Every finding on record at Suring Health and Rehab Center

Based on observation, staff interview, and record review, the facility did not maintain an infection prevention and control program designed to prevent the development and transmission of communicable disease and infection for 6 residents (R) (R12, R13, R2, R7, R14, and R15) of 12 sampled residents.R12 had a gastric tube. An enhanced barrier precautions (EBP) sign was not posted outside the entrance to R12's room. R12's care plan stated R12 was on universal precautions.R13 had a right heel wound with daily dressing changes. An EBP sign was not posted outside the entrance to R13's room. R13's care plan stated R13 was on universal precautions.R2 had a colostomy. An EBP sign was not posted outside the entrance to R2's room. R2's care plan stated R2 was on universal precautions.R7 had wounds that required daily dressing changes. An EBP sign was posted outside the entrance to R7's room. A PPE cart in R7's room contained a contact/isolation sign. R7's care plan stated R7 was on universal precautions. A PPE cart in R14's room contained a contact precautions sign. R14's medical record indicated contact precautions were discontinued in May 2026.A PPE cart in R15's room contained a contact precautions sign. R15's medical record indicated contact precautions were discontinued in May 2026.Findings include:The facility's Transmission-Based (Isolation) Precautions policy, revised 6/4/24, indicates: 1. Facility staff will apply transmission-based precautions (TBP), in addition to standard precautions, to residents who are known or suspected of being infected or colonized with certain infectious agents requiring additional controls to prevent transmission. 2. The facility will use standard approaches as defined by the Centers for Disease Control and Prevention (CDC) for TBP: airborne, contact, and droplet precautions. The category of TBP will determine the type of personal protective equipment (PPE) to be used .e. Signage that includes instructions for use of specific PPE will be placed in a conspicuous location outside the resident's room, wing, or facility-wide. Additionally, either the CDC category of TBP or instructions to see the nurse before entering will be included in the signage.The facility's Enhanced Barrier Precautions policy, revised 9/9/25, indicates: It is the guideline of this facility to implement enhanced barrier precautions (EBP) for the prevention of transmission of multidrug-resistant organisms (MDROs) .2. Initiation of EBP: .b. An order for EBP will be obtained for residents with any of the following .wounds .feeding tubes, ostomies, and indwelling medical devices. 3. Implementation of EBP: a. Make gowns and gloves available immediately near or outside the resident's room.1. R12 was admitted to the facility on [DATE] and had diagnoses including gastrostomy status and irritant contact dermatitis due to friction or contact with body fluids. A care plan, revised 4/1/25, indicated R12 was on EBP due to a feeding tube. The care plan contained an intervention, dated 12/15/25, to maintain universal precautions when providing resident care.On 6/2/26, Surveyor reviewed a staff communication list that indicated R12 was on EBP.On 6/2/26 at 9:15 AM, Surveyor did not observe an EBP sign posted near the entrance to R12's room. Surveyor observed R12's room multiple times during the day and noted an EBP sign was still not posted at 4:00 PM when Surveyor exited the facility.On 6/2/26 at 2:20 PM, Surveyor interviewed Director of Nursing (DON)-B who verified R12 had a gastric tube and should have an EBP sign posted outside the entrance to R12's room. 2. R13 was admitted to the facility on [DATE] and had diagnoses including pressure ulcer right heel stage 3 and non-pressure chronic ulcer of unspecified part of left lower leg limited to breakdown of skin. R13's Minimum Data Set (MDS) assessment, dated 3/23/26, stated R13 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating intact cognition.A care plan, revised 5/14/26, indicated R13 was on EBP due to a right heel unstageable pressure ulcer. The care plan contained an intervention, dated 10/9/25, to maintain universal precautions when providing resident care.R13's medical record cotanined the following wound care order: ~ Stage 3 right heel wound: Cleanse wound with normal saline, pat dry, apply Santyl to wound bed, cover with ADB and wrap in Kerlix once daily and as needed for wound care (dated 5/20/26)On 6/2/26 at 9:15 AM, Surveyor did not observe EBP signage posted near the entrance to R13's room. Surveyor observed R13's room multiple times during the day and noted an EBP sign was still not posted at 4:00 PM when Surveyor exited the facility.On 6/2/26 at 1:09 PM, Surveyor interviewed R13 who indicated their wound dressing is changed daily by staff. R13 did not recall an EBP sign posted on their door. On 6/2/26 at 1:38 PM, Surveyor interviewed DON-B who indicated R13 had a wound with a daily dressing change and an EBP sign should be posted near the entrance to R13's room. DON-B indicated R13 was not on universal precautions as indicated in R13's care plan. 3. R2 was admitted to the facility on [DATE] and had diagnoses including Crohn's disease of the large intestine and history of methicillin-resistant Staphylococcus aureus (MRSA) infection. A care plan, revised 5/27/26, indicated R2 was on EBP due to a colostomy. The care plan contained an intervention, dated 6/20/23, to maintain universal precautions when providing resident care.On 6/2/26, Surveyor reviewed a staff communication list that indicated R2 was on EBP.On 6/2/26 at 9:15 AM, Surveyor did not observe an EBP sign posted near the entrance to R2's room. Surveyor observed R2's room multiple times throughout the day and noted an EBP sign was still not posted at 4:00 PM when Surveyor exited the facility.On 6/2/26 at 11:35 AM, Surveyor interviewed Registered Nurse (RN)-H who indicated R2 was on EBP and had an ostomy. On 6/2/26 at 11:45 AM, Surveyor interviewed DON-B who indicated R2 was on EBP due to a colostomy. DON-B verified there should be an EBP sign posted near the entrance to R2's room. 4. R7 was admitted to the facility on [DATE] and had diagnoses including cellulitis, lymphedema, and irritant contact dermatitis. A care plan, dated 6/20/23, did not indicate R7 was on EBP or contain a wound focus. The care plan contained an intervention, dated 9/20/24, to maintain universal precautions when providing resident care.On 6/2/26, Surveyor reviewed a staff communication list that indicated R7 was on EBP.R7's medical record contained the following wound care orders: ~ Left posterior thigh wound: Cleanse wound with normal saline, pat dry, apply Aquacel to wound bed then apply sacral border foam dressing every shift and as needed with incontinence (dated 4/27/26)~ Right anterior thigh wound: Cleanse wound with normal saline, pat dry, apply house stock barrier cream to skin every shift and as needed (dated 5/27/26)~ Right lower leg wound: Cleanse with normal saline and use skin prep to wound. Cover with ABD pad daily and as needed (dated 5/31/26)On 6/2/26 at 9:15 AM, Surveyor did not observe an EBP sign posted near the entrance to R7's room. Surveyor observed a contact/isolation sign on top of a PPE cart in R7's room. Surveyor observed R7's room multiple times during the day and noted an EBP sign was still not posted at 4:00 PM when Surveyor exited the facility.On 6/2/26 at 9:52 AM, Surveyor observed a housekeeper cleaning R7's room without a gown. On 6/2/26 at 2:20 PM, Surveyor interviewed DON-B who indicated R7 was on EBP for wounds that required daily dressing changes. DON-B indicated a contact/isolation sign should not be on the PPE cart in R7's room. DON-B also indicated R7's care plan should include EBP and wound care interventions.5. R14 was admitted to the facility on [DATE] and had diagnoses included chronic obstructive pulmonary disease (COPD), respiratory failure with hypoxia, panlobular emphysema, pneumonia, and pulmonary emboli.A care plan, dated 9/20/24, indicated R14 had risk for exposure to infection/illness from the community. The care plan contained an intervention, dated 9/20/24, to maintain universal precautions when providing resident care.On 6/2/26 at 9:15 AM, Surveyor observed a contact precautions sign on top of a PPE cart in R14's room. Surveyor observed R14's room multiple times throughout the day and noted the contact precautions sign was still present at 4:00 PM when Surveyor exited the facility.On 6/2/26 at 1:38 PM, Surveyor interviewed DON-B who indicated R14 was not on precautions. DON-B indicated the contact/isolation sign should have been removed from R14's room in May 2026. DON-B indicated R14's roommate had been on contact isolation for possible pink eye and became asymptomatic the end of May.6. R15 was admitted to the facility on [DATE] and had diagnoses including cerebral infarct, encephalopathy, and hemiplegia.A care plan, dated 2/25/25, indicated R15 had risk for exposure to infection/illness from the community. The care plan contained an intervention, dated 3/20/25, to maintain universal precautions when providing resident care.On 6/2/26 at 9:15 AM, Surveyor observed a contact precautions sign on top of a PPE cart in R15's room. Surveyor observed R15's room multiple times during the day and noted the contact precautions sign was still present at 4:00 PM when Surveyor exited the facility.On 6/2/26 at 1:21 PM, Surveyor interviewed Certified Nursing Assistant (CNA)-L who was not aware R15 was on precautions. CNA-L indicated CNA-L needed to speak with the nurse to confirm if CNA-L needed to wear PPE in R15's room. On 6/2/26 at 1:38 PM, Surveyor interviewed DON-B who indicated R15 was not on precautions. DON-B indicated the contact/isolation sign should have been removed in May 2026. DON-B indicated R15 had been on contact isolation precautions for possible pink eye that cleared up the end of May.

Based on staff interview and record review, the facility did not provide pharmaceutical services to ensure the accurate administration of medication. This practice had the potential to affect more than 4 of the 40 residents residing in the facility.The facility's controlled substance record books were missing signatures for narcotic counts.Findings include:The facility's Controlled Substance Administration and Accountability policy, revised 4/15/24, indicates: It is the policy of this facility to promote safe, high-quality patient care, compliant with state and federal regulations regarding monitoring the use of controlled substances. The facility will have safeguards in place in order to prevent loss, diversion, or accidental exposure .All controlled substances are accounted for in one of the following ways: .ii. All controlled substances obtained from a non-automated medication card or cabinet are recorded on the designated usage form. Written documentation must be clearly legible with all applicable information provided .h. The controlled drug record serves the dual purpose of recording both narcotic disposition and patient administration .j. The charge nurse or designee conducts a daily visual audit of the required documentation of controlled substances .b. Areas without automated dispensing systems utilize a substantially-constructed storage unit with two locks and a paper system for 24-hour recording of controlled substance use .Inventory verification .b. For areas without automated dispensing systems, two licensed nurses account for all controlled substances and access keys at the end of each shift.On 6/2/26 at 9:43 AM, Surveyor reviewed narcotic signature books for medication cart A and noted staff verification signatures were missing in the following books on the following dates:Book 25: 3/2/26, 3/3/26, 3/5/26-3/8/26, 3/14/26-3/29/26, 4/7/26-4/9/26, 4/21/26-4/22/26, 4/24/26-4/25/26, 4/29/26, 5/1/26, 5/5/26, 5/6/26, 5/9/26-5/12/26, and 5/14/26Book 26: 3/10/26, 3/11/26, 3/17/26, 3/25/26, 3/29/26, 3/30/26, 3/31/26, 4/4/26, 4/5/26, 4/7/26-4/11/26, 4/14/26, 4/21/26, 4/22/26, 4/24/26, 4/25/26, 4/29/26, 5/1/26, 5/6/26, 5/9/26-5/11/26, 5/14/26, 5/18/26, and 5/24/26-5/25/26Book 27: 4/17/26, 4/21/26, 4/23/26, 4/27/26, 4/28/26, 4/29/26, 5/1/26, 5/5/26, 5/6/26, 5/8/26, 5/9/26-5/12/26, 5/14/26, 5/18/26, 5/21/26, and 5/24/26On 6/2/26 at 9:43 AM, Surveyor reviewed narcotic signature books for medication cart B and noted staff verification signatures were missing in the following books on the following dates:Book 24: 3/8/26, 3/10/26, 3/11/26, 3/13/26, 3/21/26- 3/26/26, 3/27/26, 3/29/26, 4/2/26, 4/7/26, 4/8/26, 4/11/26, 4/13/26, 4/14/26, 4/21/26-4/22/26, 4/24/26-4/30/26, 5/3/26, 5/5/26-5/6/26, 5/15/26, 5/20/26, and 5/25/26Book 25: 4/5/26, 4/7/26-4/9/26, 4/11/26, 4/13/26, 4/14/26, 4/21/26, 4/22/26, 4/24/26-4/27/26, 4/29/26-5/1/26, 5/3/26, 5/5/26-5/6/26, 5/14/26, and 5/20/26On 6/2/26 at 9:44 AM, Surveyor interviewed Licensed Practical Nurse (LPN)-K who indicated nurses are required to count narcotics in medication carts with another nurse at the beginning and end of each shift. LPN-K indicated nurses signing in and signing out are required to sign the controlled substance record book acknowledging the narcotic count. LPN-K acknowledged there were multiple missing signatures in the controlled substance record books.On 6/2/26 at 11:10 AM, Surveyor reviewed missing signatures in the controlled substance record books for medication carts A and B with Director of Nursing (DON)-B who indicated 2 nursing staff are required to count narcotics and sign medication controlled substance record books at each change of shift. DON-B reviewed and acknowledged the missing signatures.

Based on observation, staff and resident interview, and record review, the facility did not ensure the resident environment remained as free of accident hazards as possible for 3 residents (R) (R3, R4, and R10) of 3 sampled residents.Staff did not use a gait belt while assisting R3 with a transfer.On 4/4/26, R4 fell out of bed and fractured their right humerus (long bone in the upper arm that extends from the shoulder to the elbow). Staff indicated the bed malfunctioned and/or the mattress moved during cares. An intervention was not added to R4's care plan post-fall.R10 fell on 4/16/26. An intervention was not added to R10's care plan post-fall.Findings include:The facility's Safe Resident Handling/Mobility/Transfers policy, revised 11/29/23, indicates: .Mechanical lifting equipment or other approved transferring aids will be used based on the resident's needs to prevent manual lifting, except in medical emergencies .Resident lifting and transferring will be performed according to the resident's individual plan of care. The facility's Accidents and Supervision policy, revised 10/8/24, indicates: .Identification of Hazards and Risks: a. All staff are to be involved in observing and identifying potential hazards in the environment, while taking into consideration the unique characteristics and abilities of each resident. b. The facility should make reasonable efforts to identify the hazards and risk factors for each resident .Implementiation of Interventions .d. Documenting interventions (e.g. plans of action developed through the QAA committee or care plans for the individual resident) .The facility's Bed Maintenance and Inspections policy, revised 3/1/25, indicates: It is the policy of this facility to conduct regular inspections of all bed frames, mattresses, and bed rails if any as part of a regular maintenance program to identify and avoid areas of possible entrapment .Bed frame, mattress, and bed rail inspections will be conducted upon each item entering the facility and then placed on a regularly scheduled inspection and maintenance cycle according to the manufacturer's recommendations, to include manufacturer's timeframe recommendations. 1. R3 was admitted to the facility on [DATE] and had diagnoses including metabolic encephalopathy, hemiplegia and hemiparesis, aphasia, and history of CVA (otherwise known as stroke). R3's Minimum Data Set (MDS) assessment, dated 5/12/26, stated R3 had a Brief Interview for Mental Status (BIMS) score of 6 out of 15, indicating severe cognitive impairment. A self care deficit related to cerebrovascular accident (CVA) (stroke) care plan, revised 1/31/26, contained an intervention to transfer with the assistance of 1 staff with a Sara lift. A fall risk care plan, revised 10/3125, indicated R3 was at risk for falls, accidents, and incidents.On 6/2/26 at 1:34 PM, Surveyor observed Certified Nursing Assistant (CNA)-J transfer R3 from wheelchair to toilet via Sara lift. CNA-J moved the lift in front of R3's wheelchair and assisted R3 by lifting up the back of R3's pants. After CNA-J finished the transfer, Surveyor asked if R3 had a gait belt. CNA-J indicated maybe somewhere in the room. Surveyor observed a gait belt on R3's nightstand.On 6/2/26 at 1:40 PM, Surveyor interviewed Director of Nursing (DON)-B who confirmed staff should use a gait belt and not lift a resident up by the back of their pants. 2. R4 was admitted to the facility on [DATE] and had diagnoses including weakness, obesity, and essential tremor, and chronic obstructive pulmonary disease (COPD). R4's MDS assessment, dated 3/27/26, stated R4 had a BIMS score of 11 out of 15, indicating moderate cognitive impairment. A care plan, revised 8/15/25, indicated R4 had an activities of daily living (ADL) self-care performance deficit related to chronic respiratory failure with hypoxia. The care plan contained an intervention (dated 10/7/24) for assist of 2 staff with bed mobility. A falls care plan, dated 6/20/24, contained revised interventions (dated 4/28/26) to follow therapy recommendations for transfers - Hoyer lift with 2 staff; and physical therapy (PT)/occupational therapy (OT) to evaluate and treat as ordered or as needed (PRN). A progress note, dated 4/4/26 at 11:55 AM, indicated Medication Technician (MT)-F informed the nurse that R4 was on the floor. The nurse went to R4's room and observed R4 on their backside on the floor by the side of the bed. CNA-G had assisted R4 to the ground. R4 had a skin tear on the left forearm caused by metal from a bracelet. R4 denied hitting their head and any other injuries at the time. Staff transferred R4 back to bed via Hoyer lift and noted R4 was comfortable.A progress note, dated 4/4/26 at 5:11 PM, indicated R4 fell from bed at 9:30 AM. R4 fell to the right side and CNA-G was able to ease the force of the fall. R4 had right shoulder pain (at a level 8 out of 10) and as well as right elbow and left arm pain where R4 incurred a skin tear during the fall. R4's shoulder pain was not relieved by Tylenol and tramadol administered together at 3:40 PM. The physician gave an order to send R4 to the Emergency Department (ED) for evaluation.A progress note, dated 4/5/26 at 3:09 AM, indicated R4 returned to the facility at 11:00 PM and had a closed fracture of the right humerus neck. Instructions were to wear sling, apply ice 20 minutes several times daily, and use Tylenol as ordered for pain control. An orthopedic referral was completed. An Interdisciplinary Team (IDT) note, dated 4/10/26 at 11:34 AM, indicated R4 slid out of bed onto the floor during AM cares on 4/4/26. A Root Cause Analysis (RCA) indicated R4 had little control of their trunk and limbs due to decline and illness. Previous fall interventions were in place at the time of the fall per staff. R4's mattress was adjusted to have increased security and stability. R4 continued to decline health-wise and declined Hospice services despite education. Maintenance staff checked all beds for security and stability. New orders included to send R4 to the ED for evaluation and treatment. The note indicated R4 continued to be a fall risk due to a decline in health. The goal was to keep R4 free from major injury.On 6/2/26, Surveyor reviewed the facility's fall investigation. Witness statements indicated R4's mattress shifted off the bed frame during cares and R4 was lowered to the floor by staff in a controlled manner. MT-F notified the nurse who observed R4 on the floor adjacent to the bed. R4 didn't know what happened and stated they were getting washed up and were then on the floor. R4 was assessed and transferred back to bed via Hoyer lift. R4 was positioned comfortably in bed and monitored. R4 had experienced a recent gradual overall decline in physical condition. R4 carried a significant amount of weight through the trunk and demonstrated decreased trunk control, impaired balance, and a reduced ability to independently control and reposition their upper and lower extremities. The deficits increased R4's need for staff assistance with mobility, positioning, transfers, and ADLs. R4 weighed 298.8 pounds on 4/2/26 which contributed to R4's immobility. Maintenance staff inspected R4's bed and mattress following the incident. No structural defects, equipment malfunctions, or mechanical failures were identified. The bed was a facility-owned bariatric bed with an appropriately sized bariatric mattress designed for and compatible with the bed frame. The mattress was properly sized and able to be securely positioned to the bed frame. A facility-wide inspection of beds was completed on 4/5/26 to identify similar safety concerns and verify proper function and stability. As a precautionary measure, bed, wheel, and brake hardware were inspected and tightened as needed to ensure optimal stability and safe operation. Staff were educated on following care plans and positioning/repositioning residents. The investigation indicated R4 came to rest on the floor during morning cares after R4's mattress became displaced from the bed frame. Staff interviews, documentation review, and equipment inspections were completed. The investigation found no evidence of intentional misconduct, abuse, neglect, or failure to respond appropriately. Environmental review confirmed adequate space around the bed to allow staff to safely provide care from both sides. The root cause of the fall was determined to be mattress displacement during the provision of care. Equipment defect, environmental hazards, and/or staff misconduct were not identified as contributing factors. A witness statement from MT-F on 4/4/26 indicated MT-F was present while R4 was turned toward CNA-G during morning cares. During the turn, the bed malfunctioned and the air mattress began to slide off the bed frame toward MT-F. R4 rolled unexpectedly toward CNA-G. CNA-G attempted to prevent R4 from falling out of bed but was unable to fully stop the fall. MT-F attempted to stabilize the air mattress as it shifted toward MT-F. MT-F observed CNA-G safely and slowly assist R4 to the floor. R4 slid onto the floor and landed on their side and buttocks. A witness statement from CNA-G, dated 4/4/26, indicated the bed malfunctioned while R4 was being turned toward CNA-G during morning cares. The air mattress started to slide off the bed frame in the opposite direction which caused R4 to roll unexpectedly toward CNA-G. CNA-G attempted to prevent R4 from falling out of bed but was unable to fully stop the fall. CNA-G lowered R4 to the floor as safely and slowly as possible. R4 landed on their backside. The investigation included signed education for nursing staff on following care plans, positioning/repositioning, and the use of equipment, including ensuring all equipment is in good working condition prior to use. On 6/2/26 at 10:19 AM, Surveyor attempted to interview R4 who looked at Surveyor but did not respond. Surveyor noted R4's mattress was strapped securely to the bed via 3 straps and the air mattress was functioning. R4 was no longer wearing a sling. On 6/2/26 at 12:39 PM, Surveyor interviewed Registered Nurse (RN)-H who responded to R4's fall on 4/4/26. RN-H indicated MT-F told them that R4 was on the floor. RN-H observed CNA-G with R4 and confirmed there were 2 staff present during the transfer. RN-H indicated R4 had a cut on their arm. R4 was transferred back to bed via Hoyer lift and did not complain of pain at that time. R4 complained of shoulder pain later in the day and was transferred to the ED. On 6/2/26 at 3:30 PM, Surveyor interviewed Maintenance Director (MD)-I who indicated they inspect 5 to 6 beds each month but do not inspect all beds each month. MD-I confirmed they did a sweep of all beds in April (2026). MD-I indicated they follow manufacturer's guidelines if there are any. On 6/2/26, Surveyor requested the date R4's bed was last checked prior to the incident and the manufacturer's guidelines for the bed. On 6/2/26 at 4:07 PM, Nursing Home Administrator (NHA)-A provided documentation that R4's bed was last checked on 4/6/26. NHA-A also provided the manual for a Comfort Zone Lateral Rotating Mattress Alternating Pressure with Low Air Loss bed. Surveyor reviewed the manual which did not contain frequency for maintenance checks. NHA-A also provided an Inspection of Beds and Mattresses sheet that indicated inspections were completed on 3/31/26, 4/30/26, and 5/31/26. The inspection sheet did not list which beds were inspected. On 6/2/26, 6/3/26, and 6/11/26, Surveyor attempted to contact MT-F and CNA-G via phone with no answer and no way to leave a voicemail. On 6/2/26 at 2:18 PM, Surveyor interviewed DON-B who indicated R4's mattress slid a bit but did not go off the bed. The movement of the mattress caused R4's weight to shift off the mattress as R4's weight distribution was uneven. R4 was lowered to the ground by CNA-G. DON-B indicated the facility did immediate education. DON-B indicated staff were following the care plan and 2 staff were present during cares. DON-B indicated all beds, including R4's, were checked for safety, brakes, and mattress securement post-fall. Surveyor informed DON-B that R4's care plan did not contain an intervention added post-fall related to the root cause of the fall. 3. R10 was admitted to the facility on [DATE] and had diagnoses including discitis (a painful inflammation and infection of the invertebral discs of the spine), lymphedema, Body Mass Index (BMI) 60 to 60.9, and osteomyelitis. R10's MDS assessment, dated 4/29/26, stated R10 had a BIMS score of 15 out of 15, indicating intact cognition. A care plan, dated 9/5/25, indicated R10 was at risk for falls, accidents, and incidents related to impaired mobility. The care plan contained interventions to anticipate and meet R10's needs (dated 10/1/25); Be sure R4's call light is within reach and encourage R4 to use it for assistance as needed. R4 needs prompt response to all requests for assistance (dated 7/16/25); Follow facility fall protocol (dated 7/16/25); and Physical therapy (PT) evaluate and treat as ordered or PRN (dated 10/1/25). A care plan, initiated 1/17/26, indicated R10 was at risk for alteration in musculoskeletal status due to osteomyelitis and gout. The care plan contained an intervention to monitor for fatigue and plan activities during optimal times when pain and stiffness is abated (dated 1/17/26). A care plan, revised 7/18/25, indicated R10 had an ADL self-care performance deficit related to osteomyelitis of vertebra, thoracic region. The care plan contained an intervention for the assistance of 1 staff for transfers with a four-wheeled walker (revised 4/12/26). On 4/16/26, R10 had a witnessed fall during a transfer and fractured a toe. An IDT review note, dated 4/23/26 at 12:55 PM, indicated a nurse was called to R10's room before supper on 4/16/26. R10's knees buckled when a CNA was transferring them into bed and R10 was lowered to the floor. R10 was anxious post-fall, was assessed by the nurse, and was transferred into bed via Hoyer lift. The IDT determined the root cause of the fall was R10's movement without awareness of activity or foot placement. R10 remained a stand-by assist with the assistance of one staff. Therapy continued to work with R10. New interventions included: Educate R10 to slow down and think about R10's movements when walking and transferring; R10 will continue to work with therapy to increase strength and progress in independence. (Of note: On 6/2/26, Surveyor noted R10's care plan was not updated with the new interventions post-fall.) On 6/2/26 at 11:57 AM, Surveyor interviewed R10 who indicated a therapist spoke with them regarding the fall. R10 was educated on taking time to ensure their feet were underneath them. R10 indicated they did not ensure their feet were underneath them when their knees buckled and they went to the floor on 4/16/26. R10 indicated staff were present during the transfer and R10 can transfer with stand-by assistance. On 6/2/26 at 2:18 PM, Surveyor interviewed DON-B who indicated R10's therapist provided education post-fall. When Surveyor indicated there were no interventions added to R10's care plan post-fall so other staff were aware and could prevent the incident from potentially happening again, DON-B was surprised interventions were not added. On 6/5/26 at 2:59 PM, NHA-A sent an email to Surveyor which contained supporting documentation that revealed R10's care plan and Kardex (an abbreviated care plan used by nursing staff) were reviewed and updated after the event to ensure ongoing communication of interventions to direct care staff. Upon review of the information, Surveyor noted the care plan contained different dates than the care plan Surveyor reviewed while at the facility. The care plan sent via email contained an intervention to monitor for fatigue and plan activities during optimal times when pain and stiffness are abated that indicated the intervention was initiated on 4/20/26 and revised on 6/2/26. A care plan Surveyor reviewed while at the facility on 6/2/26 indicated the same intervention was initiated on 1/17/26.

Based on staff interview and record review, the facility did not maintain an infection prevention and control program designed to prevent the transmission of communicable disease and infection. This practice had the potential to affect more than 4 of the 46 residents residing in the facility.The facility had a COVID-19 outbreak that ended in February of 2026. The facility did not complete N95 fit testing for staff since 2022.Findings include:The facility's Respirator Protection and Fit Testing policy, revised 1/1/2026, indicates: It is the expectation to protect residents, staff, and visitors from airborne infectious disease (e.g., tuberculosis, COVID-19, influenza with aerosol-generating procedures) by ensuring appropriate respirator use and fit. The facility will implement and maintain a respiratory protection program, including medical evaluation, fit testing, training, and proper use of respirators in accordance with: Occupational Safety and Health Administration (OSHA) Respiratory Protection Standard (29 CFR 1910.134); Centers for Disease Control and Prevention (CDC) infection control guidance; and Centers for Medicare and Medicaid Services (CMS) Appendix PP (F880 Infection Prevention & Control) Definitions: Respirator: A personal protective device worn to reduce inhalation of airborne contaminants (e.g., N95 filtering facepiece respirator); Fit test: A procedure used to verify that a respirator properly fits the wearer's face.Identification of Required Staff: Fit testing is required for staff who: Provide care to residents on transmission-based precautions (airborne or enhanced droplet); Participate in aerosol-generating procedures; Work in outbreak or respiratory illness units.Fit Testing Requirements: The facility will ensure fit testing is completed: Prior to initial respirator use; Annually thereafter; Whenever a different respirator model/size is used; When physical changes occur (e.g., weight change, facial surgery, dental changes).Staff must receive training on: When respirators are required; Proper donning and doffing techniques; Limitations of respirators; Performing a user seal check; Storage and disposal procedures.The Infection Preventionist (IP) or designee is responsible for: Program implementation and monitoring; Ensuring compliance with OSHA and CMS requirements; Maintaining records; Evaluating program effectiveness annually.Surveyor reviewed the facility's fit testing binder and noted the last documented fit testing was in February of 2022 with multiple fit test forms completed in 2021.On 4/1/26 at 2:34 PM, Surveyor interviewed Certified Nursing Assistant (CNA)-F who indicated CNA-F was hired in October of 2025. CNA-F stated CNA-F was not fit tested for an N95 mask.On 4/1/26 at 2:35 and 3:28 PM, Surveyor interviewed Director of Nursing (DON)-B who verified fit testing for N95 masks was not done in the facility since 2022. DON-B indicated DON-B was not fit tested since DON-B started at the facility. DON-B stated staff should be fit tested annually. DON-B verified the facility had a COVID-19 outbreak which ended in February (2026). DON-B stated DON-B expects staff to wear an N95 mask when caring for a resident with COVID-19. DON-B stated an N95 mask should be worn by anyone who enters a the room of a resident on airborne precautions.

Based on observation, staff interview, and record review, the facility did not ensure the resident environment remained as free of accident hazards as possible for 3 residents (R) (R6, R7, and R9) of 6 sampled residents.Paint, drywall, and plaster compound were left in an unoccupied room that was accessible to residents.Findings include:The Material Safety Data Sheet (MSDS) (Date of Preparation October 17, 2015) for [NAME] SUPERPAINT Interior Satin Latex wall Paint, Extra [NAME] indicates: .Section 3 - Hazardous Identification: Routes of Exposure: Inhalation of vapor or spray mist .Effects of overexposure .In a confined area, vapors in high concentration may cause headache, nausea, or dizziness .Section 7: Handling and Storage: Keep out of the reach of children .Section 8 - Exposure Controls/Personal Protection: Precautions to be Taken in Use: Use only with adequate ventilation .Removal of old paint by sanding, scraping, or other means may generate dust or fumes that contain lead. Exposure to lead dust or fumes may cause brain damage or other adverse health effects .Containing exposure to lead or other hazardous substance requires the use of proper protective equipment, such as a properly fitted respirator (NIOSH approved) .Ventilation: Local exhaust preferable .Section 11 -Toxicological Information: Chronic Health Hazards: Long term exposure to high levels of silica dust, which can occur only when sanding or abrading the dry film, may cause lung damage (silicosis) and possibly cancer.The Material Safety Data Sheet for Joint Compound (ready mixed), Taping Compound, Mud, Finishing Compound (Version #2 revised 11/6/25) indicates: .2. Hazard Information: Physical, health, and environmental hazards not classified .7. Handling and Storage: Precautions for Safe Handling: Avoid breathing dust/fumes/gas/mist/vapors/spray. Avoid contact with eyes, skin, and clothing. Avoid prolonged exposure. Provide adequate ventilation. Wear appropriate personal protective equipment .8. Exposure Controls/Personal Protection: Respiratory Protection: Wear positive pressure self-contained breathing apparatus. In case of insufficient ventilation, wear suitable respiratory equipment .11. Toxicological Information: Skin Contact: Dust or powder may irritate the skin.The Material Safety Data Sheet for Rust-Oleum Stops Rust Gloss Protective Enamel Aerosol (revised 7/20/23) indicates: Possible Hazards: 33% of the mixture consists of ingredient(s) of unknown acute toxicity. GHS Hazard Statements Include: Extremely flammable, causes serious eye irritation, may cause drowsiness or dizziness, may cause cancer, may cause damage to organs, contains gas under pressure, may explode if heated .Precautionary Statements: Store locked up. Store in a well-ventilated place. Keep container tightly closed. On 4/1/26, Surveyor reviewed R6's medical record. R6 had a diagnosis of dementia. R6's Minimum Data Set (MDS) assessment, dated 3/16/26, had a Brief Interview for Mental Status (BIMS) score of 8 out of 15 which indicated R6 had moderate cognitive impairment. The MDS assessment indicated R6 was independent with a manual wheelchair. On 4/1/26, Surveyor reviewed R7's medical record. R7 had a diagnsis of dementia. R7's MDS assessment, dated 3/5/26, had a BIMS score of 15 out of 15 which indicated R7 had intact cognition. The MDS assessment indicated R7 was independent with ambulation.On 4/1/26, Surveyor reviewed R9's medical record. R9 had a diagnosis of dementia. R9's MDS assessment, dated 2/19/26, had a BIMS score of 9 out of 15 which indicated R9 had moderate cognitive impairment. The MDS assessment indicated R9 required supervision with ambulation and was independent with wheelchair mobility. On 4/1/26 at 1:00 PM, Surveyor observed the following items in room [ROOM NUMBER]:~ Two cans of sealed Superior Paint by [NAME] one of which had been opened ~ One opened and sealed can of interior/exterior urethane modified acrylic paint primer by [NAME] (door finish was written on top of the can)~ One can of [NAME] Pro Industrial DTM Acrylic Coating paint~ One container of all-purpose joint compound for drywall and plaster patching repairsEarlier in the day, Surveyor observed a Rust-Oleum hammered brown spray can. The label indicated: Use outdoors in a well-ventilated area. Contains liquid petroleum gas, acetone, aromatic carcinogens, acetate, and petroleum distillates. Use only with adequate ventilation.On 4/1/26 at 11:19 AM and 2:04 PM, Surveyor interviewed MD-D who stated the therapy room was painted from 3/27/26 to 3/30/26 and room [ROOM NUMBER] was painted from 3/25/26 to 3/27/26. MD-D provided MSDS sheets for the supplies found in room [ROOM NUMBER]. MD-D could not locate the facility's flammable storage policy. MD-D indicated the standard policy is to store flammable items in the garage; however, there is also a locked cabinet in the maintenance shop that contains cleaning supplies. MD-D verified the paint supplies in room [ROOM NUMBER] had been there since 3/30/26. MD-D stated resident rooms are closed during painting but are not locked. MD-D verified it was possible for a resident to enter room [ROOM NUMBER] and have access to painting supplies. MD-D confirmed the unsecured painting supplies could pose a safety hazard.On 4/1/26 at 1:15 PM, Surveyor interviewed Director of Nursing (DON)-B who verified there was a risk of residents entering room [ROOM NUMBER] and the potential for an accident to occur if painting supplies were stored in an unsecured areas. DON-B indicated there were no residents with dementia on the 200 hall and stated no residents from the 200 hall would go into room [ROOM NUMBER]. Surveyor reviewed the facility's Matrix and noted there were 6 residents identified as having dementia. Surveyor noted R6 and R9 had moderate cognitive impairment and were independent with wheelchair mobility. R9 could ambulate with supervision. Surveyor noted R6 and R7 resided in the same hallway as room [ROOM NUMBER] and R7 was independent with ambulation.

Based on observation, staff interview, and record review, the facility did not maintain an infection prevention and control program designed to prevent the transmission of communicable disease and infection. This practice had the potential to affect all 46 residents residing in the facility.R37 tested positive for Influenza on 1/21/26. There was not a contact/droplet sign or a personal protective equipment (PPE) cart outside R37's room. In addition, staff completed cares without the proper PPE.R2 was on precautions due to a diagnosis of Influenza A. Certified Nursing Assistant (CNA)-L did not don the appropriate PPE and Registered Nurse (RN)-I reused a disposable gown to enter R2's room. In addition, RN-I removed an N95 respirator prior to exiting the room.R43 was on droplet precations due to a diagnosis of Influenza A. CNA-E and CNA-K did not don appropriate PPE prior to entering R43's room.R7 tested positive for COVID-19. There was an enhanced barrier precautions (EBP) sign outside R7's room and a PPE cart that contained N95 respirators. CNA-C applied an N95 respirator over a surgical mask prior to entering R7's room. R20 had a Foley catheter. There was not an EBP sign or a PPE cart outside R20's room. In addition, staff completed cares without the proper PPE. R1 received nutrition via tube feeding. There was not an EBP sign or a PPE cart outside R1's room. In addition, CNA-D and CNA-E did not wear gowns while transferring and assisting R1 in the bathroom.R3 was on EBP. During wound care, RN-I did not wear a gown. In addition, RN-I pulled down a surgical mask to talk to R3.R12 was diagnosed with Influenza on 1/22/26. A contact/droplet sign indicated to keep the door closed. The door was observed open on multiple occasions.R48 was symptomatic for Influenza on 1/20/26. R48's roommate was diagnosed with Influenza on 1/22/26. A contact/droplet sign indicated to keep the door closed. The door was observed open on multiple occasions. R36's roommate tested positive for Influenza on 1/21/26. There was not a contact/droplet sign or a PPE cart outside R36's room.R40 had a Foley catheter. There was not an EBP sign or a PPE cart outside R40's room. The facility's respiratory line list, dated 1/6/26, indicated Licensed Practical Nurse (LPN)-F had a symptom onset date but did not identify symptoms. LPN-F tested positive for COVID-19; however, the line list did not contain retest dates. CNA-D and Social Services Director (SSD)-M did not have well dates identified on a staff/resident line list. In addition, R29's roommate was diagnosed with influenza A. R29 was not monitored for signs/symptoms of respiratory illness.Uncoverd resident clothing was observed in the hallway.Findings Include: The facility's Transmission-Based (Isolation) Precautions policy, revised 6/4/24, indicates: .2. The facility will use standard approaches as defined by the Centers for Disease Prevention and Control (CDC) for transmission-based precautions (TBP): airborne, contact, and droplet precautions. The category of TBP will determine the type of personal protective equipment (PPE) to be used .4. Residents on TBP should remain in their rooms except for medically necessary care.9. Initiation of TBP (Isolation Precautions): a. Nursing staff may place residents with suspected or confirmed infectious diarrhea, influenza, or symptoms consistent with a communicable disease on TBP/isolation empirically while awaiting confirmation. b. An order for TBP/isolation will be obtained for residents who are known or suspected to be infected or colonized with infectious agents that require additional controls to prevent transmission effectively. c. The order for TBP/isolation will specify the type of precaution and reason for TBP. The duration will depend upon the infectious agent or organism involved. d. TBP will be the least restrictive possible for the resident under the circumstances. e. Signage that includes instructions for use of specific PPE will be placed in a conspicuous location outside the resident's room, wing, or facility-wide. Additionally, either the CDC category of TBP (e.g., contact, droplet, or air borne) or instructions to see the nurse before entering will be included in the signage. f. The facility will have PPE readily available near the entrance of the resident's room and will don appropriate PPE before or upon entry into the environment of a resident on TBP. g. Use disposable or dedicated noncritical resident-care equipment (e.g., blood pressure cuff, bedside commode). If sharing noncritical equipment between residents, the equipment will be cleaned and disinfected following manufacturer's instructions with an Environmental Protection Agency (EPA)-registered disinfectant after use. 10. Contact Precautions: a.Intended to prevent transmission of pathogens that are spread by direct or indirect contact with the resident or the resident's environment. b. Make decisions regarding private room on case-by-case basis, balancing infection risks to other residents, the presence of risk factors that increase the likelihood of transmission, and the potential adverse psychological impact on the infected or colonized resident. c. Healthcare personnel caring for residents on contact precautions wear a gown and gloves for all interactions that may involve contact with the resident or potentially contaminated areas in the resident's environment. d. Donning PPE upon room entry and discarding before exiting the room is done to contain pathogens, especially those that have been implicated in transmission through environmental contamination (e.g., vancomycin-resistant enterococci (VRE), C. difficile, noroviruses and other intestinal tract pathogens, respiratory syncytial virus (RSV)) e. Residents experiencing wound drainage, fecal incontinence or diarrhea, or other discharges from the body that cannot be contained and suggest an increased potential for extensive environmental contamination and risk of transmission of a pathogen should be placed on contact precautions even before a specific organism has been identified. f. Contact precautions will be used for residents infected or colonized with multi drug-resistant organisms (MDROs) in the following situations: i.When a resident has wounds, secretions, or excretions that are unable to be covered or contained; and ii. On units or in facilities where, despite attempts to control the spread of the MDRO, ongoing transmission is occurring. 11.Droplet Precautions: a.Intended to prevent transmission of pathogens spread through close respiratory or mucous membrane contact with respiratory secretions (i.e., respiratory droplets that are generated by a resident who is coughing, sneezing, or talking). b. A private room is preferential, but if not available, the resident can be cohorted with a resident with the same infectious agent. c. If a resident who requires droplet precautions has to share a room with a resident who does not have the same infection, the facility will make a decision regarding resident placement on a case-by-case basis after considering infection risks to other residents in the room and available alternatives. d. Draw curtain between beds in multi-bedrooms when one resident is infected with a pathogen that is transmitted by the droplet route. Maintain at least 3 feet of separation between beds. e. Healthcare personnel will wear a face mask for close contact with an infectious resident. Based upon the pathogen or clinical syndrome, if there is risk of exposure of mucous membranes or substantial spraying of respiratory secretions is anticipated, gloves and a gown as well as goggles (or face shield) should be worn. g. Residents on droplet recautions who must be transported outside of the room should wear a facemask if tolerated, and follow respiratory hygiene/cough etiquette as described in the facility's Standard Precautions Infection Control policy. 12. Airborne Precautions: a. Airborne Precautions prevent transmission of pathogens that remain infectious over long distances when suspended in the air. b. The preferred placement for patients who require airborne precautions is in an airborne infection isolation room (AIIR). c. This facility does not have an airborne infection isolation room; therefore, residents who have confirmed infection requiring airborne precautions will be transferred to an acute care hospital that has an available AIIR. d. If unable to transfer resident to an AIIR room, as in the case of COVID-19 infection, the facility will follow CDC guidance as to cohorting, private room accommodation, and/or designated units and staff will wear a fit-tested N95 or higher-level respirator and other appropriate PPE while delivering care to the resident. The facility's Enhanced Barrier Precautions policy, revised 9/9/25, indicates: It is the guideline of this facility to implement enhanced barrier precautions (EBP) for the prevention of transmission of multidrug-resistant organisms (MDROs). EBP refers to an infection control intervention designed to reduce transmission of MDROs that employs targeted gown and glove use during high-contact resident care activities .High-contact resident care activities include: dressing, bathing, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use: central lines, urinary catheters, feeding tubes .wound care: any skin opening requiring a dressing .2. Initiation of EBP: An order for EBP will be obtained for residents with any of the following .indwelling medical devices (e.g., tube feeding) even if the resident is not known to be infected or colonized with an MDRO. 3. Implementation of EBP: a. Make gowns and gloves available immediately near or outside the resident's room. 4. High-contact resident care activities include: dressing, bathing, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use: central lines, urinary catheters, feeding tubes .wound care: any skin opening requiring a dressing. The facility's undated Respiratory Illness Checklist indicates: .1. Immediate Response: Confirm the diagnosis. Verify laboratory or clinical diagnosis, notify the attending physician and nurse supervisor, record date/time of symptom onset and positive test, update the master list .Isolate the Resident: Place resident in a single room if possible, implement transmission-based precautions (TBP) (e.g., droplet or airborne depending on the pathogen), post isolation signage at the door indicating required personal protective equipment (PPE). Alert Key Personnel: Inform facility Administrator/Nursing Director. 2. Resident Care Management: Clinical Monitoring .Place COVID order in Treatment Administration Records (TARs) and add in intake and output to this as well as vital signs every shift x 14 days. Document progression in nursing notes . The facility's Infection Prevention and Control Program, revised 2/5/25, indicates: .9. COVID-19 Testing: a. Anyone with even mild symptoms of COVID-19, regardless of vaccination status, should receive a viral test for SARS-CoV-2 as soon as possible. b. Asymptomatic residents with close contact with someone with SARS-CoV-2 infection should have a series of three viral tests for SARS-CoV-2 infection .Clean linen shall be delivered to resident care units on covered linen carts with covers down .Linen shall be stored on all resident care units on covered carts, shelves, in bins, drawers, or linen closets. The CDC.gov/long-term-care-facilities respiratory virus tool kit indicates: Healthcare personnel (HCP) who enter the room of a resident with signs or symptoms of an unknown respiratory viral infection that is consistent with SARS-CoV-2 infection should adhere to standard precautions and use a Niosh-approved particulate respirator with N95 filters or higher, gown, gloves, and eye protection (i.e., goggles or a face shield that covers the front and sides of the face). This PPE can be adjusted once the cause of the infection is identified. Recommendations on PPE for respiratory viruses are available in Appendix A of the 2007 Guideline for Isolation Precautions. The CDC.gov How to Use Your N95 indicates: Your N95 respirator must form a seal to your face to work properly. Your breath must pass through the N95 respirator and not around its edges. Jewelry, glasses, and facial hair can cause gaps between your face and the edge of the respirator. The N95 respirator works better if you are clean shaven. Gaps can also occur if your N95 respirator is too big, too small, or was not put on correctly. 1. From 1/26/26 to 1/28/26, Surveyor reviewed R37's medical record. R37 was admitted to the facility on [DATE] and had diagnoses including chronic obstructive pulmonary disease (COPD) with acute exacerbation, acute kidney failure, and unspecified dementia. R37's Minimum Data Set (MDS) assessment, dated 11/19/25, had a Brief Interview for Mental Status (BIMS) score of 9 out of 15 which indicated R36 had moderately impaired cognition. R37's medical record indicated a diagnosis of Influenza was added on 1/22/26. A progress note, dated 1/21/26 at 5:59 AM, indicated R37 had an elevated temperature. A progress note, dated 1/22/26 at 11:29 AM, indicated a chest X-ray revealed mild right lower lobe infiltrate. R37 tested positive for Influenza A. A progress note, dated 1/22/26 at 6:38 PM, indicated a chest X-ray was probable for right lower lung pneumonia. The physician ordered Tamiflu and to treat R37 for probable pneumonia. Surveyor reviewed R37's temperatures which were as follows: ~ On 1/22/26 at 6:31 AM - 98.8 degrees Fahrenheit (F) ~ On 1/21/26 at 5:08 PM - 100.4 degrees F ~ On 1/21/26 at 12:49 PM - 101.5 degrees F ~ On 1/21/26 at 10:54 AM - 100.4 degrees F ~ On 1/21/26 at 2:30 AM - 100.4 degrees F ~ On 1/20/26 at 8:08 PM - 98.7 degrees F On 1/26/26 at 10:20 AM, Surveyor noted there was not a TBP sign or PPE cart outside R37's room. Surveyor observed R37 in the room with a visitor. On 1/26/26 at 10:34 AM, R37 asked Surveyor if R37's portable oxygen tank was out of oxygen. Surveyor asked CNA-N to assist R37. Surveyor observed CNA-N enter R37's room without donning PPE. CNA-N indicated R37 was out of oxygen and wheeled R37 unmasked out of the room to fill the portable tank. CNA-N filled R37's portable tank and wheeled R37 back to R37's room. CNA-N did not complete hand hygiene when exiting R37's room. On 1/26/26 at 10:50 AM, Surveyor interviewed CNA-N who indicated R37 was not on contact/droplet precautions. CNA-N stated staff rely on signs outside residents' doors for whether or not to use TBP, including the appropriate PPE to wear and precautions to follow. CNA-N indicated there was an Outbreak List at the nurses' station. CNA-N stated if a resident is on the Outbreak List, he/she is on contact/droplet precautions and a date is listed that indicates when precautions can be discontinued. CNA-N stated residents have the right to leave their rooms; however, staff suggest residents on contact/droplet precautions wear a mask when leaving their rooms. CNA-N confirmed staff should complete hand hygiene when exiting a resident's room. On 1/26/26 at 2:00 PM, Surveyor observed an Outbreak List at the nurses' station. R37 was not on the Outbreak List. On 1/26/26 at 3:00 PM, Surveyor did not observe a precautions sign or a PPE cart outside R37's room. On 1/27/26 at 10:30 AM, Surveyor did not observe a precautions sign or a PPE cart outside R37's room and observed CNA-C wheel R37 unmasked to the dining room for a Resident Council meeting. On 1/27/26 at 2:00 PM, Surveyor observed R37 in the common area for an activity without a mask. On 1/28/26 at 1:34 PM, Surveyor interviewed Director of Nursing (DON)-B who stated R37 was symptomatic on 1/20/26 and tested positive for Influenza on 1/21/26. DON-A stated R37 should have been placed on contact/droplet precautions on 1/20/26 when R37 became symptomatic. DON-B verified R37 was not on the Outbreak List. DON-B was not aware a contact/droplet sign was not outside R37's room. 2. From 1/26/26 to 1/28/26, Surveyor reviewed R2's medical record. R2 had diagnoses including anxiety and chronic respiratory failure. A care plan, dated 1/23/26, indicated R2 tested positive for influenza A on 1/23/26. The care plan contained an intervention for staff to follow universal precautions for suspected Influenza. A sign outside R2's room indicated R2 was on droplet/contact precautions. The sign contained pictures of a gown, gloves, eye protection, and an N95 respirator. On 1/26/26 at 10:59 AM, Surveyor observed CNA-L enter R2's room wearing a gown and gloves. Upon exiting the room, Surveyor interviewed CNA-L who verified CNA-L should have worn an N95 respirator per the sign outside R2's room. On 1/27/26 at 10:04 AM, Surveyor observed RN-I enter R2's room and don a used disposable gown hung on the inside of the door. RN-I exited the room without an N95 mask. Surveyor interviewed RN-I who stated RN-I reuses gowns once so the facility does not run out. RN-I indicated the facility had not run out of gowns to RN-I's knowledge. 3. From 1/26/26 to 1/28/26, Surveyor reviewed R43's medical record. R43 had diagnoses including heart failure, hypertension, and anxiety. R43 was diagnosed with influenza A and became symptomatic on 1/26/26. A sign outside R43's room indicated R43 was on droplet/contact precautions. The sign contained pictures of PPE to don, including a gown, gloves, eye protection, and an N95 respirator. On 1/26/26 at 11:08 AM, Surveyor observed CNA-K enter R43's room without donning PPE. Upon exiting the room, Surveyor interviewed CNA-K who verified CNA-K should have worn a gown, gloves, eye protection, and an N95 respirator and should have washed hands per the sign outside R43's room. On 1/26/26 at 11:27 AM, Surveyor observed CNA-E enter R43's room wearing a gown and a surgical mask and close the door. Upon exiting the room, Surveyor interviewed CNA-E who stated CNA-E stayed by the door inside the room and did not have to wear PPE. 4. From 1/26/26 to 1/28/26, Surveyor reviewed R7's medical record. R7 was admitted to the facility on [DATE] and had diagnoses including COVID-19, gastrostomy status, and obstructive and reflux uropathy. A care plan, revised 1/25/26, indicated R7 tested positive for COVID-19. On 1/27/26 at 9:30 AM, Surveyor observed an EBP sign and a PPE cart outside R7's room. Surveyor interviewed LPN-F who stated R7 had a Foley catheter and should also be on isolation precautions because R7 tested positive for COVID-19 a few days prior. LPN-F confirmed the sign was incorrect. On 1/27/26 at 10:41 AM, Surveyor observed CNA-C answer R7's call light. CNA-C donned a gown in the hallway and put an N95 respirator over a surgical mask. CNA-C donned the rest of the required PPE and entered R7's room. On 1/27/26 at 12:28 PM, Surveyor interviewed CNA-C who indicated CNA-C does not normally wear an N95 respirator over a surgical mask and must have forgotten to take the surgical mask off. On 1/28/26 at 11:54 AM, Surveyor interviewed DON-B who indicated signage outside R7's room should be correct and staff should not wear an N95 mask over a surgical mask. 5. From 1/26/26 to 1/28/26, Surveyor reviewed R20's medical record. R20 was admitted to the facility on [DATE] and had diagnoses including COPD, mild cognitive impairment of unknown etiology, osteomyelitis of vertebra, anxiety, multiple left rib fractures, and chronic hepatitis. R20's MDS assessment, dated 1/8/26, had a BIMS score of 13 out of 15 which indicated R20 had intact cognition. A care plan, dated 1/3/26, indicated R20 had a Foley catheter and was on EBP. The care plan contained a goal that R20 would be free from signs/symptoms of acute infection. The care plan contained interventions to: Dispose of PPE after removal and prior to exiting the room or before providing care for another resident in the same room; [NAME] a gown and gloves when in R20's room; Note: Face protection may also be needed if performing activity with risk of splash or spray. R20's medical record contained the following order: ~ Record Foley output every shift (dated 1/26/26) A care plan indicated R20 had osteomyelitis of thoracic vertebra. The care plan contained a goal that R20 would be free from complications related to infection. The care plan contained interventions to provide EBP and follow the facility's policy and procedure for line listing, summarizing, and reporting. On 1/26/26 at 10:20 AM, Surveyor noted there was not an EBP sign or PPE cart outside R20's room. On 1/26/26 at 10:40 AM, Surveyor noted a catheter bag was hung on the right side of the bed. On 1/26/26 at 11:00 AM, Surveyor observed CNA-C enter the room without a gown and assist R20 with dressing. On 1/27/26 at 10:02 AM, Surveyor observed CNA-D enter R20's room without PPE. Surveyor observed CNA-D and CNA-C complete catheter care with gloves but not gowns. CNA-D placed soiled washcloths and linen on the floor. CNA-D removed gloves after catheter care and assisted R20 with dressing. CNA-C assisted CNA-D with connecting a sling to a Hoyer lift. Without a gown or gloves, CNA-D removed the soiled linen from the floor and put the linen in a plastic bag. CNA-D then donned gloves, put lotion on R20's feet, and put R20's socks on with the assistance of CNA-C. CNA-D then removed gloves and CNA-C and CNA-D transferred R20 from bed to Broda chair via Hoyer lift. Without a gown or gloves, CNA-D moved R20's catheter bag to the side of the Broda chair and made R20's bed. CNA-D then assisted with R20's jacket and hat. CNA-C completed hand hygiene prior to exiting the room. CNA-D wheeled R20 to the dining room and did not complete hand hygiene during or after resident care or prior to exiting R20's room. On 1/27/26 at 1:23 PM, Surveyor interviewed CNA-D who veriified R20 had a catheter and should have an EBP sign outside R20's room. CNA-D confirmed CNA-D should have worn a gown and gloves when in contact with R20 during cares. CNA-D indicated staff follow precautions signs for direction. CNA-D also verified linens should be placed in a bag and not on a resident's floor. On 1/27/26 at 1:45 PM, Surveyor observed an EBP sign on R20's door. On 1/28/26 at 1:34 PM, Surveyor interviewed DON-B who was not aware that R20 was not on EBP and an EBP sign was not outside R20's room prior to 1/27/26. When Surveyor asked about the EBP sign on R20's door as of 1/27/26, DON-B stated DON-B reviewed residents who required TBP and posted signs as needed. DON-B verified staff should wear gloves, a gown, and possibly a face shield when providing care for R20. 6. From 1/26/26 to 1/28/26, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] and had diagnoses including moderate protein calorie malnutrition and gastrostomy status. A care plan, initiated 12/15/25, indicated R1 was on EBP. On 1/27/26 at 10:56 AM, Surveyor observed CNA-D and CNA-E transfer R1 to the bathroom. There was not an EBP sign or a PPE cart outside R1's room. CNA-D and CNA-E entered R1's room and donned gloves, but did not don gowns. CNA-D and CNA-E put a sling around R1 and transferred R1 to the toilet via EZ stand. CNA-D assisted R1 with personal hygiene. CNA-D provided R1 with a washcloth, provided cuing, and helped R1 get dressed. On 1/27/26 at 10:44 AM, Surveyor interviewed CNA-E. When asked if R1 was on EBP due to parenteral feeding, CNA-E stated R1 should be on EBP but staff only needed to wear PPE if working with R1's tube feeding. CNA-E confirmed there was not an EBP sign outside R1's room. CNA-E indicated signs do not always get changed appropriately, especially on weekends. On 1/28/26 at 11:54 AM, Surveyor interviewed DON-B who stated R1's room should be identified so staff use PPE during high-contact resident care. Surveyor informed DON-B that on 1/26/26 a sign outside R1's door indicated R1 was on droplet isolation due to being COVID-19 positive; however, there was not a sign or cart outside R1's room on 1/28/26. DON-B indicated R1 came off isolation precautions on 1/27/26 and an EBP sign and PPE cart should have been put outside R1's room. When Surveyor informed DON-B that staff were not aware a gown should be worn while transferring a resident on EBP, DON-B stated sometimes CNAs moved carts and signs that should not be moved. DON-B stated DON-B tried lists and checklists for staff and education was ongoing. 7. From 1/26/26 to 1/28/26, Surveyor reviewed R3's medical record. R3 was admitted to the facility on [DATE] and had diagnoses including pressure injury of right heel stage 3, COPD, and atrial fibrillation. R3's MDS assessment, dated 9/20/25, had a BIMS score of 15 of 15 which indicated R3 had intact cognition. A care plan, dated 9/17/25, indicated R3 was on EBP due to a stage 3 right heel pressure injury. R3's medical record contained an order for daily and as needed wound care. On 1/27/26 at 10:26 AM, Surveyor observed LPN-J complete hand hygiene and don a gown and gloves. Surveyor also observed RN-I complete hand hygiene and don gloves. RN-I held R3's right foot/heel in an elevated position while LPN-J completed wound care. LPN-J and RN-I both wore surgical masks. The facility had confirmed cases of COVID-19 and Influenza A. During the observation, RN-I pulled down RN-I's surgical mask to talk to R3. On 1/27/26 at 10:36 AM, Surveyor interviewed RN-I who stated RN-I did not have to wear a gown while assisting with wound care if RN-I did not touch any wound drainage. On 1/27/26 at 10:38 AM, Surveyor interviewed LPN-J who stated RN-I did not have to wear a gown while assisting with wound care because RN-I did not touch any wound drainage. On 1/27/26 at 3:24 PM, Surveyor interviewed DON-B who was also the facility's Infection Preventionist (IP). DON-B stated droplet/contact precautions included airborne precautions and stated if staff see a sign for droplet/contact precautions, they should wash hands and don a gown, gloves, eye protection, and an N95 respirator. DON-B indicated staff should not reuse disposable gowns and stated staff who provide wound care or wound care assistance should wear a gown and gloves. DON-B confirmed the facility was in an outbreak and stated staff should wear surgical masks when working the floor. 8. From 1/26/26 to 1/28/26, Surveyor reviewed R12's medical record. R12 was admitted to the facility on [DATE] and had diagnoses including COPD, chronic respiratory failure with hypoxia, panlobular emphysema, and history of malignant neoplasm of bronchus and lung. R12's MDS assessment, dated 12/13/25, had a BIMS score of 12 out of 15 which indicated R12 had moderately impaired cognition. R12's medical record contained a diagnosis of Influenza (dated 1/22/26) and a diagnosis of pneumonia (dated 1/26/26). A progress note, dated 1/21/26 at 7:21PM, indicated R12 fell on 1/19/26 and had increased weakness. R12's oxygen saturation was 85-91% on 2 liters of oxygen. R12 had respiratory distress and R12's lungs sounded coarse with a wet cough. R12 was sent to the Emergency Department (ED). A progress note, dated 1/22/26 at 6:52 PM, indicated R12 tested positive for Influenza. A progress note, dated 1/22/26 at 10:25 PM, indicated R12 returned to the facility with a diagnosis of Influenza and would start Oseltamivir. Isolation precautions were initiated. A progress note, dated 1/26/26 at 4:45 PM, indicated R12 was weak and lethargic with increased confusion, decreased orientation, rapid and shallow breathing, and a temperature of 101.7 degrees. A COVID-19 swab was unsuccessful. R12 was transferred to the hospital. A progress note, dated1/28/26 at 4:54 PM, indicated R12 returned from the hospital and was treated for pneumonia and Influenza. R12 was placed on contact isolation precautions. On 1/26/26 at 10:20 AM Surveyor noted R12's door was open and R12 was in bed. There was a contact/droplet sign on R12's door and a PPE cart outside the room. On 1/26/26 at 10:40 AM, Surveyor interviewed CNA-N who indicated R12 was on contact/droplet precautions and tested positive for Influenza. When Surveyor indicated the precautions sign stated to keep the door closed, CNA-N indicated doors for residents on contact/droplet precautions should be kept closed unless the residents are fall risks. CNA-N indicated R12 and R12's roommate were not fall risks. On 1/26/26 at 2:00 PM, Surveyor observed an Outbreak List at the nurses' station. R12 was on the list with a last date of isolation on 1/31/26. On 1/26/26 at 3:06 PM, Surveyor noted R12's door was open. R12 was in bed and a contact/droplet sign was on the door. On 1/28/26 at 1:34 PM, Surveyor interviewed DON-B who indicated residents on contact/droplet precautions should have their doors closed to reduce transmission. DON-B verified R12 went to the hospital for respiratory distress on 1/21/26 and was diagnosed with Influenza. DON-B stated Influenza had spread down the hall. 9. From 1/26/26 to 1/28/26, Surveyor reviewed R48's medical record. R48 was admitted to the facility on [DATE] and had diagnoses including encephalopathy, hemiplegia, cerebral infarction due to unspecified occlusion or stenosis of left middle cerebral artery, and monoplegia of upper limb following cerebral infarction. R48's MDS assessment, dated 11/16/25, had a BIMS score of 3 out of 15 which indicated R36 had severely impaired cognition. A Hospice progress note, dated 1/23/26 at 4:44 PM, indicated R48's roommate (R12) tested positive for Influenza B. R48 had a temperature of 100.1 degrees and refused an Influenza swab. Hospice advised facility staff to use contact/droplet precautions for R48. On 1/26/26 at 10:20 AM, Surveyor noted R48's door was open and R48 was in a wheelchair in the room. There was a contact/droplet sign on the door and a PPE cart outside the room. On 1/26/26 at 10:40 AM, Surveyor interviewed CNA-N who indicated R48's roommate (R12) was on contact/droplet precautions and was positive for Influenza. CNA-N confirmed R48 declined an Influenza test. CNA-N indicated R48 was symptomatic with an elevated temperature so staff followed contact/droplet precautions. When Surveyor indicated the sign outside the room indicated to keep the door closed, CNA-N indicated doors for residents on contact/droplet precautions should be kept closed unless the resident(s) in the room are fall risks. CNA-N indicated R48 and R12 were not fall risks. On 1/26/26 at 2:00 PM, Surveyor observed an Outbreak List at the nurses' station. R48 was not on the Outbreak List. R12 was on the Outbreak List with a last date of isolation on 1/31/26. On 1/26/26 at 3:06 PM, Surveyor noted R48's door was open and R48 was in a wheelchair in the room. There was a contact/droplet sign on the door. On 1/27/26 at 8:30 AM, Surveyor noted R48's door was open and R48 was in bed. There was a contact/droplet sign on the door. On 1/27/26 at 1:45 PM, Surveyor noted R48's door was open and R48 was in a wheelchair in the room. There was a contact/droplet sign on the door. On 1/27/26 at 2:00 PM, Surveyor observed an Outbreak List at the nurses' station. R48 was on the Outbreak List with a last date of isolation on 1/31/26 with fever listed next to the date. On 1/28/26 at 1:34 PM, Surveyor interviewed DON-B who stated residents on contact/droplet precautions should have their doors closed to reduce transmission. DON-B indicated DON-B was told by Hospice staff that R48 had an elevated temperature but declined COVID-19 and Influenza tests. D

Based on staff interview and record review, the facility did not implement their antibiotic stewardship program to ensure the accurate use of antibiotics for 4 residents (R) (R13, R9, R11, and R2) of 7 sampled residents.R13 did not meet Loeb's criteria for a urinary tract infection (UTI) but received antibiotic therapy. The physician was not consulted to determine if the antibiotic should have been continued when R13 did not meet the criteria for a UTI.R9 did not meet Loeb's criteria for a UTI but received antibiotic therapy. The physician was not consulted to determine if the antibiotic should have been continued when R9 did not meet the criteria for a UTI.R11 did not meet Loeb's criteria for a respiratory tract infection but received antibiotic therapy.R2 was prescribed a prophylactic antibiotic. R2's medical record did not indicate the prophylactic antibiotic was routinely assessed for continued use.The facility's Antibiotic Stewardship Program policy, revised 5/29/24, indicates: .a. Infection Preventionist - utilizes expertise and data to inform strategies to improve antibiotic use to include tracking of antibiotic starts, monitoring adherence to evidence-based published criteria during the evaluation and management of treated infections, and reviewing antibiotic resistance patterns in the facility to understand which infections are caused by resistant organisms .Clinical justification for the use of an antibiotic beyond the initial duration ordered such as a review of laboratory reports/cultures in order to determine if the antibiotic remains indicated or if adjustments to therapy should be made. 1. From 1/27/26 to 1/28/26, Surveyor reviewed R13's medical record. R13 was admitted to the facility on [DATE] and had diagnoses including osteomyelitis of vertebra, lymphedema, and methicillin-resistant Staphylococcus aureus (MRSA) infection. R13's Minimum Data Set (MDS) assessment, dated 1/26/26, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R13 had intact cognition. A care plan, dated 10/31/25, indicated R13 was colonized with MRSA then completed MRSA decolonization with an infectious disease physician. The care plan also indicated R13 was at risk for bladder incontinence related to impaired mobility and contained an intervention to monitor for signs/symptoms of a UTI. R13's medical record included Loeb's criteria for a UTI on a surveillance line list that indicated the date of infection was 10/21/25. The form indicated R13 did not meet Loeb criteria for a UTI without an indwelling catheter to treat with antibiotic therapy. There was not a culture attached to the Loeb criteria and no signs/symptoms of a UTI were identified. R13 received Levaquin/linezolid antibiotic therapy for a UTI according to the line list. The facility did not update the physician that R13 did not meet the criteria for infection and antibiotic use. The UTI was identified at the hospital. On 1/27/26 at 3:18 PM, Surveyor interviewed Director of Nursing (DON)-B who indicated the facility's provider should have been contacted to see if antibiotic therapy for a UTI should have been continued upon R13's return from the hospital. 2. From 1/27/26 to 1/28/26, Surveyor reviewed R9's medical record. R9 was admitted to the facility on [DATE] and had diagnoses including spastic quadriplegic cerebral palsy, depression, anxiety, and obstructive and reflux uropathy. R9's MDS assessment, dated 12/5/25, had a BIMS score of 15 out of 15 which indicated R9 had intact cognition. R9's medical record included a Loeb's criteria form for UTI that indicated R9 met the criteria for infection on 11/3/25. The required culture was not attached to the form which indicated a culture was necessary to ensure appropriate antibiotic treatment. R9 was started on Levaquin for treatment of a UTI according to a surveillance line list with the pathogen listed as pending. On 1/27/26 at 3:18 PM, Surveyor interviewed DON-B who indicated staff sometimes call the hospital for culture results. DON-B reviewed R9's hospital record and found the culture related to R9's current UTI treatment. The results on 10/31/25 indicated the culture grew normal flora. DON-B confirmed R9 did not meet the criteria for antibiotic treatment of a UTI. 3. From 1/27/26 to 1/28/26, Surveyor reviewed R11's medical record. R11 was admitted to the facility on [DATE] and had diagnoses including Alzheimer's disease, chronic kidney disease, and acute and chronic respiratory failure. R11's MDS assessment, dated 12/24/25, had a BIMS score of 00 out of 15 which indicated R11's cognition was severely limited. R11's medical record included documentation on the December 2025 surveillance line list that indicated beginning on 12/2/25, R11 was treated prophylactically for chest with doxycycline and that R11 met Loeb's criteria for a respiratory infection. Upon review, R11 did not meet the criteria for antibiotic therapy. On 1/27/26 at 2:36 PM, Surveyor interviewed DON-B who indicated R11 had chest X-rays on 11/22/25 and 12/3/25; however, the chest X-rays did not indicate a new infiltrate. DON-B reviewed R11's medical record and identified signs/symptoms, including a decreased oxygen saturation rate (88%), increased cough/wheezing, and the need for more assistance with activities of daily living (ADLs), which were not indicated on R11's Loeb criteria form. DON-B verified R11 did not meet Loeb's criteria without a chest X-ray that identified a new infiltrate consistent with pneumonia. 4. From 1/26/26 to 1/28/26, Surveyor review R2's medical record. R2 was initially admitted to the facility on [DATE] and readmitted on [DATE] and had diagnoses including bilateral primary osteoarthritis of knee, lymphedema, and cellulitis to left and right lower limb. R2's MDS assessment, dated 11/14/25, had a BIMS score of 15 out of 15 which indicated R2 had intact cognition. R2 was responsible for R2's healthcare decisions. R2 had an order for cefdinir 300 milligrams (mg) twice daily with a start date of 9/13/25. The indication for use was sepsis of knee/prophylaxis. R2's medical record did not contain a duration for the antibiotic or a plan for periodic re-evaluation to determine if the antibiotic was still necessary. On 1/28/26 at 12:48 PM, Surveyor interviewed DON-B who stated the facility used Loeb criteria for antibiotic use, but would be switching to McGeer's criteria. DON-B confirmed an assessment was not completed for R2's prophylactic antibiotic therapy and indicated R2 had been on the antibiotic for a long time. DON-B stated the facility's provider addresses the need for the prophylactic medication in visit notes. A provider visit note, dated 1/13/26, indicated R2 had chronic lymphedema with recurrent bilateral cellulitis and was taking bumex, potassium and chronic cefdinir. No additional information or justification for antibiotic use was indicated in the provider note.

Based on observation, staff, resident, and family interview, and record review, the facility did not ensure adaptive equipment to maintain the current level of function and prevent contracture was provided for 1 resident (R) (R6) of 1 sampled resident.R6 did not have rolled towels placed in the left hand and elbow crease and as ordered. In addition, R6's care plan contained an intervention for a left hand splint to be worn at all times. The splint was not consistently applied.Findings Include:The facility's Restorative policy, revised 2/5/25, indicates: It is the guideline of this facility to provide maintenance and restorative services designed to maintain or improve a resident's abilities to the highest practicable level. Restorative nursing program refers to nursing interventions that promote the resident's ability to adapt and adjust to living as independently and safely as possible. This concept actively focuses on achieving and maintaining all physical, mental, and psychosocial functioning .3. Nursing personnel are trained in basic maintenance nursing care that does not require the use of a qualified therapist or licensed nurse oversight. This training may include, but it is not limited to: a. Maintaining proper positioning and body alignment .6. Residents, as identified during the comprehensive assessment process, will receive services from restorative aids when they are assessed to have a need for restorative services. The services may include .splint or brace assistance.From 1/26/26 to 1/28/26, Surveyor reviewed R6's medical record. R6 was admitted to the facility on [DATE] and had diagnoses including multiple sclerosis, hemiplegia, chronic pain, osteoarthritis, schizoaffective disorder, bipolar disorder, and anxiety. R6's Minimum Data Set (MDS) assessment, dated 1/18/26, had a Brief Interview for Mental Status (BIMS) score of 4 out of 15 which indicated R6 had severely impaired cognition.A care plan, initiated 4/29/21 and revised 1/4/26, indicated R6 had an activities of daily living (ADL) self care performance deficit related to multiple sclerosis and impaired mobility. The care plan contained a goal is to maintain current level of function through the review date (3/10/26). The care plan contained interventions (dated 7/24/25) to wear a left hand splint for contracture/management at all times or as tolerated, monitor every shift, and document when R6 chooses not to wear the brace. A care plan, initiated 3/30/23 and revised 1/4/26, indicated R6 had left-sided hemiplegia. The care plan contained a goal to remain free of complications or discomfort related to hemiplegia through 3/10/26. The care plan contained interventions for a left hand splint to be worn at all times or as tolerated to prevent contracture and to monitor skin for signs and symptoms of breakdown.Surveyor reviewed R6's Kardex (an abbreviated care plan used by nursing staff) which contained the following: R6 Dressing/splint therapy: left hand elbow contracture. Place rolled hand towel in elbow crease. Place rolled towel in left hand. R6's medical record contained the following physician orders:~ Therapy: Left hand elbow contractures. (R6) needs to have rolled washcloth in left hand-be sure thumb is on outside of fingers. Rolled hand towel in elbow crease. Certified Nursing Assistants (CNAs) may place; every shift per therapy recommendations (dated 4/7/25).~ Check skin for breakdown every 4 hours while brace is on. Document any skin impairment noted and implement treatment. Update doctor regarding skin impairment and initiated treatment (dated 6/20/23).Surveyor reviewed R6's Treatment Administration Record (TAR) for 12/1/25 to 1/27/26 and noted the following:~ Therapy-left hand elbow contractures. (R6) needs to have rolled washcloth in left hand. Be sure thumb is on outside of fingers. Rolled hand towel in elbow crease (dated 4/7/25) was documented as completed 3 shifts per day except the 1/11/26 night shift (blank) and the 12/27/25 AM shift (documented as other). On 1/26/26 at 11:03 AM, Surveyor observed R6 in a wheelchair in R6's room without a rolled towel in the left hand or elbow crease. Surveyor did not observe a brace or splint on R6's left upper extremity (as indicated in R6's care plan).On 1/26/26 at 3:10 PM, Surveyor interviewed R6 and R6's Family Member ((FM)-S). Surveyor noted R6 did not have a rolled towel in the left hand or elbow crease. R6 and FM-S indicated staff do not provide a rolled towel for R6's left hand and elbow crease. FM-S indicated R6 had previous hand lacerations because R6's nails dug into the palm of R6's left hand. FM-S stated R6 had worn a splint on the left wrist/hand. R6 and FM-S were not aware where the splint was kept and said they had not seen it in months. On 1/27/26 at 10:05 AM, Surveyor observed R6 in a wheelchair in the community room visiting with a therapy dog without a rolled towel in the left hand or elbow crease. Surveyor did not observe a brace or splint on R6's left upper extremity.On 1/27/26 at 1:19 PM, Surveyor observed R6 in a wheelchair in the community room during an activity without a rolled towel in the left hand or elbow crease. Surveyor did not observe a brace or splint on R6's left upper extremity.On 1/28/26 at 11:00 AM, Surveyor observed R6 in a wheelchair in the community room without a rolled towel in the left hand or elbow crease. Surveyor did not observe a brace or splint on R6's left upper extremity.On 1/27/26 at 1:23 PM, Surveyor interviewed CNA-D who indicated staff attempt to put a rolled towel in R6's left hand and elbow crease, however, R6 prefers to go without. CNA-D indicated CNA-D did not think a rolled towel helped R6 in any way and would not change the contraction to R6's left hand.On 1/28/26 at 1:34 PM, Surveyor interviewed Director of Nursing (DON)-B who verified R6's left arm and hand were contracted. DON-B indicated staff put a rolled towel in R6's left hand and elbow crease to prevent yeast growth and skin breakdown. DON-B indicated staff move R6's left arm during cares but R6 currently did not have a restorative therapy program. DON-B indicated R6 refused the rolled towel at times. DON-B indicated staff should document refusals on R6's TAR and stated nurses chart placement of the rolled towel each shift.

Based on staff interview and record review, the facility did not ensure a written Notice of Medicare Non-Coverage (NOMNC) form (which is used to inform residents of their final day of Medicare Part A insurance coverage and standard claim appeal rights and instructions) was thoroughly completed when provided to 3 residents (R) (R57, R58, and R59) of 3 sampled residents. R57, R58, and R59 were issued written NOMNC forms when their Medicare Part A services were ending. The facility did not ensure the forms included all of the required information. Findings include: Notice Instructions for Notice of Medicare Non-Coverage (NOMNC) (a Centers for Medicare and Medicaid Services (CMS)-10123 form) indicates a Medicare provider/plan .must deliver a completed copy of this notice to beneficiaries/enrollees receiving covered skilled nursing services. The CMS-10123 form requires providers to manually or electronically enter coverage type, effective date, and a Quality Improvement Organization (QIO) name and number. 1. From 1/26/26 to 1/28/26, Surveyor reviewed R57's medical record. R57 was admitted to the facility on [DATE] and had a diagnosis of cellulitis. R57's Minimum Data Set (MDS) assessment, dated 12/20/25, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R57 had intact cognition. R57's had an activated Power of Attorney for Healthcare (POAHC) who was responsible for assisting R57 with healthcare decisions. R57's medical record indicated R57's Medicare Part A coverage ended on 12/20/25 and R57 was discharged from the facility on 12/20/25. Surveyor reviewed R57's NOMNC form which was signed on 12/17/25. Fields on the form were incomplete, including the coverage type, effective date, and the required QIO name and contact information for an appeal. (See interviews under example 3.) 2. From 1/26/26 to 1/28/26, Surveyor reviewed R58's medical record. R58 was admitted to the facility on [DATE] and had diagnoses including overactive bladder and asthma. R58's MDS assessment, dated 9/25/25, had a BIMS score of 15 out of 15 which indicated R58 had intact cognition. R58 was responsible for R58's healthcare decisions. R58's medical record indicated R58's Medicare Part A coverage ended on 9/25/25 and R58 was discharged from the facility on 9/25/25. Surveyor reviewed R58's NOMNC form which was signed on 9/22/25. Fields on the form were incomplete, including the coverage type, effective date, and the required QIO name and contact information for an appeal. (See interviews under example 3.) 3. From 1/26/26 to 1/28/26, Surveyor reviewed R59's medical record. R59 was admitted to the facility on [DATE] and had a diagnosis of cellulitis of the right upper limb. R59's MDS assessment, dated 7/9/25, had a BIMS score of 15 out of 15 which indicated R59 had intact cognition. R59 was responsible for R59's healthcare decisions. R59's medical record indicated R59's Medicare Part A coverage ended on 7/9/25 and R59 was discharged from the facility on 7/9/25. Surveyor reviewed R59's NOMNC form which was signed on 7/3/25. Fields on the form were incomplete, including the coverage type, effective date, and required QIO name and contact information for an appeal. On 1/28/26 at 11:11 AM, Surveyor interviewed Social Service Designee (SSD)-M who issues NOMNC forms. SSD-M indicated SSD-M receives a last cover date (LCD) from therapy, completes the forms on a computer, prints the forms, and issues the forms to residents. SSD-M indicated the NOMNC form is used to inform residents when Medicare services are ending and what the resident's appeal rights are. SSD-M was not aware of the name and contact information for the QIO or where to find it. SSD-M acknowledged R57, R58, and R59's NOMNC forms were incomplete. On 1/28/26 at 11:51 AM, Surveyor interviewed Nursing Home Administrator (NHA)-A who stated Medicare Part A NOMNC forms are completed by therapy. NHA-A stated SSD-M only completes managed care NOMNC forms. NHA-A stated if a resident is not in therapy, the Business Office issues the NOMNC form. NHA-A was confused why SSD-M thought SSD-M was responsible for issuing Medicare Part A NOMNC forms. NHA-A acknowledged R57, R58, and R59's forms were not thoroughly completed.

Based on staff interview and record review, the facility did not ensure proper physician or Power of Attorney for Healthcare (POAHC) notification for 3 residents (R) (R36, R22, and R5) of 12 sampled residents.R36's physician was not notified of an elevated blood pressure on 1/28/26. R36's physician was not notified when R36's pulse was less than 50 on 1/27/25, 1/22/26, 1/21/26, 1/20/26, 1/19/26, 1/17/25, and 1/16/26. In addition, R36's physician was not notified when R36's anti-hypertensive medication was held.R22's physician was not notified when R22's anti-hypertensive medication was held.R5 tested positive for Influenza A on 1/23/26. R5's POAHC was not notified of the positive test or that R5 started Tamiflu.Findings include: The facility's Notification of Change policy, revised 8/27/24, indicates: The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician, and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification. Changes of condition require an evaluation, using the SBAR communication form and progress note evaluation and ensures proper documentation notification has been made. Definitions: .Clinical Complications.Need to alter treatment significantly means, a need to stop a form of treatment because of adverse consequences (such as an adverse drug reaction), or commence a new form of treatment to deal with a problem (for example, the use of a medical procedure or therapy that has not been used on that resident before) .Compliance guidelines: The facility must inform the resident, consult with the resident's physician, and or notify the resident, family member, or legal representative when there is a change requiring such notification. Circumstances requiring notification include: 1. Accidents .2. Significant change in the resident's physical, mental, or psychosocial conditions, such as deterioration in health, mental, or psychosocial status .3. Circumstances that require a need to alter treatment. This may include a. new treatment .b. Discontinuation of current treatment due to: .i. Adverse consequences; ii. Acute condition; iii. Exacerbation of a chronic condition. 1. From 1/26/26 to 1/28/26, Surveyor reviewed R36's medical record. R36 was admitted to the facility on [DATE] and had diagnoses including essential hypertension, syndrome of inappropriate secretion of antidiuretic hormone, hypo-osmolality and hyponatremia, hyperlipemia, abdominal aortic aneurysm-not ruptured, and unspecified dementia. R36's Minimum Data Set (MDS) assessment, dated 1/8/26, had a Brief Interview for Mental Status (BIMS) score of 8 out of 15 which indicated R36 had moderate cognitive impairment. On 1/28/26, Surveyor reviewed R36's January 2026 Medication Administration Record (MAR) and noted the following orders: ~ Lisinopril oral tablet 40 milligrams (mg) Give 40 mg by mouth once daily for hypertension (dated 1/1/25) ~ Clonidine HCl oral tablet 0.2 mg Give 0.2 mg by mouth two times daily for hypertension Hold for systolic blood pressure (SBP) <100 diastolic blood pressure (DBP) <60 or pulse <50. If held update physician (dated 11/5/25) ~ Metoprolol tartrate oral tablet 37.5 mg Give 37.5 mg by mouth two times daily related to essential hypertension (dated 12/19/25) ~ Amlodipine besylate oral tablet 10 mg Give 10 mg by mouth once daily for hypertension (dated 1/14/26) ~ Hydrochlorothiazide oral tablet 25 mg Give 25 mg by mouth once daily related to essential hypertension (dated 1/14/26) On 1/28/26 at 1:34 PM, Surveyor reviewed the facility's standing orders with Director of Nursing (DON)-B. The facility had a standing order to hold blood pressure (BP) medication if systolic BP is less than 100, diastolic BP is less than 60, or pulse is less than 50 and to update the provider if the resident is symptomatic or after the first missed dose. On 1/28/26 Surveyor reviewed R36's MAR, administration notes, vital signs, and progress notes and noted there was no documentation that the provider was notified that R36 had an elevated blood pressure (BP) of 193/105 on 1/28/26. R36's January 2026 MAR indicated the following: ~ R36's 6:00 AM/7:00 AM doses of metoprolol, amlodipine, lisinopril, hydrochlorothiazide, and clonidine were held on 1/27/26 due to a low pulse of 48. ~ R36's 6:00 PM doses of metoprolol and clonidine were administered on 1/22/26; however, R36's pulse was 44. ~ R36's 6:00 PM doses of metoprolol and clonidine were administered on 1/21/26; however, R36's pulse was 46. ~ R36's 6:00 PM doses of metoprolol and clonidine were administered on 1/20/26; however, R36's pulse was 45. ~ R36's 6:00 PM doses of metoprolol and clonidine were administered on 1/19/26; however, R36's pulse was 48. ~ R36's 6:00 AM/7:00 AM doses metoprolol, amlodipine, lisinopril, hydrochlorothiazide, and clonidine were held on 1/17/26 for a low pulse of 47. ~ R36's 6:00 PM dose of clonidine was administered on 1/16/26; however. R36's pulse was 46. R36's medical record did not indicate the physician was notified when R36's pulse was below 50 and the medications were held or when the medications were administered despite R36's low pulse. On 1/28/26 at 1:00 PM, Surveyor interviewed Licensed Practical Nurse (LPN)-F who verified LPN-F did not notify the physician when R36's medications were held on 1/27/26. On 1/28/26 at 1:34 PM, Surveyor interviewed Director of Nursing (DON)-B who indicated nurses shoud notify the provider if medications are held and/or vital signs are outside the parameters for administration. DON-B reviewed R36's held medications for 1/27/26 and elevated BP on 1/28/26 and indicated the provider should have been notified regarding the held medications and diastolic BP reading greater than 100. DON-B stated the facility has standing orders to hold BP medication if systolic BP is less than 100, diastolic BP is less than 60, or pulse is less than 50, and to update the provider if the resident is symptomatic or after the first missed dose of medication. DON-B stated if a resident's pulse is less than 50, BP medication should be held and the provider should be updated immediately. 2. From 1/26/26 to 1/28/26, Surveyor reviewed R22's medical record. R22 was admitted to the facility on [DATE] and had diagnoses including hypertension, type 2 diabetes, and right lower leg fracture. R22's MDS assessment, dated 12/20/25, had a BIMS score of 15 out of 15 which indicated R22 had intact cognition. On 1/27/26 at 8:30 AM, Surveyor observed LPN-F administer medication to R22. LPN-F stated LPN-F obtained R22's BP earlier that morning which was low so LPN-F held R22's hydrochlorothiazide and lisinopril. R22's medical record contained the following orders: ~ Hydrochlorothiazide oral tablet 12.5 milligrams (mg) Give 1 tablet by mouth once daily related to essential (primary) hypertension (dated 9/23/25) ~ Lisinopril oral tablet 20 mg Give 20 mg by mouth once daily related to essential (primary) hypertension. Hold for systolic (BP) less than 100 (dated 11/3/25) On 1/28/26 at 1:34 PM, Surveyor reviewed the facility's standing orders with DON-B. The facility had a standing order to hold BP medication if systolic BP is less than 100, diastolic BP is less than 60, or pulse is less than 50, and update the provider if symptomatic or after the first missed dose. R22's MAR indicated the following: ~ R22's hydrochlorothiazide was held on 1/27/26 at 8:34 AM due to a BP of 110/57. ~ R22's lisinopril was held on 1/27/26 at 8:34 AM due to a BP of 110/57. ~ R22's lisinopril was held on 1/28/26 at 8:31 AM due to a BP of 106/53. R22's medical record contained the following vital signs: ~ On 1/27/26 at 7:32 AM, R22's BP was 110/57 as documented by LPN-F. (Of note: R22's systolic BP was greater than 100.) ~ On 1/28/26 at 6:58 AM, R22's BP was 106/53 as documented by LPN-F. (Of note: R22's systolic BP was greater than 100.) R22's medical record did not indicate the provider was notified when R22's medications were held on 1/27/26 and 1/28/26. On 1/27/26 at 8:30 AM, Surveyor interviewed LPN-F who verified LPN-F did not administer lisinopril or hydrochlorothiazide on 1/27/26 or 1/28/26 because R22's BP was outside the parameters to administer the medication. LPN-F confirmed LPN-F did not notify the provider. On 1/28/26 at 1:34 PM, Surveyor interviewed DON-B who stated R22 did not have an order to hold BP medication for a BP of 110/57 or 106/53. DON-B indicated hydrochlorothiazide and lisinopril should have been administered because R22's systolic BP was greater than 100. DON-B stated the faciity has standing orders to hold BP medication if a resident's systolic BP is less than 100, diastolic BP is less than 60, or pulse is less than 50 and to update the provider if the resident is symptomatic or after the first missed dose of the medication. DON-B confirmed LPN-F did not notify the physician when the medications were held on 1/27/26 and 1/28/26. 3. From 1/26/26 to 1/28/26, Surveyor reviewed R5's medical record. R5 was admitted to the facility on [DATE] and had diagnoses including Influenza A, cerebral infarction, and dysphagia. R5's MDS assessment, dated 11/19/25, had a BIMS score of 13 out of 15 which indicated R5 had intact cognition. R5 had an activated POAHC ((POAHC)-G). A progress note to the physician, dated 1/22/26 at 4:07 PM, indicated R5 started not feeling well on the night of 1/21/26. R5 had a fever of 101.5 degrees on the morning of 1/22/26 and complained of a runny nose and feeling tired. R5 was COVID-19 negative on the morning of 1/22/26 and was put on isolation precautions. R5 was on a wing with active influenza. The provider recommended a respiratory panel. A progress note, dated 1/23/26 at 7:09 PM, indicated R5's respiratory panel was positive for Influenza A. R5 had an order for Tamiflu two times daily for 5 days. On 1/26/26 at 11:01 AM, Surveyor interviewed POAHC-G via phone. POAHC-G knew the facility tested for COVID-19 the week prior but had not heard anything. POAHC-G was not aware that R5 had Influenza A. On 1/27/25 at 2:34 PM, Family Member (FM)-H approached Surveyor and stated POAHC-G received a call last week that the facility was going to test R5 for COVID-19 and was then told they were testing for Influenza; however, they were not updated with the results. FM-H was in the facility and was not told that R5 was ill or on isolation precautions. On 1/28/26 at 11:54 AM, Surveyor interviewed DON-B who confirmed POAHC-G was not notified when R5 tested positive for Influenza A.

Based on observation, staff interview, and record review, the facility did not provide the necessary tube feeding services for 1 resident (R) (R7) of 2 sampled residents. Certified Nursing Assistant (CNA)-D turned off R7's tube feeding before it was complete and without checking with a nurse. Findings include: The facility's Care and Treatment of Tube Feedings policy, revised 8/21/24, indicates: The resident's plan of care will address the use of feeding tube, including strategies to prevent complications. From 1/26/26 to 1/28/26, Surveyor reviewed R7's medical record. R7 was admitted to the facility on [DATE] and had a diagnosis of gastrostomy status. A care plan, revised 1/8/26, indicated R7 had an alteration in nutrition because R7 required tube feeding following a hospital stay. The care plan contained an intervention for Osmolite 1.2 474 milliliters (ml) via gastrostomy (G) tube three times daily .Observe .toleration to tube feeding.On 1/27/26 at 9:38 AM, Surveyor observed CNA-D exit R7's room and tell Licensed Practical Nurse (LPN)-F that R7's tube feeding was done and CNA-D turned the pump off. LPN-F thanked CNA-D and stated CNA-D should not have turned off the pump. LPN-F stated to Surveyor that R7's tube feeding was not complete and indicated the pump only allowed 400 ml to be infused at once. LPN-F indicated R7's tube feeding was 474 ml total and LPN-F needed to add 74 ml to R7's tube feeding. LPN-F stated CNAs should not turn off a tube feeding pump that is beeping since the tube could be clogged or something else could be wrong.On 1/27/26 at 1:23 PM, Surveyor interviewed CNA-D who verified CNA-D should not turn off a tube feeding pump and should instead tell the nurse if a tube feeding pump is beeping. On 1/28/26 at 11:54 AM, Surveyor interviewed Director of Nursing (DON)-B who indicated only licensed staff should manage tube feedings for residents.

Based on observation, staff interview, and record review, the facility did not provide pharmaceutical services to ensure the accurate administration of medication for 2 residents (R) (R36 and R22) of 7 sampled residents. R36's vital signs were not completed on 1/27/26 prior to administering metoprolol and clonidine. R36's vital signs were not completed timely on 1/27/26, 1/22/26, 1/21/26, 1/20/26, 1/19/26, 1/18/26, and 1/17/26 prior to administering and/or holding metoprolol, amlodipine, lisinopril, hydrochlorothiazide, and clonidine for a low pulse. R36's physician and standing orders to hold metoprolol and clonidine when R36's pulse was less than 50 were not followed on 1/22/26, 1/21/26, 1/20/26, 1/19/26, and 1/16/26. In addition, R36's metoprolol, amlodipine, lisinopril, hydrochlorothiazide, and clonidine were not administrated timely on 1/27/26, 1/22/26, 1/21/26, 1/20/26, 1/18/26, and 1/17/26.R22's physician and standing orders were not followed when staff held lisinopril and hydrochlorothiazide on 1/27/26. Findings include:The facility's Medication Administration policy, revised 11/12/24, indicates: .10. Ensure the six rights of medication administration are followed: .e. Right time .b. Administer within 60 minutes prior to or after scheduled time unless otherwise ordered by physician.The facility's undated Medication Pass Times document indicates:~ AM Med Pass: 6:00 AM to 10:30 AM~ Noon Med Pass: 11:00 AM to 2:00 PM~ PM Med Pass: 3:00 PM to 6:00 PM~ Bedtime (HS) Med Pass: 7:00 PM to 10:00 PM1. From 1/26/26 to 1/28/26, Surveyor reviewed R36's medical record. R36 was admitted to the facility on [DATE] and had diagnoses including essential hypertension, syndrome of inappropriate secretion of antidiuretic hormone, hypo-osmolality and hyponatremia, hyperlipidemia, abdominal aortic aneurysm-not ruptured, and unspecified dementia. R36's Minimum Data Set (MDS) assessment, dated 1/8/26, had a Brief Interview for Mental Status (BIMS) score of 8 out of 15 which indicated R36 had moderately impaired cognition.A care plan, revised 1/27/26, indicated R36 had altered cardiovascular status related to hypertension, high cholesterol, and an abdominal aortic aneurysm-not ruptured. The care plan contained an intervention (dated 1/1/25) to monitor/document/report as needed any signs/symptoms of coronary artery disease. A care plan, initiated on 1/1/25, indicated R36 had potential for altered fluid maintenance related to syndrome of inappropriate secretion of antidiuretic hormone. The care plan contained an intervention (dated 1/22/25) to monitor/document/report as needed any signs/symptoms of fluid overload, including edema, weight gain, crackles in the lungs, and/or increased blood pressure.A physician progress note, dated 1/20/26, indicated hydrochlorothiazide 25 milligrams (mg) daily was added on 1/13/26 due to high blood pressure (BP). The note indicated R36 had resistant hypertension and had been closely monitored due to hypertension. R22's medical record contained the following orders:~ Lisinopril oral tablet 40 mg Give 40 mg by mouth once daily for hypertension (dated 1/1/25)~ Clonidine HCl oral tablet 0.2 mg Give 0.2 mg by mouth twice daily for hypertension Hold for systolic blood pressure (SBP) <100 diastolic blood pressure (DBP) <60 or pulse <50. If held update MD (dated 11/5/25)~ Metoprolol tartrate oral tablet 37.5 mg Give 37.5 mg by mouth twice daily related to essential hypertension (dated 12/19/25)~ Amlodipine besylate oral tablet 10 mg Give 10 mg by mouth once daily for hypertension (dated 1/14/26)~ Hydrochlorothiazide oral tablet 25 mg Give 25 mg by mouth once daily related to essential hypertension (dated 1/14/26) On 1/28/26 at 1:34 PM. Surveyor reviewed the facility's standing orders with Director of Nursing (DON)-B. The facility had a standing order to hold blood pressure medication if systolic (BP) is less than 100, diastolic (BP) is less than 60, or pulse is less than 50, and update provider if symptomatic or after first missed dose.On 1/28/26 Surveyor reviewed R36's Medication Administration Record (MAR), administration notes, vital signs, and progress notes which indicated the following: ~ On 1/28/26 at 7:08 AM, R36's BP was 193/105. Clonidine, metoprolol, amlodipine, lisinopril, and hydrochlorothiazide were held on the morning of 1/27/26. ~ On 1/27/26 at 7:04 PM, R36's 6:00 PM doses of clonidine and metoprolol were administered. No evening vital signs were documented. ~ On 1/27/26, R36's 6:00 AM/7:00 AM doses of metoprolol, amlodipine, lisinopril, hydrochlorothiazide, and clonidine were held due to a low pulse. R36 had a pulse of 48 at 7:05 AM.~ On 1/22/26 at 6:45 PM, R36's 6:00 PM doses of metoprolol and clonidine were administered. R36 had a pulse of 44 at 4:35 PM.~ On 1/22/26 at 1:23 PM, R36's 7:00 AM doses of metoprolol, lisonopril, and clonidine were administered. ~ On 1/22/26 at 1:22 PM, R36's 7:00 AM dose of amlodipine was administered. ~ On 1/22/26 at 10:10 AM, R36's 6:00 AM dose of hydrochlorothiazide was administered.~ On 1/21/26 at 6:43 PM, R36's 6:00 PM doses of metoprolol and clonidine were administered. R36's vital signs on 1/21/26 at 5:05 PM were pulse 46, BP 168/80. ~ On 1/21/26 at 10:54 AM, R36's 7:00 AM doses of metoprolol, amlodipine, lisinopril, and clonidine were administered. ~ On 1/21/26 at 10:53 AM, R36's 6:00 AM dose of hydrochlorothiazide was administered.~ On 1/20/26 at 6:36 PM, R36's 6:00 PM doses of metoprolol and clonidine were administered. R36's vital signs on 1/20/26 at 5:13 PM were pulse 45, BP 195/90.~ On 1/20/26 at 10:37 AM, R36's 6:00 AM/7:00 AM doses of metoprolol, clonidine, and hydrochlorothiazide were administered. ~ On 1/20/26 at 10:38 AM, R36's 7:00 AM doses of amlodipine and lisinopril were administered.~ On 1/19/26 at 6:54 PM, R36's 6:00 PM dose of metoprolol and clonidine were administered. R36's vital signs on 1/19/26 at 5:18 PM were pulse 48, BP 198/85.~ On 1/18/26 at 11:35 AM, R36's 7:00 AM doses of metoprolol and clonidine were administered. R36 had a pulse of 62 at 8:14 AM. ~ On 1/18/26 at 11:27 AM, R36's 7:00 AM doses of amlodipine and lisinopril were administered. R36 had a pulse of 62 at 8:14 AM. ~ On 1/18/26 at 11:34 AM, R36's 6:00 AM dose of hydrochlorothiazide was administered. R36 had a pulse of 62 at 8:14 AM.~ On 1/17/26 at 9:14 AM, R36's 6:00 AM/7:00 AM doses of metoprolol, amlodipine, lisinopril, and hydrochlorothiazide were held due to a low pulse. R36 had pulse of 47 at 7:28 AM. ~ On 1/17/26 at 9:14 AM, R36's 7:00 AM dose of clonidine was held due to a low pulse. R36 had a pulse of 47 at 7:28 AM. ~ On 1/16/26 at 5:14 PM, R36's 6:00 PM dose of clonidine HCl was administered. R36 had a pulse of 46 at 5:12 PM. On 1/28/26 at 1:00 PM, Surveyor interviewed Licensed Practical Nurse (LPN)-F who stated AM medication pass is from 7:00 AM to 10:00 AM. LPN-F stated LPN-F takes residents' vital signs prior to starting medication administration. On 1/28/26 at 1:34 PM, Surveyor interviewed Director of Nursing (DON)-B who stated nurses should obtain vital signs for residents who require vital sign evaluation just prior to medication administration and should contact the provider regarding holding medications and/or vital signs that are outside the parameters for administration. DON-B reviewed R36's held medications on 1/27/26 and elevated BP on 1/28/26. DON-B stated the facility has standing orders to hold blood pressure medication if systolic (BP) is less than 100, diastolic (BP) is less than 60, or pulse is less than 50, and update provider if resident is symptomatic or after the first missed dose of medication. DON-B stated if a resident's pulse is less than 50, BP medication should be held. DON-B stated the facility's medication pass times are posted and medications should be administered within the time frames. DON-B indicated medications should be given within an hour of the ordered time. DON-B stated standing orders are not in a resident's medical record. 2. From 1/26/26 to 1/28/26, Surveyor reviewed R22's medical record. R22 was admitted to the facility on [DATE] and had diagnoses including hypertension, type 2 diabetes, and right lower leg fracture. R22's MDS assessment, dated 12/20/25, had a BIMS score of 15 out of 15 which indicated R22 had intact cognition.A care plan, revised 10/9/25, indicated R22 had hypertension. The care plan contained an intervention (dated 10/9/25) to give anti-hypertensives as ordered. On 1/27/26 at 8:30 AM, Surveyor observed LPN-F administer medication to R22. LPN-F stated LPN-F obtained R22's BP earlier that morning which was low so LPN-F held R22's hydrochlorothiazide and lisinopril.R22 had the following medication orders:~ Hydrochlorothiazide oral tablet 12.5 mg Give 1 tablet by mouth once daily related to essential (primary) hypertension (dated 9/23/25)~ Lisinopril oral tablet 20 mg Give 20 mg by mouth once daily related to essential (primary) hypertension. Hold for systolic BP less than 100 (dated 11/3/25)Surveyor reviewed R22's MAR which contained the following information:~ On 1/27/26, R22's hydrochlorothiazide was held due to a low BP of 110/57.~ On 1/27/26, R22's lisinopril was held due to a low BP of 110/57.~ On 1/28/26, R22's lisinopril was held for a low BP of 106/53. On 1/28/26, Surveyor reviewed R22's vital signs and noted the following:~ On 1/27/26 at 7:32 AM, R22's BP was 110/57 as documented by LPN-F. (Of note: R22's systolic BP was greater than 100.) ~ On 1/28/26 at 6:58 AM, R22's BP was 106/53 as documented by LPN-F. (Of note: R22's systolic BP was greater than 100.) On 1/27/26 at 8:30 AM, Surveyor interviewed LPN-F who verified LPN-F did not administer lisinopril on 1/27/26 or 1/28/26 or hydrochlorothiazide on 1/27/26 because R22's BP was outside the parameters for administration.On 1/28/26 at 1:34 PM, Surveyor interviewed DON-Bw who verified R22 does not have an order to hold BP medication for a BP of 110/57 or 106/53. DON-B confirmed R22's order states to hold BP medication if R22's systolic BP is less than 100. DON-B stated lisinopril and hydrochlorothiazide should have been administered because R22's systolic BP was greater than 100.

Based on observation, staff interview and record review, the facility did not ensure a stock medication was labeled and administerd in accordance with manufacturer's recommendations for 1 resident (R) (R54) and 1 staff (Registered Nurse (RN)-R). On [DATE], the medication room contained Tuberculin Purified Protein Derivative, Mantoux (an injectable solution used for skin testing to diagnose latent tuberculosis (TB) infections) which had a handwritten date of 4/25 or 4/28 on the outer package. Staff confirmed the medication should contain an open date and that once opened, the solution should be used within 30 days. The solution was used to administer TB tests for R54 and RN-R. Findings include: The Centers for Disease Prevention and Control (CDC) Mantoux Tuberculin Skin Test Facilitator Guide 2003 instructs to date the tuberculin vial when opening and discard it after 30 days. The facility's policy Medication Administration policy, with a review date of [DATE], indicates: .13. Identify expiration date. If expired, notify nurse manager. On [DATE] at 1:33 PM, Surveyor observed the facility's medication room refrigerator which contained a clear plastic bag with a brown prescription bottle inside. Inside the brown bottle was a clear vial labeled Mantoux Tuberculin which contained enough solution to cover the bottom of the vial. The vial, the bottle, and the clear bag each contained labels; the label on the bag contained a hand-written date of either 4/25 or 4/28 (the last number was difficult to read due to marker ink blending the lines). The bottle and the vial did not contain hand-written dates. The vial had a manufacturer's expiration date of 4/2028. The vial's lot number was 4CA261. Surveyor noted it was the only Mantoux Tuberculin vial in the medication room refrigerator. On [DATE] at 1:35 PM, Surveyor interviewed RN-I who indicated the hand-written date read 4/25 and the hand-written date on the label would be the date the vial was opened. RN-I indicated once opened, the vial was only good for 30 days. RN-I indicated the vial was past the date it should be used and threw the vial away. On [DATE] at 1:36 PM, RN-R entered the medication room. RN-I stated the facility needed to go through their medications and informed RN-R that the vial of tuberculin was expired and thrown away. On [DATE] at 2:00 PM, Surveyor reviewed Medication Administration Records (MARs) for residents admitted in the past 60 days amd noted some of the MARs indicated two step Mantoux Tuberculin was given with a lot number starting with 4CA. The remainder of the lot number was not documented in the MARs. Surveyor reviewed R54's medical record which included an order for two step Mantoux one time only until [DATE], step one now and repeat in 2 weeks. The MAR indicated in the [DATE] box, 04/28 4ca26 with RN-I's initials. On [DATE], R54's MAR indicated the results of the Mantoux Tuberculin were negative. On [DATE] at 3:24 PM, Surveyor interviewed RN-R who stated it is difficult to document the entire lot number on the MAR because there is not enough space. RN-R stated RN-R was made aware that afternoon that the vial of Mantoux Tuberculin in the medication storage room had an incorrect or missing open date. RN-R stated RN-R had just received a TB test from the same vial because RN-R had recently started employment and needed a TB test. RN-R showed Surveyor paperwork for the test which contained the lot number of 4ca261. RN-R verified RN-R used the same vial the evening prior for a newly admitted resident who needed a TB test. RN-R verified it was the only vial the facility had. RN-R stated when opening a new vial, RN-R writes the open date on the vial and puts the vial in a bag or writes the open date on the brown plastic prescription bottle if the vial is stored in the bottle. RN-R stated the solution is only good for 30 days once opened. RN-R confirmed nursing staff should go by the open date when determining efficacy of the solution. RN-R stated RN-R thought the nurse who opened the vial got confused because the manufacturer's expiration date on the vial is good for as long as the hand-written date that was put on the bag's label (4/28). RN-R thought the hand-written date was 4/28 versus 4/25 as indicated by RN-I. RN-R stated RN-R saw nurses label open dates incorrectly or label the bag versus the solution container and then the actual open date was unknown. On [DATE] at 3:29 PM, Surveyor interviewed Director of Nursing (DON)-B who stated Mantoux Tuberculin vials should have a hand-written date on the vial's label when the vial is opened. DON-B indicated the facility has had to throw vials away because nurses put the vial in a brown medication bottle where the open date could not be confirmed. Nursing Home Administrator (NHA)-A was present and indicated the vial of Mantoux Tuberculin thrown away by RN-I was the only vial in the medication room and a new vial would be ordered.

Based on observation, staff and resident interview, and record review, the facility did not ensure the resident environment remained as free of accident hazards as possible for 1 resident (R) (R20) of 3 sampled residents.Staff did not ensure R20's cigarettes, lighter, and e-cigarette were kept in a secure location. In addition, a smoking evaluation completed for R20 was not accurate and indicated R20 could store smoking materials independently.Findings include:The facility's Smoking policy, dated 10/25/22, indicates: Facilities may permit residents to smoke tobacco products. In these facilities, assessment of capabilities and deficits determines whether or not supervision is required. If the facility identifies that the resident needs assistance and supervision for smoking, the facility includes this information in the care plan, and reviews and revises the plan periodically as needed. The facility must ensure precautions are taken for residents' individual safety, as well as the safety of others in the facility. Such precautions may include .Supervising residents whose assessments and care plans indicate a need for assistance and supervised smoking; Limiting the accessibility of matches and lighters by residents who need supervision when smoking for safety reasons .Residents who wish to use e-cigarettes should be assessed for their ability to safely manage the device.From 1/26/26 to 1/28/26, Surveyor reviewed R20's medical record. R20 was admitted to the facility on [DATE] and had diagnoses including chronic obstructive pulmonary disease, mild cognitive impairment of unknown etiology, osteomyelitis of vertebra, anxiety, multiple left rib fractures, and chronic hepatitis. R20's Minimum Data Set (MDS) assessment, dated 1/8/26, had a Brief Interview for Mental Status (BIMS) score of 13 out of 15 which indicated R20 had intact cognition.R20's facesheet contained the following: Special Instructions: ***SUPERVISED SMOKER: ALL SMOKING MATERIALS MUST BE KEPT LOCKED UP IN MED ROOM.A smoking evaluation, dated 1/3/26, indicated R20 did not need the facility to store R20's cigarettes and lighter but required supervision to smoke. (Of note: The smoking evaluation did not assess the use of e-cigarettes.)A care plan, initiated 1/5/26 and revised 1/22/26, indicated R20 smokes cigarettes. The care plan contained a goal that R20 will not suffer injury from unsafe use of smoking and/or smokeless tobacco. The care plan contained the following interventions: Instruct (R20) regarding the facility policy on smoking/smokeless tobacco: locations, times, safety concerns; Keep cigarettes with staff; Notify charge nurse immediately if it is suspected (R20) has violated facility smoking/smokeless tobacco policy; (R20) requires supervision while smoking.R20's medical record contained the following order:~ RESIDENT SMOKES: Resident assessed as a SUPERVISED smoker. Observe smoking safety, to include; no smoking materials on person if supervised smoker, no smoking within facility (only in designated smoking areas), no smoking while oxygen is present. Intervene immediately and notify management every shift (dated 1/27/26).On 1/27/26 at 3:54 PM, Surveyor reviewed R20's Kardex (an abbreviated care plan used by nursing staff) that indicated: (R20) is a supervised smoker. All smoking materials must be kept locked up in medication room. Safety: (R20) requires supervision while smoking.On 1/26/26 at 10:40 AM, Surveyor interviewed R20 who stated R20 is not allowed to smoke at 8:00 PM. R20 stated the nurse provides an e-cigarette to use in place of going outside; however, the e-cigarette has a dead battery and no longer works. Surveyor observed an e-cigarette on R20's bedside table. R20 stated R20 had cigarettes and a lighter in a jacket pocket in R20's room. R20 stated staff threaten to take the cigarettes and lighter away but don't because R20 follows the rules.On 1/26/26 at 11:21 AM, Surveyor observed R20 in a wheelchair with cigarettes in hand. R20 stated R20 was waiting for staff to take R20 outside to smoke. On 1/26/26 at 12:15 PM, Surveyor observed Certified Nursing Assistant (CNA)-N wheel R20 outside to smoke and observed R20 smoking outside. CNA-N stayed with R20 and then wheeled R20 back into the facility.On 1/26/26 at 3:05 PM, Surveyor observed an e-cigarette on R20's bedside table. On 1/27/26 at 10:15 AM, Surveyor observed CNA-D and CNA-C transfer R20 from bed to wheelchair via Hoyer lift. CNA-D assisted R20 with donning a jacket. When R20 aked if R20's cigarettes and lighter were in the jacket pocket, CNA-D checked the pocket and told R20 they were not in R20's jacket. When R20 asked CNA-D to check R20's hat, CNA-D retrieved cigarettes and a lighter from the hat and handed them to R20. R20 stated, I don't think I am supposed to have my cigarettes. CNA-D looked at Surveyor and did not respond.On 1/27/26 at 1:23 PM, Surveyor interviewed CNA-D who stated residents who require supervision to smoke should have their smoking supplies stored in the medication room. CNA-D indicated R20 was a supervised smoker and should not have had smoking supplies in the room. On 1/28/26 at 11:25 AM, Surveyor interviewed R20 who stated a staff member took R20's e-cigarette on the 1/27/26 PM shift to charge it. R20 stated R20 prefers to smoke cigarettes. Surveyor observed a box of cigarettes and a lighter in a winter hat on R20's table. On 1/28/26 at 1:34 PM, Surveyor interviewed Director of Nursing (DON)-B who verified R20 required supervision to smoke and confirmed all smoking supplies should be stored in the medication room. DON-B stated supervised smokers are not allowed to keep smoking supplies in their room. Surveyor reviewed R20's 1/3/26 smoking assessment with DON-B who verified the smoking assessment indicated R20 can keep smoking supplies in R20's room which was an error because R20 was a supervised smoker. DON-B indicated the facility's smoking times are 9:00 AM, 1:30 PM, 5:30 PM, and 8:00 PM. DON-B indicated staff take residents outside to smoke at those times and provide supervision while smoking. DON-B was not aware that R20 had an e-cigarette and was not aware that staff provided e-cigarettes to residents.

Based on staff and resident interview and record review, the facility did not ensure the resident environment was free from abuse for 5 residents (R) (R3, R5, R6, R10, and R11) of 10 sampled residents. R3, R5, R6, R10, and R11 reported to staff on multiple occasions that Certified Nursing Assistant (CNA)-D was rough with cares and they did not want CNA-D to provide care or enter their rooms. The facility did not implement measures to ensure R3, R5, R6, R10, R11 and other residents were free from abuse. Findings include: The facility's Abuse, Neglect, and Exploitation policy, revised 7/1/25, indicates: It is the policy of the facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies that prohibit and prevent abuse .V. Investigation of Alleged Abuse: A. An immediate investigation is warranted when suspicion of abuse .or reports of abuse occur .VI. Protection of Resident: The facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation. Examples include: A. Responding immediately to protect the alleged victim(s) and integrity of the investigation, a. This should include staying with the alleged perpetrator to ensure no further contact (verbal or physical) until removal from the facility/environment . 1. From 1/6/26 to 1/7/26, Surveyor reviewed R3's medical record. R3 was admitted to the facility on [DATE] and had diagnoses including fracture of the left humerus, type 2 diabetes with neuropathy, anxiety disorder, and cellulitis of the left lower extremity (LLE) and right lower extremity (RLE). R3's Minimum Data Set (MDS) assessment, dated 12/16/25, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R3 had intact cognition. R3 was responsible for R3's healthcare decisions. On 1/6/26 at 1:53 PM, Surveyor interviewed R3 who stated R3 was physically and mentally abused since R3 was admitted to the facility and was yelled at for being incontinent. R3 indicated CNA-D was rough with cares, had a bad attitude, would not get R3 out of bed to use the bathroom, and made R3 use a bedpan. R3 stated CNA-D often pinched or jabbed R3 in the hip during cares which was painful. R3 reported the concerns to Nursing Home Administrator (NHA)-A four days after R3 was admitted . R3 felt NHA-A did not take the allegations seriously and did not follow-up with R3. R3 stated NHA-A told R3 that R3 might be anxious or depressed and need medication. R3 stated R3 was not anxious or depressed and declined medication but worried staff would put something in R3's medication to sedate R3. R3 stated R3 had thrown out medications when the nurse did not tell R3 which medications were administered. R3 stated R3 specifically told NHA-A that R3 felt physically and mentally abused. R3 stated several staff were aware of the issues with CNA-D and other residents reported similar concerns. A provider visit note, dated 11/11/25 at 5:51 PM, indicated R3 expressed concerns to the provider regarding care at the facility and wanted to transfer to another facility. The provider asked NHA-A speak with R3 about the concerns. A progress note, completed by NHA-A and dated 11/13/25 at 8:40 AM, indicated a care conference was held with R3 on 11/11/25 to discuss R3's care concerns, including transfers and safety with bed mobility. NHA-A indicated therapy would work with R3 on transfer status and bed mobility. The note indicated R3 appeared anxious and tearful. Telehealth therapy and medications were offered but R3 declined. The note did not list specific care concerns. The note indicated referrals were sent to other nursing facilities, however, no other facilities were able to accept R3. On 1/6/26 at 3:35 PM, Surveyor interviewed Director of Nursing (DON)-B who indicated the facility did not have an investigation for R3's concerns. 2. From 1/6/26 to 1/7/26, Surveyor reviewed R5's medical record. R5 was admitted to the facility on [DATE] and had diagnoses including rheumatoid arthritis, history of stroke, depression, and peripheral vascular disease. R5's MDS assessment, dated 12/23/25, had a BIMS score of 9 out of 15 which indicated R5 had moderately impaired cognition. R5 had an activated Power of Attorney for Healthcare (POAHC) to assist with healthcare decisions. On 1/7/26 at 9:23 AM, Surveyor interviewed R5 who stated CNA-D was rough with cares on the night shift and R5 did not want CNA-D to provide care for R5. R5 could not recall if CNA-D provided care for R5 after R5 reported the concerns. On 1/7/26 at 1:11 PM, Surveyor interviewed R5's Family Member ((FM)-I) who stated R5's family reported concerns to staff about CNA-D. FM-I stated CNA-D was mean and rough with cares for R5 and was mean when communicating with R5's family. FM-I stated R5 did not want CNA-D in R5's room. FM-I stated CNA-D worked for an agency and was no longer at the facility. 3. From 1/6/26 to 1/7/26, Surveyor reviewed R6's medical record. R6 was admitted to the facility on [DATE] and had diagnoses including osteoarthritis, chronic kidney disease, osteoporosis, and edema. R6's MDS assessment, dated 12/24/25, had a BIMS score of 15 out of 15 which indicated R6 had intact cognition. R6 was responsible for R6's healthcare decisions. On 1/7/26 at 2:48 PM, Surveyor interviewed R6 who stated CNA-D worked too fast and was rough with transfers, including when CNA-D transferred R6 to the toilet. R6 indicated R6 self-transferred from the toilet despite the fact that it was unsafe so that CNA-D would not touch R6. When CNA-D reminded R6 of R6's transfer restrictions, R6 told CNA-D not to touch R6. R6 told an (unidentified) CNA about the concerns and reported the concerns three times before CNA-D stopped entering R6's room. R6 did not receive follow-up about the concerns and stated R6 had not seen CNA-D in a while. 4. On 1/7/26, Surveyor reviewed R10's medical record. R10 was admitted to the facility on [DATE] and had diagnoses including osteomyelitis of vertebra and severe septic shock. R10's MDS assessment, dated 10/27/25, had a BIMS score of 15 out of 15 which indicated R10 had intact cognition. R10 was responsible for R10's healthcare decisions. On 1/7/26 at 2:10 PM, Surveyor interviewed R10 who stated CNA-D was aggressive during cares on the night shift. R10 stated when CNA-D assisted R10 with the urinal, CNA-D pushed the urinal too hard and hit R10's testicles. R10 reported the concern to an (unidentified) nurse(s) multiple times. R10 stated R10 did not want CNA-D in R10's room. R10 did not receive follow-up regarding the concern and stated CNA-D no longer worked at the facility. 5. On 1/7/26, Surveyor reviewed R11's medical record. R11 was admitted to the facility on [DATE] and had diagnoses including cerebral infarction and spastic hemiplegia affecting the right dominant side. R11's MDS assessment, dated 11/4/25, had a BIMS score of 13 out of 15 which indicated R11 had intact cognition. R11 was responsible for R11's healthcare decisions. On 1/7/26 at 2:30 PM, Surveyor interviewed R11 who stated CNA-D was mean and rough with cares and R11 was fearful of CNA-D. R11 was unsure if R11 reported the concern to staff but made it known to CNA-D that CNA-D was not allowed in R11's room. R11 had not seen CNA-D in a while. On 1/7/26 at 4:45 AM, Surveyor interviewed CNA-E who worked with CNA-D on the night shift. CNA-E verified CNA-D often put residents on bedpans instead of taking them to the bathroom. CNA-E stated several residents reported concerns to staff regarding rough care from CNA-D. CNA-E stated CNA-E often had to assist residents on CNA-D's unit because CNA-D was not allowed in their rooms; however, CNA-D sometimes entered their rooms. CNA-E stated allegations of abuse should be reported to the charge nurse, the DON, or the NHA. On 1/7/26 at 11:54 AM, Surveyor interview CNA-F who verified residents complained about CNA-D and stated CNA-D was rough and short-tempered. CNA-F stated the concerns were reported to nursing and management. CNA-F stated there was a list of residents who did not allow CNA-D in their rooms, including R6, R5, and R11. On 1/7/26 at 12:45 PM, Surveyor interviewed CNA-G who stated several residents had concerns with CNA-D and reported that CNA-D was rough with cares. CNA-G reported the concerns to (unidentified) charge nurses and (unidentified) members of administration. CNA-G was unsure if the concerns were investigated. On 1/7/26 at 3:03 PM, Surveyor interviewed unit manager Licensed Practical Nurse (LPN)-H who stated several residents did not want CNA-D to provide care and did not want CNA-D in their room because CNA-D was rough with cares. LPN-H reported the concerns to DON-B. LPN-H verified CNA-D no longer worked at the facility. On 1/7/26 at 2:25 PM, Surveyor interviewed NHA-A, DON-B and LPN-H. NHA-A indicated some residents were discriminatory toward staff and did not want to work with CNA-D because of CNA-D's ethnicity and accent. NHA-A, DON-B, and LPN-H indicated several residents did not want CNA-D to provide care or enter their rooms due to cultural and racial differences. NHA-A denied receiving any reports from staff or residents that CNA-D was rough. NHA-A indicated the facility would thoroughly investigate any concern that a staff member was rough through the grievance process or a self-report to the State Agency. DON-B stated the facility would also initiate pairs with cares to ensure the resident's needs were appropriately met. NHA-A verified there were no grievances, facility-reported incidents, or investigations completed for the concerns with CNA-D.

Based on staff, resident, and resident representative interview and record review, the facility did not ensure allegations of abuse were reported to the State Agency (SA) for 5 residents (R) (R3, R5, R6, R10, and R11) of 10 sampled residents. R3, R5, R6, R10, and R11 reported to staff that Certified Nursing Assistant (CNA)-D was rough with cares. The facility did not report the allegation of abuse to the SA. Findings include: The facility's Abuse, Neglect, and Exploitation policy, revised 7/1/25, indicates: Reporting/Response: Report all alleged violations to the Administrator, State Agency, Adult Protective Services, and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes: a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury or b. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. 1. From 1/6/26 to 1/7/26, Surveyor reviewed R3's medical record. R3 was admitted to the facility on [DATE] and had diagnoses including fracture of the left humerus, type 2 diabetes with neuropathy, anxiety disorder, and cellulitis of the left lower extremity (LLE) and right lower extremity (RLE). R3's Minimum Data Set (MDS) assessment, dated 12/16/25, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R3 had intact cognition. R3 was responsible for R3's healthcare decisions. On 1/6/26 at 1:53 PM, Surveyor interview R3 who stated R3 was physically and mentally abused and yelled at for being incontinent since R3 was admitted to the facility. R3 stated CNA-D was rough with cares, had a bad attitude, would not get R3 out of bed to use the bathroom, and made R3 use the bedpan. R3 stated CNA-D often pinched or jabbed R3 in the hip during cares which was painful. R3 reported the concerns to Nursing Home Administrator (NHA)-A four days after R3 was admitted . R3 did not feel NHA-A took the allegations seriously and did not receive any follow-up. R3 stated NHA-A told R3 that R3 may be anxious or depressed and need medication. R3 stated R3 was not anxious or depressed and declined medication but worried that staff would put something in R3's medication to sedate R3. R3 stated R3 had thrown medications away when the nurse did not tell R3 which medications were administered. R3 stated R3 told NHA-A that R3 felt mentally and physically abused. R3 stated several staff were aware of the issues with CNA-D and several residents reported similar concerns. A progress note, completed by NHA-A and dated 11/13/25 at 8:40 AM, indicated a care conference was held with R3 on 11/11/25 to discuss R3's concerns, including concerns with transfers and safety with bed mobility. The note indicated R3 appeared anxious and tearful and declined Telehealth therapy and medications. The note did not indicate the specific concerns R3 had with CNA-D. 2. From 1/6/26 to 1/7/26, Surveyor reviewed R5's medical record. R5 was admitted to the facility on [DATE] and had diagnoses including rheumatoid arthritis, history of stroke, depression, and peripheral vascular disease. R5's MDS assessment, dated 12/23/25, had a BIMS score of 9 out of 15 which indicated R5 had moderately impaired cognition. R5 had an activated Power of Attorney for Healthcare (POAHC) to assist with healthcare decisions. On 1/7/26 at 9:23 AM, Surveyor interviewed R5 who stated CNA-D was rough with cares on the night shift and R5 did not want CNA-D to provide care for R5. On 1/7/26 at 1:11 PM, Surveyor interview R5's Family Member ((FM)-I) who stated R5's family reported concerns about CNA-D to staff. FM-I stated CNA-D was mean and rough with cares for R5 and was mean when communicating with R5's family. FM-I stated R5 did not want CNA-D in R5's room. 3. From 1/6/26 to 1/7/26, Surveyor reviewed R6's medical record. R6 was admitted to the facility on [DATE] and had diagnoses including osteoarthritis, chronic kidney disease, osteoporosis, and edema. R6's MDS assessment, dated 12/24/25, had a BIMS score of 15 out of 15 which indicated R6 had intact cognition. R6 was responsible for R6's healthcare decisions. On 1/7/26 at 2:48 PM, Surveyor interviewed R6 who stated CNA-D worked too fast and was rough with transfers, including when CNA-D transferred R6 to the toilet. R6 stated R6 self-transferred from the toilet despite the fact it was unsafe so CNA-D would not touch R6. When CNA-D reminded R6 of R6's transfer restrictions, R6 told CNA-D not to touch R6. R6 stated R6 told an (unidentified) CNA about the concerns and reported the concerns three times before CNA-D stopped entering R6's room. R6 did not receive follow-up about the concerns. 4. On 1/7/26, Surveyor reviewed R10's medical record. R10 was admitted to the facility on [DATE] and had diagnoses including osteomyelitis of vertebra and severe septic shock. R10's MDS assessment, dated 10/27/25, had a BIMS score of 15 out of 15 which indicated R10 had intact cognition. R10 was responsible for R10's healthcare decisions. On 1/7/26 at 2:10 PM, Surveyor interviewed R10 who stated CNA-D was aggressive with cares on the night shift and R10 did not want CNA-D in R10's room. R10 stated when CNA-D assisted R10 with a urinal, CNA-D pushed the urinal too hard and hit R10's testicles. R10 reported the concern to an (unidentified) nurse(s) on multiple occasions. R10 did not receive any follow-up about the concern. 5. On 1/7/26, Surveyor reviewed R11's medical record. R11 was admitted to the facility 6/27/20 and had diagnoses including cerebral infarction and spastic hemiplegia affecting the right dominant side. R11's MDS assessment, dated 11/4/25, had a BIMS score of 13 out of 15 which indicated R11 had intact cognition. R11 was responsible for R11's healthcare decisions. On 1/7/26 at 2:30 PM, Surveyor interviewed R11 who stated CNA-D was mean and rough with cares and R11 was fearful of CNA-D. R11 could not recall if R11 reported the concerns to staff but made it known to CNA-D that CNA-D was not allowed in R11's room. On 1/7/26 at 4:45 AM, Surveyor interviewed CNA-E who verified several residents reported concerns to staff regarding rough care from CNA-D. CNA-E stated CNA-E often had to assist residents on CNA-D's unit because CNA-D was not allowed in their rooms. CNA-E stated the concerns were reported to administration multiple times by staff and residents. CNA-E stated allegations of abuse should be reported to the NHA, the Director of Nursing (DON), or the charge nurse. On 1/7/26 at 11:54 AM, Surveyor interviewed CNA-F who verified residents reported that CNA-D was rough and short-tempered and there was a list of residents who did not allow CNA-D in their rooms, including R5, R6, and R11. CNA-F stated the concerns were reported to nursing and management. On 1/7/26 at 12:45 PM, Surveyor interviewed CNA-G who verified several residents reported concerns with CNA-D, including that CNA-D was rough with cares. CNA-G reported the concerns to (unidentified) charge nurses and (an unidentified member of) administration. On 1/7/26 at 3:03 PM, Surveyor interviewed unit manager Licensed Practical Nurse (LPN)-H who verified several residents reported that CNA-D was rough and did not want CNA-D to provide care for them or be in their rooms. LPN-H reported the concerns to DON-B. On 1/7/26 at 2:25 PM, Surveyor interviewed NHA-A, DON-B and LPN-H. NHA-A indicated some residents were discriminatory toward staff and did not want to work with CNA-D because of CNA-D's ethnicity and accent. NHA-A, DON-B, and LPN-H verified several residents did not want CNA-D to provide care or enter their rooms but thought it was due to cultural and racial differences. NHA-A denied receiving any reports from staff or residents that CNA-D was rough with cares. NHA-A confirmed a facility-reported incident (FRI) should be submitted to the SA for all allegations of abuse.

Based on staff, resident, and resident representative interview and record review, the facility did not ensure allegations of abuse were thoroughly investigated for 6 residents (R3, R1, R5, R6, R10, and R11) of 10 sampled residents. R3 reported an allegation of abuse to Nursing Home Administrator (NHA)-A regarding Certified Nursing Assistant (CNA)-D. The facility did not thoroughly investigate the allegation of abuse. R1's Power of Attorney for Healthcare (POAHC) reported allegations of abuse to the local police department. The facility did not thoroughly investigate the allegations of abuse. R5 and R5's family reported that CNA-D was rough with cares and R5 did not want CNA-D to provide care or enter R5's room. The facility did not thoroughly investigate the allegation of abuse. R6 reported that CNA-D was rough with cares and did not want CNA-D to touch R6. The facility did not thoroughly investigate the allegation of abuse. R10 reported that CNA-D was aggressive with cares and pushed a urinal into R10's testicles. R10 did not want CNA-D in R10's room. The facility did not thoroughly investigate the allegation of abuse. R11 reported that CNA-D was mean and rough with cares. R11 was fearful of CNA-D and did not want CNA-D in R11's room. The facility did not thoroughly investigate the allegation of abuse.Findings include: The facility's Abuse, Neglect, and Exploitation policy, revised 7/1/25, indicates: An immediate investigation is warranted when suspicion of abuse, neglect, or reports of abuse, neglect, or exploitation occur. B. Written procedures for investigations include: .3. Investigating different types of alleged violations. 4. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations. 5. Focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent, and cause. 6. Providing complete and thorough documentation of the investigation. VI. Protection of the Resident: The facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation. 1.From 1/6/26 to 1/7/26, Surveyor reviewed R3's medical record. R3 was admitted to the facility on [DATE] and had diagnoses including fracture of the left humerus, type 2 diabetes with neuropathy, anxiety disorder, and cellulitis of the left lower extremity (LLE) and right lower extremity (RLE). R3's Minimum Data Set (MDS) assessment, dated 12/16/25, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R3 had intact cognition. R3 was responsible for R3's healthcare decisions. On 1/6/26 at 1:53 PM, Surveyor interview R3 who stated R3 was physically and mentally abused and yelled at for being incontinent since R3 was admitted to the facility. R3 stated CNA-D was rough with cares, had a bad attitude, would not get R3 out of bed to use the bathroom, and made R3 use the bedpan. R3 stated CNA-D often pinched or jabbed R3 in the hip during cares which was painful. R3 reported the concerns to NHA-A four days after R3 was admitted . R3 felt NHA-A did not take the allegations seriously and denied any follow-up from NHA-A. R3 stated NHA-A indicated R3 may be anxious or depressed and need medication. R3 stated R3 was not anxious or depressed and declined medication but was worried that staff would put something in R3's medication to sedate R3. R3 stated R3 threw away medications if the nurse did not tell R3 which medications were administered. R3 stated R3 specifically told NHA-A that R3 felt physically and mentally abused. R3 stated several staff were aware of the issues with CNA-D because other residents reported similar concerns. A progress note, completed by NHA-A and dated 11/13/25 at 8:40 AM, indicated a care conference was held with R3 on 11/11/25 to discuss R3's care concerns, including transfers and safety with bed mobility. NHA-A stated therapy would work with R1 on transfer status and bed mobility. The note indicated R3 appeared anxious and tearful. Telehealth therapy and medication were offered to R3 who declined. The note did not contain specific concerns regarding cares and indicated referrals were sent to other nursing facilities which could not accept R3. Surveyor reviewed the facility's facility-reported incidents (FRIs) and grievances which did not contain an investigation for R3's allegation of abuse. 2. From 1/6/26 to 1/7/26, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] and had diagnoses including adult failure to thrive, unspecified mood (affective) disorder, and generalized anxiety disorder. R1's MDS assessment, dated 10/9/25, had a BIMS score of 3 out of 15 which indicated R1 had severely impaired cognition. R1 had an activated POAHC ((POACH)-C) to assist with decision making. On 11/5/25, POAHC-C contacted the local police department when POAHC-C could not get a hold of anyone at the facility and was concerned for R1's welfare. The police did a welfare check and informed the facility of POAHC-C's allegations. The facility initiated an investigation and submitted a FRI to the State Agency (SA). The FRI indicated POAHC-C called the police and reported an allegation of abuse involving R1. The police chief went to the facility and informed staff that POAHC-C alleged the facility had engaged in abusive practices, including discontinuing R1's therapy and administering medication to sedate R1. Surveyor noted the investigation did not contain interviews with R1, POAHC-C, or other residents and staff. On 1/7/26 at 11:41 AM and 2:00 PM, Surveyor interviewed NHA-A who stated resident interviews were completed and NHA-A would find them. NHA-A confirmed staff interviews were not completed as part of the investigation. NHA-A stated POAHC-C did not return a phone call though an attempt to contact POAHC-C was not included in the investigation. On 1/7/26 at 1:30 PM, Surveyor reviewed resident interviews that NHA-A stated were found in R1's closed medical record. Surveyor noted the interviews were not dated and the interview questions were general and did not pertain to the specific allegations of overmedicating residents and discontinuing therapy. 3. From 1/6/26 to 1/7/26, Surveyor reviewed R5's medical record. R5 was admitted to the facility on [DATE] and had diagnoses including rheumatoid arthritis, history of stroke, depression, and peripheral vascular disease. R5's MDS assessment, dated 12/23/25, had a BIMS score of 9 out of 15 which indicated R5 had moderately impaired cognition. R5 had an activated POAHC who assisted with healthcare decisions. On 1/7/26 at 9:23 AM, Surveyor interviewed R5 who stated CNA-D was rough with cares on the night shift and R5 did not want CNA-D to provide care to R5. R5 could not recall if CNA-D provided care for R5 since R5 reported the concerns. On 1/7/26 at 1:11 PM, Surveyor interview R5's Family Member ((FM)-I) who stated R5's family reported concerns to staff about CNA-D. FM-I stated CNA-D was mean and rough with cares for R5 and was mean when communicating with R5's family. FM-I stated R5 did not want CNA-D in R5's room. FM-I stated CNA-D worked for an agency and was no longer at the facility. Surveyor reviewed the facility's FRIs and grievances which did not contain an investigation for R5 or R5's family's allegations of abuse. 4. From 1/6/26 to 1/7/26, Surveyor reviewed R6's medical record. R6 was admitted to the facility on [DATE] and had diagnoses including osteoarthritis, chronic kidney disease, osteoporosis, and edema. R6's MDS assessment, dated 12/24/25, had a BIMS score of 15 out of 15 which indicated R6's had intact cognition. R6 was responsible for R6's healthcare decisions. On 1/7/26 at 2:48 PM, Surveyor interviewed R6 who stated CNA-D worked too fast and was rough with transfers, including when CNA-D transferred R6 to the toilet. R6 stated R6 self-transferred from the toilet despite the fact it was unsafe so that CNA-D would not touch R6. When CNA-D reminded R6 of R6's transfer restrictions, R6 told CNA-D not to touch R6. R6 told an (unidentified) CNA about the concerns and reported the concerns three times before CNA-D stopped entering R6's room. R6 did not receive follow-up about the concerns but had not seen CNA-D in a while. Surveyor reviewed the facility's FRIs and grievances which did not contain an investigation for R6's allegation of abuse. 5. On 1/7/26, Surveyor reviewed R10's medical record. R10 was admitted to the facility on [DATE] and had diagnoses including osteomyelitis of vertebra and severe septic shock. R10's MDS assessment, dated 10/27/25, had a BIMS score of 15 out of 15 which indicated R10 had intact cognition. R10 was responsible for R10's healthcare decisions. On 1/7/26 at 2:10 PM, Surveyor interviewed R10 who stated agency CNA-D was aggressive with cares on the night shift. R10 stated when CNA-D assisted R10 with a urinal, CNA-D pushed the urinal too hard and hit R10's testicles. R10 reported the concern to an (unidentified) nurse(s) on multiple occasions and did not want CNA-D in R10's room. R10 did not receive follow up regarding the concern. Surveyor reviewed the facility's FRIs and grievances which did not contain an investigation for R10's allegation of abuse. 6. On 1/7/26, Surveyor reviewed R11's medical record. R11 was admitted to the facility on [DATE] and had diagnoses including cerebral infarction and spastic hemiplegia affecting the right dominant side. R11's MDS assessment, dated 11/4/25, had a BIMS score of 13 out of 15 which indicated R11 had intact cognition. R11 was responsible for R11's healthcare decisions. On 1/7/26 at 2:30 PM, Surveyor interviewed R11 who stated CNA-D was mean and rough with cares and R11 was fearful of CNA-D. R11 did not recall if R11 reported the concern to staff but made it known to CNA-D that CNA-D was not allowed in R11's room. On 1/7/26 at 4:45 PM, Surveyor interviewed CNA-E who confirmed several residents reported to staff that CNA-D was rough cares. CNA-E stated CNA-E often had to assist residents on CNA-D's unit because CNA-D was not allowed in their rooms; however, sometimes CNA-D still went in their rooms. CNA-E stated the concerns were reported to administration multiple times by staff and residents. On 1/7/26 at 11:54 AM, Surveyor interview CNA-F who verified that residents reported CNA-D was rough and short-tempered and stated there was a list of residents who did not allow CNA-D in their rooms. CNA-F verified the concerns were reported to nursing and management by staff and residents. CNA-F stated R6, R5 and R11 were among the residents who voiced concerns about CNA-D. On 1/7/26 at 12:45 PM, Surveyor interviewed CNA-G who confirmed several residents reported concerns with CNA-D and stated CNA-D was rough with cares. CNA-G reported the concerns to (unidentified) charge nurses and (unidentified members of) administration. On 1/7/26 at 3:03 PM, Surveyor interviewed unit manager Licensed Practical Nurse (LPN)-H who verified several residents reported that CNA-D was rough with cares and did not want CNA-D to provide cares or enter their rooms. LPN-H reported the concerns to Director of Nursing (DON)-B and stated CNA-D did not work in the facility any longer. On 1/7/26 at 2:25 PM, Surveyor interviewed NHA-A, DON-B and LPN-H. NHA-A indicated some residents were discriminatory toward staff and did not want to work with CNA-D because of CNA-D's ethnicity and accent. NHA-A, DON-B, and LPN-H confirmed several residents did not want CNA-D to provide care or enter their rooms but thought it was due to cultural and racial differences. NHA-A denied receiving any reports from staff or residents that CNA-D was rough with cares. NHA-A verified a concern that a staff member was rough with cares should be thoroughly investigated and verified the the facility did not thoroughly investigate R3, R1, R5, R6, R10, and R11's allegations of abuse.

Based on staff and resident interview and record review, the facility did not ensure 1 of 5 sampled residents (R1) received care and treatment in accordance with professional standards of practice (N6, Wisconsin Nurse Practice Act) and failed to ensure a change of condition was recognized and acted upon timely.On 8/26/25, R1 complained of increased pain and difficulty breathing. The Nurse Practitioner (NP) was notified and indicated R1 could have additional acetaminophen up to 4000 milligrams (mg) in a 24 hour period in addition to tramadol and could use diclofenac or stock pain reliever for back/shoulder pain. The NP also gave an order to try to wean R1 off oxygen which the NP presumed was used for anxiety/pain and indicated if R1 continued to require oxygen, staff should notify the NP. The orders were not transcribed in R1's medical record at that time. According to staff interviews, R1 was tearful, reported ongoing pain and difficulty breathing, and cried out in pain during the evening hours. R1's medical record did not contain evidence of assessments of R1's condition or documentation that R1 required oxygen throughout the evening. There were no additional updates to the NP or Medical Doctor (MD) until R1 requested to go to the emergency room (ER). At the ER, R1 was diagnosed with sepsis, right pleural effusion, and acute renal failure and was subsequently transferred to another hospital and admitted to the Intensive Care Unit (ICU). The facility's failure to recognize a change of condition, complete thorough assessments, and provide timely care for a resident with increased pain and difficulty breathing despite the use of oxygen led to a finding of immediate jeopardy that began on 8/26/25. Nursing Home Administrator (NHA)-A was notified of the immediate jeopardy on 9/5/25 at 9:57 AM. The immediate jeopardy was removed on 9/5/25, however, the deficient practice continues at a scope/severity level D (potential for more than minimal harm/isolated) as the facility continues to implement its action planFindings include:The facility's Pain Management policy, dated 2/5/25, indicates the facility must ensure pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences. Facility staff should use a systematic approach for recognition, assessment, treatment, and monitoring of pain. The facility's Notification of Changes policy, dated 3/2025, indicates the facility must inform the resident, consult with the resident's physician, and/or notify the resident's family member or legal representative when there is a change in condition such as a significant change in the resident's physical, mental, or psychosocial condition and circumstances that require a need to alter treatment. According to the Wisconsin Nurse Practice Act, N6.03(1): A Registered Nurse (RN) shall utilize the nursing process in the execution of general nursing procedures in the maintenance of health, prevention of illness or care of the ill. The nursing process consists of the steps of assessment, planning, intervention, and evaluation. This standard is met through performance of each of the following steps of the nursing process: (a) Assessment. Assessment is the systematic and continual collection and analysis of data about the health status of a patient culminating in the formulation of a nursing diagnosis. (b) Planning. Planning is developing a nursing plan of care for a patient which includes goals and priorities derived from the nursing diagnosis. (c) Intervention. Intervention is the nursing action to implement the plan of care by directly administering care or by directing and supervising nursing acts delegated to L.P.N.s (Licensed Practical Nurse) or less skilled assistants. (d) Evaluation. Evaluation is the determination of a patient's progress or lack of progress toward goal achievement which may lead to modification of the nursing diagnosis.On 9/3/25, Surveyor reviewed R1's medical record. R1 had diagnoses including heart failure, diabetes, anxiety, and lymphedema. R1's Minimum Data Set (MDS) assessment, dated 6/28/25, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R1 had intact cognition. R1 was R1's own decision maker.A care plan, dated 7/23/25, indicated R1 had altered respiratory status/difficulty breathing related to heart failure with a goal to maintain a normal breathing pattern. The care plan contained interventions to use oxygen per nasal cannula 1 to 4 liters per minute (LPM) as needed for shortness of breath (SOB), respiratory distress, or comfort; and monitor for signs/symptoms of respiratory distress and report to physician as needed, including increased respirations, decreased pulse oximetry, increased heart rate, restlessness, diaphoresis, headaches, lethargy, confusion, cough, pleuritic pain, accessory muscle usage, and skin color changes to blue/grey.R1's Medication Administration Record (MAR) indicated R1 received scheduled acetaminophen (a non-opioid anlagesic medication used to treat mild to moderate pain) 1000 mg three times daily for pain (up to 4000 mg total per day) (start date 6/21/25); tramadol (an opioid medication used to treat pain) 50-100 mg every 6 hours as needed for pain related to lymphedema (start date 6/3/25); and acetaminophen 650 mg every 4 hours as needed for fever/pain (start date 4/22/25). R1 also had an order in pending status on 8/27/25 for diclofenac sodium gel (a pain relieving medication) apply to back/shoulder topically every 6 hours as needed for pain.R1's medical record indicated R1 complained of right shoulder and back pain at a level 5 out of 10 (based on a numeric scale of 10 being the worst pain) and difficulty breathing on 8/26/25 at 2:00 AM. Tramadol 100 mg was administered and supplemental oxygen was provided via nasal cannula at 2 LPM. R1 attributed the pain to a pulled shoulder muscle from using the sit-to-stand lift. Unit Manager (UM)-E documented at 4:33 AM that the pain medication was effective and R1 had a pain level of 0 out of 10.On 8/26/25 at 8:04 AM, UM-E notified R1's physician that R1 had increased shoulder and back pain during the night that R1 attributed to using a sit-to-stand lift and complaints of SOB while lying in bed. R1's vital signs were assessed. R1 had a pulse rate of 93 and an oxygen saturation level of 94% on room air. R1 was placed on supplemental oxygen which helped R1's SOB so R1 was able to sleep. R1's MAR indicated R1 received tramadol 100 mg for pain at a level 7 out of 10 on 8/26/25 at 8:38 AM.On 8/26/25 at 9:35 AM, an NP responded to the 8:04 AM update and indicated R1 could have additional acetaminophen up to 4000 mg in a 24 hour period in addition to tramadol and could use diclofenac or stock pain reliever for back/shoulder pain. An order indicated to try to wean R1 off oxygen which the NP presumed was used for anxiety/pain and indicated if R1 continued to require oxygen, staff should notify the NP. On 9/3/25 at 1:11 PM and at 3:31 PM, Surveyor interviewed Certified Nursing Assistant (CNA)-F who gave R1 a shower on 8/26/25. CNA-F indicated CNA-F usually provides R1's shower right away in the morning because it is an extensive process due to R1's edema wraps and routine. CNA-F stated R1 was using oxygen when CNA-F entered the room and R1 stated staff thought oxygen would help R1's pain. R1 indicated the pain was all over and not anywhere specific. CNA-F indicated CNA-F usually asks the nurse to administer pain medication prior R1's shower because R1 is usually in pain and cries at the start of the shower, however, CNA-F can get R1 to relax and calm down as the shower proceeds. CNA-F indicated it takes time to complete R1s shower but R1 usually enjoys it CNA-F indicated when R1 received a shower on 8/26/25 between 10:00 and 11:00 AM, R1's pain was different than usual. R1 cried throughout the shower and screamed out in pain when CNA-F reached out to R1 without making contact. CNA-F rushed through R1's shower due to R1's discomfort. CNA-F did not observe R1 struggling to breathe though and indicated R1 was still crying when CNA-F took R1 back to R1's room. After the shower, CNA-F informed the nurse who indicated they would check on R1. CNA-F stated that at approximately 2:00 PM, CNA-F went back to check on R1 because CNA-F was concerned about R1's condition in the shower. CNA-F indicated R1 looked worn out and was sitting in bed bent over a bedside table with R1's head down. CNA-F put a blanket over R1 and told R1 to tell the nurse if R1 felt worse.R1's medical record indicated R1's pain was at a level 0 out of 10 on 8/26/25 at 11:07 AM and was also at a level 0 out of 10 when R1's scheduled acetaminophen was administered at 11:36 AM.On 9/3/25 at 10:53 AM, Surveyor interviewed Licensed Practical Nurse (LPN)-H who worked the 8/26/25 AM shift. LPN-H was notified during report that R1 had increased pain during the night and UM-E sent a message to the NP. UM-E informed LPN-H that UM-E administered oxygen to R1 during the night. LPN-H checked on R1 between 6:00 and 7:00 AM and indicated R1 was sleeping. LPN-H stated the next time LPN-H heard something was at approximately 9:00 AM when CNA-F asked for something for pain for R1. LPN-H administered R1 PRN tramadol and checked R1's vitals signs. LPN-H spoke to R1 and indicated everything seemed okay. LPN-H stated R1 later received a shower and LPN-H didn't hear from R1 for the remainder of the shift. LPN-H approached the NP who was in the building that day. The NP indicated the NP was not planning to see R1 but had gotten an update through the system. LPN-H stated R1 did not complain of pain or breathing issues. In a subsequent interview at 12:39 PM, LPN-H did not recall if R1 used oxygen during the shift. LPN-H indicated the last time LPN-H saw R1 was at approximately1:00 PM when LPN-H administered R1's scheduled acetaminophen. When asked if LPN-H saw the NP's response and orders at 9:35 AM, LPN-H indicated LPN-H did not see either at that time but processed the orders during LPN-H's next shift which started on 8/26/25 at 10:00 PM and went through 6:00 AM on 8/27/25.R1's MAR indicated R1 was only administered scheduled acetaminophen on 8/26/25 at 9:07 PM and R1's pain was at a level 0 out of 10. The MAR did not indicate any PRN pain medication was administered to R1 after 8:38 AM on 8/26/25. Surveyor also noted NP's orders received by the facility at 9:35 AM on 8/26/25 after UM-E notified the physician were not transcribed into R1's medical record until 8/27/25 at 3:32 AM. On 9/3/25 at 10:24 AM, Surveyor interviewed CNA-G who worked the 8/26/25 PM shift. CNA-G started at approximately 2:00 PM and was told in report that R1 was lethargic and not feeling well and wasn't R1's usual self. CNA-G indicated there was no mention of pain, nausea, or breathing difficulties. When CNA-G entered R1's room at approximately 3:00 PM, R1 complained of pain on the right side around the rib cage and arm and asked to be transferred to the commode. CNA-G indicated R1 would only let CNA-G raise R1 so far in the EZ Stand (a mechanical lift) during the transfer because it hurt too much. CNA-G stated R1 provided no energy or help during the lifting process and stated it hurt around R1's rib change and to move R1's arm up. CNA-G positioned R1 on the commode and notified RN-D that R1 would like pain medication. RN-D stated RN-D would check with R1. R1 then activated the call light, told CNA-G that R1 could not breathe, and asked to be transferred to the recliner. CNA-G transferred R1 into the recliner and put oxygen on R1 until RN-D could assess R1. When R1 activated the call light again after dinner trays were passed, CNA-G told R1 that CNA-G would ask RN-D for pain medication. R1 told CNA-G that RN-D had already been in R1's room and R1 wanted something stronger. CNA-G retrieved the pulse oximeter, walked into the hallway, and told RN-D that R1 was having dificulty breathing. RN-D said RN-D would get there as soon as RN-D could. CNA-G answered other residents' call lights and then heard moaning from R1's room between 6:30 and 7:00 PM. CNA-G entered R1's room and asked what CNA-G could do. R1 said R1 just hurt. CNA-G notified RN-D. CNA-G stated staff tried to make R1 comfortable by offering repositioning, pillows under R1's back, and heat/ice. CNA-G was in the process of putting other residents to bed and heard R1 call out, Help me. Help me. It hurts. It hurts. CNA-G and RN-D immediately entered R1's room. RN-D said the only thing RN-D could do was send R1 out to be evaluated. CNA-G indicated R1 usually had pain but didn't usually yell like that during transfers. CNA-G did not know what RN-D gave R1 for pain or what else RN-D had done. On 9/4/25 at 2:36 PM, Surveyor interviewed RN-D via phone who indicated RN-D was not updated on any concerns for R1 during shift report. RN-D indicated RN-D administered metformin to R1 prior to 6:30 PM and R1 did not report any pain. RN-D did not recall being told by staff that R1 complained of pain between 3:00 and 4:00 PM. RN-D also didn't recall being told by a CNA that R1 was still in pain, had difficulty breathing, and needed oxygen after 4:00 PM. RN-D indicated R1 always used oxygen and RN-D did not expect to be updated that R1 needed oxygen. (Of note: R1's medical record did not indicate R1 always used oxygen.) RN-D also didn't recall being informed by staff that R1 was in pain after dinner trays were passed. RN-D indicated RN-D heard R1 cying in pain across the hall at approximately 6:30 PM. RN-D checked on R1 who indicated R1 was in pain which could have been due to therapy. RN-D checked R1's vital signs which RN-D indicated were fine, however, RN-D didn't document the vital signs and could not recall what they were. RN-D stated RN-D focused on a musculoskeletal assessment but did not document the assessment or inform Surveyor of the results. RN-D indicated R1 complained of pain in the shoulder and thorax and RN-D provided scheduled acetaminophen at that time. R1 refused tramadol and Biofreeze (a topical pain reliever) because R1 wanted something later if the pain got worse. RN-D did not complete a pain assessment at that time but asked R1 the location of the pain. RN-D was going to contact the physician for a different pain reliever but didn't do so because R1 wanted to go to the hospital. RN-D then focused on calling the physician so R1 could be transferred. When Surveyor indicated R1's scheduled acetaminophen was administered at 9:07 PM and R1's pain was rated at a level 0 out of 10, RN-D indicated R1 did not indicate R1 had pain until approximatey 20 minutes later. Between 9:00 and 10:00 PM, R1 told RN-D that R1 had difficulty breathing and wanted to go to the hospital. RN-D did not complete a respiratory assessment because RN-D called the physician and 911 and R1 did not want RN-D to touch R1. RN-D notified Director of Nursing (DON)-B between 9:00 and 10:00 PM that R1 was transferred to the hospital but had not spoken to DON-B prior. A progress note, dated 8/26/25 at 9:25 PM, indicated the physician was notified that R1 had increased pain on the right side of the chest and difficulty breathing and wanted to go to the ER. At approximately 10:30 PM, R1 left the facility with 911 transport to the hospital. A progress note at 11:52 PM indicated R1 refused tramadol and acetaminophen when offered. Hospital documentation indicated R1 arrived at the hospital on 8/26/25 at 10:42 PM and had diagnoses including sepsis, right pleural effusion, and acute renal failure. At 11:17 PM, R1 received fentanyl (an opioid medication used to treat pain) 100 micrograms (mcg). At 11:32 PM, R1 had a fever of 102.5 degrees Fahrenheit (F) and was placed on oxygen at 5 LPM. At midnight, R1 received acetaminophen 1000 mg and ketorolac tromethamine (a nonsteroidal anti-inflammatory medication used to treat pain) 15 mg. On 8/27/25 at 1:40 PM, R1 was transferred to the ICU at another hospital. On 9/3/25 at 6:59 PM, Surveyor interviewed R1 who was in the hospital. R1 indicated R1 was tired all day on 8/26/25 and it hurt to breathe. R1's pain and breathing got progressively worse throughout the day. R1 indicated sometime after supper between 7:00 and 9:00 PM, R1 told RN-D that something needed to be done and asked to go to the hospital. R1 was transferred to the ER and diagnosed with sepsis and a bacterial infection and told that R1's lungs were filled with fluid. R1 could not recall if R1 was offered tramadol or received pain medication at the facility that day but stated if R1 did receive pain mediation, it didn't work because R1 was in a lot of pain and it was hard to breathe. R1 stated R1 was fuzzy on the details of the day. R1 stated staff knew R1 was hurting and having difficulty breathing and at approximately 9:00, R1 couldn't take it any longer. RN-D entered R1's room close to 7:00 PM. R1 thought RN-D was going to give R1 Tylenol, however, R1 wasn't sure if R1 received it and told RN-D that R1 needed something stronger. R1 did not recall if R1 received a stronger medication. R1 recalled telling a CNA that R1 needed to see a nurse. R1 stated R1's pain was at a level 10 out of 10 that evening and was like nothing R1 had felt before. R1 stated staff did not send R1 to the ER until R1 requested to go. R1 stated staff offered ice and heat and indicated it was easier for R1 to sit up than lay down. R1 did not recall using oxygen during the day but stated R1 used oxygen toward the evening and the night prior.On 9/3/25 at 3:44 PM, Surveyor interviewed R1's primary MD ((MD)-C) from the facility who indicated when R1 complained of a different type of pain in the shower, staff should've notified MD-C about R1's change in condition. MD-C also indicated if anything is off or if a resident isn't acting like themself, staff should notify MD-C. MD-C indicated if R1 had increased SOB despite the use of oxygen, did not get better with oxygen, or needed increased oxygen, staff should've notified MD-C. On 9/3/25 at 4:13 PM, Surveyor interviewed DON-B who indicated the orders received from the NP at 9:35 AM on 8/26/25 for increased acetaminophen, diclofenac cream, and to wean R1 from oxygen should have been transcribed in R1's medical record within 2 hours of receipt of the orders. DON-B indicated the nurse who provided care for R1 should have completed a full assessment, including vital signs and a range of motion assessment, and updated the physician with the results. DON-B also indicated staff should have administered as needed diclofenac gel, acetaminophen, and/or tramadol and should have documented the actions taken to alleviate R1's pain in real time. DON-B indicated if a resident has pain, staff should complete a pain assessment, provide non-pharmacological interventions, and/or administer and document medications. DON-B spoke with RN-D who cared for R1 from 6:00 PM until R1 was transferred to the ER regarding the steps to take to provide care for R1. DON-B indicated RN-D did not complete the steps DON-B had provided. DON-B discussed with staff the importance of visualizing a resident to ensure pain medication is effective and confirmed oxygen use should be documented in the resident's medical record. DON-B indicated staff discussed implementing a triple carbon copy system so if staff have a concern, they can fill out a copy and give it to the nurse, DON-B, and NHA-A to ensure follow-up.The failure to recognize and act upon a change in condition in a timely manner led to serious harm for R1 who was still hospitalized on [DATE] and created a finding of immediate jeopardy. The immediate jeopardy was removed on 9/5/25, however, the deficient practice conitnues at a scope/severity level D (potential for more than minimal harm/isolated) as the facility continues to implement the following action plan:Completed a head-to-toe assessment for all in-house residents.Implemented an eInteract Point Click Care (PCC) Evaluation for Change in Condition and use of internet tools and resources.Reviewed in-house residents in daily Interdisciplinary Team (IDT) meetings for completion, documention, and identification of a change in condition, assessments (including vital signs), and provider notification.Educated staff on the facility's policies regarding notification, pain management, identifying a change in condition, and transcription and documentation of orders.Implemented audits and reviewed progress notes for change of condition response.

Based on staff interview and record review, the facility did not ensure notifications were completed in a timely manner following a fall with injury for 1 resident (R) (R1) of 7 sampled residents. R1 incurred a head injury during a Hoyer lift transfer on 11/14/24 when the lift tipped over on R1 and a metal bar struck R1 in the forehead. The facility did not notify R1's Hospice agency until 11/19/24 or R1's physician until 11/21/24. Findings include: The facility's Incidents and Accidents policy, dated 12/29/22, indicates: .5. The following incidents/accidents require an incident/accident report but are not limited to: .equipment malfunction, observed accidents/incidents, resident injuries due to staff handling .9. The nurse will contact the resident's practitioner to inform them of the incident/accident, report any injuries or other findings, and obtain orders if indicated, which may include transportation to the hospital dependent upon the nature of the injury(ies) .12. Documentation should include the date, time, nature of the incident, location, initial findings, immediate interventions, notification, and orders obtained or follow-up interventions. From 1/22/25 to 1/23/25, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] and had diagnoses including hemiplegia of the right side, type 2 diabetes, and history of transient ischemic attack (TIA) and cerebral infarct (stroke). R1's Minimum Data Set (MDS) assessment, 12/15/24, had a Brief Interview for Mental Status (BIMS) score of 13 out of 15 which indicated R1 had intact cognition. R1 started Hospice services in March of 2024. R1's medical record indicated R1 was injured during a Hoyer lift transfer on 11/14/24 when the lift tipped over on R1 and a metal bar struck R1 in the forehead. A note, dated 11/14/24 at 1:18 PM, indicated R1 had a red area on the face related to an injury from the Hoyer lift. The note instructed staff to monitor R1 for bruising. A note, dated 11/19/24, indicated R1 complained of a headache and vomiting. Documentation indicated R1 had a headache for the past 2 days along with dizziness and double vision and had trouble grabbing items. It was also noted that R1 had a large indent above the right eyebrow with redness and bruising. A note sent via the facility's medical record/charting system indicated Medical Doctor (MD)-C was notified on 11/21/24 at 12:15 PM that R1 was struck in the head with a Hoyer lift (on 11/14/24) and staff wanted to inform MD-C of R1's head injury, symptoms, and condition. On 1/22/25 at 11:19 AM, Surveyor interviewed Hospice Registered Nurse (HRN-D) who confirmed HRN-D first saw R1 on 11/19/24 following the incident on 11/14/24. R1's Hospice records indicated facility staff notified Hospice of the incident on 11/19/24. Facility staff reported that R1 was hit in the head with a Hoyer lift and had been complaining of blurred vision and headaches since the incident. HRN-D documented that R1 had a small 5 centimeter (cm) swelling on forehead. On 1/22/25 at 1:40 PM, Surveyor interviewed Director of Nursing (DON)-B who verified MD-C was first notified of the incident on 11/21/24. DON-B confirmed a Hospice CNA indicated they updated the Hospice agency following the incident, however, the facility did not directly notify the Hospice agency until 11/19/24. On 1/23/25 at 8:17 AM, Surveyor interviewed Certified Nursing Assistant (CNA)-E who confirmed CNA-E was in R1's room at the time of the incident and indicated DON-B was aware of the incident. On 1/23/25 at 11:39 AM, Surveyor interviewed Nursing Home Administrator (NHA)-A who indicated R1 was seen by HRN-D on 11/19/24. NHA-A confirmed MD-C was not notified of the incident until 11/21/24 via the facility's medical record/charting system. On 1/23/25 at 12:28 PM, Surveyor interviewed MD-C who confirmed MD-C was not aware of the incident until 11/21/24 when a note was sent to MD-C. MD-C denied any communication with the Hospice agency related to the incident. MD-C indicated MD-C had no knowledge that R1 had signs or symptoms of a head injury before the 11/21/24 note. MD-C indicated MD-C would expect the facility to document the injury, notify MD-C right away, and monitor R1 for signs and symptoms related to the incident.

Based on staff interview and record review, the facility did not ensure the resident environment remained as free of accident hazards as possible for 1 resident (R) (R1) of 3 sampled residents. R1 was transferred from bed to Broda chair via Hoyer lift on 11/14/24. Staff did not ensure R1's catheter bag was disconnected from the bed prior to the transfer which created resistance and caused the Hoyer lift to fall and strike R1 in the head. R1 exhibited signs and symptoms of a head injury but was not offered the opportunity to seek medical evaluation at the hospital. Findings include: The facility's Accidents and Supervision policy, revised 12/29/22, indicates: The resident environment will remain as free of accident hazards as possible. Each resident will receive adequate supervision and assistive devices to prevent accidents .b. The facility should make a reasonable effort to identify the hazards and risk factors for each resident .3. Implementation of Interventions: Use specific interventions to try to reduce a resident's risks from hazards in the environment. The process includes: a. Communicating the interventions to all relevant staff .c. Providing training as needed .e. Ensuring the interventions are put into action .h. Facility-based interventions may include, but are not limited to .i. Educating staff . The facility's Incidents and Accidents policy, revised 12/29/22, indicates: It is the policy of this facility for staff to utilize risk management to report, investigate, and review any accidents or incidents that occur or allegedly occur on facility property and may involve .a resident .The purpose of incident reporting can include: .Conducting root cause analysis to ascertain causative/contributing factors .to avoid further occurrences .5. The following incidents/accidents require an incident/accident report but are not limited to: .Observed accidents/incidents .7. Any injuries will be assessed by the licensed nurse or practitioner and the affected individual will not be moved until safe to do so .9. The nurse will contact the resident's practitioner to inform them of the incident/accident, report any injuries or other findings, and obtain orders, if indicated, which may include transportation to the hospital dependent upon the nature of the injury(ies) . From 1/22/25 to 1/23/25, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] and had diagnoses including hemiplegia (paralysis one side of the body) of the right side, diabetes, morbid obesity, pressure ulcers, and asthma. R1's Minimum Data Set (MDS) assessment, dated 12/15/24, had a Brief Interview for Mental Status (BIMS) score of 13 out of 15 which indicated R1 was not cognitively impaired. R1 was responsible for R1's healthcare decisions. On 1/22/25, Surveyor reviewed the facility's Verification of Investigation that was completed on 11/14/24 following a fall that occurred when Certified Nursing Assistant (CNA)-E and Hospice CNA (HCNA)-H transferred R1 with a Hoyer lift. The investigation indicated R1's catheter bag was attached to the Hoyer lift during the transfer which caused the lift to tip over onto R1. The investigation indicated HCNA-H (who was new to caring for R1) left the facility afterward and reported the incident to the Hospice agency. The facility contacted R1's Hospice nurse and requested HCNA-H not return to the facility. Surveyor noted the investigation did not contain physical assessments of R1 following the incident, a statement from R1's roommate (R2), other resident interviews, staff statements, or documentation that indicated all staff who completed Hoyer transfers received education. On 1/22/25, Surveyor requested physical assessments of R1 following the incident, a witness statement from R2, other resident interviews, statements from staff who were involved or witnessed the incident, and proof of staff education. The facility did not provide the information during the survey. On 1/22/25 at 9:47 AM, Surveyor interviewed R2 (R1's former roommate) who indicated R1 had severe pain and headaches every day following the fall on 11/14/24. On 1/22/25 at 12:23 PM, Surveyor interviewed CNA-G who verified CNA-G provided assistance following R1's fall on 11/14/24. CNA-G indicated R1 was confused, dizzy, and unable to state where R1 was. CNA-G indicated R1 looked at CNA-G and stated R1 could not see CNA-G. CNA-G indicated it was difficult to get R1 up in the Hoyer after the incident because R1 became winded, dizzy, and constantly had headaches. CNA-G indicated CNA-G did not get R1 up as much after the incident due to R1's medical condition. On 1/23/25 at 7:55 AM, Surveyor interviewed CNA-E who indicated on 11/14/24 at approximately 11:15 AM, CNA-E and HCNA-H were transferring R1 from bed to Broda chair when R1's catheter bag got caught and caused the Hoyer lift to fall over and land on R1's forehead. R1's catheter was pulled out and CNA-E called for assistance. Licensed Practical Nurse (LPN)-F and CNA-G entered the room and lifted the Hoyer off of R1. CNA-E indicated R1 sustained a dent in the forehead above the right eyebrow and complained of headaches a couple of days later. CNA-E indicated R1's eyes shook when R1 stared at CNA-E which occurred until R1 passed away on 12/19/24. CNA-E informed the charge nurse of R1's condition and was told it was normal. CNA-E indicated CNA-E was not interviewed regarding the incident and denied receiving education about Hoyer lift transfers following the incident. On 1/23/25 at 11:00 AM, Surveyor interviewed LPN-F who recalled the incident on 11/14/24. LPN-F indicated R1 had a red and tender-to-touch area on the forehead. LPN-F indicated R1's neurological assessments were normal. LPN-F did not state why LPN-F did not document the assessments. On 1/22/25 at 1:38 PM and 1/23/25 at 11:43 AM, Surveyor interviewed Director of Nursing (DON)-B who indicated LPN-F completed a physical assessment of R1 on 11/14/24 but verified the assessment was not documented on the date of the incident. DON-B was unaware if background checks or competencies were completed for HCNA-H prior to providing care for R1. DON-B verified staff and resident interviews were not completed following the incident. DON-B indicated DON-B verbally educated CNA-E, HCNA-H, and LPN-F following the incident to slow down when performing care and advocate for safety, however, no other staff were provided education. DON-B verified R1 was not offered the opportunity to be examined at the hospital following the injury. DON-B also verified the facility did not notify R1's Hospice agency of the incident until 11/19/24 or notify R1's primary physician until 11/21/24.

Based on observation, staff and resident interviews and record review, the facility did not assure 1 (resident #6) of 11 sampled residents received the necessary care and services to attain or maintain the highest practicable physical well-being. Resident #6 re-entered the facility on 4/4/11 after sustaining a left [MEDICAL CONDITION] requiring surgical repair. The resident was assessed to have increased pain with movement and during cares. The resident's medication regime included the use of as needed pain medication. When staff noted increased pain with every two hour repositioning in bed and during cares, no changes in the resident's plan of care were implemented to include interventions to diminish pain during times when pain was expressed by the resident. The resident's plan of care indicated staff were to alert a nurse promptly of indicators of resident pain. That plan of care intervention was not implemented consistently. Additionally, the resident had a plan of care intervention for the use of an abductor wedge cushion between her legs at all times when the resident was in bed and with repositioning from side-to-side in bed. The wedge was to prevent dislocation of the newly inserted hip prosthesis. The resident's plan of care to utilize the wedge when the resident was in bed was not implemented consistently. Findings include: Resident #6's admission face sheet, dated 7/28/09, indicated the resident had [DIAGNOSES REDACTED]. At the time of survey, the resident was [AGE] years old. On 4/1/11 the resident was admitted to the hospital for evaluation of a fall and inability to move her left leg. The resident was hospitalized with a [DIAGNOSES REDACTED]. The resident was readmitted to the facility at 2:30 p.m. on 4/4/11. Prior to hospitalization , the resident was assessed, per an MDS (Minimum Data Set), dated 3/2/11, to be independent in all activities of daily living, totally continent of bowel and bladder, independently ambulatory and had scored 3 of 15 on her cognitive assessment (the higher the score, the more cognizant). The resident's hospital re-admission orders [REDACTED]. The facility completed a comprehensive pain assessment for resident #6 on 4/4/11. The pain assessment indicated the resident's level of pain at the time of the assessment was 7 (on a 0-10 scale. O being no pain, 10 being worst pain); the worst the pain got was listed as a 9-10; the best the pain got was listed as a 4; and the resident's acceptable level of pain was listed as a 4. The assessment indicated the quality of the pain was sharp pain and sometimes throbbing pain. The assessment also indicated aggravating factors for pain included treatment and procedures, movement and positioning and activities of daily living. Alleviating factors for pain included repositioning, heat or cold, medications and rest. Effects of pain were listed as activities of daily living and ambulation. Current pain medications included as needed Tylenol and as needed [MEDICATION NAME]. Coaching listed on the pain assessment indicated "...use call light for assistance." The problem listed on the assessment indicated, "...pain related to left [MEDICAL CONDITION]." The approach indicated, "...administer pain meds routinely by asking on pain levels. Use hip precautions." The goal of the pain assessment indicated, "...increased comfort, decreased pain, provide optimal bone and wound healing." Resident #6's comfort plan of care dated 4/5/11 directed staff to report pain to the nurse promptly, assess physical symptoms, administer pain meds as ordered and notify the doctor as needed with exacerbation of pain. The goal of the comfort plan of care indicated the resident would express feelings of comfort, or of pain relief, within a reasonable time after pain medication administration. The goal also indicated the resident would express satisfaction with the pain medication regimen and would have increased comfort and decreased pain. On 4/5/11 at 7:10 a.m. surveyor # interviewed LPN (Licensed Practical Nurse)-F regarding pain medication administration for resident #6. LPN-F verified resident #6 had received the last dose of as needed pain medication at 11:30 p.m. on 4/4/11. On 4/5/11 at 7:15 a.m. surveyor # observed CNA (Certified Nursing Assistant)-K enter resident #6's room. The resident was lying in bed and elected to stay in bed for breakfast stating, "My hip is so sore." CNA-K replied, "I'll tell the nurse after I do your cares." The resident asked to utilize the bedpan and again stated, "My leg is pretty sore." CNA-K attempted to roll resident #6 onto the bedpan. The resident stated, "My leg hurts. Ouch!" CNA-K continued to roll the resident onto her side, all the time the resident was verbalizing, "Oh, oh, ouch!" The surveyor observed the resident to be moaning and panting through her open mouth. The resident's eyes were tightly shut. The resident had a pained look on her face and was stating, "My hip is so sore." CNA-K stopped the activity and left the room to seek assistance. The surveyor asked resident #6 to rate her pain. Resident #6 replied "7 or 8." CNA-K and CNA-L re-entered resident #6's room and assisted the resident with cares. Resident #6 stated to CNA-L, "This leg is real sore" and pointed to her left hip. Both CNAs rolled the resident onto her right side in attempts to place the resident onto the bedpan. During the repositioning, the resident was grimacing, moaning, panting and stating, "Oh it hurts!" The resident voided into the bed pan, and both staff rolled the resident to her side as she stated, "Oh, oh, ouch. It hurts so bad!" Staff then rolled the resident onto her back, and the resident stated, "Ouch, ouch!" At 7:45 a.m. RN (Registered Nurse)-M entered resident #6's room and removed a dressing from the resident's left hip incision. RN-M instructed CNA-K to roll the resident onto her right side in order to place a clean dressing on the hip incision. As the resident was rolled onto her side she stated, "Ouch, oh, oh, ouch!" The surveyor observed the resident to be breathing heavily through her open mouth and winching. The resident was then rolled onto her back; stated, "Oh, oh, oh, ouch" and grabbed her left hip. RN-M stated, "I'll go check on when your last pain pill was to see if you got one." CNA-K then placed a pillow under the resident's left side. The resident was groaning and stated, "Ouch, oh." The surveyor immediately interviewed CNA-K. The surveyor asked CNA-K when resident #6 had last received pain medication. CNA-K stated, "I have no idea." During the above observation, staff did not ensure resident #6 received pain medication prior to cares and did not stop cares and bed mobility and alert the nurse to pain when the resident had verbal and non-verbal indicators of pain, as directed by the resident's plan of care. On 4/5/11 at 8:00 a.m. surveyor # interviewed LPN-F regarding the above observations of care for resident #6. LPN-F stated, "I would expect that staff stop cares and tell me if she (resident #6) complains of pain." On 4/5/11 at 8:15 a.m. surveyor # interviewed DON (Director of Nursing)-B. DON-B stated, "If a resident is having pain, staff should stop what they are doing and have the nurse assess the resident." On 4/5/11 at 1:00 p.m. surveyor # entered resident #6's room. The resident asked the surveyor how to summon staff, because she needed to utilize a bed pan. The resident's call light was located on her chest. The resident could not demonstrate to the surveyor how to activate the call light, so the surveyor summoned CNA-K and CNA-U to the resident's room. Staff entered the resident's room; and as they rolled the resident onto her side, she stated, "Oh dear. Oh, oh, oh, ouch. I hurt so hard." Staff placed the resident on the bed pan, and again the resident verbalized pain during rolling. CNA-K stated, "We'll have to see if we can get you another pain pill." The resident was rolled onto her side to remove the bed pan and placed on her back. Again, the resident verbalized, "I hurt so hard" as she was grimacing with both eyes shut tightly and breathing heavily through her open mouth. The resident was rolled onto her side for staff to perform pericare, and the resident verbalized indicators of pain stating, "Oh it hurts. It's my hip!" The resident was told she needed to be boosted in bed and needed to have pillows under her heels. The resident responded, "Just leave me. I'm good where I am." Staff boosted the resident; and during the repositioning, the resident stated, "Ouch, oh, oh." The surveyor immediately interviewed CNA-K. CNA-K stated, "She (resident #6) has reacted this way with all repositioning at least every two hours today. I haven't told the nurse today, because she can only have pain medication every four hours." On 4/5/11 at 1:30 p.m. surveyor # interviewed MT (Medication Technician)-A regarding resident #6. MT-A stated, "She (resident #6) had a pain pill at 8:10 a.m. today, and we asked her at 12:10 p.m. today if she was having any pain. She stated she would call us and let us know if she needed any pain medication later." MT-A verified that at 12:10 p.m., during the pain assessment of resident #6, the resident was lying still in bed. On 4/5/11 at 1:32 p.m. RN-M stated to surveyor # , "We will fax her (resident #6) doctor to see if we can get her on scheduled pain medication. That would be better. When the resident is left alone and not moved, her pain is tolerable. It's when she is repositioned or pericare is done when she has pain." On 4/5/11 at 1:40 p.m. surveyor # interviewed PTA (Physical Therapy Assistant)-N. PTA-N stated, "Part of the importance of successful rehabilitation after a [MEDICAL CONDITION] is pain control." A fax dated 4/5/11 at 2:45 p.m. indicated, "Faxed to let doctor know resident (#6) not very good about asking for pain med (medication)." The physician changed the resident's pain medication regime to include scheduled [MEDICATION NAME] three times daily and to continue with Tylenol as needed for pain. Resident #6's re-admission plan of care included the use of a wedge abductor cushion between her legs to be utilized at all times while the resident was in bed and during repositioning in bed. The wedge cushion was part of a hip precaution plan of care to prevent the newly implanted hip prosthesis from dislocating. On 4/5/11 at 7:15 a.m. surveyor # observed CNA-K and CNA-L providing cares for resident #6. The cares involved rolling the resident from side-to-side in bed several times. During the observation of the cares, the wedge cushion was not placed between the resident's legs during bed mobility when rolling the resident from side-to-side. On 4/5/11 at 7:45 a.m. surveyor # observed RN-M ask CNA-K to roll resident # 6 onto her side to aid in a wound dressing change. The resident was rolled onto her right side without the use of a wedge cushion between her legs. The resident was positioned onto her back at 8:00 a.m., and the wedge cushion was not placed between her legs. On 4/5/11 at 8:02 a.m. surveyor # interviewed LPN-F regarding the above observations. LPN-F verified resident #6 was to have a wedge abductor pillow placed between her legs at all times to keep her legs apart. On 4/5/11 at 8:05 a.m. surveyor # interviewed CNA-K regarding the wedge abductor pillow for resident #6. CNA-K verified she had been unaware of the hip precautions including the use of the wedge cushion to keep resident #6's legs from crossing. On 4/5/11 at 8:15 a.m. surveyor # interviewed DON-B regarding resident #6. DON-B verified a hip abductor wedge cushion was to be utilized at all times when resident #6 was in bed, to include when staff assisted the resident to roll from side-to-side. On 4/5/11 at 1:05 p.m. surveyor # observed CNA-K and CNA-U assisting resident #6 onto the bedpan. The resident was rolled several times back and forth in bed during the provision of the cares. Staff did not utilize the hip abductor wedge between the resident's legs during the bed mobility. On 4/5/11 at 1:40 p.m. surveyor # interviewed PTA-N regarding the necessity of the wedge abductor pillow. PTA-N stated, "If the abductor pillow is not utilized and if the leg crosses midline, it's very likely that fresh post operative hip replacements can pop out of the socket. The joint is expanded due to surgery, and thing are very lax in that area."