Every finding on record at Stonehenge of Cedar City

Based on interview, observation and record review, the facility did not ensure that 1 of 2 sample residents were free of accident hazards as is possible; received adequate supervision and assistance devices to prevent accidents. Specifically, one resident was burned after heat source was placed on his abdomen. This will be cited at a harm level but at past non-compliance. Resident identifier: 1. It was determined the provider's non-compliance with the requirements of participation had caused harm. The harm was related to the State Operations Manual, Appendix PP, [S483.25(d) Accidents. The facility must ensure that - S483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and S483.25(d)(2) Each resident receives adequate supervision and assistance devices to prevent accidents, F689, at a scope and severity of G.] However, based on the facility's corrective actions and a review of its current compliance in this regulatory area, the deficiency was determined to be past noncompliance. The facility developed and implemented a corrective action plan before the abbreviated survey start date. The facility's corrective action plan, which was developed and implemented by 5/12/26 included the following measures: The facility implemented the following: ADON [Assistant Director of Nursing] discovered burn on resident's stomach at 10:25 am [AM] on 5/12/26. ADON notified administrator of burn at 10:35 am [AM] 5/12/26. Incident report submitted to state 11:35 am [AM] 5/12/26. MD [Medical Doctor] notified at 10:30 am [AM] on 5/12/26. Incident submitted to the APS [Adult Protective Services] on 6:25 pm [PM] on 5/12/26. Resident was assessed by wound nurse and MD was notified. Treatment was started 5/12/26. Daily skin checks have been implemented. 5/12/26. Educated staff on 5/12/26 on the facility protocol that hot packs can only be managed by the therapy department and under their direct supervision due to potential for burns. 5/12/26 QA [Quality Assurance] committee reviewed incident during an Ad Hoc [for this] Meeting on 5/13/26 and a POC [Plan of Correction] was implemented. Psychosocial Assessment was completed on 5/15/26 to assess for any residual distress or anguish. Resident Care Plan was reviewed and updated on 5/12/26. The alleged perpetrator was terminated with last shift worked the night of 5/11/26 when the incident occurred. Signage has been placed on the microwave in the staff breakroom as a reminder that no hot packs are allowed. Ongoing education will be provided to staff regarding the facility protocol regarding use of hot packs. On 5/19/26, the survey team verified that all these interventions were completed before the survey start date. Findings include: Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included paraplegia, osteomyelitis, and neuromuscular dysfunction of bladder.Resident 1's medical record was reviewed on 5/19/26. On 5/12/26 at 11:34 AM, resident 1 was interviewed and stated that he had a burn on his abdomen. Resident 1 stated the burn was about 4 inches below where he can feel. Resident 1's burn was observed on his abdomen and it was pink with healing blisters.Resident 1 stated he was having muscle spasms and was struggling to breathe in his abdominal area and asked for a heating pad. Resident 1 stated the staff member wrapped whatever it was in his shirt and put it on his abdomen. Resident 1 stated he did not realize it was so hot and had burned his skin till the next day. Resident 1 stated it took the pain away and he was able to breathe better. Resident 1 stated that was the first time he had been provided a heat pack. On 5/12/26 at 11:47 AM, a nurses progress note indicated the following: While doing care-resident alerted nurse to check skin on right lower abdomen. There is a 9x5cm [centimeter] burn with blisters that are full and 1 that has popped. Resident stated that he asked an aide to get a heat pack. The aide brought him one. I had asked what kind. He did not know-he described it as something in plastic and then wrapped in one of the shirts. He did not know how long it was on. He was tired, had been sleeping and woke up in pain. Spoke to [Name of Nurse Practitioner] for treatment and initiated.On 5/12/26 at 5:15 PM, a nurses progress note indicated the following: Around 530pm (PM)-resident came to my office and showed me his abdomen. The blisters are bigger and a few other blisters popped. Applied a dressing to protect the area. I needed to shave some of the abdominal hair to make the dressing stick. [Name of Nurse Practitioner] approved. Will continue to monitor.On 5/12/26, the facility completed an investigation into the incident that occurred on 5/11/26 with resident 1. The investigation report indicated that Resident stated that he asked the night CNA [Certified Nursing Assistant] on the evening of 5/11/26 to get a heating pack because his stomach was hurting. The CNA returned later with a heat pack and put it on his stomach. The resident could not state what the heat pack was but did state it was in a plastic bag. The resident does not have sensation below his chest and was not able to feel the heat on his skin and could not detect a burn. The resident said the heat did help with his stomach discomfort. The next morning, on 5/12/26, the ADON was in the resident's room and [resident 1] asked her to look at his stomach. The ADON discovered redness which was noted to blister that afternoon on the right side of his abdomen. The ADON asked where it came from and [resident 1] said it was from a heat pack that the night CNA bought (sic) in. The ADON and CNA coordinator attempted to contact CNA multiple times by phone on 5/12/26 but had no response. The CNA . has since been terminated. [The ADON] entered the resident's room on the morning of 5/12/26 at 10:25 AM. The resident asked her to look at his abdomen which revealed a pinkened area measuring 9 cm x 5 cm with blisters on the right side of his abdomen. Upon questioning, the resident revealed that he had requested a hot pack the night before from a CNA due to abdominal discomfort. He reported he didn't know what the heat pack was only that it was in a plastic bag and also wrapped in his shirt. [The ADON] reported the incident to the Administrator and MD immediately. Treatment was initiated. The resident denied any pain or discomfort during the interaction. [The ADON] denied any knowledge of staff use of hot packs. She stated she that (sic) therapy manages the hydrocollator packs and that they are secured when the therapy department leaves for the day. [The ADON] attempted to contact alleged perpetrator multiple times on 5/12/26 with no response. [Name of Certified Occupational Therapy Aide] was interviewed on 5/12/26 by [name of Clinical Resource staff]. She was able to state the facility protocol that only therapy can manage and supervise use of hot packs. She also stated that the hydrocollator hot pads are secured behind two locked doors when therapy leaves for the day. [Name of CNA/Restorative Aide] was interviewed on 5/15/26, by ED [Executive Director]. She knew the facility policy that only therapy staff can use the hot pads in the building. Night nurse on shift was not aware of heat pack being used. She denied any report by the alleged perpetrator of resident abdominal discomfort on the night of 5/11/26. Resident is not in pain and does not have feeling below his chest.On 5/19/26 at 10:20 AM, an interview was conducted with the ADON. The ADON stated that when she first observed resident 1's skin on 5/12/26, there was a first degree burn on resident 1's abdomen that was 6 x 3 inches in size, and small blister that was less than the size of a pencil eraser. The ADON further stated that later that day, at approximately 5:30 PM, a second blister appeared. The ADON stated that the following morning, on 5/13/26, there were an additional 3 to 4 blisters present, but that they were smaller than a pencil eraser. The ADON stated that the blisters indicated that the resident had received a second degree burn. The ADON stated that through her investigation, it appeared that the CNA heated up a towel, wrapped it up in plastic, then wrapped it in a t-shirt, and placed it on resident 1's abdomen. The ADON stated that when she discovered the burn, she contacted the Nurse Practitioner, who gave orders for Neosporin with burn cream and island dressing. The ADON stated that the current treatment for the burn was Neosporin with burn cream twice a day.

Based on observation, interview and record review, for 3 of 30 sampled residents, the facility did not treat each resident with respect and dignity and care for each resident in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. Specifically, residents reported they had incontinent episodes waiting for staff to answer their call lights. Resident 55 was cited at a harm level because she stopped drinking because staff were too busy to help her to the bathroom. Resident identifiers: 34, 54 and 55. Findings Included: 1. Resident 55 was admitted to the facility on [DATE] with diagnoses which included periprosthetic fracture hip fracture, hemiplegia and hemiparesis following cerebral infarction, artificial hip joint, major depressive disorder and anxiety. On 3/23/26 at 2:14 PM, an interview was conducted with resident 55. Resident 55 stated there were not enough staff, especially from 6:00 PM until 6:00 AM because there were 3 CNA's for the whole facility. Resident 55 stated the CNA's can't get to everyone in the 3 different hallways. Resident 55 stated sometimes she rang the call light and had to wait for a long time. Resident 55 stated she had incontinent episodes when she first came because she was unable to hold it. Resident 55 stated one time she waited 35 minutes for staff to respond to her call light. Resident 55 stated she was unable to use her leg so she had to wait for staff assistance to the bathroom. Resident 55 stated when she was incontinent due to staff delays in response to her call light, it made her feel miserable because she does not usually pee the bed. Resident 55 stated she was afraid to drink much because they [staff] are so busy. Resident 55 stated she was going to tell the Administrator to come stay the night and see what staff do. Resident 55's medical record was reviewed 3/23/26 through 3/26/26. A LN - Bowel and Bladder Evaluation dated 2/17/26 revealed resident 55 was continent and there was no need to complete the evaluation. According to CNA documentation in the tasks section resident 55 had incontinent bladder episodes on 2/27/26, 3/1/26, 3/2/26 and 3/3/26. According to the progress note dated 2/17/26, 2/23/26, 3/16/26, and 3/23/26 resident 55 was continent of bladder. A care plan dated 2/17/26 revealed resident 55 was at risk of bowel/bladder incontinence related to impaired mobility. An intervention revealed INCONTINENT: Check as required for incontinence. Wash, rinse and dry perineum. Change clothing PRN after incontinence episodes. On 3/25/26 at 3:30 PM, an interview was conducted with CNA 3. CNA 3 stated resident 55 was cognitive and was continent of bowel and bladder. CNA 3 stated resident 55 required assistance to the bathroom and usually used the call light for assistance. On 3/25/26 at 3:35 PM, an interview was conducted with LPN 1. LPN 1 stated resident 55 was alert and oriented to person, place, time and situation (A&Ox4) with some forgetfulness. LPN 1 stated resident 55 was continent of bowel and bladder. LPN 1 stated the nurses were provided report from the hospital nurse and would ask the patient upon admission their bowel and bladder status. LPN 1 stated if the resident was not alert and oriented, the nurse would ask a care taker the questions. LPN 1 stated for the first 72 hours checks were done every 2 hours to determine if they were continent or incontinent. 2. Resident 54 was admitted to the facility on [DATE] with diagnoses which included trochanteric fracture of left femur, fall on same level, chronic pain, lupus, and epilepsy. On 3/23/26 at 1:53 PM, an interview was conducted with resident 54. Resident 54 stated there were not enough staff and she had to wait an hour for her call light to be answered. Resident 54 stated staff did not make it in time to take her to the bathroom. Resident 54 stated she peed in her brief because there were not enough staff to help her to the bathroom. Resident 54 stated a night nurse reported she had told management there were not enough staff. Resident 54 stated she did not like laying in her wet brief. Resident 54's medical record was reviewed 3/23/26 through 3/26/26. A Licensed Nurse (LN)- Bowel and Bladder Evaluation dated 3/14/26 revealed resident 54 was continent and did not need the evaluation completed. The category revealed resident 54 was continent or good candidate. According to the Certified Nursing Assistant (CNA) tasks for the last 30 days, resident was incontinent of bladder once a day from 3/14/26 through 3/24/26. A previous admission Minimum Data Set, dated [DATE] revealed resident 54 was not on a toileting program, was frequently incontinent of urine and always continent of bowel. Nursing progress notes dated 3/21/26, 3/22/26, 3/23/26 and 3/24/26 at 6:59 AM, revealed Resident continent of bladder. A care plan dated 3/16/26 revealed that resident 54 was at risk of bowel/bladder incontinence related to Impaired Mobility. An intervention included INCONTINENT: Check as required for incontinence. Wash, rinse and dry perineum. Change clothing PRN [as needed] after incontinence episodes. On 3/25/26 at 3:31 PM, an interview was conducted with CNA 3. CNA 3 stated resident 54 was fairly cognitive. CNA 3 stated sometimes resident 54 will ask for the same thing within 5 minutes but was cognitive for the most part. CNA 3 stated resident 54 was continent of bowel and bladder. CNA 3 stated residents were generally checked on every 2 hours and then checked on before meals. CNA 3 stated residents used their call lights in between those times if they needed to use the restroom. On 3/25/26 at 3:33 PM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated resident 54 was able to hold a conversation and knew why she was admitted to the facility but had some confusion. LPN 1 stated resident 54 was continent of bowel and bladder. LPN 1 stated there were no residents on a bowel and bladder retraining program in the 100 hallway. [It should be noted resident 54, 55 and 34 resided in the 100 hallway.] 3. Resident 34 was admitted to the facility on [DATE] with diagnoses which included metabolic encephalopathy, acute respiratory failure with hypoxia, pneumonia, urinary tract infection and end stage renal disease with dialysis. On 3/23/26 at 2:34 PM, an interview was conducted with resident 34. Resident 34 stated she had been left on the toilet and had to get herself off the toilet and back to bed because there were not enough staff. Resident 34's medical record was reviewed 3/23/26 through 3/26/26. A LN-Bowel and Bladder Evaluation completed on 3/10/26 revealed resident 34 was continent and scored a 3. A score of 0-4 indicated the resident was a good candidate for bowel and bladder re-training. Resident 34 had been incontinent in the last 7 days. Resident 34 was alert and oriented. There were contributing factors such as surgery, infection, short-term physical trauma, and willingness for resident 34. According to tasks for the previous 30 days. Resident 34 was continent of bowel except on 3/24/26 and had 2 incontinent of bladder episodes on 3/20/26 and 3/21/26. A nursing admission note dated 3/10/26 at 4:34 PM revealed, .Pt [patient] is incontinent of B&B [bowel and bladder],. A physician's note dated 3/15/26 at 10:06 AM revealed, Resident is continent of urine. Resident voids via toilet. A physician's note dated 3/18/26 at 6:30 AM, .Resident is incontinent of urine. Resident uses adult briefs. New onset incontinence: No. A physician note dated 3/24/26 revealed, .No urinary complaints. Resident is continent of urine. Resident is occasionally incontinent (less than 7 episodes of incontinence). Resident voids via toilet. On 3/25/26 at 3:28 PM, an interview was conducted with CNA 3. CNA 3 stated he was not aware of any residents on a bowel and bladder retraining program. CNA 3 stated resident 34 was continent of bowel and bladder. CNA 3 stated resident 34 was cognitively aware and knew who the CNA was. CNA 3 stated no residents had complained of an accident waiting for staff. On 3/25/26 at 3:34 PM, an interview was conducted with LPN 1. LPN 1 stated resident 34 was alert and oriented x 4. LPN 1 stated resident 34 was soft spoken and quiet but definitely oriented. LPN 1 stated resident 34 was continent of bowel and bladder. On 3/25/26 at 3:14 PM, an interview was conducted with CNA 1. CNA 1 stated there were a couple residents on a toileting program. CNA 1 stated there were no residents on the 100 hallway on a toileting program. CNA 1 stated not all residents were on rounds every 2 hours and those residents used their call lights for assistance. CNA 1 stated there was a resident who was normally continent of bowel and bladder but had an incontinent bowel movement episode. CNA 1 stated that particular resident was not scheduled to be checked every 2 hours. CNA 1 stated the resident was not at the facility anymore. CNA 1 stated she was not aware of which residents were continent and on rounds in the 100 hallway. On 3/26/26 at 9:37 AM, an interview was conducted with the Director of Nursing (DON). The DON stated resident 55 was forgetful and repeated herself but was alert and oriented x 4 with some forgetfulness. The DON stated resident 55 would be able to voice a concern. The DON stated she was not sure if resident 55 was continent or incontinent. The DON stated resident 54 was alert and oriented x4 with some forgetfulness. The DON stated she was not sure if resident 54 was continent or incontinent. The DON stated resident 54 was recently readmitted but was continent during her last admission. The DON stated resident 34 was alert and oriented x 4 but was forgetful. The DON stated resident 34 was continent of bladder and bowel.

Based on observation, interview, and record review, for the 10 of 30 sampled residents, facility did not have sufficient nursing staff with appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psycho-social well-being of each resident. Specifically, for 10 out of 30 sampled residents, multiple residents voiced concerns with call light wait times and not receiving assistance with the bathroom which led to incontinent episodes. In addition, concerns with regards to staffing issues and long call light times were raised as grievances and during resident council meetings on repeated occasions. This will be cited at harm level. Resident identifiers: 3, 6, 8, 10, 16, 21, 34, 54, 55 and 56. Findings included: Resident Interviews 1. Resident 55 was admitted to the facility on [DATE] with diagnoses which included periprosthetic fracture hip fracture, hemiplegia and hemiparesis following cerebral infarction, artificial hip joint, major depressive disorder and anxiety. On 3/23/26 at 2:14 PM, an interview was conducted with resident 55. Resident 55 stated there were not enough staff, especially from 6:00 PM until 6:00 AM because there were 3 CNA's for the whole facility. Resident 55 stated the CNA's can't get to everyone in the 3 different hallways. Resident 55 stated sometimes she rang the call light and had to wait for a long time. Resident 55 stated she had incontinent episodes when she first came because she was unable to hold it. Resident 55 stated one time she waited 35 minutes for staff to respond to her call light. Resident 55 stated she was unable to use her leg so she had to wait for staff assistance to the bathroom. Resident 55 stated when she was incontinent due to staff delays in response to her call light, it made her feel miserable because she does not usually pee the bed. Resident 55 stated she was afraid to drink much because they [staff] are so busy. Resident 55 stated she was going to tell the Administrator to come stay the night and see what staff do. Resident 55's medical record was reviewed 3/23/26 through 3/26/26. According to CNA documentation in the tasks section resident 55 had incontinent bladder episodes on 2/27/26, 3/1/26, 3/2/26 and 3/3/26. On 3/25/26 at 3:30 PM, an interview was conducted with CNA 3. CNA 3 stated resident 55 was cognitive and was continent of bowel and bladder. CNA 3 stated resident 55 required assistance to the bathroom and usually used the call light for assistance. On 3/25/26 at 3:35 PM, an interview was conducted with LPN 1. LPN 1 stated resident 55 was alert and oriented to person, place, time and situation (A&Ox4) with some forgetfulness. LPN 1 stated resident 55 was continent of bowel and bladder. LPN 1 stated the nurses were provided report from the hospital nurse and would ask the patient upon admission their bowel and bladder status. LPN 1 stated if the resident was not alert and oriented, the nurse would ask a care taker the questions. LPN 1 stated for the first 72 hours checks were done every 2 hours to determine if they were continent or incontinent. 2. Resident 54 was admitted to the facility on [DATE] with diagnoses which included trochanteric fracture of left femur, fall on same level, chronic pain, lupus, and epilepsy. On 3/23/26 at 1:53 PM, an interview was conducted with resident 54. Resident 54 stated there were not enough staff and she had to wait an hour for her call light to be answered. Resident 54 stated staff did not make it in time to take her to the bathroom. Resident 54 stated she peed in her brief because there were not enough staff to help her to the bathroom. Resident 54 stated a night nurse reported she had told management there were not enough staff. Resident 54 stated she did not like laying in her wet brief. Resident 54's medical record was reviewed 3/23/26 through 3/26/26. According to the Certified Nursing Assistant (CNA) tasks for the last 30 days, resident was incontient of bladder once a day from 3/14/26 through 3/24/26. On 3/25/26 at 3:31 PM, an interview was conducted with CNA 3. CNA 3 stated resident 54 was fairly cognitive. CNA 3 stated sometimes resident 54 will ask for the same thing within 5 minutes but was cognitive for the most part. CNA 3 stated resident 54 was continent of bowel and bladder. CNA 3 stated residents were generally checked on every 2 hours and then checked on before meals. CNA 3 stated residents used their call lights in between those times if they needed to use the restroom. On 3/25/26 at 3:33 PM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated resident 54 was able to hold a conversation and knew why she was admitted to the facility but had some confusion. LPN 1 stated resident 54 was continent of bowel and bladder. LPN 1 stated there were no residents on a bowel and bladder retraining program in the 100 hallway. [It should be noted resident 54, 55 and 34 resided in the 100 hallway.] 3. Resident 34 was admitted to the facility on [DATE] with diagnoses which included metabolic encephalopathy, acute respiratory failure with hypoxia, pneumonia, urinary tract infection and end stage renal disease with dialysis. On 3/23/26 at 2:34 PM, an interview was conducted with resident 34. Resident 34 stated she had been left on the toilet and had to get herself off the toilet and back to bed because there were not enough staff. Resident 34's medical record was reviewed 3/23/26 through 3/26/26. According to tasks for the previous 30 days. Resident 34 was continent of bowel except on 3/24/26 and had 2 incontinent of bladder episodes on 3/20/26 and 3/21/26. On 3/25/26 at 3:28 PM, an interview was conducted with CNA 3. CNA 3 stated resident 34 was continent of bowel and bladder. CNA 3 stated resident 34 was cognitively aware. CNA 3 stated no residents had complained of an accident waiting for staff. On 3/25/26 at 3:34 PM, an interview was conducted with LPN 1. LPN 1 stated resident 34 was alert and oriented x 4. LPN 1 stated resident 34 was soft spoken and quiet but definitely oriented. LPN 1 stated resident 34 was continent of bowel and bladder. On 3/25/26 at 3:14 PM, an interview was conducted with CNA 1. CNA 1 stated there was a resident who was normally continent of bowel and bladder but had an incontinent bowel movement episode. CNA 1 stated the resident was not scheduled to be checked every 2 hours. CNA 1 stated the resident was not at the facility anymore. CNA 1 stated she was not aware of which residents were continent and on rounds in the 100 hallway. 4. On 3/23/26 at 1:18 PM, an interview was conducted with resident 8. Resident 8 stated that with the new ownership a lot of CNAs no longer work at the facility. Resident 8 stated that she had to wait a long time for call lights to be answered and there was not enough staff to assist the residents. 5. On 3/23/26 at 1:10 PM, an interview was conducted with resident 10 and she stated that she often had long wait times, up to 45 minutes, when she used her call light. 6. On 3/23/26 at 1:33 PM, an interview was conducted with resident 6 and he stated that it frequently took a long time for staff to answer the call lights. Resident 6 stated that the call light wait time was really long during the change of shift. 7. On 3/23/26 at 2:09 PM, an interview was conducted with resident 3. Resident 3 stated that she was the Resident Council President. Resident 3 stated that during resident council meetings, the residents had complained that, ever since the facility changed ownership, getting call lights answered took longer. Resident 3 stated that she was told by the residents that it took 30 to 40 minutes before they had their call lights answered. Resident 3 stated that more CNAs were needed for the night shift, as only two CNAs were scheduled and occasionally only one more came in for a swing shift. Resident 3 stated that there were not enough CNAs to be able to handle the needs of all the residents during the evening and bedtime hours. 8. On 3/23/26 at 2:08 PM, an interview was conducted with resident 21's family member. The family member stated staff were really busy and when resident 21 put on his call light, he had to be patient and wait. 9. On 3/23/26 at 2:23 PM, an interview was conducted with resident 56. Resident 56 stated over the weekend there were not many staff. Resident 56 stated he was mostly independent so he was able to wait for staff. 10. On 3/23/26 at 1:24 PM, an interview was conducted with resident 16. Resident 16 stated he did not have function in his left arm and he had to wait for his call light to be answered for about 10 minutes. Call light observations: 11. On 3/23/26 at 1:30 PM, an observation of a call light activated for room [ROOM NUMBER] was made. At 1:38 PM, the call light for room [ROOM NUMBER] was answered. It should be noted the call light was alarming for 8 minutes before it was answered. 12. On 3/24/26 at 10:08 AM, an observation of a call light activated for room [ROOM NUMBER] was made. At 10:18 AM, another alert went out over the facility's alert system. At 10:21 AM, the call light for room [ROOM NUMBER] was answered. It should be noted that the call light was alarming for 13 minutes before the call light was answered. 13. On 3/24/26 at 10:13 AM, an observation of a call light activated for room [ROOM NUMBER] was made. At 10:23 AM, another alert went out over the facility's alert system. At 10:24 AM, the call light for room [ROOM NUMBER] was answered. It should be noted that the call light was alarming for 11 minutes before the call light was answered. 14. On 3/24/26 at 2:49 PM, an observation of a call light activated for room [ROOM NUMBER] was made. At 2:58 PM, the call light for room [ROOM NUMBER] was answered. It should be noted that the call light was alarming for 9 minutes before the call light was answered. 15. On 3/24/26 at 2:50 PM, an observation of a call light was activated for room [ROOM NUMBER] was made. At 2:58 PM, the call light for room [ROOM NUMBER] was answered. It should be noted that the call light was alarming for 8 minutes before the call light was answered. Staff Interviews: 16. On 3/25/26 at 3:35 PM, an interview was conducted with Registered Nurse (RN) 3. RN 3 stated CNA staffing depended on census but she was not aware of the exact numbers. RN 3 stated she had staff complain of not being able to answer call lights timely. RN 3 stated staff also complained of not being able to complete charting when the census was higher. RN 3 stated that since the ownership change, CNA's hours were cut back a little. 17. On 3/24/26 at 1:57 PM, an interview was conducted with Staff Member 1 and they stated that they were asked to work a lot of overtime because a lot of staff quit in November. Staff Member 1 stated that they were not always able to finish showers due to being understaffed. Staff Member 1 stated that resident 10 had an incontinent episode because she had to wait too long for them to answer the call light. Staff Member 1 did not know how long resident 10 had to wait but that resident 10 told them that she was waiting about 45 minutes until they answered her call light. Staff Member 1 stated this incident occurred during the day shift. Staff Member 1 stated resident 10 could not get up on her own and required assistance to go to the bathroom. 18. Grievances were reviewed and revealed the following: a. On 10/15/25, Left waiting on my bed for the CNAs to take me to breakfast which happens all the time. I am sick of not being on time for my breakfast or all of my meals, for that matter. This is ridiculous!!! You need more staff. Steps taken to investigate the grievance was Resident Advocate checked call light response time. Call light was on at 8:15 AM, resident did not get to breakfast until 9:30 AM. The summary of findings/conclusion was Call light response time left resident waiting for over one hour. Resident advocate informed DON. DON educated staff on call light response time goal of 5-6 minutes not one hour. DON will continue to monitor & [and] improve response times with nursing staff. b. On 11/10/25, Resident reports dissatisfaction with call light response. Resident asked CNA for a snack from the resident fridge that is hers, and CNA initially agreed to bring it, but the request was not fulfilled. Resident states this made her feel ignored & frustrated. The Summary of Findings/Conclusion were Resident was informed staff are reminded to follow-through on all call light requests. CNA's will ensure timely delivery of requested items in the future. c. On 11/21/25, Resident feels there are not enough CNAs on the floor, especially during evening. and call light times are too slow, they do not get to me fast enough. The Summary of findings/conclusion was DON reviewed staffing schedule. Staff was fully staffed. DON sees no need to add any additional staff. Nursing staff instructed to prioritize call light response times. Follow up visit to confirm call light response times. d. On 12/17/25, I am sick of the call light not being answered in a timely manner. I have been here waiting for 2 & a half hours. My brief has needed changed for that whole time. Summary of findings/conclusion: Resident advocate checked call light response system. Resident's call light was on for 15 minutes (not 2 & half hours). Staff made a goal to answer call lights within 5-6 minutes and if not before and we since reached this goal of 6 minutes. e. On 1/5/26, Resident was left on the toilet for almost 3 hours. Resident was helped onto the toilet at 6:10 AM and CNA's did not return until 9:00 AM. Resident stated sitting on the toilet that long hurt his back and bum. Resident stated this was unacceptable & this cannot happen again because it is really unfair. The summary of findings/conclusion was .CNA's will make sure, reminder resident is checked on more frequently when toileted. f. On 1/28/26, Resident's spouse & resident feels staff response to call lights has been slow since resident got here and requires more timely assistance. The summary of findings/conclusion: After investigating RA (Resident Advocate) did find that staff needs to be aware in their call light responses. RA notified DON. DON trained & educated staff to ensure quicker call light response times. Resident verbalized understanding and both the resident & spouse are satisfied with plan for quicker response times and thanks the staff for listening to their concern. g. On 2/3/26, 'The CNAs didn't answer my call lights. I have been waiting for 45 minutes.' The summary of findings/conclusion: Resident Advocate checked call light response system. Resident's call light was on for 10 minutes (not 45 minutes). Staff made a goal to answer call lights within 5-6 minutes or if not before. h. On 2/5/26, Resident expressed concern that call light response times are too slow- Resident reported feeling that help was not available promptly. The Summary of findings/conclusion was Resident was informed that no call light was activated during the reported time. Staff reinforced proper call light use & resident verbalized understanding. On 3/26/26 at 8:27 AM, an interview was conducted with the RA. The RA stated there was a trend of call light response grievances when we had the change in ownership. The RA stated the new ownership decreased the staff. The RA stated she and the DON were tracking call light response times. The RA stated the goal was to be under 5 minutes average. The RA stated there was a time when a call light had gone for as long as 40 minutes. The RA stated the average call light response time was 10 minutes and had decreased to about 6 minutes. The RA stated the DON made assignments for CNA's and gave CNA's a sense of ownership for their hallway to answer call lights quicker. 19. Resident council notes were reviewed and revealed the following: a. On 1/23/25: .[Name of resident] said his call light sometimes takes a long time to answer and he had an accident because it was too long. A How will you address these concerns? was provided with Reminded CNAs that call lights are a priority. b. On 4/30/25: .Residents get upset when there is only one CNA in the dining room at dinner to help residents eat and get back to their rooms. A How will you address these concerns? was provided with Certain CNAs are assigned to be in the dining room at meal times. Will remind them to be in the dining room. c. On 7/30/25: .[Name of resident] wishes the CNAs would finish with one resident before going to help another resident or starting something else. A How will you address these concerns? was provided with Remind CNA to finish helping the resident's [sic] they are working with before starting another task. d. On 9/24/25: .Call lights taking a long time to get answered. A How will you address these concerns? was provided with Remind CNAs that call lights are the first priority before doing other tasks. e. On 10/22/25: .Call lights taking a long time to get answered. A How will you address these concerns? was provided with Remind CNAs that call lights are the first priority before doing other tasks. f. On 11/19/25: .1. Call lights taking a long time to get answered 2. Residents want more CNAs in the dining room at mealtimes. A How will you address these concerns? was provided with 1. Remind CNAs that call lights are the first priority before doing other tasks. Working to resolve. 2. Two CNAs are assigned to be in the dining room. Restorative CNA is also helping in the dining for breakfast and lunch. g. On 12/24/25: .1. [Resident name] is upset about getting left on the toilet for so long 2. Residents are not happy about getting to breakfast so late A How will you address these concerns? was provided with 1. Have reminded CNAs to finish current tasks before going on to another task. 2. New CNA assignments have been made. Hoping this will help improve call light times and getting residents to meals on time. h. On 1/28/26: .[Resident name] says the call lights are still taking a long time especially when she's in the bathroom. The CNAs put her on the toilet and they don't come back for a long time. A How will you address these concerns? was provided with New CNA assignments have been made which will hopefully reduce the call light times. 20. A review of the Facility Assessment revealed: .Acuity Several factors are considered when determining staffing needs based on acuity. These include MDS [Minimum Data Set] Section GG data, PDPM [patient driven payment model] case-mix, special treatments and conditions, and resident support and care needs. Other individual factors may be considered, as needed. For skilled residents, much of this data is combined to establish our quality metric for each individual resident. For long-term care residents, the primary sources of information needed to assist in the calculation of acuity included special treatments and conditions [sic] medical conditions and co-morbidities, and the extent to which resident support and care needs are needed for the individual resident.Staffing Plan, Posted Staffing Information, and Staff Assignments The staffing plan, using census and the criteria described previously, will be used to create the baseline staffing plan that will address resident needs, expected outcomes, quality measures, and acuity at any given time in the Facility. It will be created using a range for staffing levels. The baseline staffing plan will be added as a QAPI [Quality Assurance Performance Improvement] plan to review, refine, and revise staffing levels on a quarterly basis as data comes available. The Facility reports direct care hours through the Centers for Medicare and Medicaid Services (CMS) Payroll Based Journal (PBJ). Staffing schedules are maintained and are adjusted to accommodate vacations, sick time, and fluctuations in census and resident care needs. All departments have the ability to flex hours to meet an increase or decrease in census. If necessary, the Facility has contracts in place for temporary agency personnel for nursing Based on our resident population and their care needs, we have made a good faith effort and approach to ensure we have sufficient and qualified staff to meet the needs of our residents at any given time. The Facility periodically interviews residents for preferences on waking and sleep times, shower schedules, etc. Should an individual identify, or express preferences related to individual choice, cultural needs, or other factors, their plan of care is adjusted to meet their person-centered care preferences when able. If the Facility is unable to meet a request, the resident is advised, and the Facility will collaborate with the resident and/resident representative to achieve the best solution or compromise possible. Individual Staff Assignment The Facility considers the fluctuation in census, acuity levels, resident needs or preferences, staff competencies and skill sets when determining staffing schedules and assignments and staffs accordingly. The Facility has consistent assignments for direct care nursing staff (licensed nurses and nursing assistants) and therapists, to the extent possible, for the purpose of continuity of care. Staffing needs for each shift are determined and adjusted as necessary based on key strategies. During Normal Operations1. Resident Acuity and Census:Regularly assess the acuity levels and needs of residents using tools like the Minimum Data Set (MDS) and Resident Assessment Instrument (RAI).Track the number of residents and their care requirements to determine the appropriate sta ng levels.2. Shift Planning:Use a scheduling plan to determine shift scheduling based on resident needs, sta availability, and skill mix.Build exibility into schedules to accommodate unexpected changes in resident needs or sta availability.3. Communication:Conduct daily/shift huddles and shift-to-shift report to review resident needs and adjust sta ng as necessary.Implement feedback mechanisms for sta to report changes in real time to a change in resident condition that may require sta ng adjustments outside of the established communication processes. On 3/25/26 at 1:16 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that staffing coverage was based off of the current census of residents in the facility, not acuity. The DON stated that the facility was currently fully staffed. The DON stated that when the new corporation took over for the facility on 11/1/25, staffing was cut back. On 3/26/26 at 9:41 AM, a follow-up interview was conducted with the DON. The DON stated there had been a lot of issues with call lights since staffing was cut. The DON stated that they have trained CNAs about call lights being answered was the first priority. The DON stated that they continue to educate staff and the facility goal is to answer call lights in under six minutes. The DON stated that she thinks the call light average was as high as 10 minutes. On 3/26/26 at 9:57 AM, an interview was conducted with the Administrator (ADM). The ADM stated that with the previous company the facility was staffed a lot higher and call lights were not a big issue. The ADM stated that staffing was based on the facility census and acuity was taken into consideration. The ADM stated that the facility floor nurses had been educated that they also needed to respond to call lights and not just the CNAs.

Based on interview and record review, the facility failed to make prompt efforts to resolve grievances that residents might have. Specifically, grievances regarding staffing issues were not resolved. Findings included: A review of the grievances revealed the following: 1. On 10/15/25, Left waiting on my bed for the CNAs [Certified Nursing Assistant] to take me to breakfast which happens all the time. I am sick of not being on time for my breakfast or all of my meals, for that matter. This is ridiculous!!! You need more staff. Steps taken to investigate the grievance was Resident Advocate checked call light response time. Call light was on at 8:15 AM, resident did not get to breakfast until 9:30 AM. The summary of findings/conclusion was Call light response time left resident waiting for over one hour. Resident advocate informed DON [Director of Nursing]. DON educated staff on call light response time goal of 5-6 minutes not one hour. DON will continue to monitor & [and] improve response times with nursing staff. 2. On 11/10/25, Resident reports dissatisfaction with call light response. Resident asked CNA for a snack from the resident fridge that is hers, and CNA initially agreed to bring it, but the request was not fulfilled. Resident states this made her feel ignored & frustrated. The Summary of Findings/Conclusion were Resident was informed staff are reminded to follow-through on all call light requests. CNA's will ensure timely delivery of requested items in the future. 3. On 11/21/25, Resident feels there are not enough CNAs on the floor, especially during evening. and call light times are too slow, they do not get to me fast enough. The Summary of findings/conclusion was DON reviewed staffing schedule. Staff was fully staffed. DON sees no need to add any additional staff. Nursing staff instructed to prioritize call light response times. Follow up visit to confirm call light response times. 4. On 12/17/25, I am sick of the call light not being answered in a timely manner. I have been here waiting for 2 & a half hours. My brief has needed changed for that whole time. Summary of findings/conclusion: Resident advocate checked call light response system. Resident's call light was on for 15 minutes (not 2 & half hours). Staff made a goal to answer call lights within 5-6 minutes and if not before and we since reached this goal of 6 minutes. 5. On 1/5/26, Resident was left on the toilet for almost 3 hours. Resident was helped onto the toilet at 6:10 AM and CNA's did not return until 9:00 AM. Resident stated sitting on the toilet that long hurt his back and bum. Resident stated this was unacceptable & this cannot happen again because it is really unfair. The summary of findings/conclusion was .CNA's will make sure, reminder resident is checked on more frequently when toileted. 6. On 1/28/26, Resident's spouse & resident feels staff response to call lights has been slow since resident got here and requires more timely assistance. The summary of findings/conclusion: After investigating RA (Resident Advocate) did find that staff needs to be aware in their call light responses. RA notified DON. DON trained & educated staff to ensure quicker call light response times. Resident verbalized understanding and both the resident & spouse are satisfied with plan for quicker response times and thanks the staff for listening to their concern. 7. On 2/3/26, 'The CNAs didn't answer my call lights. I have been waiting for 45 minutes.' The summary of findings/conclusion: Resident Advocate checked call light response system. Resident's call light was on for 10 minutes (not 45 minutes). Staff made a goal to answer call lights within 5-6 minutes or if not before. 8. On 2/5/26, Resident expressed concern that call light response times are too slow- Resident reported feeling that help was not available promptly. The Summary of findings/conclusion was Resident was informed that no call light was activated during the reported time. Staff reinforced proper call light use & resident verbalized understanding. On 3/26/26 at 8:27 AM, an interview was conducted with the RA. The RA stated when a resident had a grievance, they knew to talk to her. The RA stated she asked what happened and used a grievance form to document. The RA stated if it is something like a call light time, she discussed it with the Director of Nursing (DON) to determine how to resolve grievances. The RA stated she made sure there was a follow-up to every grievance. The RA stated she liked to resolve grievances the same day. The RA stated there was a trend of call light response grievances when they had the change in ownership. The RA stated the new ownership decreased the staff. The RA stated she and the DON were tracking call light response times. The RA stated the goal was to be under 5 minutes average. The RA stated there was a time when a call light had gone for as long as 40 minutes. The RA stated the average call light response time was 10 minutes and had decreased to about 6 minutes. The RA stated the DON made assignments for CNA's and gave CNA's a sense of ownership for their hallway to answer call lights quicker.

Based on record review and interview, for 4 of 30 sampled residents, the facility failed to ensure that a complete copy of the discharge/transfer documentation was maintained in the clinical record and a resident did not have a discharge summary. Specifically, the facility failed to document the discharge location, document what paperwork was sent with a resident to the hospital, a reconciliation of all pre-discharge medications with the resident's post-discharge medications (both prescribed and over-the-counter) and complete a discharge summary. Resident identifiers: 1, 2, 50 and 52. Findings included: 1. Resident 1 was admitted to the facility on [DATE] and discharged [DATE] with diagnoses which included pneumonitis due to inhalation of food and vomit, dysphagia, and chronic kidney disease, stage 3. Review of resident 1's medical record was completed on 3/23/26 through 3/26/26. On 3/21/26 at 12:27 pm, a Discharge Nursing Note revealed, Patient was admitted to [name redacted] on 01/27/2026 for aspiration PNA [pneumonia].Daughter was there during discharge ppw [paperwork] and teaching. Medications were sent with patient and faxed to [name redacted] Pharmacy. It should be noted that the facility did not document the discharge location. On 3/26/26 at 8:44 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that she believed the discharge progress note covered all the required discharge information for resident 1. The DON stated that she was unable to locate resident 1's discharge paperwork in the medical record. 2. Resident 50 was admitted to the facility on [DATE] with diagnoses which included chronic heart failure, thrombophilia, and pleural effusion. Review of resident 50's medical record was completed on 3/23/26 through 3/26/26. On 1/27/26 at 7:09 AM, a Nursing Note revealed, Pt [patient] c/o [complained of] not getting enough breaths to breath [sic]. O2 [oxygen] sats [saturations] would not get above 90% on 5 LPM [liters per minute] NC [nasal cannula]. MD [Medical Doctor] notified. Pt sent to ED [Emergancy Department] for further evaluation via ambulance. Pt left building @ [at] 0709am [7:09 AM]. It should be noted that the facility failed to record which documents accompanied resident 50 during his hospital transfer, and this information was missing from his medical record. It should also be noted that the facility did not have a transfer notice for resident 50 located in his medical record. On 3/26/26 at 8:44 AM, an interview was conducted with the DON.The DON stated that resident 50 was discharged to the hospital and did not return to the facility. The DON stated that she believed the discharge progress note covered all the required discharge information for resident 50. The DON stated that resident 50 may not have had any discharge paperwork since he went to the hospital. 3. Resident 2 was admitted to the facility on [DATE] with diagnoses which included metabolic encephalopathy and acute cystitis with hematuria. Review of resident 2's medical record was completed on 3/23/26 through 3/26/26. On 3/21/26 at 12:43 AM, a Discharge Nursing Note revealed, [name redacted] was admitted to [name redacted] on 1/23/2026 for cystitis, DM2 [diabetes mellitus type 2] and metabolic encephalopathy.discharged with [name redacted] HH [Home Health], transported by his daughter [name redacted]. She was also present for discharge PPW. He does have a rash on his inner thighs, which required a clotrimazole for tx [treatment]. He was sent home with all medications, including the cream. Medication sheet was faxed to [name redacted] Pharmacy. Patient left with all personal belongings, a copy of discharge ppw and medication. All questions were addressed. It should be noted that the facility did not document what documentation or medication was sent with the resident. On 3/26/26 at 8:44 AM, an interview was conducted with the DON. The DON stated that she believed the discharge progress note covered all the required discharge information for resident 2. The DON stated that she was unable to locate resident discharge paperwork in the medical record. On 3/26/26 at 9:10 AM, an interview with Licensed Practical Nurse (LPN) 1 was conducted. LPN 1 stated that when a resident needed to be discharged from the facility, she would contact the physician with the resident's status and obtain an order for transport. LPN 1 stated that she would contact the charge nurse at the receiving facility and give a report on the resident. LPN 1 stated that she would enter a progress note for the resident which included: information relayed to the physician regarding the resident's status or change in condition, and how the resident was transported, with the time of transport and the reason. LPN 1 stated that she would provide a copy of the resident's face sheet and physician's orders to the transport team. LPN 1 stated that she did not recall if a copy of the transfer packet was made for the facility. LPN 1 stated that when a resident returned from an outside facility, she would collect the paperwork that was sent with the resident, enter a progress note, and then place the paperwork into the medical records basket. On 3/25/26 at 1:59 PM, an interview with the Social Services Director (SSD) was conducted. The SSD stated that the discharge planning process began upon a resident's admission, at which time the Interdisciplinary Team met with the family. The SSD stated that when evaluating a resident for discharge, the team assessed the resident's specific needs, including Durable Medical Equipment, home health services, and any insurance coverage to ensure a safe transition. The SSD stated that she would oversee that the physician had conducted a face-to-face exam and that all necessary orders and follow-up appointments were included in the discharge paperwork. The SSD stated she would provide a Notice of Medicare Non-Coverage two days prior to the discharge and again on the actual date of discharge, while explaining the appeal process to the resident. The SSD stated that she would send a discharge notice to the Ombudsman's office and provide an emergency transfer notice when applicable. The SSD stated that she would oversee the upload of physician orders and ensure that the nursing staff had scanned the Discharge Plan of Care along with the complete discharge packet to the resident's medical record. The SSD stated that she would follow up with home health services after the resident's discharge to ensure those services were initiated. On 3/26/26 at 9:24 AM, a follow-up interview was conducted with the DON. The DON stated that she located resident 1's and resident 2's discharge paperwork in Medical Records waiting to be scanned and attached to the medical chart. The DON stated that she expected medical records to be scanned and attached to the residents medical chart within 48 hours from receipt of the documentation. The DON did not provide the discharge information that she located. 4. Resident 52 was admitted to the facility on [DATE] and discharged on 2/19/26 with diagnoses which included displaced fracture to right femur, fall, diabetes mellitus, anxiety and cirrhosis of liver. Resident 52's medical record was reviewed 3/23/26 through 3/26/26. A nursing note dated 2/19/26 at 4:06 PM revealed, Patient discharged this afternoon after speaking with social worker and admin (Administrator). Sent patients home gabapentin home with her 20 tabs[tablets]counted with [name removed] RN [Registered Nurse]. It should be noted there was no discharge summary with a recapitulation of the resident's stay. On 2/19/26 at 7:05 PM, an electronic Medication Administration Record Administration Note revealed Pt[patient] left facility via family members car to go home and not come back to facility. On 3/24/26 at 2:48 PM, an interview was conducted with the DON. The DON stated there was a discharge packet that nurses used. The DON stated the Resident Advocate arranged for any supplies, like oxygen and started the discharge packet. The DON stated when the resident was ready to discharge, the nurse went through the packet, went over the medications and appointments. The DON stated if the resident wanted to take medications home, then the nurse removed the stickers and sent it to the pharmacy to bill the resident. The DON stated the nurse helped the resident to the car and made a discharge note. The DON stated resident 52 should have had a discharge summary in addition to the notes.

Based on observation, interview and record review, for 5 of 30 sampled residents, the facility did not provide each resident with food and drink that was palatable, attractive, and at a safe and appetizing temperature. Specifically, there were individual resident complaints resident council minutes and grievances regarding the food palatability. In addition, the test tray was not palatable, attractive or served at an appetizing temperature. Resident identifiers: 8, 21, 24, 46 and 54.Findings included:1. On 3/23/26 at 1:53 PM, an interview was conducted with resident 54. Resident 54 stated the food was so/so and it was bland. Resident 54 stated if she did not like what was served, staff did not offer her something different. Resident 54 stated she did not like dark meat but felt like she only got dark meat. 2. On 3/23/26 at 2:08 PM, an interview was conducted with resident 21's family member. The family member stated resident 21 did not have a good appetite and he either eats it or doesn't. The family member stated the chicken was served dry and needed more moisture on the food. 3. On 3/23/26 at 1:23 PM, an interview was conducted with resident 8. Resident 8 stated that the food was horrible and looked nasty. Resident 8 stated that the food did not taste good. 4. On 3/23/26 at 2:40 PM, an interview was conducted with resident 24. Resident 24 stated that the food was disgusting and she did not want to eat it. 5. On 3/23/26 at 3:51 PM, an interview was conducted with resident 46. Resident 46 stated, food, not good. 6. On 3/25/26 at 4:47 PM, a test tray was requested. The last tray was plated and put into the cart at 4:48 PM. The test tray was placed in the cart at 4:49 PM. At 4:50 PM, the cart was taken to the 100 hallway. Certified Nursing Assistant (CNA) 1 was observed to tell the dietary aide she would pass the trays. At 4:51 PM, the first tray was delivered to room [ROOM NUMBER]. The last tray was delivered at 5:01 PM to room [ROOM NUMBER]. The test tray temperatures were obtained at 5:10 PM. The chicken tender was 128.6 degrees Fahrenheit. The tater tots were 115.8 degrees Fahrenheit. The carrot coin salad was 49.2 degrees Fahrenheit. The plate was observed to have a light brown chicken tender, light brown tater tots with an orange carrot salad in a bowl on the side. There was a serving of white cake and apple juice. There was no plate warmer between the plate and the plastic base. The tater tots had a mushy texture and were cold to the taste. The chicken tender was dry, tough to chew and was salty to the taste. 7. A grievance dated 1/14/26 revealed that a resident stated meals were served too cold and requested food to be served at proper temperature. Summary of findings included dietary staff reminded to serve meals at proper temperature. Resident informed and verbalized understanding; will continue to monitor meal quality. 8. A grievance dated 1/9/26 revealed resident reports distaste with facility meals, stating there was not enough variety, no fruit options, not enough fruit, and that meals contain too many carbohydrates. The resident expressed concern that the diets were not healthy enough to support recovery and overall well being. Resident Council: 9. Resident Council minutes dated 2/27/25: .New Concerns: 1. [Resident name]-sometimes her hamburger is too raw. 10. Resident Council minutes dated 1/28/26: .New Concerns: .2. Residents don't like the vegetables roasted. They say they sometimes taste burned. 3. [Resident name] said she can't cut or chew the pork chops 4. Some of the residents that eat in their rooms say the food is cold by the time they get it with the CNAs passing trays. On 3/26/26 at 9:19 AM, an interview was conducted with the Dietary Manager (DM). The DM stated he met with the 200 and 300 hallways regularly to hear food complaints. The DM stated the kitchen's hours were cut and they did not deliver trays to residents since the change in ownership. The DM stated dietary delivered the trays to the hallways and the CNA's passed the trays to the residents. The DM stated cold food was because the CNA's were not passing the trays fast enough. On 3/26/26 at 9:58 AM, an interview was conducted with the Administrator. The Administrator stated he knew for a little bit there were complaints about food quality and there was a new budget. The Administrator stated residents liked fruit, so the budget was increased which helped. The Administrator stated there were other food complaints so the menus were changed to accommodate what residents preferred. The Administrator stated he sampled a tray weekly or more often if there were complaints. The Administrator stated the last reviews were very good.

Based on observation, interview, and record review, it was determined, for 1 out of 30 sampled residents, that the facility failed to ensure each resident was given the appropriate treatment and services to maintain or improve his or her ability to carry out the activities of daily living (ADLs), consistent with the resident's comprehensive assessment and plan of care. This failure included the facility not ensuring that each resident was given the appropriate treatment and services to maintain or improve his or her ability to carry out the activities of daily living for dining-eating, including meals and snacks. Specifically, one resident was not provided with bite-sized cut food or opened food containers when they were assessed as requiring this assistance. Resident identifier: 10. Findings included: On 3/23/26 at 1:10 PM, an interview was conducted with resident 10 in her room and she stated that she was unable to cut up her own food because her right arm was broken and only had use of her left hand. Resident 10 lifted up and guided her right arm with her left hand and stated that this was how she was able to use her right arm. A concurrent observation was made, resident 10's lunch was in front of her which had cut up chicken and potatoes on her plate. Her family was in her room and stated that they had to cut up her lunch for her today and that it was not the only time they had to cut it up for her. On 3/24/26 at 7:55 AM, an observation was made of resident 10's breakfast being served to her in her room. After the staff left her room, an observation of her plate was made, her french toast was cut into bite-sized pieces, sausage links were whole, there was food in a bowl with a lid on it, an individual syrup packet that was not opened, and a closed apple juice box that had a straw wrapped in plastic and stuck to the side of the juice box. On 3/24/26 at 12:11 PM, an observation was made of resident 10 who was sitting in her room alone, her lunch was in front of her and the pork cutlet on the plate was cut into long strips. Resident 10 stated that she had pain in her right arm and would have to cut the meat into smaller pieces to eat it. Resident 10's medical record was reviewed on 3/23/26 through 3/26/26. Resident 10 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included fracture of shaft of humerus, right arm; dementia; memory deficit following cerebrovascular disease; polyneuropathy; osteoarthritis; chronic pain syndrome; major depressive disorder; and right artificial shoulder joint. A Significant change in status Minimum Data Set (MDS) assessment dated [DATE] indicated a Brief Interview for Mental Status (BIMS) score of 9 which indicated a moderate cognitive impairment. It further indicated impairment to one upper extremity and required setup or clean-up assistance with eating. The Care Plan Report indicated a Focus of I have an ADL Self Care PerformanceDeficit r/t [related to] Dementia, Impaired balance initiated on 10/30/25 with the Intervention/Task that included, EATING: I require setup or clean up assistance to eat. A physician's order dated 11/21/25 indicated, REGULAR diet REGULAR texture, Regular consistency. A Nursing progress note dated 2/16/26 at 9:28 AM indicated, This morning when I was giving the resident her morning medications, she reported that since her fall that occurred most recently, her L [left] arm has been hurting a lot. Obviously, her R [right] arm is always in pain, but now her L arm is also hurting significantly, and she reported concern about this. On 3/24/26 at 1:57 PM, an interview was conducted with Certified Nurse Assistant (CNA) 2 who stated that resident 10 could request assistance with cutting her food but that the kitchen was supposed to cut it up for her because it was hard for her to use both hands to cut it up herself. CNA 2 stated resident 10 would move her right arm by guiding it with her left arm. On 3/24/26 at 2:39 PM, an interview was conducted with the Dietary Manager (DM), who stated that it depended on the type of food, but if a resident needed food cut up it would usually be cut up into bite-sized pieces. The DM stated he sometimes cut food into strips, including the pork cutlets. A concurrent review of resident 10's meal card was conducted with the DM; there were no instructions to cut up resident 10's food. The DM stated that there were only two cooks and they knew what the resident's preferences were. The DM stated he thought resident 10 needed her food cut up because she had a hard time chewing. On 3/25/26 at 9:56 AM, an interview was conducted with the MDS Coordinator and she stated that resident 10 needed her food cut up and assistance with taking off lids for meal setup because it would be too hard to do that with the use of one arm. The MDS Coordinator stated that it was not in the orders and that the nurses should have ensured that was being done. On 3/25/26 at 10:10 AM, an interview was conducted with Registered Nurse (RN) 2, who stated that resident 10 needed assistance with setup of meals and that lids should have been removed for her. RN 2 stated that resident 10 was probably not able to cut her own food because she could only use her left hand and that she had frequent pain in her right arm. RN 2 stated resident 10 was on the diet where the kitchen cut up her food but that it was not in her physician orders. RN 2 further stated that resident 10 would not usually ask for help even when she needed it.

Based on observation, interview, and record review the facility failed to ensure that the resident environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistive devices to prevent accidents. Specifically, for 1 out of 30 sampled residents, a high fall-risk resident did not have interventions put in place after falls, and interventions were repeated. Resident identifier: 7. Findings included: Resident 7 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included unspecified dementia, muscle weakness, and other abnormalities of gait and mobility. Resident 7's medical record was reviewed 3/23/26 through 3/26/26. A review of resident 7's care plan revealed that resident 7 was at risk for falls related to confusion, abnormal gait, and opioid use. A review of resident 7's Minimum Data Set (MDS) dated [DATE] revealed that resident 7 had a Brief Interview of Mental Status (BIMS) score of 3. A score of 0-7 indicated severe cognitive impairment. On 3/24/26 at 2:49 PM, an observation was made of resident 7's room. Resident 7 was not observed to be in the room and her oxygen tubing was observed to be on the floor. On 3/24/26 at 2:52 PM, an observation was made of resident 7 exiting her bathroom unassisted by staff. Resident 7 was observed to be ambulating around her room with a shuffling gait and to get her foot caught in the nasal cannula tubing that was on the floor. A review of resident 7's progress notes revealed the following: a. On 6/16/26 at 11:09 AM, a nurse's note documented, Patient had a [sic] unwitnessed fall at 8 AM this morning. She was transferring from her bed to her recliner for breakfast and fell landing on her right foot and face described by the patient. Nothing broke her fall. She has abrasions and a skin tear to her right eyebrow and nose. Vital signs are stable at this time. Pt [patient] is going to be sent to the insta care to receive facial x-rays and an x-ray on her right foot. Interventions that were initiated after this fall included: Neurological checks for 24 hours, frequent safety checks on resident 7, call light within reach, and to continue interventions on the at-risk plan. [It should be noted that the facility was unable to provide the frequent safety check documentation for resident 7.] b. On 6/25/25 at 11:30 PM, a nurse's note documented, Resident's roommate heard her fall in the bathroom and came out to the nurses desk to alert us of the fall. We went into the bathroom and found [resident 7] on the floor laying on her right side with her face to the ground. She was moaning and asking for help to get up. Pt was carefully help [sic] to a sitting position on the floor, and a full assessment was done on her. Pt has a hematoma on right eyebrow that is new from this fall. Pt still has face bruising from her last fall so needing to monitor her for this. Pt's right shoulder was hurting her and states she can't move it because it hurts. When we would touch her right shoulder she would grimace and ask us to stop touching it because it hurts. Pt was alert and responsive and verbalizes appropriately. She is able to follow my finger and able to follow commands. Her speech is clear and she understands up [sic] when speaking to her. She could squeeze with her left hand but not with her right because of the pain. The interventions that were initiated after this fall were to round on resident 7 and to assist with personal cares every 2 hours. This fall resulted in a right humeral head fracture. c. On 6/27/25 at 4:06 PM, a nurse's note documented, CNA [Certified Nursing Assistant] walked in room as resident slid to knees on floor in front of recliner. Assessed, sling in place to arm, she had moved it so her elbow was further towards back than it had been. Assisted her to reposition arm at side. Color remains pink, cap [capillary] refill < [less than] 3seconds to nail beds, able to move hand and fingers, no increase or change in pain to R [right] arm. She was assisted to stand by staff and set back in recliner. Call light is clipped to her shirt and she was reminded to use it if needing assist. Ice pack placedto [sic] R upper arm. There were no interventions implemented after this fall. It should also be noted that resident 7 had been assessed as having severe cognitive impairment, and therefore may not be able to remember to use her call light to ask for staff assistance. d. On 8/6/25 at 3:38 PM, a nurse's note documented, Resident roommate notified nurse that resident needed help, staff entered room and resident was already standing up from being on her knees on R side of bed. When staff asked what happened, she said she rolled off the bed (Bed was in lowest position near the floor) and reported she was trying to get her 'soda' that activity staff had set on the bedside table. Resident assisted to L [left] side of bed and soda placed near her for her to eat. Call light in reach and bed remains in low position. DON [Director of Nursing] is aware of incident. There were no interventions implemented after this fall. e. On 8/23/25 at 11:27 AM, a nurse's note documented, Resident had an unwitnessed fall at approx. [approximately] 6:45AM. Resident stated that she was trying to get out of bed to make her bed when she lost her balance and fell. When [name redacted] LPN [Licensed Practical Nurse] asked if resident hit her head resident stated that she did. She has a small goose egg on the right side of her head. She also stated that she hit her right lower thoracic part of her back as well as her right hip. The intervention for this fall was for resident 7 to use her call light to ask staff for assistance to use the bathroom and to ensure the call light was within reach of the resident. [It should be noted that the call light within reach of the resident was an intervention used after the fall on 6/16/25. The reminder to use her call light was an intervention used after the fall on 6/27/25. It should also be noted that resident 7 had been assessed as having severe cognitive impairment, and therefore may not be able to remember to use her call light to ask for staff assistance.] f. On 9/24/25 at 6:56 AM, a nurse's note documented, 09/24/2025 [Resident 7] had a fall this morning at 0600 [6:00 AM]. Nurse heard a crash at the nurses station. Nurse and aide found her face down on the floor next to her bed. Patient stated, 'I was trying to make the bed and fell down.' Nurse assessed patient for injuries. Nurse and aide rolled patient to back, sat her up, and lifted her into wheelchair. Patient has two abrasions on forehead and bruising around her nose. No other skin abnormalities or injuries were obtained. Patient reported having a headache. The intervention for this fall was to remind resident 7 to ask for assistance with bed making. It should be noted that resident 7 had been assessed as having severe cognitive impairment and therefore may not be able to remember to ask for assistance with bed making. g. On 11/26/25 at 5:31 PM, a nursing note documented, Staff approached nurses station reporting pt fell in dining rm [room]. Nurses to dining rm. Pt found kneeling on floor in front of walker. Pt only described kneeling et [and] legs are tingling. Denies pain. Pt slowly assisted into chair. Denies hitting head. RN [registered nurse] completed head to toe assessment. No apparent injuries, skin intact et redness to bilateral knees. The intervention for this fall was to remind resident 7 to ask for assistance with transfers. It should be noted that resident 7 had been assessed as having severe cognitive impairment and therefore may not be able to remember to ask for staff assistance with transfers. h. On 2/10/26 at 6:29 PM, a nurse's note documented, Nurse reported per residents roommates visitors, that resident had been on knees on floor, kneeling, she was helped to stand by visitor. When nurse entered room, visitor was standing with resident. Nurse redirected visitor to let staff assist resident. She was assisted to sit on her bed at that time. Resident told nurse she was 'kneeling to pray and couldn't get up off floor' . The intervention initiated for this fall was neurological checks as ordered. [Neurological checks were used as an intervention for the fall on 6/16/25.] It should be noted that neurological checks were not an appropriate intervention to prevent future incidents. i. On 3/14/26 at 11:45 PM, a nurse's note documented, Heard noise from [name redacted] found resident on the floor in her room on her Left side. She was awake and alert she said she was making her bed and fell. The intervention initiated for this fall was to leave the curtain open at night to monitor resident 7. A review of the facility's fall policy titled Assessing Falls and Their Causes revealed: Purpose The purposes of this procedure are to provide guidelines for assessing a resident after a fall and to assist staff in identifying causes of the fall.Documentation When a resident falls, the following information should be recorded in the resident's medical record: 1. The condition in which the resident was found (e.g., resident found lying on the floor between bed and chair).2. Assessment data, including vital signs and any obvious injuries.3. Interventions, first aid, or treatment administered.4. Notification of the physician and family, as indicated.5. Completion of a falls risk assessment. 6. Appropriate interventions taken to prevent future falls.7. The signature and title of the person recording the data.On 3/25/26 at 8:30 AM, an interview was conducted with Licensed Practical Nurse (LPN)1. LPN 1 stated that she did not put interventions for falls on care plans and thought that the MDS Coordinator did this. LPN 1 stated that new interventions needed to be implemented after a resident had a fall to prevent future falls. LPN 1 stated that a fall was defined as any change in gravity and if she saw a resident on their knees she would consider this a fall. On 3/25/26 at 8:44 AM, an interview was conducted with CNA 1. CNA 1 stated that resident 7 was a fall risk and that she had to round on her every 2 hours. CNA 1 stated that resident 7 was a 1 person transfer and could walk assisted with a walker. CNA 1 stated that she felt more comfortable assisting resident 7 with walking, than having the resident walk alone. CNA 1 stated that she thought the nurses would inform her if resident 7 had any fall interventions that she needed to know about. On 3/25/26 at 10:39 AM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated that there was a fall protocol at the facility and fall charting was completed for 72 hours post-fall. RN 1 stated that resident 7 was a high fall risk and was forgetful. RN 1 stated that resident 7 overestimated her ability to walk unassisted and walked with a shuffled gait that required the use of a walker. RN 1 stated that all interventions needed to be care planned. RN 1 stated that there were times that resident 7's cognition varied and she was unable to use a call light for assistance. RN 1 stated that if a resident was assisted to the ground or if they were found on their knees she would consider that a fall. On 3/25/26 at 1:06 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that a fall was anything with a change of elevation. The DON stated that if a resident was found on their knees then that would be a change in elevation and be considered a fall. The DON stated that neurological checks were performed for 24 hours and fall alert charting was completed for 72 hours after. The DON stated that resident 7 was a fall risk and that she had several falls while in the facility. The DON stated that all fall interventions were care planned and new interventions were initiated after every fall. The DON stated that interventions were created and implemented by the floor nurses and that they were addressed in the daily morning meeting. The DON stated that continuing interventions on the at-risk plan meant that there were not any new interventions implemented. The DON stated that neurological checks were not interventions to prevent falls, but more of an assessment after a fall. On 3/25/26 at 3:22 PM, an interview was conducted with the MDS Coordinator. The MDS Coordinator stated that fall interventions were put on the care plan by the staff nurses because they were the ones that cared for the residents. The MDS Coordinator stated that interventions should not be repeated and after each fall a resident should have a new intervention implemented. The MDS Coordinator stated that neurological exams were not interventions. On 3/26/26 at 9:36 AM, a follow-up interview was conducted with the DON. The DON stated that resident 7 was not cognitive enough to use her call light and using the call light as an intervention was not a good one and providing education to resident 7 would not prevent future falls. The DON stated that safety checks were just rounds that were done every 2 hours. The DON stated that there were no interventions for the falls that occurred on 6/27/25 and 8/6/25.

Based on interview and record review, for 2 out of 30 sampled residents, the facility failed to ensure each resident received food prepared in a form designed to meet individual needs. Specifically, two residents received snacks that were not pureed or minced and moist. Resident identifiers: 25 and 37. Findings included: 1. Resident 25 was admitted to the facility on [DATE] with diagnoses which included dementia and Alzheimer's disease. Resident 25's medical record was reviewed 3/23/26 though 3/26/26. A physician's order dated 12/12/25 indicated resident 25 was on a pureed textured diet. A Nursing progress note dated 1/26/26 at 4:59 AM indicated, .gave ham sandwiches and potato chips with chocolate ensure during the night. A Nursing progress note dated 2/1/26 at 3:01 AM indicated, resident is awake and alert gave ham sandwich and potato chips. A Nursing progress note dated 2/7/26 at 11:47 PM indicated, 2300 [11:00 PM] Resident has been awake in living room no sandwiches were available I gave her potato chips. 2345 [11:45 PM] resident appeared to be sleeping calmly at this time. An Activities progress note dated 3/18/26 at 4:33 PM indicated, Resident ate the ice cream cone. On 3/24/26 at 3:49 PM, an interview was conducted with Certified Nurse Assistant (CNA) 2, who stated that resident 25 had a pureed diet because she stopped eating and would let her food sit in her mouth. CNA 2 stated she had seen resident 25 eat cake sometimes. CNA 2 stated resident 25 would receive evening snacks like pudding, jello or graham crackers that could get soggy in her mouth. On 3/25/26 at 10:17 AM, an interview was conducted with Registered Nurse (RN) 2 who stated resident 25 was on a pureed diet because she had dementia and she would keep food in her mouth. RN 2 stated she crushed her medications because she would spit them out when given whole pills. On 3/25/26 at 1:45 PM, an interview was conducted with the Speech Therapist (ST) who stated that he did not screen resident 25 and that she did not have a swallow evaluation. The ST stated that normally he would have liked to do a swallow screen if a resident was downgraded to a pureed diet and that nursing should have contacted him for sure. The ST stated nurses could downgrade a diet if it was for safety, but then they should notify him to evaluate them. The ST stated that if a patient was on a pureed diet, unless there were exceptions, they would need their whole diet to be pureed and that chips and sandwiches were not on a pureed diet. The ST further stated that if a resident was letting food sit in their mouth, then having food that was not pureed would be a choking concern. On 3/25/26 at 2:26 PM, an interview was conducted with the Assistant Director of Nursing (ADON), who stated that they changed resident 25's diet to pureed because she was not eating well on a regular diet as evidenced by her cheeking her food, holding it in her mouth, and not chewing. The ADON stated she, the Director of Nursing (DON), and the nurse practitioner decided to downgrade resident 25's diet to pureed and the resident did well with that. The ADON stated she was aware that resident 25 ate some of her ice cream cone during an activity. On 3/26/26 at 8:46 AM, an interview was conducted with the Activities Director (AD) and she stated resident 25 was given an ice cream cone but that she only ate the softened parts and did not eat the whole ice cream cone. 2. Resident 37 was admitted to the facility on [DATE] with diagnoses which included dementia. Resident 37's medical record was reviewed 3/23/26 though 3/26/26. A BIMS [Brief Evaluation for Mental Status] Evaluation progress note dated 3/19/26 at 9:04 AM indicated resident 37's BIMS score was 3 which indicated a severe cognitive impairment. A physician's order dated 7/17/25 indicated, REGULAR diet MINCED & MOIST- Level 5 texture, Regular consistency, for loose teeth CUT UP FOODS. An Activities progress note dated 2/25/26 at 7:00 PM indicated, .Peanut cluster cooking social.She did enjoy eating the peanut cluster. On 3/26/26 at 8:46 AM, an interview was conducted with the AD who stated she did not know why resident 37 was on a pureed diet but that she was given a bird's nest snack during the activity yesterday, which the resident did not eat. The AD stated the bird's nest snack contained crunchy chow mein noodles with a peep and candy eggs on top. The AD stated that if there was a change in the resident's diet she would not know unless the nurse or CNA told her. On 3/26/26 at 9:23 AM, an interview was conducted with RN 2, who stated that resident 37 did not have the mental capacity to chew and that she required a lot of cueing when she ate. RN 2 stated that she did not know if the resident could chew crunchy noodles or candy but if the resident was served a food that was not minced and moist she would be concerned that resident 37 would choke. RN 2 stated she thought all snacks that were provided during activities went through the kitchen and they would make sure it was the ordered diet. On 3/26/26 at 9:38 AM, an interview was conducted with the Dietary Manager (DM) and he stated that Activities did their own snacks and that they did not ensure the residents were getting the correct diets. On 3/25/26 at 2:23 PM, an interview was conducted with the DON who stated they have a speech therapist they can call when a resident needed to be screened but he worked at another job and this facility was not a high priority for him. The DON stated they talked to the doctor about changing diet textures due to the limited availability of the speech therapist. The DON stated that staff were expected to follow the physician's orders.

Based on staff interview, review of medical records, and review of the policy and procedures, facility staff did not report to the State Agency bruising of unknown origin for 1 resident in the sample of 5. (Resident identifier: 1.) Findings include: A nursing note, dated January 27, 2025, for resident 1, noted that staff found bruising to the neck, back and sides. On 2/5/2025, the licensor interviewed Admin 1. Admin 1 stated the bruising to resident 1 ' s back and sides were present at the time of admission to the facility. Admin 1 stated that resident 1 was assessed and that the bruising to the anterior neck was caused by a shirt that resident 1 was wearing. Admin 1 stated that resident 1 was admitted to the hospital with a new diagnosis of hemophilia, which contributed to the bruising. Admin 1 stated because of the shirt and new diagnosis, resident 1 did not have an injury of unknown origin and that a critical incident was not reported to the State Agency within one business day as required. The licensor reviewed the facility ' s Abuse Reporting Policy which indicated that the state licensing/certification agency responsible for surveying/licensing the facility was to be notified within 24 hours of an allegation that does not involve abuse or result in serious bodily injury. On 2/5/2025 at 9:40 AM, the licensor conducted an interview with Admin 1. Admin 1 stated that the incident of unknown bruising was not reported to the office.

Based on observation, interview, record review, and facility policy review, the facility failed to provide fingernail care for 1 (Resident #15) of 2 residents sampled for activities of daily living (ADLs). Findings included: A review of a facility policy titled Fingernails/Toenails, Care of, dated February 2018, revealed The purposes of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections. The policy revealed, General Guidelines. 1. Nail care includes daily cleaning and regular trimming. 2. Proper nail care can aid in the prevention of skin problems around the nail bed and 4. Trimmed and smooth nails prevent the resident from accidentally scratching and injuring his or her skin. The policy further revealed, The following information should be recorded in the resident's medical record: 1. The date and time that nail care was given. 2. The name and title of the individual(s) who administered the nail care. 3. The condition of the resident's nails and nail bed. The policy revealed documentation should also include 4. Any difficulties in cutting the resident's nails. 5. Any problems or complaints made by the resident with his/her hands or feet or any complaints related to the procedure. 6. If the resident refused the treatment, the reason(s) why and the intervention taken. A review of Resident #15's Admission Record revealed the facility admitted the resident on 12/09/2022 with diagnoses including dementia and peripheral vascular disease (narrowed arteries). A review of a quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/16/2023, revealed Resident #15 had a Brief Interview for Mental Status (BIMS) score of 1, which indicated the resident had severe cognitive impairment. The MDS revealed the resident required extensive staff assistance with bed mobility, transfers, locomotion on and off their unit, dressing, toilet use, and personal hygiene. The MDS revealed the resident was totally dependent on staff for bathing. A review of Resident #15's care plan revealed a focus statement, revised on 06/06/2023, that indicated the resident had an ADL self-care performance deficit related to abnormal gait and balance, confusion, dementia, and weakness. The care plan revealed the resident required partial assistance with personal hygiene and interventions included instructions for staff to provide assistance. The care plan revealed the resident required total assistance with bathing, and interventions included instructions for staff to provide assistance. The care plan contained instructions for staff to report to a nurse if the resident refused care, evaluate for the potential causes and barriers, ask the resident why they were refusing, and attempt alternative approaches. An observation on 11/27/2023 at 10:27 AM revealed Resident #15's fingernails were long and appeared dirty. An observation on 11/27/2023 at 12:25 PM revealed Resident #15's fingernails were long with a brown substance under five of them. An observation on 11/28/2023 at 12:30 PM revealed Resident #15's fingernails were long and appeared dirty. An observation on 11/29/2023 at 11:05 AM revealed Resident #15's fingernails were long and brownish-colored. During an interview on 11/29/2023 at 11:41 AM, Certified Nursing Assistant (CNA) #1 stated Resident #15's nails were dirty. CNA #1 said staff should provide nail care and clean residents' nails if they appeared dirty. During an interview on 11/29/2023 at 11:59 AM, CNA #2 stated all personal care for residents should be completed during showers. She stated personal care included shaving and cleaning fingernails, noting she thought CNAs could cut fingernails, if needed. CNA #2 stated she had not provided a shower for Resident #15, but noted the resident did not refuse care. She stated if a resident refused care, it should be documented and reported to the Director of Nursing (DON). She stated when a resident refused, three different CNAs were to offer to provide care at different times to the resident, noting then a nurse would offer care. She said when a resident refused care, facility staff were supposed to document the refusals on a refusal form and in the electronic medical record. During an observation with CNA #2 on 11/29/2023 at 12:10 PM, CNA #2 stated Resident #15's fingernails were very long and needed care. During an interview on 11/30/2023 at 9:28 AM, CNA #4 stated Resident #15 received showers on the night shift, noting she gave the resident a shower a couple of weeks prior. CNA #4 stated she did not clean or cut Resident #15's fingernails during the shower in question because she did not think she was supposed to. During an observation and interview on 11/29/2023 at 12:18 PM, Registered Nurse (RN) #3 inspected Resident #15's nails and stated the resident's nails needed care. After Resident #15 stated their fingernails were tender, RN #3 expressed that the resident had possibly refused nail care due to nail tenderness. She stated if the resident had refused nail care, it should have been reported to a nurse. During an observation and interview on 11/29/2023 at 12:48 PM, the DON observed Resident #15's fingernails and said the resident's nails need to be cleaned and cut. She stated the resident's nails needed to be cleaned and cut on the resident's shower days. She stated if a resident refused care, a nurse should be informed. During an interview on 11/30/2023 at 9:03 AM, the Administrator stated he expected nail care to be offered with showers. The Administrator stated he spoke to some staff who said they had offered nail care and Resident #15 refused, but the refusals were not documented. The Administrator stated he observed Resident #15's nails before they were cleaned and cut and thought it had been longer than a couple of weeks since the resident's nails had been cut.

Based upon interview and record review it was determined that the facility did not ensure that the Infection Preventionist (IP) had completed specialized training in infection prevention and control. Specifically, the designated IP had not completed the designated training. Findings include: On 12/01/21 at 8:20 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that she was the Infection Preventionist (IP) for the facility. The DON stated she had not completed the specialized training from the Centers for Disease Control and Prevention (CDC) as she was new to her position as DON. The DON stated that the Assistant Director of Nursing (ADON) and Minimum Data Set (MDS) nurse were also new to their positions and had not completed the specialized training either.

Based on interview and record the review it was determined, for 2 of 15 sample residents, the facility did not ensure that patient privacy was protected. Specifically, another resident's name was used in another residents medical record. Resident identifier: 4 and 35. Findings include: Resident 4 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 4's record was reviewed on 11/28/21. A nurses note dated 11/28/21 stated LPN (Licensed Practical Nurse) [1] and RN (Registered Nurse) [1] came from different hallways and noted [Resident 4's name] and other resident [Resident 35's name] on the floor laying next to each other in the living room by the nurses station. On 11/30/21 at 10:34 AM, an interview was conducted with RN 3. RN 3 stated that when charting resident names were not used to protect the privacy of all residents. On 12/01/21 at 10:53 AM, an interview with the Director of Nursing (DON) was conducted. The DON stated that staff members should not be charting other resident's names in the chart. The DON stated that both residents were best friends and were getting up to take a walk together.

Based on interview and record review it was determined, for 1 of 15 sample residents, that the facility did not ensure that all allegations involving abuse were reported no later than 2 hour after the allegation was made but no later than 24 hours if the event that cause the allegation did not involve abuse or did not result in bodily injury. The finial investigation was provide to the State Survey Agency within 5 working days of the incident. Specifically, an incident involving a report of verbal abuse was not reported to the State Survey Agency (SSA) or investigated for 10 days after the incident. Resident identifier: 37. Findings include: Resident 37 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the facility reported incident revealed that the facility contacted the State Agency on 7/16/21 regarding an incident that occurred on 7/6/21. Resident 37's medical record was reviewed. A nursing progress note revealed on 7/6/21 at 3:55 AM, Pt (patient) complaining about nursing staff. Staff has taken care of each of pt's needs and requests. Pt is safe in bed. Staff has answered pt's call light each time in a timely manner. Staff spend over an hour in pt's room to help make pt. comfortable during last call light call. A Resident Advocate (RA) note dated 7/6/21 at 2:35 PM, Residents daughter and son in law came to RA's office with some concerns about how the night CNA's (Certified Nursing Assistant) had been acting on the night shift and their concerns for their mothers care. RA took these concerns to ADON (Assistant Director of Nursing), Administrator, PT (Physical Therapist) and DON (Director of Nursing). Staff will look into the concerns and do any disciplinary actions that are needed to fix any concerns. RA gave residents daughter her personal number to call her personally if there is any problems or concerns with her care. RA has followed up with staff and family to make sure there is communication and resolution with any concerns being taken care of. The final investigation for resident 37 was submitted to the SSA on 7/16/21. The timeline of events revealed that on 7/6/21 at 3:00 AM, a family member received a call from resident 37, who reported a CNA yelled at her. At 6:00 AM, the family member went to the facility and reported to the nurse that a resident 37 stated a night nurse yelled at her. At around 9:00 AM, the nurse notified the ADON and Administrator. At 9:30 AM, the family members returned to the facility to talk with the RA and report that resident 37 had called them during the night and reported a staff member yelled at her. At 10:00 AM, the RN notified the Administrator and the ADON of potential verbal abuse. At 12:00 PM, DON talked with the family and RA to address concerns regarding staff. The family told the DON and RA the same concerns as they did at 9:30 AM when they met with the RA. The DON told the family he would start an investigation. At 12:15 PM, the DON talked to resident 37, who answered no when asked if staff yelled at her last night. The DON Felt like she understood the questions and was alert and oriented. At 12:30 PM, the DON followed up with the RA and Administrator and It was decided that verbal abuse did not occur but we wanted to inform the Ombudsman of the situation and investigation. At 2:00 PM, the nurse called the ADON. The ADON interviewed the nurse. At 11:00 PM, the DON interviewed the CNA that was working the night of the allegation. On 7/7/21 the DON interviewed the other CNA and the DON follow up with the RA and Administrator regarding the findings. It was Determined that no verbal abuse occurred. On 11/30/21 at 11:33 AM, an interview was conducted with the RA. The RA stated that the facility staff investigated the incident on 7/6/21 as a potential abuse, because resident 37's family member reported verbal abuse by a staff member. The RA stated that the family member stated it was abuse because one of the staff members yelled at resident 37. The RA stated there was a call with the State Survey Agency Director because the ombudsman contacted the SSA. On 12/01/21 at 8:07 AM, an interview was conducted with the Administrator. The Administrator stated the facility completed an investigation and resident 37 said it wasn't abuse. The Administrator stated that he made the Ombudsman aware of the situation and the ombudsman talked to the State Survey Agency Director. The Administrator stated that the State Survey Agency Director had a conference call with the facility staff. The Administrator stated he was guided to report the abuse allegation and submit a final investigation. The Administrator stated he did not initially report the abuse because the investigation revealed there was no abuse within 2 hours of the report. The Administrator stated that he maybe learned about the abuse allegation about 9:00 AM but did not report by 11:00 AM because the resident stated she had not been yelled at. The Administrator stated that he did not report the abuse allegation because it was not abuse. [Note: The abuse allegation was reported to the nurse at 6:00 AM and there was no investigation within 2 hours.] On 12/1/21 at 9:00 AM, a follow up interview was conducted with the Administrator. The Administrator stated that he reviewed his timeline and he was made aware of the verbal abuse allegation at approximately 10:15 AM and was able to rule out abuse by 12:15 PM. The Administrator stated that the resident stated no one yelled at her so that was why it was not reported. The Administrator stated that he was not aware it was an abuse allegation when notified at 9:00 AM. The Administrator stated that all interviews were not completed within 2 hours but the allegation of abuse was unsubstantiated within 2 hours so there was no reason to report. The Administrator stated he reported the allegation and investigation to the SSA after the State Survey Agency Director instructed him to report it.

Based on interview and record review it was determined, for 1 of 15 sample residents, assessment was not accurately reflect the resident's status. Specifically, a resident receiving hospice services was not reflected on the resident's assessment. Resident identifier: 9. Findings include: Resident 9 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 9's medical record was reviewed on 11/30/21. The facility Matrix revealed that resident 9 was receiving hospice services. Resident 9's quarterly Minimum Data Set (MDS) dated [DATE] revealed resident was not receiving hospice care. There was no physician's order or care plan located in resident 9's medical record for hospice services. On 11/30/21 at 2:38 PM, an interview was conducted with Registered Nurse (RN) 3. RN 3 stated that resident 9 was receiving hospice services. RN 3 stated there should be an order and a card in the front of the resident's medical record with the hospice company and phone numbers. RN 3 stated that hospice companies leave notes in the resident's medical record. RN 3 stated resident 9 did not have notes and hospice staff communicated verbally with the facility staff. RN 3 stated there should be a plan of care regarding hospice and if there was not one, she would talk to the hospice company. On 11/30/21 at 3:08 PM, an interview was conducted with Licensed Practical Nurse (LPN) 2. LPN 2 stated that there were phone numbers for hospice companies on the Report sheet that the nurses used. LPN 2 stated that I believe most of the time will communicate verbally with hospice companies. LPN 2 stated she was not familiar with care plans and was unable to find a hospice care plan in resident 9's medical record. On 11/30/21 at 2:50 PM, an interview was conducted with the MDS coordinator. The MDS coordinator stated that she did comprehensive care plans with the MDS assessments. The MDS coordinator stated resident 9 received hospice services. The MDS coordinator stated that resident 9 had been receiving hospice services since at least March 2021. The MDS coordinator stated the hospice services should have been checked on the MDS in September 2021.

Based on interview and record review it was determined, for 1 of 15 sample residents, that the facility did not develop and implement a comprehensive person-centered care plan. Specifically, a resident did not have a hospice care plan. Resident identifier: 9. Findings include: Resident 9 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 9's medical record was reviewed on 11/30/21. The facility Matrix revealed that resident 9 was receiving hospice services. Resident 9's quarterly Minimum Data Set (MDS) dated [DATE] revealed resident was not receiving hospice care. There was no physician's order or care plan located in resident 9's medical record for hospice services. On 11/30/21 at 2:38 PM, an interview was conducted with Registered Nurse (RN) 3. RN 3 stated that resident 9 was receiving hospice services. RN 3 stated there should be an order and a card in the front of the resident's medical record with the hospice company and phone numbers. RN 3 stated that hospice companies leave notes in the resident's medical record. RN 3 stated resident 9 did not have notes and hospice staff communicated verbally with the facility staff. RN 3 stated there should be a plan of care regarding hospice and if there was not one, she would talk to the hospice company. On 11/30/21 at 3:08 PM, an interview was conducted with Licensed Practical Nurse (LPN) 2. LPN 2 stated that there were phone numbers for hospice companies on the Report sheet that the nurses used. LPN 2 stated that I believe most of the time will communicate verbally with hospice companies. LPN 2 stated she was not familiar with care plans and was unable to find a hospice care plan in resident 9's medical record. On 11/30/21 at 2:50 PM, an interview was conducted with the MDS coordinator. The MDS coordinator stated that she did comprehensive care plans with the MDS assessments. The MDS coordinator stated resident 9 received hospice services. The MDS coordinator stated that resident 9 should have a care plan regarding hospice from the hospice agency. On 12/01/21 at 8:29 AM, an interview was conducted with the Director of Nursing (DON). The DON stated usually hospice nurses were in the building 2 to 3 times per week. The DON stated that the hospice nurses and aides verbally communicated with staff. The DON stated hospice care plans should be provided to the facility. The DON stated that she texted the hospice yesterday to have them send the care plan information and visit notes. On 12/1/21 at approximately 8:45 AM, the DON provided a physician's order from the hospice agency that revealed resident 9 was to receive hospice services. The order was dated 2/28/21. It should be noted that nursing staff were unable to find the physician's order in resident 9's medical record.

Based on interview and record the review, for 1 of 15 sample residents, it was determined that the facility did not ensure that the qualified staff members were providing care for residents. Specifically, a nursing student provided assistance for a resident unsupervised by staff which resulted in an avoidable fall. Resident identifier: 18. Findings include: Resident 18 was admitted on [DATE] with diagnoses which included right femur fracture, history of falling, personal history of [CONDITION(S)], and [CONDITION(S)]. Resident 18's medical record was reviewed on 11/30/21. A nurses note dated 10/30/21 at 11:11 AM stated Pt (Patient) had an assisted fall in the bathroom with nursing assistant students from [name of school]. Pt was wearing regular socks, no grippy socks or shoes were put on before taking her to the bathroom and her feet slipped, so the NA (Nursing Assistant) students helped her to the ground. They notified me of the assisted fall and stated that she did not hit her head. No injuries noted. VSS (Vital Signs Stable) WNL (within normal limit). Will continue to monitor A&O's (Alert and Orientation) for 12 hours. Pt placed on 72 hour fall charting. MD (Medical Doctor) notified. On 12/01/21 at 11:24 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that nursing students should not have been working with a resident without a staff member present.

Based on interview and record review it was determined, for 1 of 15 sample residents, that the facility did not ensure each resident's drug regimen was free from unnecessary drugs. An unnecessary drug was any drug used without adequate monitoring. Specifically, a resident with two blood pressure medications were administered when the pulse was outside of the physician ordered parameters. Resident identifier: 23. Findings include: Resident 23 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] On 11/29/21 at 2:05 PM, an interview was conducted with resident 23. Resident 23 stated her blood pressure kept going down and she had to lay down to get her dizziness to go away. Resident 23 stated she did not think she had a change in medications. Resident 23's medical record was reviewed on 11/30/21. physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] 1. On 8/29/21, [MEDICATION(S)] Tablet 6.25 milligrams to give 1 tablet twice daily for [CONDITION(S)] and hypertension ([CONDITION(S)]). The order further revealed to hold the medication if resident 23's systolic blood pressure (SBP) was less than 100, if diastolic blood pressure (DBP) was less than 50 or if resident 23's heart rate (HR) was less than 60. 2. On 8/30/21, [MEDICATION(S)] Tablet to administer 20 milligram by mouth one time a day for [CONDITION(S)]. The order further revealed to hold the medication for SBP less than 100, DBP less than 50 or HR less than 60. Resident 23's Medication Administration Records (MAR)were reviewed: 1. September 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] a. On 9/13/21 with a heart rate of 58, b. On 9/14/21 with a heart rate of 57, c. On 9/16/21 with a heart rate of 59, d. On 9/19/21 with a heart rate of 50, e. On 9/20/21 with a heart rate of 57, f. On 9/21/21 with a heart rate of 56. The [MEDICATION(S)] was administered: a. On 9/14/21 with a heart rate of 57, b. On 9/17/21 with a heart rate of 57, c. On 9/20/21 with a heart rate of 57 d. On 9/21/21 with a heart rate of 56, e. On 9/30/21 with a heart rate of 57. 2. The October 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] a. On 10/8/21 with a heart rate of 58, b. On 10/14/21 with a heart rate of 59, c. On 10/23/21 with a heart rate of 58 d. On 10/25/21, the medication was administered twice with a heart rates of 58 and 54. The [MEDICATION(S)] was administered: a. On 10/14/21 with a heart rate of 59, b. On 10/23/21 with a heart rate of 58, c. On 10/25/21 with a heart rate of 58, d. On 10/26/21 with a heart rate of 57, e. On 10/28/21 with a heart rate of 57. 3. The November 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] a. On 11/9/21, the medication was administered twice with a heart rates of 55 and 56, b. On 11/10/21 with a heart rate of 57, c. On 11/15/21 with a heart rate of 58, d. On 11/21/21 with a heart rate of 59, e. On 11/24/21 with a heart rate of 59, f. On 11/30/21 with a heart rate of 57. The [MEDICATION(S)] was administered: a. On 11/2/21 with a heart rate of 54, b. On 11/9/21 with a heart rate of 55, c. On 11/10/21 with a heart rate of 57, d. On 11/24/21 with a heart rate of 59. On 12/1/21 at 8:26 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that blood pressure medications should be administered according to physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON stated that if the heart rate was outside of the parameters the medications should not be administered. The DON stated the medications should have been held.

Based on interview and record review, it was determined that the facility did not conduct COVID-19 testing of staff as frequently as required based on the parameters set forth by the Centers for Disease Control and Prevention (CDC). In addition, the facility did not document that staff testing was completed and the results of each staff test. Specifically, a staff member that was unvaccinated was not tested twice weekly when working at the facility. Findings include: On 12/01/21 at 10:15 AM, the staff testing was reviewed. A calendar provided by the facility revealed on 11/15/21 the COVID-19 county transmission rate was 19.8% which was red. On 11/22/21 the COVID-19 county transmission rate was 19.2% which was red. The facility was on outbreak testing for all staff. Record showed that on 11/29/21 the COVID-19 county transmission rate was 16.5% which was red and the facility was in outbreak testing for all staff. Staff member (SM) 4's testing was reviewed. SM 4 was documented as unvaccinated on the paperwork provided by the facility. The testing results revealed that SM 4 had a COVID-19 test on 11/21/21 where she tested positive. The testing results further revealed that SM 4 tested negative on 11/18/21. There was no other testing documented for SM 4 on the form provided. SM 4's work schedule was reviewed. SM 4 worked on 11/3/21, 11/6/21, 11/7/21, 11/10/21 and 11/14/21. On 12/01/21 at 12:21 PM, Human Resources (HR) Director was interviewed. HR Director stated that the facility was currently in outbreak status and all staff were required to have a COVID-19 test performed twice per week. HR Director stated that there was no documentation that SM 4 was tested for COVID-19 on the shifts worked prior to 11/18/21. HR Director stated that night shift staff had verbalized they were completing COVID-19 testing but did not document testing or test results. HR Director stated that SM 4 had been told she would be taken off the schedule if she did not start completing COVID-19 testing twice weekly, so she tested on [DATE].

Based on observation, interview and record review it, the facility failed to properly follow infection control practices to prevent COVID-19. Specifically, dietary staff members were observed to serve resident's meals without applying Personal Protective Equipment (PPE) and were observed to remove plate domes from resident rooms and placed them into the meal cart with unserved meals. In addition, residents were observed sitting closer than 6 feet in the dining room without masks. Resident identifiers: 4 and 5. Findings include: 1. On 11/17/2020 at 12:05 PM, an observation was made of the Dietary Manager (DM) in the 100 hall. The DM was observed to be wearing a surgical mask and safety glasses. The DM was observed to enter room [ROOM NUMBER] with a lunch meal tray. The DM was observed to place the meal tray in from of the resident on an over bed table. The resident was observed to not have a mask on. The DM was observed to removed the lids and plastic covering from the beverages. The DM was observed to removed the dome covering the plate. The DM was observed to place the dome in the meal cart. The meal cart was observed to have unserved meals in the cart. The DM was further observed to enter room [ROOM NUMBER] and place the meal tray in from of the resident. The resident did not have a mask on. The DM was observed to remove the coverings from the beverages and removed the dome covering the plate. The DM was observed to place the dome into the food cart with unserved food. 3. On 11/17/2020 at 12:13 PM, an observation was made of a Dietary Staff Member (DSM) in the 100 hall. The DSM was observed to be wearing a surgical mask and eye covering and not wearing gloves or a gown. The DSM was observed delivering meal trays between rooms with isolation precautions and non-isolated rooms, and placed the dome covering the plate in the meal cart. The meal cart was observed to have unserved meals in the cart. The meals were delivered in the following order: a. room [ROOM NUMBER] b. room [ROOM NUMBER] c. room [ROOM NUMBER] (isolation) d. room [ROOM NUMBER] e. room [ROOM NUMBER] f. room [ROOM NUMBER] (isolation) g. room [ROOM NUMBER] h. room [ROOM NUMBER] (isolation) On 11/17/2020 at approximately 12:15 PM, an interview was conducted with Certified Nursing Assistant (CNA) 1. CNA 1 stated that when delivering food tray all the items on the tray were left in the residents room until residents were done eating and then staff removed the tray. CNA 1 stated that the domes for plates were to be left in the resident room until the resident was finished eating. CNA 1 stated that staff removed all the dirty trays from residents rooms into a cart. CNA 1 stated that the domes were not to be removed and placed in the cart with unserved food. On 11/17/2020 at approximately 12:40 PM, an interview was conducted with Registered Nurse (RN) 2. RN 2 stated that residents who were new to the facility were on 14 day isolation, but not on precautions. RN 2 stated that they were on isolation to ensure that they did not have COVID-19. On 11/17/2020 at 12:45 PM, an interview was conducted with the DM. The DM stated that there had been no changes in the procedure to deliver residents meals since the COVID-19 pandemic began. On 11/17/2020 at 12:47 PM, an interview was conducted with the DSM. The DSM stated that if a resident was on precautions, meals were served in disposable containers, but no residents were on precautions in the building. On 11/17/2020 at 12:57 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that any staff members who went into isolation rooms needed to wear gloves, in addition to masks and eyewear, when they were within 6 feet of a resident. The DON stated that the plate domes were to be left in the resident rooms until all meals had been delivered to the residents, to avoid possible contamination in the meal cart. The DON stated that there should be a sign on the door of each new resident to remind staff to wear gloves, masks and eye coverings. The sign on the door of rooms 102, 109, 113, and 116 was titled New Admission 14-Day Quarantine and revealed that Staff Must: . Wear a mask mask before entering room (surgical mask), Wear eye shield or goggles, wear gloves and gown when providing direct contact care, Try and maintain 6' distance when applicable. 2. On 11/17/2020 at 11:45 AM, an observation was made of 2 residents in wheel chairs in the dining room. Residents 4 and 5 were observed less than 6 feet from each other without masks. Resident 4's was observed in his wheelchair parked between resident 5's table and his table. Resident 5 was observed in a geri chair, which was reclined to approximately 70 degrees, which did not allow resident 5 to move himself in the chair. Both residents were observed to wait until approximately 12:30 PM for assistance with eating. a. Resident 4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 4's medical record was reviewed on 11/18/2020. Resident 4 had a Minimum Data Set (MDS) assessment dated [DATE]. The MDS revealed that resident 4 required extensive assistance to complete all activities, including feeding himself, and that he had impairment to all four extremities. Resident 4 was unable to move himself in his wheelchair. b. Resident 5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 5's medical record was reviewed on 11/17/2020. Resident 5 had an MDS assessment dated [DATE], which revealed that resident 5 required extensive assistance to complete all activities, including feeding himself. On 11/17/2020 at approximately 12:15 PM, an interview was conducted with RN 1. RN 1 stated that all residents wore masks in the dining room until their food arrived. RN 1 stated that residents were to be placed 6 feet apart in the dining room. On 11/17/2020 at approximately 12:15 PM, an interview was conducted with CNA 1. CNA 1 stated that all residents were to be placed 6 feet apart in the dining room. On 11/17/2020 at 12:45 PM, an interview was conducted with the DM. The DM stated that each resident was placed at their own table to maintain social distance while in the dining room. On 11/17/2020 at 12:57 PM, the DON was interviewed. The DON stated that residents should maintain a 6 foot distance and wear masks to prevent the possible spread of COVID-19. The DON stated that staff should move residents who were too close together, particularly if the residents were not wearing masks. The DON stated that staff should remind residents to wear masks when they were in common areas or within 6 feet of other residents.

Based on observation, interview, and record review it was determined, for 2 of 21 sampled residents, that the facility did not ensure that the resident's environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents. Specifically, the facility did not provide adequate supervision to prevent falls from occurring and care planned interventions were not implemented. A resident experienced multiple falls and had to be transported to the emergency room after sustaining a laceration to the head. Resident identifiers: 11 and 22. Findings include: 1. Resident 11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 11's medical record was reviewed on 9/10/19. An admission Minimum Data Set (MDS) assessment dated [DATE], documented that resident 11 did not have a Brief Interview for Mental Status (BIMS) conducted. Resident 11 was assessed as rarely or never understood. In addition, the staff documented that resident 11 required extensive assistance of one to two people for activities of daily living. A Fall Score form dated 6/22/19, revealed resident 11 had a score of 75. (Note: Morse Fall Scoring of 45 or higher categorizes resident 11 as high risk for falling.) (Note: A baseline care plan was not developed when resident 11 was admitted to the facility. A fall care plan was not developed for resident 11 until 7/6/19.) A review of the Progress Notes and Care Plans for resident 11 documented the following entries: a. On 6/23/19 at 12:32 AM, Bed in low position and call light within reach. b. On 6/23/19 at 8:43 PM, Resident was found by the Certified Nursing Assistant (CNA) sitting on the fall mat leaning against her bed. (Note: No new interventions were implemented.) c. On 7/6/19 at 4:26 PM, Resident was observed on the ground at 3:15 PM. Resident was previously taking a nap in her bed. The resident across the hall witnessed resident 11 roll out of bed. Blanchable redness was noted on her forehead. Bed was in lowest position, floor mats were in place, and the call light was within reach at the time of the fall. A Care Plan Focus dated 7/6/19 and revised on 9/4/19, documented The resident has had an actual fall 9/4/19 with no apparent injury r/t (related to) Poor Balance, Poor Communication/comprehension, unsteady gait, weakness. The goal developed was, The resident will resume usual activities without further incident through the review date. An intervention developed for 7/6/19 was, Post fall interventions: Bed in Lowest Position. Post fall interventions: Educate Resident. Post fall interventions: Educate Family. (Note: The intervention to have resident 11's bed in the lowest position was implemented on 6/23/19.) d. On 7/7/19 at 10:03 AM, Resident had call light within reach and reminded often how to use it. Resident was alert and oriented to self. (Note: Resident 11 was assessed with [REDACTED]. A resident that was severely impaired cognitively would have a BIMS score of 0 to 7.) e. On 7/9/19 at 10:08 PM, Resident had call light within reach, bed lowered to the lowest position, and any unwanted obstacles were removed from the room. (Note: An Admission MDS assessment dated [DATE], documented that resident 11 required extensive assistance of one person for locomotion on and off the unit.) f. On 7/11/19 at 10:25 PM, Resident was sitting in the hallway by the nurses station. Resident had a jumpsuit on and had her arms inside her clothes. Resident was found lying on the floor in front of her wheelchair. Resident appeared to have slipped out of the wheelchair. A Care Plan intervention dated 7/11/19, documented Post fall interventions: Offer Snack/Drink. g. On 7/13/19 at 10:24 PM, Resident was on 72 hour charting for a recent fall. The resident was laying on the floor on the right side of the bed on her right shoulder. (Note: No new interventions were implemented.) h. On 7/16/19 at 9:25 PM, Resident had both of her hands in her clothing. It appeared that she was trying to get her arms free and she fell forward out of her chair in the living room. Resident reopened a skin tear on the right elbow. A Care Plan intervention dated 7/16/19, documented Post fall interventions: Clothing that is not too easily removed. i. On 7/28/19 at 11:13 PM, Licensed Practical Nurse witnessed resident fall out of her wheelchair after attempting to undress out of her shirt. Resident fell forward landing on her left side. Resident hit the side of her head. Resident had a skin tear on her left elbow and abrasions and bruising to her forehead. (Note: No new interventions were implemented.) j. On 8/5/19 at 4:49 PM, Resident was observed on the floor in her room near the bed. Resident was laying on the floor mat and had blood coming from her head. The Registered Nurse (RN) assessed and the resident had a laceration on the top of her head. First aid given by staff and resident was transported to the emergency room (ER) for possible stitches. k. On 8/5/19 at 6:43 PM, Resident returned from the ER after getting staples to the laceration on her scalp from the fall this afternoon. The ER performed a computed tomography scan of the residents head and neck which showed no injuries. (Note: No new interventions were implemented.) l. On 8/17/19 at 4:36 AM, A CNA found the resident laying on her left side on the floor mat. Resident had a left elbow skin tear. The bleeding was controlled with direct pressure. (Note: No new interventions were implemented.) m. On 8/21/19 at 2:02 PM, Resident was observed on the floor on the side of her bed by the CN[NAME] Resident was propping herself up on her right forearm. Residents forearm appeared red from pressure. A Care Plan intervention dated 8/22/19, documented Post fall interventions: Call light within Reach. (Note: The intervention to have resident 11's call light within reach was implemented on 6/23/19.) n. On 8/30/19 at 2:59 AM, Resident was found on the floor by her bed at 1:00 AM. Resident was face down. Resident has a new skin tear on her right elbow. (Note: No new interventions were implemented.) o. On 8/30/19 at 6:36 AM, Resident was found at 6:00 AM for the second time of the night. (Note: No new interventions were implemented.) p. On 9/4/19 at 9:59 AM, Resident tipped out of wheelchair at the nurses station today at 7:00 AM. Resident had a new skin tear to her left elbow and some redness to her forehead from bumping her head on a neighboring wheelchair. A Care Plan intervention dated 9/4/19, documented Provide activities that promote exercise and strength building where possible. Provide 1:1 (one on one) activities if bed bound. On 9/11/19 at 10:13 AM, an interview was conducted with the MDS coordinator. The MDS coordinator stated that a baseline care plan was not initiated for resident 11. The MDS coordinator stated that the first care plan regarding falls was initiated on 7/6/19. The MDS coordinator stated that he would complete the comprehensive care plans for the residents. On 9/11/19 at 10:41 AM, an interview was conducted with CNA 1. CNA 1 stated that she would try and keep resident 11 up in her wheelchair throughout the day. CNA 1 stated that when resident 11 was in her bed she would roll out. CNA 1 stated that resident 11 was on two hour checks. CNA 1 stated that the two hour resident checks were not charted. CNA 1 stated that if a resident had a fall she would chart the resident checks every thirty minutes. CNA 1 stated that a fall mat was implemented for resident 11 after her first fall out of bed. CNA 1 could not recall if there were any interventions prior to resident 11's first fall. CNA 1 further stated that resident 11 required full assistance with ADLs and was only oriented to herself. CNA 1 stated that resident 11 was not able to ambulate on her own and required a wheelchair. On 9/11/19 at 11:08 AM, an interview was conducted with RN 2. RN 2 stated that there were no interventions in place to keep resident 11 safe from falls. RN 2 stated that resident 11 should be dressed in one piece outfits to keep her from removing her clothes. RN 2 stated that the staff would try and keep resident 11 where they could see her. RN 2 stated that the staff had tried to put resident 11 in the recliner in the dayroom but resident 11 did not want to stay in the recliner. RN 2 stated that the staff would try and keep resident 11 active throughout the day. RN 2 stated that resident 11 was stiff and would try to get up from her wheelchair on her own. RN 2 stated that the floor nurses would up date the resident care plans. RN 2 stated that the admission nurse would implement the baseline careplans. RN 2 further stated that resident 11 had a Call don't fall sign in her room, bed rails, a fall mat, and two hour checks to ensure that resident 11 was dry. RN 2 stated the Call don't fall sign was placed in a resident room on the wall where the resident was able to see the sign. RN 2 stated that the sign was a reminder for the resident to use their call light for assistance. On 9/11/19 at 11:18 AM, an observation was conducted of resident 11's room. Resident 11's room was observed with the Call don't fall sign on the wall and a floor mat was observed on each side of the bed. Resident 11's bed did not have side rails present and the bed was not in the lowest position. 2. Resident 22 was admitted to the facility on [DATE] with a readmission on 6/16/17 with [DIAGNOSES REDACTED]. Resident 22's medical record was reviewed on 9/10/19. A Quarterly MDS assessment dated [DATE], documented that resident 22 had a BIMS score of 5. (Note: A resident that was severely impaired cognitively would have a BIMS score of 0 to 7.) In addition, the staff documented resident 22 required limited assistance of one person for bed mobility, locomotion on the unit, toilet use, personal hygiene, and dressing. Resident 22 required extensive assistance of one person for transfers and locomotion off the unit. A Fall Score form dated 1/10/19, documented resident 22 with a score of 50. (Note: Morse Fall Scoring of 45 or higher categorizes resident 22 as high risk for falling.) A review of the Progress Notes and Care Plans for resident 22 documented the following entries: A Care Plan Focus dated 10/17/18, 5/29/19, and revised on 5/30/19, documented (Resident 22) is at high risk for falls r/t weakness, limited mobility, recent left femur fracture. The goal developed was, Resident to have no falls unreported to MD (Medical Doctor) during facility stay. Staff and resident to practice injury prevention measures for resident during facility stay. The resident will be free of falls through the review date. The interventions developed for 10/17/18, Anticipate and meet The resident's needs. Be sure The resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. Ensure that the resident is wearing appropriate footwear such as shoes or non-skid socks when ambulating or mobilizing with w/c (wheelchair) or walker. Follow facility protocol. Encourage the resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility. A Care Plan intervention dated 1/29/19, documented Post fall interventions: Educate Resident. Post fall interventions: Every 2-hour comfort/toilet rounds. A Care Plan intervention dated 2/28/19, documented 'Call don't Fall sign in room, bed in lowest position, and call light within reach. a. On 5/2/19 at 12:50 AM, Resident came out to the nurses station to get help with her bed. Walking back into her room the resident tried to open the curtain and got caught on it and fell on the left side of her body. Resident landed on her left hip. Resident was not able to bare any weight. Resident complained of pain. Resident did not want to go to the ER at that time. b. On 5/2/19 at 11:03 AM, A portable X-ray was ordered. Resident 22 had left hip arthoplasty with displacement of the acetabular component. [MEDICAL CONDITION] trochanter of the left femur. The family has chosen to not proceed with surgical interventions. (Note: No new interventions were implemented.) c. On 5/15/19 at 3:53 AM, Resident 22 was found on the floor next to the bed sitting upright and yelling out. A Care Plan intervention dated 5/15/19, documented Post fall interventions: Every 1-hour comfort/toilet rounds. d. On 6/8/19 at 3:16 PM, RN heard resident yelling. Resident was observed sitting on the floor next to the bed. Resident was leaning on her right arm. Resident had a goose egg and bruising above her right eye, a skin tear on her right shin, and right elbow. A Care Plan intervention dated 6/8/19, documented Post fall interventions: Offer snack/drink. e. On 6/28/19 at 6:42 AM, Resident was found sitting on the floor next to the bed. Resident had a small skin tear on her left arm. (Note: No new interventions were implemented.) f. On 7/6/19 at 3:57 AM, The staff at the nurses station heard a noise of a wheelchair sliding. Resident was found on the floor next to her bed. (Note: No new interventions were implemented.) g. On 8/6/19 at 12:09 AM, Resident was heard from the nurses station calling for help. Resident was found near the bed on the floor laying on her left side. (Note: No new interventions were implemented.) h. On 8/13/19 at 3:47 PM, Resident was found calling for help. Resident was found next to her bed. (Note: No new interventions were implemented.) i. On 8/14/19 at 9:21 AM, Resident tried getting out of bed to go to the bathroom and slipped. A care plan intervention dated 8/14/19, documented Post fall interventions: Often used items within reach. j. On 8/22/19 at 3:10 AM, Resident was heard calling out for help from the nurses station. Resident was observed sitting on the floor next to the bed. Resident stated that she was transferring to her wheelchair and slipped out of bed. (Note: No new interventions were implemented.) k. On 9/2/19 at 1:19 PM, Resident was found at 9:15 AM. Resident was calling out and was observed on the floor next to the bed. Resident reported trying to go to the bathroom. A care plan intervention dated 9/2/19, documented Post fall interventions: Floor mats. (Note: The floor mat was documented in the incident report as being present during previous falls.) On 9/11/19 at 11:29 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that the admitting nurse completed the baseline care plan within 24 to 48 hours of admission. The DON stated that the resident care plan would be addressed at all the interdisciplinary team meetings (IDTs). The DON stated that the resident family, caregiver, and the resident were included in the IDT meeting. The DON stated that the floor nurse would be responsible for implementing the care plan. The DON further stated that the floor nurse was responsible for revising the care plan and implementing interventions when necessary. The DON stated that himself and the Assistant Director of Nursing reviewed the care plans and education was provided to the staff when necessary. No additional information was provided regarding interventions to prevent falls for resident 11 or resident 22. On 9/11/19 at 1:04 PM, an interview was conducted with CNA 1. CNA 1 stated that resident 22 was a one person assist with activities of daily living. CNA 1 stated that resident 22 tried to be independent. CNA 1 stated that resident 22 was oriented and able to make her needs known. CNA 1 stated that the staff took resident 22's walker away from her to help prevent falls. On 9/11/19 at 1:34 PM, an interview was conducted with RN 2. RN 2 stated that resident 22 used her call light if she required assistance. RN 2 stated that resident 22 would let staff assist her more. RN 2 stated that resident 22 had the floor mats in her room, the Call don't fall sign, and the staff checked on her every two hours. RN 2 stated that resident 22 was able to voice when she was needed to use the bathroom. RN 2 further stated that she would leave resident 22's blinds open during the day to help orient resident 22 to the time of day.

Based on observation, interview, and record review it was determined, for 1 of 21 sampled residents, that the facility did not ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. Specifically, the pain management provided to resident 23 was not effective and did not take into account non-verbal expressions of pain, particularly during wound care. Resident identifier: 23. Finding include: Resident 23 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 9/10/19 at 9:36 AM, resident 23 was interviewed. Resident 23 stated that his feet hurt like a Son of a gun when staff changed the bandages. Resident 23 stated that staff changed his bandages daily. Resident 23 stated that the medication he was offered did not help the pain. On 9/10/19 at 3:05 PM, resident 23 was interviewed. Resident 23 stated that that his feet hurt. Resident 23 stated that he had to ask for pain medication but the medication did not work. Resident 23 stated it hurt's like a son of a gun when the nurses changed the bandages on his feet. Resident 23 stated that he would like stronger pain medication before his feet were touched. Resident 23 stated that he did not always receive medication before bandage changes. Resident 23's feet were observed to be covered with his toes exposed. Resident 23's toes were observed swollen and the toe nails were thick and pulling up from the skin. The area between resident 23's toes was observed to be a blackish yellow with open wounds between the toes. There was some cotton observed between the toes. Resident 23's medical record was reviewed on 9/10/19. A care plan dated 8/13/19 revealed, (Resident 23) has potential for alteration in comfort r/t (related to) chronic ulcers of lower extremities, current infection, limited mobility. Some of the goals developed were, The resident will not have discomfort related to side effects of [MEDICATION NAME] through the review date. The resident will verbalize adequate relief of pain or ability to cope with incompletely relieved pain through the review date. The interventions developed were: 1. Administer [MEDICATION NAME] as per MD (Medical Doctor) orders. 2. Monitor/document for side effects of pain medication. 3. Monitor/record/report to Nurse and s/s (signs and symptoms) of non-verbal pain: Changes in breathing (noisy, deep/shallow, labored, fast/slow); Vocalizations (grunting, moans, yelling out, silence); Mood/behavior changes (more irritable, restless, aggressive, squirmy, constant motion); Eyes (wide open/narrow slits/shut, glazed, tearing, no focus); Face (sad, crying, worried, scared, clenched teeth, grimacing) Body (tense, rigid, rocking, curled up, thrashing). 4. Monitor/document for probable cause of each pain episode. Remove/limit causes where possible. 5. Identify, record and treat the resident's existing conditions which may increase pain and or discomfort. 6. Identify and record previous pain history and management of that pain and impact on function. Identify previous response to [MEDICATION NAME] including pain relief, side effects and impact on function. 7. Notify physician if interventions are unsuccessful or if current complaint is a significant change from residents past experience of pain. Resident 23's (MONTH) 2019 Medication Administration Record [REDACTED] a. A physician's orders [REDACTED]. The order was discontinued on 9/6/19. b. An active physician's orders [REDACTED].Give 2 tablet by mouth every 8 hours as needed for pain related to non-pressure chronic ulcer of other part of right foot with fat layer exposed. Resident's pain was documented when the Tylenol was administered. Resident 23's pain was documented as an 8 on 8/20/19, 8/27/19, and 8/31/19. Resident 23's (MONTH) 2019 MAR indicated [REDACTED] a. A physician's orders [REDACTED]. b. Resident 23's documented pain level was between 5 and 6 from 9/1/19 through 9/9/19 when the Tylenol was administered. On 9/10/19 at 4:06 PM, an observation was made of resident 23. Resident 23 was observed in his wheelchair in his room. Registered Nurse (RN) 1 was observed to enter resident 23's room with Licensed Practical Nurse (LPN) 1. RN 1 was observed to kneel on the ground in front of resident 23. LPN 1 was observed to kneel to the left side of resident 23. RN 1 stated to the surveyor as he started to cut off the dressing on the left foot that, it's quiet painful for him. Resident 23 was observed to raise his shoulders by his ears and close his eyes as RN 1 cut off the dressing. RN 1 was observed to ask resident 23 if he was having pain and if he wanted medication for his pain. Resident 23 stated what? RN 1 stated that all resident 23 had was Tylenol. Resident 23 stated he did not want any at this time. RN 1 stated I'll get you medication if it's still painful after. RN 1 removed the gauze under the dressing. Some of the gauze was observed to stick to the back of resident 23's Lower leg above the ankle. RN 1 stated he needed to use normal saline solution to remove the remaining dressing. RN 1 stated the back of resident 23's left lower leg above the ankle was a vascular wound that was weeping. RN 1 was observed to put the normal saline on resident 23's wound. Resident 23 was observed to take a deep breath and exhale. RN 1 asked Resident 23 is it painful? Resident 23 responded, yes. RN 1 was observed to ask resident 23 if he was okay. Resident 23 responded by shaking his head no. RN 1 was observed to remove a [MEDICATION NAME] swab from packaging and rub between resident 23's toes. RN 1 asked resident 23 if that hurt. Resident 23 stated no. Resident 23 was observed to flinch and pull his foot back while RN 1 was placing the [MEDICATION NAME] swab between resident 23's toes. Resident 23 was observed to move back and forth in his wheelchair taking deep breaths as RN 1 put the [MEDICATION NAME] swab between his toes. RN 1 was observed to tell resident 23 you're tough. Resident 23 was observed to have facial grimacing, with his eyes closed, while RN 1 put the [MEDICATION NAME] swab between the resident's toes and on top of his big toe. On 9/10/19 at 4:20 PM, RN 1 was observed to put cotton between resident 23's toes. Resident 23 was observed to have facial grimacing with repetitive raising and lowering of his head, and closed eyes as RN 1 was placing the cotton. RN 1 was observed to place a pad on the back of resident 23's ankle. The Nurse Practitioner (NP) was observed to enter the room. The NP asked resident 23 if RN 1 was doing a good job. Resident 23 was observed to respond by saying No. The NP asked resident 23 if he hurt. Resident 23 was observed not to respond. On 9/10/19 at 4:22 PM, the NP asked RN 1 if resident 23 was being followed by a wound care team. RN 1 replied Yes and stated the resident was on an antibiotic. RN 1 was observed to tell the NP that resident 23 was having pain. RN 1 stated to the NP that resident 23's [MEDICATION NAME] had recently been doubled. RN 1 stated to the NP that resident 23 received Tylenol for pain. RN 1 stated that he Would like to see something for pain when we change the dressing. The NP stated that he would defer all pain medication to the MD 1. RN 1 stated that the facility staff were changing the dressings on his feet daily. On 9/10/19 at 4:27 PM, an observation was made of RN 1 cutting off the dressing on resident 23's right foot. Resident 23's foot was black on the top and on the toes. RN 1 stated to the NP that [MEDICATION NAME] and wool was used between resident 23's toes. The NP was observed to tell RN 1 that he would defer to the wound clinic for wound care. RN 1 was observed to tell the NP that the raised area above the resident's big toe was new. The NP stated they could culture it and send it off (to the laboratory). The NP stated, We can maximize his medications. The NP stated, Pain management and blood flow to feet was what he was concerned about for this resident. The NP was observed to touch resident 23's leg and resident 23 was observed to flinch. The NP stated that wound care would address his feet and he would talk to MD 1 about pain medication because of the pain with dressing changes and changing the wound vac. On 9/10/19 at 4:40 PM, resident 23 stated that his pain was maybe an 8. RN 1 stated that he usually did not verbalize pain. RN 1 stated, You can just tell he's in pain and will pull away his foot. RN 1 stated, I feel bad for him. RN 1 stated he had been trying to get him more pain medication for the dressing changes. On 9/10/19 at 4:42 PM, RN 1 stated to resident 23, this is the part that hurts, I'm going to be as gentle as possible. Resident 23 was observed to open his eyes wide and then he closed them while grimacing and gritting his teeth together. RN 1 placed cotton between resident 23's toes. On 9/10/19 at 4:46 PM, RN 1 stated to resident 23 that they were all done. RN 1 was observed to ask resident 23 if he wanted a Tylenol. Resident 23 stated nah. On 9/10/19 at 4:52 PM, the Director of Nursing (DON) was observed to ask resident 23 about his pain. The DON used a facial chart to show resident 23 different pain levels. Resident 23 was observed to point to the 6 and stated he was at a 6. Resident 23's progress notes revealed the following entries: a. On 8/15/19 at 10:04 AM, .Pain: Patient verbalizes pain. Patient rates pain 5 on a scale of 0-10. Resident exhibits non-verbal signs of pain. b. On 8/16/19 at 7:03 AM, .Pain: Patient verbalizes pain. Patient rates pain 8 on a scale of 0-10. c. On 8/17/19 at 2:05 AM, .Pain: Patient verbalizes pain. Patient rates pain 5 on a scale of 0-10. d. On 8/17/19 at 7:03 AM, .Pain: Patient does not verbalize pain. Resident exhibits non-verbal signs of pain. Grimacing. e. On 8/19/19 at 5:23 PM, .Pain: Patient verbalizes pain. Patient rates pain 5 on a scale of 0-10. bilateral feet Resident exhibits non-verbal signs of pain. f. On 8/19/19 5:49 PM, .Wound care done to bilateral feet. Pt (patient) did better at elevating feet this afternoon, c/o (complaints of) pain in feet which was managed with Tylenol. g. On 8/19/19 at 10:52 PM, .Pain: Patient verbalizes pain. Patient rates pain 4 on a scale of 0-10. h. On 8/20/19 at 6:38 AM, .Pain: Patient verbalizes pain. Patient rates pain 8 on a scale of 0-10. bilateral feet pain managed with prn (as needed) tylenol Resident exhibits non-verbal signs of pain. i. On 8/22/19 at 10:32 AM, .Pain: Patient verbalizes pain. Patient rates pain 3 on a scale of 0-10. Resident exhibits non-verbal signs of pain. j. On 8/24/19 at 6:43 AM, .Pain: Patient verbalizes pain. Patient rates pain 5 on a scale of 0-10. bilateral feet Pain managed with prn tylenol and positioning. Resident exhibits non-verbal signs of pain. k. On 8/24/19 at 1:42 PM, .Pt's pain level is baseline, c/o pain in bilateral feet. Tylenol used to manage pain. l. On 8/25/19 at 6:40 AM, .Pain: Patient verbalizes pain. Patient rates pain 6 on a scale of 0-10. bilateral feet Resident exhibits non-verbal signs of pain. m. On 8/25/19 at 3:43 PM, .Pt's pain level is baseline, c/o pain in bilateral feet. Tylenol used to manage pain. He reports increased pain during wound care, while wearing boots, and when feet are elevated. Pt educated on importance of elevating feet and keeping heels floated for wound healing and 4+ weeping [MEDICAL CONDITION]. Though pt is non-compliant with those orders, when reminded he makes more effort to try to be compliant. n. On 8/26/19 at 12:25 AM, .Pain: Patient verbalizes pain. Patient rates pain 4 on a scale of 0-10. bilateral feet Resident exhibits non-verbal signs of pain. o. On 8/26/19 at 6:47 AM, .Pain: Patient verbalizes pain. Patient rates pain 8 on a scale of 0-10. bilateral feet Pt experienced increased pain this morning from normal. Resident exhibits non-verbal signs of pain. sharp, shooting, achey (sic). p. On 8/28/19 at 6:25 AM, .Pain: Patient verbalizes pain. Patient rates pain 5 on a scale of 0-10. bilateral feet Tylenol 1000 mg given for pain. Pain worse during wound care. Resident exhibits non-verbal signs of pain. q. On 8/30/19 at 1:16 AM, .Pain: Patient verbalizes pain. Patient rates pain 5 on a scale of 0-10. BLE (bilateral lower extremities). r. On 8/31/19 at 1:59 AM, .Pain: Patient verbalizes pain. Patient rates pain 4 on a scale of 0-10. BLE . s. On 9/2/19 at 2:56 PM, Pt was give 2 500mg tablets of tylenol 30 minutes prior to changing his dressings on his feet. pt shows through facial expression and stating that he is in a lot of pain. Pt constantly pulls his legs in toward him while doing his wounds. t. On 9/3/19 at 1:01 AM, .Pain: Patient does not verbalize pain. Patient rates pain 0 on a scale of 0-10. Resident exhibits non-verbal signs of pain. non verbal display of grimacing and withdrawal. u. On 9/3/19 at 6:53 AM, .Pain: Patient verbalizes pain. Patient rates pain 6 on a scale of 0-10. BLE Pt c/o BLE pain, especially during wound care. Resident exhibits non-verbal signs of pain. v. On 9/4/19 at 6:40 AM, .Pain: Patient verbalizes pain. Patient rates pain 7 on a scale of 0-10. general achy,sharp Resident exhibits non-verbal signs of pain. holds breath, grunts, grimices (sic). w. On 9/5/19 at 7:07 AM, .Pain: Patient verbalizes pain. Patient rates pain 4 on a scale of 0-10. BLE Resident exhibits non-verbal signs of pain. x. On 9/5/19 at 2:25 PM a physicians note from MD 1 revealed, .Plan: .Pain due to severe [MEDICAL CONDITION], wounds, [MEDICAL CONDITION] - Increase [MEDICATION NAME] from 300mg TID (three times daily) to 600mg TID. y. On 9/6/19 at 12:26 AM, .Pain: Patient verbalizes pain. Patient rates pain 5 on a scale of 0-10. BLE. z. On 9/6/19 at 6:47 AM, .Pain: Patient verbalizes pain. Patient rates pain 7 on a scale of 0-10. BIL (sic) legs Resident exhibits non-verbal signs of pain. grimacing, guarding. aa. On 9/6/19 at 9:40 AM, pt c/o increased pain. MD increases [MEDICATION NAME] to 600mg TID. (Local pharmacy) and pt notified. bb. On 9/7/19 at 6:30 AM, .Pain: Patient does not verbalize pain. Resident exhibits non-verbal signs of pain. grimmices (sic). cc. On 9/8/19 at 6:49 AM, .Pain: Patient verbalizes pain. Patient rates pain 7 on a scale of 0-10. bilateral feet pt c/o foot pain which is increased with wound care and elevation. Resident exhibits non-verbal signs of pain. dd. On 9/9/19 at 6:50 AM, .Pain: Patient verbalizes pain. Patient rates pain 6 on a scale of 0-10. bilat feet Increased pain with wound care. Resident exhibits non-verbal signs of pain. ee. On 9/10/19 at 4:20 AM, .Pain: Patient does not verbalize pain. Patient rates pain 0 on a scale of 0-10. On 9/10/19 at 5:00 PM, RN 1 was interviewed. RN 1 stated that he had just talked to the wound nurse about resident 23's pain. RN 1 stated the facility recently hired a new set of physician's. RN 1 stated he did not feel the [MEDICATION NAME] helped with resident 23's pain during the dressing change and when resident 23 went to the wound clinic. RN 1 stated the wound nurse told him he was going to contact MD 1 regarding resident 23's pain during dressing changes. RN 1 stated that MD 2 was contacted and he increased resident 23's [MEDICATION NAME]. RN 1 stated the NP asked for the facility staff to contact MD 1 in regards to pain medication orders. RN 1 stated that resident 23 usually stated that he was okay during a dressing change but noticed his eyes were big and his body was stiff which demonstrated pain. On 9/11/19 at 7:19 AM, the Wound Nurse (WN) was interviewed. The WN stated he had talk to the wound care doctor and the wound care doctor told him he would send over an order for [REDACTED]. The WN stated that today was the first time he had contacted a physician regarding pain medication. The WN stated the nurses had asked MD 2 for pain medication for resident 23, but he was not sure how many times they had made the request. On 9/11/19 at 9:39 AM, an interview was conducted with a Wound Care Technician (WCT) from the wound clinic used to provide treatment for [REDACTED]. The WCT stated she was not sure if resident 23 received pain medication. The WCT stated that resident 23's son had discussed pain medication with the Wound Care Physician. The WCT stated she had observed resident 23 during dressing changes at the wound clinic and that resident 23 did not verbalize pain but expressed pain physically. The WCT described resident 23's physical demonstrations of pain as wiggling around, facial grimacing, and gritting his teeth during wound dressing changes. On 9/11/19 at 10:05 AM, an interview was conducted with MD 1. MD 1 stated his first day in the facility was 9/5/19. MD 1 stated he was notified of resident 23's pain for the first time on 9/5/19. MD 1 stated he had talked with a nurse at the facility about resident 23's pain. MD 1 stated he assessed resident 23's pain and resident 23 described pain that was more consistent with [MEDICAL CONDITION]. MD 1 stated resident 23 described his pain as pins and needles which was more neuropathic pain. MD 1 stated he increased resident 23's [MEDICATION NAME] to alleviate the pain. MD 1 stated, I understand they (facility staff) were trying to control his pain and balance his pain with also not sedating him. MD 1 stated he was unaware that resident 23 was experiencing pain during dressing changes and would have looked into that a little more and addressed that pain. On 9/11/19 at 10:13 AM, the DON was interviewed. The DON stated he had not been notified that resident 23 was having pain during wound dressing changes. The DON stated resident 23's pain during dressing changes should be directly communicated to the physician. The DON stated the nurses should call the physician or use the communication form to notify the physician regarding a resident's pain. The DON stated resident 23 did not have narcotic pain medication prior to admission because resident 23's daughter was caring for him and taking his pain medication. The DON stated the Wound Care physician was contacted that morning and was told the Wound Care physician was going to provide orders for pain medication. The DON stated he was not aware why the Wound Care physician did not provide orders prior to today for pain management. The DON stated the facility had another medical director prior to 9/1/19 who was upset his contract was ending and refused to sign things. On 9/16/19, the facility provided the survey team additional information regarding resident 23. The additional information included a form titled, Therapists progress notes that were from the wound clinic and dated 8/15/19. This form included a statement that resident 23 had tolerated the procedure well at wound care and that the resident verbalized understanding. Additional information provided by the facility on 9/16/19, included a statement from MD 1. MD 1's written statement was, Clarification regarding cognition: Based on his (resident 23) detailed level of description of the process of his wound care and his detailed description of his dislike for the sounds he hears with wound care, I believe that cognitively he is adequately oriented to be able to express if his pain is inadequately controlled during wound care. Given his baseline dementia and prior reported difficulty with self-control when requesting narcotics, I recommend caution in prescribing narcotics for (resident 23) as he is especially vulnerable to dependency and inappropriate use upon eventual discharge. I would prefer to focus on titrating neuropathic pain meds as appropriate to manage pain, with continued use of PRN Tylenol for pain.MD 1's name was typed. (Note: There was no information in resident 23's medical record regarding a concern of narcotics. In addition, there was no information about resident 23 not liking the sound of the dressing changes in the medical record.) Additional information provided on 9/16/19 was a form titled, Occupational Therapy (OT) OT Evaluation & Plan of Treatment dated 8/13/19, revealed Pain at rest: Intensity = 5/10.Pain with Movement Intensity = 5/10.Pain Assessment method = Patient verbalized pain level; Does pain limit patient's functional activities? = Yes; IDT (interdisciplinary team) Pain interventions - unknown. Additional information provided on 9/16/19 was a form titled, OT treatment encounter note, dated 9/12/19. The survey team exited the facility on 9/11/19. The note revealed, Upon entering patients room patient was noted to be in his wheelchair. Patient looked as if he was in pain and patient was asked if he was in pain. Patient stated, 'yeah I'm hurting'. He was then asked, 'how bad is it' and he replied, 'how do you guys do it here'? When told that we use 0-10 he stated, 'it's a 50'! Clinician stated, 'wow it must be pretty bad' and patient stated, 'yeah'. When asked about what a pain pill might do for him he first stated, 'it would take aware all the good stuff. I don't take them'. Patient was the (sic) asked if the pain pill would help with his pain he stated, 'yes'. When asked if he wanted a pain pill he said, 'no'. Patient demonstrated understanding of pain scale and that a pain pill could help, but he refused treatment. (Note: There was no information in resident 23's medical record regarding resident 23 being assessed for pain medication. In addition, there was no information regarding other interventions to alleviate the pain during dressing changes.)