings: Review of Resident #16's record revealed an admitted [DATE] and diagnoses including Paraplegia unspecified, unspecified muscle weakness, lack of coordination, and a history of falling. Review of Resident #16's Minimum Data Set Assessment with an Assessment Reference Date of 05/14/2023 revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating the resident was cognitively intact. Review of the facility's incident logs revealed Resident #16 had a witnessed fall in his room on 07/09/2023 at 6:58 a.m. Further review of the incident report for the associated fall revealed Resident #16 fell while S4 CNA (Certified Nursing Assistant) was providing care in the resident's room. The report was written by S3 LPN (Licensed Practical Nurse). The report included in part: Immediate actions taken-resident was helped from floor back to bed. Writer assessed. S3 LPN's report narrative further indicated she saw no visible signs of injury, but the resident did complain of bilateral knee pain. The resident was already on scheduled pain medication which he had received that day at 6:00 a.m. The 24 hour follow-up done on 07/10/2023 revealed the resident had no visible signs of injury, but continued to complain of bilateral knee pain, and X-ray of bilateral knees was obtained. Review of Resident #16's X-ray report dated 07/10/2023 revealed Resident #16 had a closed fracture of the lateral portion of the right tibial plateau, a closed fracture of the right fibula, and a closed fracture of the right proximal tibia. Review of S4 CNA's written statement dated 07/10/2023 revealed she was providing care for Resident #16 when he fell from the bed. The statement indicated S4 CNA asked S3 LPN if she could help her and she told me she wasn't going down the hall because I was down there. Review of S3 LPN's personnel records revealed a Confidential Employee Corrective Action Form dated 02/25/2022 for Unsatisfactory Performance. Further review revealed Conduct that was observed and/or substantiated included not assessing a resident that had fallen & was sent out to the hospital on 02/20/2022. Suggestions for improvement or immediate action that needed to take place included any resident that falls must be assessed by the charge nurse in a timely manner. The form was signed by S3 LPN and S2 DON (Director of Nursing) on 03/01/2022, and signed by S1 Administrator on 03/03/2022. Further review of S3 LPN's personnel records revealed a second Confidential Employee Corrective Action Form dated 07/11/2023 for unsatisfactory Performance. Type of action warranted=Final. Conduct that was observed and/or substantiated: Resident suffered a fall on 07/09/2023 that was assigned to employee. Employee failed to assess the resident promptly after she was notified by the CNA of the incident. Employee (nurse) gave instructions to another CNA to assist getting resident up off the floor despite her not assessing the resident for injuries. The resident suffered major injury from this fall. Suggestions for improvement or immediate action that needs to take place: Employee (nurse) will be immediately terminated due to lack of urgency to care for a post fall injury that the resident sustained. The form was signed by S3 LPN, S2 DON, and S1 Administrator of 07/11/2023. During an interview on 08/08/2023 at 10:45 a.m. S2 DON confirmed S3 LPN was terminated 07/11/2023 as a result of not assessing Resident #16 in a timely manner after his fall. S2 DON confirmed S4 CNA gave a statement that the nurse did not come assess the resident prior to him being assisted back in bed, but instead instructed another CNA to help get him in bed. During an interview on 08/08/2023 at 1:45 p.m. S5 CNA reported S4 CNA came to the nursing station the morning of 07/09/2023 to get S3 LPN to assess Resident #16 and to get help to get him up, and S3 LPN said she wasn't going down there while the CNA was down there. S5 CNA further reported S3 LPN told her to go down and help S4 CNA get the resident back in bed. S5 CNA confirmed she and S4 CNA assisted resident #16 back to bed before the nurse assessed him for injuries. S5 CNA further reported she asked S3 LPN again to go assess resident #16 after they got him back in bed, and she said no she wasn't going. During an interview on 08/08/2023 at 3:18 p.m. Resident #16 reported S4 CNA was changing his linens and his diaper on 07/09/2023 when he rolled of the bed and landed on his knees. Resident #16 indicated he was able to participate in his care, and S4 CNA was the only staff member in the room when he fell from the bed. Resident #16 indicated S4 CNA left the room to get S3 LPN to come assesses him, and returned with another CNA who helped put him back in the bed. Resident #16 reported he could not remember when the nurse came to assess him but he knew it was not before the CNAs put him back in bed. During a telephone interview on 08/09/2023 at 6:55 a.m. S4 CNA confirmed she was the CNA providing care for Resident #16 on 07/09/2023 when he fell out of the bed. S4 CNA indicated she assisted him to sit and then went and got the nurse to tell her Resident #16 was on the floor and she needed to come assess him so they could get him back in bed. S4 CNA reported the nurse, S3 LPN, said she was not coming down there while I was down there and told S5 CNA to go help me put him back to bed, which we are not supposed to do until after a nurse assesses. S4 CNA reported she did not know when S3 LPN got up and went to check on him, but knew it was not right away because she got up and started passing medications to other residents. During an interview on 08/08/2023 at 4:35 p.m. S1 Administrator and S2 DON reported video footage had been reviewed and it was approximately 1.5 hours after S3 LPN was notified of Resident #16's fall before she went in his room to assess him. S1 Administrator and S2 DON indicated S3 LPN was on video passing medications to other residents. S1 Administrator and S2 DON confirmed S3 LPN had been previously written up for failing to assess a resident in a timely manner after a fall in February of 2022. S1 Administrator and S2 DON indicated S3 LPN was terminated when it was determined she had not assessed Resident #16 when the CNAs notified her of the fall, and before the CNAs moved the resident.

Based on record review and interview the provider failed to ensure a Medical Director or designee attended a quarterly QAA (Quality Assessment and Assurance) Committee meeting for the second quarter of the year 2023. Findings: Record review of the provider's quarterly QAA Committee meetings failed to reveal a signature of the Medical Director or designee for the second quarter of the year 2023. During an interview on 08/09/2023 at 4:50 p.m., S2 Director of Nursing reviewed the quarterly QAA Committee meetings that were held on the months of April, May, and June of 2023. S2 Director of Nursing verified a signature was not completed by the Medical Director or designee for the second quarter of 2023 QAA Committee meetings.

Based record reviews and interview the facility failed to ensure there was a sufficient number of skilled licensed nurses, nurse aides, and other nursing personnel to provide care and respond to each Resident's basic needs. The facility failed to provide the minimum required staffing hours for 4 of 26 weekend days reviewed. Findings: Review of the facility's PBJ (Payroll Based Journal) Staffing Data Report for FY (Fiscal Year) Quarter 1 2023 (October 1-December 31) revealed the submitted weekend staffing data was excessively low. Review of the facility's staffing pattern reports for weekends from FY Quarter 1 2023 revealed the facility provided 245.85 hours on 10/30/2022 and were required to provide 282.0 hours. Further review revealed the facility provided 262.34 hours on 12/3/2022 and were required to provide 272.6 hours, and the facility provided 265.48 hours on 12/10/2022 and were required to provide 282.0 hours and the facility provided 274.6 hours on 12/11/2022 and were required to provide 282.0 hours. During an interview on 6/21/2023 at 2:44 p.m. S1 Director of Nursing and S2 Regional [NAME] President reviewed the facility's staffing pattern reports for weekends from FY Quarter 1 2023 and acknowledged the facility did not provide the minimum hours required on 10/30/2022, 12/03/2022, 12/10/2022 and 12/11/2022 and should have.

Based on interviews and record reviews, the facility failed to ensure residents who are unable to carry out activities of daily living receive the necessary services to maintain grooming and personal hygiene by failing to ensure residents received a bath or shower for 4 (#1, #51, #84, #275) of 9 (#1, #25, #48, #51, #66, #84, #103, #106, #275) residents reviewed for activities of daily living. Findings: Resident #1 Review of Resident #1's Medical Records revealed admitted [DATE] with the following diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's Care Plan revealed: - Always incontinent of bowel - assist me to bathroom or commode as needed - Require staff assistance for all ADLs - Risk for pressure ulcers r/t impaired mobility - daily observation of skin with routine care; need a full skin evaluation weekly by a nurse Review of Resident #1's MDS (Minimum Data Set) dated 3/24/22: - Section C: Cognitive Pattern - BIMS (Brief Interview for Mental Status) score of 11 indicating mildly impaired cognition - Section G: Functional Status - bed mobility limited assistance/1 person; transfer, personal hygiene extensive/2 person; dressing, bathing total dependence/1 person; eating supervision/1 person; toilet use extensive/1 person. - Section H: Bladder and Bowel - always incontinent of both - Section M: Skin Conditions - resident has (1) unhealed stage 4 pressure ulcer Review of Resident #1's June and July 2022 Bath Day Roster failed to reveal a bath/shower was provided daily on the following days: June: 1, 3, 4, 5, 7, 8, 10, 11, 12, 13, 15, 16, 17, 20, 21, 23, 25, 26, 27, and 29th July: 1-5, 8, 9, 21-26th During an interview on 7/27/22 at 10:45 AM S1 DON (Director of Nursing) confirmed Resident #1 did not have documentation of receiving a bath or shower daily for the months of June and July and should have. Resident #275 Record review of Resident #275's medical record revealed Resident #275 was admitted to the facility on [DATE] with an admitting diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #275's MDS dated [DATE] revealed the following, in part: - Section G, bathing self-performance was marked 3, physical help in part of bathing activity, one person physical assist. During a telephone interview on 7/27/22 at 7:10 AM, Resident #275's resident representative (daughter) indicated Resident #275 did not receive bathing services during the resident's stay at the facility. During an interview on 7/27/22 at 10:10 AM, S1 DON verified there was not documentation of Resident # 275 getting bathed during her eight day stay at the facility. Resident #51 Review of Resident #51's medical record revealed Resident #51 was admitted to facility on 1/18/22 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #51's quarterly MDS (Minimum Data Set) dated 5/30/22 revealed in part: -Section C Cognitive patterns: BIMS (Brief Interview for Mental Status) score of 14 indicating cognition intact. -Section G Functional status: Requires extensive assist of one person with bathing, personal hygiene, and dressing. Review of Resident #51's current care plan revealed problem of self care deficit and incontinence care with approaches including but not limited to assist as needed in aspects of self care that are problematic to resident. Review of Resident #51's Bath Day Roster for 6/1/22 thru 7/27/22 revealed Resident #51 received a complete bed bath on 8 of the 30 days in the month of June, received zero showers during the month of June, and received zero bed baths or showers during the month of July. During an interview on 7/25/22 at 8:56 AM Resident #51 reported she was not receiving baths. During an interview on 7/27/22 at 7:25 AM S3 CNA (Certified Nursing Assistant) reported residents should receive a bath every day except Sunday. S3 CNA further reported Sundays were not scheduled bath days. During an interview on 7/27/22 at 10:20 AM Resident #51 reported she was unable to recall when she last received a shower. During an interview on 7/27/22 at 10:40 AM S4 CNA reported residents can have a shower or bath whenever they need it but the facility does have a bathing schedule. S4 CNA further reported CNAs document each resident's bath or shower in the kiosk bath day roster. During an interview on 7/27/22 at 10:45 AM S1 DON (Director of Nursing) confirmed Resident #51 did not have documentation of receiving a bath or shower for the month of July and should have. Resident #84 Review of Resident #84's medical record revealed Resident #84 was admitted to facility on 1/3/22 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #84's quarterly MDS (Minimum Data Set) dated 6/17/22 revealed in part: -Section C Cognitive pattern: BIMS (Brief Inteview for Mental Status) score of 12 indicating mildly impaired cognition. -Section G Functional status- Requires extensive assist of one person with bathing and dressing. Requires limited assist of one person with personal hygiene. Review of Resident #84's current care plan revealed problem of assistance with all ADLs (Activities of Daily Living) with approaches including but not limited to give verbal cues to help prompt, allow rest breaks between tasks, break tasks up into smaller steps. Review of Resident #84's Bath Day Roster for 6/1/22 thru 7/27/22 revealed Resident #84 received a complete bed bath or a shower on 6 days out of the 30 days in the month of June and received zero bed baths or showers during the month of July. During an interview on 07/25/22 at 9:13 AM Resident #84 reported she had not received a bath very often and further reported when she received a bath, the staff simply wiped her off. During an interview on 7/27/22 at 7:25 AM S3 CNA (Certified Nursing Assistant) reported residents should receive a bath every day except Sunday. S3 CNA further reported Sundays were not scheduled bath days. During an interview on 7/27/22 at 10:15 AM Resident #84 reported she had received one shower since she had been at the facility. Resident #84 further reported she received the one shower last Friday when her daughters came to visit and assisted her with showering. Resident #84 reported she would like to get a shower, but only receives a bed bath sometimes. During an interview on 7/27/22 at 10:40 AM S4 CNA reported residents can have a shower or bath whenever they need it but the facility does have a bathing schedule. S4 CNA further reported CNAs document each resident's bath or shower in the kiosk bath day roster. During an interview on 7/27/22 at 10:45 AM S1 DON (Director of Nursing) confirmed Resident #84 did not have documentation of receiving a bath or shower for the month of July and should have.

Based on record reviews, the facility failed to ensure that 1 (#1) resident out of 40 sampled residents reviewed who experienced a significant change in status was comprehensively assessed using the CMS (Center for Medicare & Medicaid Services)-specified Resident Assessment Instrument. Resident #1 was hospitalized for a femur fracture following a fall. Findings: Review of Resident #1's MDS (Minimum Data Set) Assessments failed to reveal a significant change assessment for a fall resulting in a femur fracture occurring on 7/10/22. Review of Facility's Incident Log revealed a fall on 7/10/22 in resident room resulting in a fracture. Resident #1 was sent to the emergency room . Review of Resident #1's Care Plan revealed: At risk for falls - 7/10/22 - incontinent care being provided; resident turned to her side and turned too far causing lower body to slide off bed and resulted in fall to floor; transferred to hospital admitted with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] During an interview on 7/27/22 at 11:50am S2 MDS LPN (licensed practical nurse) confirmed a MDS Assessment was not completed for Resident #1 after a significant change occurred following a fall with fracture and should have been.

Based on record review and interview, the facility failed to ensure assessments were completed accurately and reflected the residents status for two (Resident #48 and Resident #125) out of a total of 40 sampled residents. Findings: Resident #48 Resident # 48 was admitted to the facility on [DATE]. Record review of Resident #48's Quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 02/04/2022 revealed the following, in part: - Section G- Functional Status: Resident #48 required setup help with bed mobility, transfers, toileting, and eating. Record review of Resident #48's Quarterly 5day MDS with an ARD of 05/06/2022 revealed the following, in part: - Section G showed the resident required one person assist with bed mobility, transfers, toileting, and eating. During an interview on 07/27/2022 at 3:50 PM, S2MDS nurse indicated Resident #48 did not have a decline of ADLs (activities of daily living) from 02/04/2022 MDS to 05/06/2022 MDS section G functional status. S2MDS nurse further indicated the CNAs (Certified Nursing Assistants) were not charting appropriately and that caused the MDS from 02/04/2022 to be inaccurate and the resident's functional status should have been the same as the functional status that was on the MDS dated [DATE]. Resident #125 Record review of Resident #125's Progress Note dated 06/07/2022 revealed, in part: - Resident #125 had a care plan conference with the interdisciplinary team and Resident #125's responsible party. The conference confirmed Resident #125 planned to discharge home with family. Record review of Resident #125's telephone order dated 06/15/2022 revealed, in part: - Resident #125 had a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #125's Discharge MDS with ARD of 06/17/2022 revealed, in part: - Resident #125 had a planned discharge; return was not anticipated; and discharged to an acute hospital. Record review of Resident #125's progress noted dated 06/17/2022 revealed, in part: - Resident #125 discharged home in stable condition with all medications and personal belongings. During an interview on 07/27/2022 at 08:55 AM, S1DON (Director of Nursing) acknowledged Resident #125 discharged home on 06/17/2022 with her family. S1DON confirmed the Discharge MDS with an ARD date of 06/17/2022 indicated Resident #125 discharged to an acute hospital was inaccurate. During an interview on 07/27/2022 at 11:20 AM, S5LPN/MDS (Licensed Practical Nurse) acknowledged she completed the discharge status on Resident#125's Discharge MDS with an ARD date of 06/17/2022 inaccurately. S5 LPN/MDS confirmed the discharge status should have indicated Resident #125 discharged to the community (private home).

Based on record review and interview the facility failed to provide documentation of a CNA (Certified Nursing Assistant) registry check upon hire for one (S4CNA) of five (S4CNA, S6CNA, S7CNA, S8CNA, S9CNA) CNA personnel files reviewed. Findings: Record review of S4CNA's personnel file revealed a hire date of 10/05/2017. S4CNA's registry check was dated 11/04/2020. During an interview on 07/27/2022 at 5:40 PM, S10Administrator indicated he could not provide documentation that a CNA registry check was completed upon hire for S4CNA.

Based on record review, observation, and interviews the facility failed to ensure necessary services were provided for 2 (#1, #5) out of 5 (#1, #2, #3, #4, #5) sampled residents in accordance with professional standards of practice and their comprehensive care plan. The facility failed to ensure staff performed proper transfer assistance with a mechanical lift for residents reviewed for activities of daily living. Findings: Review of Facility's policy: Using a Mechanical Lifting Machine revealed the purpose of this procedure is to establish the general principles of safe lifting using a mechanical lifting device. General Guidelines: 1. At least two (2) people are needed to safely move a resident with a mechanical lift. Resident #1 Review of Resident #1's Care Plan on admit revealed due to self-care deficit with approaches: assist as needed in aspects of self-care that are problematic to resident, interdisciplinary team to develop and incorporate comprehensive plan of care to maintain residents continued safety and well-being. Review of Resident #1's Admit day 5 MDS (Minimum Data Set) dated 2/15/22 revealed Resident #1 required extensive assistance with two person physical assist. During an interview on 4/5/2022 at 10:00 AM S6 CNA (Certified Nurse Assistant) reported Resident #1 required total assistance from the staff and a mechanical lift for transfers. S6 CNA reported during the week of March 14, 2022 as she was performing a transfer with the mechanical lift resident #1's family member was present and was interfering with the transfer of Resident #1. S6 CNA reported she then walked out of the room to get assistance from the nurse leaving Resident #1 sitting in the in the mechanical lift. S6 CNA reported S7 LPN (Licensed Practical Nurse) and S8 Nurse Practitioner assistant entered Resident #1's room and assisted the resident to bed. S6 CNA confirmed there should have been 2 staff members present to transfer Resident #1 in the mechanical lift and Resident #1 should not have been left unattended in mechanical lift. Resident #5 Review of Resident #5's Care Plan revealed need for assistance with ADL's (activities of daily living) exhibited by extensive assistance with transfers with approaches for staff to provide assistance with transfers as needed, require extensive assist of 2 persons and the mechanical lift for transfers. Review of Resident #5's Quarterly MDS dated [DATE] revealed Resident #5 required extensive assistance with two person physical assist with transfers. Observation on 4/5/2022 at 9:30 AM revealed S4 CNA exit Resident #5's room with mechanical lift. During an interview on 4/5/2022 at 9:30 AM S4 CNA reported she just transferred Resident #5 from the bed to the chair using the mechanical lift by herself and there should be 2 staff present to transfer residents in the mechanical lift. During an interview on 4/5/2022 at 3:00 PM S1 Administrator reviewed the facility's mechanical lift policy and confirmed there should be 2 people present when transferring a resident using the mechanical lift.

Based on record reviews, interviews and observations, facility failed to ensure a resident received treatment and care in accordance with professional standards of practice for 1 (#1) of 8 (#1, #2, #3, #4, #5, #6, #7, #8) residents reviewed for quality of care out of 10 total sampled residents. The facility failed to ensure the resident's (#1) blood glucose was monitored while receiving insulin. An actual harm occurred for resident #1 on 03/29/2020 at 2:50 a.m. when the resident was found unresponsive to tactile and verbal stimuli with a blood glucose level of 36 mg/dl. The resident, who had a history of [REDACTED]. However, there was no evidence of routine monitoring of the resident's blood glucose levels on 03/26/2020 and 03/28/2020. After being found unresponsive on 03/29/2020 at 2:50 a.m., 911 was called and the resident was transferred to a local hospital where she received 250 milliliters of D10 ([MEDICATION NAME] 10%) and was diagnosed with [REDACTED]. Findings: A review of the facility's Nursing Care of the Resident with Diabetes Mellitus Policy revealed: Glucose Monitoring: (1.) The management of individuals with diabetes mellitus should follow relevant protocols and guidelines (3.) Residents whose blood sugar is poorly controlled or those taking insulin may require more frequent monitoring, depending on the situation. Documentation: (14.) Blood sugar results and other pertinent laboratory studies A review of Resident #1's medical record revealed an admitted [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's March physician's orders [REDACTED]. Review of Resident #1's Nurses Notes revealed the following entries: 03/29/2020 3:39am - 0250 writer called to resident room by aide. Aide stated that resident did not awake during pericare and that was unusual. Resident was observed lying supine with eyes closed. VS (vital signs) as follows 195/77, P82, R24, unable to obtain temp (temperature). One touch was 36. 911 contacted at 0307. One touch was 26 when checked by fire dept. (department). Resident departed from facility via (by way of) 911 stretcher at 0325 and transported to hospital Review of Resident #1's hospital records dated 03/29/2020 revealed the following: Nurses Notes: - 3:56am - presenting complaint: EMS (emergency medical service) states: Patient was found by nursing home staff unresponsive, staff attempted sternal rub and patient remained unresponsive. EMS checked one touch was 26, gave 250ml (milliliter) of D10 ([MEDICATION NAME] 10%) - 8:03am - D10 at 60ml/hr (hour), OT (one touch) Q (every) 30 minutes . Physician ER Documentation: - 4:04am - The patient presents with decreased responsiveness. Found unresponsive at ECF (extended care facility)_blood sugar was 26 on arrival by EMS and they bolused D10 - Exam: Neuro - Orientation: Not oriented to person, place, time. - 4:48am - Daughter states that yesterday AM she checked in on her mother and she was out of it and not really responding. Discharge Summary - admitted 3.29.2020. discharged 4.1.2020. - Hospital Course: The patient is a [AGE] year old insulin dependent diabetes discharged to skilled nursing home with acute mental status change and severe [DIAGNOSES REDACTED] with glucose level at 26 .After admission, the patient required D10 drip until discharge the patient's mental status change mostly secondary to metabolic [MEDICAL CONDITION] secondary to low sugar and urinary tract infection . Review of the resident's MAR indicated [REDACTED] Record review revealed there were no orders for routine monitoring of the resident's blood glucose levels. Further record review revealed no evidence the resident's blood glucose levels were monitored on 03/26/2020 or 03/28/2020. However, the resident's blood glucose levels were obtained on 03/25/2020 at 2:25 p.m. with a result of 218 mg/dl and on 3/27/2020 at 6:00 a.m. (118 mg.dl) at 11:30 am (131 mg/dl) and at 2:00 p.m. (127 mg/dl). On 03/29/2020, the resident's blood glucose level was not checked until the resident was found unresponsive at 2:50 a.m. Review of the resident's Comprehensive Metabolic Panel (CMP) lab results done on 03/27/2020 at 4:39 a.m., revealed the resident's blood glucose level was 32 (normal range 74-109mg/ml (milligrams/milliliter). Review of Resident #1's Interdisciplinary Team Note revealed the following entry dated: 03/27/2020 Late entry reflecting 2:00pm - .received call from lab r/t (related to) the following critical lab results from lab drawn at 4:30am: Glucose=32 Writer rechecked residents FSBS (Finger stick blood sugar) and it was WNL (within normal limits) at 127 at 2:05pm .Will notify NP (Nurse Practitioner). Observation on 6/5/2020 at 9:50 a.m. revealed Resident #2 (diabetic) in his room sitting in his wheelchair, dressed with long pants on, sock and shoe on left foot, right BKA with leg immobilizer in place, clean in appearance, clean and short fingernails, baseball cap on, face mask in place, call light within reach. Further observation revealed Resident #2 holding a see through plastic bag with a sandwich, mayonnaise packet, sugar-free shortbread cookies, and apple juice. Resident #2 was oriented. During an interview on 06/08/2020 at 11:50 am, S16 NP verified there is no routine checking of blood glucose listed on physician standing orders. NP further reported that if the Resident #1 did not have orders to check blood sugar, the nurse should have questioned it and notified her to get orders. NP verified she was not notified of the glucose critical lab value of 32 on 03/27/2020. During a telephone interview on 06/08/2020 at 12:10 pm a contracted agency LPN confirmed she was taking care of Resident #1 on 03/28/2020; she worked 11p-7a. The LPN reported as she was coming in that evening she walked down the hallway and looked in Resident #1's room. The LPN stated Resident #1 looked like she was sleeping and could hear her snoring. She reported that during the shift the aide called her to Resident #1's room because she wasn't waking up during incontinence check. The LPN confirmed Resident #1 was not responding so she took vital signs and remembered Resident #1 was a diabetic so she checked her blood sugar and it was 36. The contracted agency LPN confirmed she called 911. During an interview on 06/09/2020 at 2:45 pm S18 LPN reported during her shift on 03/27/2020 the contracted agency LPN called her to Resident #1's room. LPN (which one) reported when she entered the room, Resident #1 looked like she was sleeping but would not respond to verbal/tactile stimuli. LPN indicated they checked her vital signs and checked her blood sugar which was 36; 911 was called. During an interview on 06/09/2020 at 3:15 pm S4 ADON verified there was no evidence the resident's blood glucose levels were monitored on 03/26/2020 or 03/28/2020, and that on 03/29/2020, the resident's blood glucose level was not checked until the resident was found unresponsive at 2:50 a.m. S4ADON further indicated if there were no orders for blood glucose checks, the nurse may not complete them. S4 ADON stated, If it was me I would do them. Observation on 6/10/2020 at 10:20 am revealed Resident #5 (diabetic) lying in bed on air loss mattress turned to right side. Resident with no odors noted, well-groomed and dressed. Feeding pump noted in room; resident receives continuous feeding in the evening and night. Resident is non-verbal/aphasic. During an interview on 06/10/2020 at 1:45 pm S5 ADON verified blood sugar checks were not done routinely on Resident #1 on 3/26 and 3/28 and should have been. S5 ADON reported that any resident who is receiving insulin should get routine blood sugar checks. S5 ADON reported if Resident #1 didn't have orders for blood sugar monitoring the NP or MD should have been contacted. Observation on 6/10/2020 at 3:40 pm revealed Resident #6 (diabetic) sitting in wheelchair in room, dressed, well-groomed, with clean trimmed nails and no odors. Resident #6 has a brace on right lower leg with feet elevated and protected. Resident #6 is oriented and pleasant. During an interview on 06/11/2020 at 11:24 am S4 ADON verified she received critical glucose lab value of 32 for Resident #1 on 03/27/2020 from the lab and charted she would notify NP. S4 ADON reported she normally would notify the NP but stated, I don't know what happened that day and it should have been reported. S4 ADON confirmed there is no further documentation to show where the NP was notified of blood glucose was 32.