Every finding on record at Teays Valley Center

Based on observation, and staff interviews, the facility failed to maintain an effective pest control program relating to ants in room [ROOM NUMBER]. This was a random opportunity for discovery. Resident identifier: #59. Facility Census: 115. Findings included: During a walkthrough in room [ROOM NUMBER] on 07/21/26 at 11:30 AM, it was observed that a dried red sticky substance had been spilled on the floor beside Resident #59's bed and was covered with ants. Resident #59 stated she spilled her protein medication cup when she tried to throw it away and missed the trash can. Staff Interviews: In an interview with Nurse Manager #1, on 07/21/26 at 11:40 AM, she acknowledged the spill and the ants crawling in it. She stated she would have housekeeping clean it up. In a walkthrough and interview with the Director of Nursing #3, on 07/21/26 at 11:50 AM, she verified the spill was still there with ants in it and began to clean it up immediately.

Based on record review and staff interview, the facility failed to have a Registered Nurse on duty for eight (8) hours a day, seven (7) days a week full time. This was found to be true for one (1) of 19 days reviewed during the long term care survey process. Facility census: 120.Findings included: On 04/21/25, the facility Daily Nurse Staffing Form only recorded one Registered Nurse (RN) working 4.0 hours. On 02/18/26 at 12:15 PM, surveyor asked the Nursing Home Administrator (NHA) if the posted Daily Nurse Staffing Form was correct. The NHA stated the RN was on call, but came in to work four (4) hours that day. This was additionally verified by a Time Detail Report from the facility's time keeping system.

Based on record review and staff interview, the facility failed to develop or implement the care plan for residents care. This was true for three (3) care plans reviewed during this survey. Resident Identifiers: #3, #9 and #63. Facility Census: 120 Findings Included: a) Resident #3 On 02/17/26 at 12:30 PM a record review of medical diagnosis for Resident #3 shows there is a diagnosis of Bipolar. A review of the care plan found no diagnosis of Bipolar under the Focus of impaired/decline in cognitive function in impaired thought processes nor any where on the care plan. On 02/17/26 at 1:00 PM the above was confirmed with the Administrator that the diagnosis of Bipolar was not developed on the care plan. b) Resident #9 On 02/17/26 at 2:40 PM record review of Resident #9s care plan shows his preference as having a shower as he is dependent with all care based on his medical diagnoses. This was also confirmed with his Medical Power of Attorney during a telephone conversation for a representative interview. Record review of the GG-bathing task shows the resident is not receiving his showers as outlined in the care plan, but instead receiving bed baths often. On 02/17/26 at 3:00 PM the above was confirmed with the Administrator the care plan was not being implemented to ensure the resident is receiving his showers as outlined on the care plan. c) Resident #63 On 02/17/26 at 12:35 PM record review shows Resident #63 has a Physicians order for Defined Perimeter Mattress to bed for safety. The care plan for this resident states Focus: Resident is at risk for falls d/t cognitive loss, lack of safety awareness, impaired mobility, possible medication side effects. Interventions: Defined Perimeter Mattress On 02/17/26 at 2:00 PM the above was confirmed with the Administrator the care plan was not being implemented to ensure the resident was provided a defined perimeter mattress for safety as outlined on the care plan.

Based on record review and staff interview the facility failed to ensure they had verification that a bed hold policy/notice had been given to one (1) residents and/or their legal representative at the time they were transferred from the facility. Resident identifier: #50. Facility census: 120. a) Resident #50 This resident was on hospital leave from 08/22/25 until 08/27/25. The resident had capacity to make his/her own medical decisions. On 08/22/25, the resident was transferred to an acute care facility for shortness or breath with hypoxemia. A review of the medical record found no bed hold notice. This was requested from the facility on 02/17/26 at 8:45 AM. On 02/17/26 at 10:50 AM, the bed hold notice was provided by the Nursing Home Administrator (NHA), but it was not signed by the resident. When asked why the resident's signature was not obtained, the NHA acknowledged signatures should have been obtained, or verbal consent documented.

Based on record review and staff interview the facility failed to administer Activities of Daily Living assistance with residents. This was true for three (3) of five (5) records reviewed. Resident Identifiers: #9, 57, 59. Facility Census:120 . a) Resident #59 02/17/26 1:43 PM a review of Resident #59's hygiene tasks did not indicate the resident refused care, instead it stated the care was not applicable. This made it appear that no attempt was made to provide oral care to resident. This was discussed with nursing home administrator on 02/17/26 at 1:40 PM. b) Resident #57 02/16/26 9:54 AM an observation revealed the resident had severe plaque build up on teeth. The care plan called for teeth brushing twice a day.02/17/2026 12:28 PM during an interview with the DON at 11:48 AM the DON confirmed staff was not checking resident refused and instead checking not applicable. It was discussed that this made it appear the care was not provided as opposed to resident refusing care. c) Resident #9 On 02/16/26 at 9:42 AM during a telephone interview with Resident #9's Medical Power of Attorney (MPOA) it was stated that she comes into the facility daily and her husband often appears unkept. She sometimes has to remind the staff that it is Wednesday or Saturday and the Resident is scheduled a shower that day, otherwise he may not get one. She states that the resident and herself, prefers him to have a shower and the staff are aware. On 02/17/26 at 9:00 AM during record review it was noted the care plan states Resident/Patient requires assistance/is dependent for ADL care in bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion, toileting related to recent hospitalization, increased weakness, decreased functional mobility. The care plan also states It is important to me to have a shower with my care. The resident has a medical diagnosis of Dementia and Parkinson's Disease. According to the facility shower scheduled provided by the Director of Nursing (DON) Resident #9 is scheduled a shower on Wednesday and Saturday and all showers are provided on day shift. Record review of the Task for GG-Bathing for the last 30 days Resident #9 was scheduled a shower on the following dates: 01/21/26 - received a bed bath 01/24/26- documented as not applicable 01/28/26 - received a shower 01/31/26 - received a bed bath 02/04/26- documented as not applicable 02/07/26- documented as not applicable 02/11/26- received a shower 02/14/26- received a shower Over the course of the 30 day lookback, Resident #9 was eligible for eight (8) showers of which he received one (3) shower and two (2) bed baths, five (5) of eight (8) opportunities. On 02/17/26 at 10:15 AM it was confirmed with the Director of Nursing that Resident #9 did not have his showers as scheduled.

Based on observation and staff interview facility failed to ensure food is stored, prepared and served in a sanitary manner, and cleaning of the kitchen is kept at facility policy standards. This observation was from the annual Long Term Care Facility Survey process. This deficient practice had the potential to affect more than a minimal number of residents who received nutrition from the kitchen.Facility census: 120.Findings includea) Policy review titled: Environment Review of procedures reads in part.1- The Dining Service Director will ensure that the kitchen is maintained in a clean and sanitary manner, including floors, walls, ceilings, lighting and ventilation.2- The Dining Service Director will ensure that all employees are knowledgeable in the the proper procedures for cleaning and sanitizing of all food service equipment and surfaces.3- All food contact surfaces will be cleaned and sanitized after each use.4- the Dining Service Director will ensure that a routine cleaning schedule is in place for all cooking equipment, food storage areas, and surfaces.6-All trash will be contained in covered leak-proof containers that prevent cross contamination.Policy review titled: Food Storage: Dry Goods.-Procedures review reads in part:1- All items will be stored on shelves at least six (6) inches above the floor.2- Storage areas will be neat, arranged for easy identification, and date marked as appropriate.C)Policy review titled: Food Storage: Cold Foods-Policy Statement All time/temperature control for Safety (TCS) foods, frozen and refrigerated, will be appropriately stored in accordance with guidelines of the FDA Food Code-Procedures review reads in part:1- All food items will be stored six (6) inches above the floor and (18) inches below the sprinkler unit.4- An accurate thermometer will be kept in each refrigerator and freezer. A written record of daily temperatures will be recorded.5- All foods will be stored wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination. On 02/15/26 at around 10:45 AM, an initial dining department walk through was completed, [NAME] #7 accompanied surveyor as the Account Manager was not in the facility at this time.02/15/26 at around 10:45 AM during initial dining department walk through with [NAME] #7 observation revealed the microwave with food debris and sticky substance on inside and outside of door and handle. [NAME] #7 confirmed. 02/15/26 at around 1:30 PM during tour with Account Manager debris and sticky substance on outside and inside of microwave remained, Account Manager confirmed, reporting We will get it cleaned.02/15/26 at around 10:45 AM during initial dining department walk through with [NAME] #7 observed the two (2) door reach in refrigerator gaskets on both doors with black substance along the inside grooves, dried sticky substance on outside of door, along bottom of doors. Dried sticky substance on bottom shelves of refrigerator. [NAME] #7 confirmed. 02/15/26 at around 1:30 PM during tour with Account Manager black substance along the inside grooves, dried sticky substance on outside of door, along bottom of doors and shelf remain. Account Manager confirmed, reporting we will get this clean.02/15/26 at around 10:45 AM during initial dining department walk through with [NAME] #7, observed in the two (2) door reach in refrigerator, a meal box with name [NAME] dated 02/11/26 - 02/16/26. Questioned cook #7 she informed this surveyor, it was an employee's.During return visit on 02/15/26 at around 200PM with Account Manager, this container remained in the reach. The Account Manager confirmed it needed to be removed.02/15/26 at around 10:45 AM during initial dinning department walk through with [NAME] #7, observed all prep tables throughout the kitchen on the bottom shelves having food debris and sticky substances cook #7 confirmed reporting they need cleaned. 02/16/25 at around 10:30AM during revisit to kitchen with Account Manager sticky substances and food debris remain on the bottoms of the prep tables. Account Manager confirmed, reporting these will be cleaned02/15/26 at around 10:45 AM during initial dining department walk through with [NAME] #7, observed stove top drip tray with large amount of debris. [NAME] #7 confirmed reports I will clean it before my shift ends. On 02/16/26 at around10AM ,during a revisit to the kitchen area, the drip pan continued to have a large amount of food debris and sticky substance on the drip pan and thick debris to back splash on stove top, District Manager for Food and Nutrition, in the kitchen and confirmed. Reporting it needs cleaned.02/15/26 at around 10:45AM during initial dining department walk through with [NAME] #7, observed the top of the steamer with moderate amount of sticky substance. [NAME] #7 confirmed. On 02/16/26 at 10AM during a revisit observed the top of the steamer continued to have sticky substances. Account Manager in the kitchen and confirmed. Reporting it will be cleaned02/15/25 at around 10:45AM during initial dining department walk through with [NAME] #7, observe the double oven doors and inside of the ovens having a large amount of dried sticky substances cannot see inside of oven doors glass and with large amounts of debris on inside of the ovens, along sides and on bottom of heating area. [NAME] #7 confirmed, reporting they do need cleaned. 02/16/26 at 10AM during a revisit, observed the ovens continue to have the large amounts of dried sticky substances, glass doors remained covered with the sticky substances, inside continued to have the debris, District Manager for Food and Nutrition in facility confirmed, reporting we will work on getting this clean02/15/26 at around 10:45 Am during initial dining department walk through with [NAME] #7, the following observations were made in the dry stock room:The floor had a large amount of dark black substance,Food debris was present along the centers of the floorCook #7 confirmed and reported the floors really need mopped. 02/15/26 at around 1:30 PM during tour with Account Manager, floor remained needing mopped, Account Manager said, Ill ensure it is mopped and they continue to mop each evening.On 02/16/26, at around 10:00 AM during a follow up visit, the floor had been mopped Account Manager reported, I got this done last night, will ensure they continue to mop nightly. On 02/17/26 around 11:00 AM, a follow up visit revealed the floor had a small amount of dark residue along the center. Account Manager confirmed the evening shift is mopping nightly02/15/26 at around 10:45 AM during initial dining department walk through with [NAME] #7 observed in the dry stock room, two (2)Gallons of water from [NAME] Mountain sitting on floor, [NAME] #7 said, These need up off the floor. On 02/16/26 at around 10:00 AM during a follow up visit, these gallons of water remained sitting on the floor in front of the shelving system. Account Manager with surveyor said, I'll get these picked up.02/15/26 at around 10:45AM during initial dining department walk through with [NAME] #7, observed near the exit door a hole was noted in the wall near the floor just above the baseboard, daylight could be seen. Paint peeling from the wall, baseboard loose along edging. Paint peeling from the wall along the area entering the walk-in hall. [NAME] #7 confirmed. On 02/16/2026 at around 11:30 AM during return visit to kitchen, Account manager confirmed the areas needed to be repaired and reported a work order had been in the system since 03/28/24, presented with a copy of work order. 02/16/25 at around 11:00AM Administrator in area with Surveyor , District Manager and Account Manager, confirmed the hole in the wall at exit door, the paint peeling on the walls reporting, maintenance will be made aware. At around 1:36 PM on 02/16/26 Regional Maintenance Director correcting the issue at this time.02/15/26 at around 10:45AM during initial dining department walk through with [NAME] #7, observed in the walk -in refrigerator, the gasket to the door, with large amount of black dried substance, door with sticky substance on handle and along door edge, cook #7 confirmed. On 02/16/26 at around10AM during return visit to kitchen, Account Manager confirmed reports we are working on cleaning02/15/26 at around 10:45AM during initial dining department walk through with [NAME] #7, observed in the walk-in refrigerator, the fan with debris on bottom of the fans, black sticky in substance, notice substance black in color blowing outward. On the ceiling across from the fan a moderate amount of black flaky debris hangs from the ceiling and wall. [NAME] #7 confirmed. 02/16/26 at around 10AM during a revisit to the kitchen, the debris remain, Account Manager with surveyor reports I asked maintenance to turn off the fan so we can clean that.02/15/26 at around 10:45AM during initial dining department walk through with [NAME] # 7 in walk-in refrigerator, a case of potatoes touching the ceiling. [NAME] #7 confirmed. On 02/16/26 at around 10:00 AM during return visit to the kitchen the case of potatoes remained, Account Manager confirmed this needed corrected.On 2/17/26 at around 2:00 PM, during a return visit the case of potatoes remained touching the ceiling, Account Manager said, I will get this corrected.02/15/26 at around 10:45AM during the initial dining department walk through with [NAME] #7 the following was observed in the walk -in refrigerator: Food debris under shelves on floor,Sticky substance also on the floorCook #7 confirmed the above findings in the walk-in refrigerator On 02/15/26 at around 1:30 PM the Account Manager said, We will get this cleaned02/15/26 at around 10:45AM during initial dining department walk through with [NAME] #7 the following was observed: In the freezer two (2) cases of ice cream were touching the ceiling. [NAME] #7 confirmed this observation. On 02/15/26 at around 1:50 PM during walk through with the Account Manager, the cases remained touching the ceiling of the freezer. Account Manager confirmed, and said, It will be corrected.02/15/26 at around 10:45 AM during the initial dining department walk through with [NAME] #7 the following was observed:In the freezer a case of pizza and vegetables were sitting on the floor.Cook #7 confirmed. At around 1:30 PM on same day, Account manager with surveyor confirmed the cases were on the floor and reported I will place it on a crate or on a shelf to get off the floor.02/15/26 at around 10:45 AM during initial dining department walk through with [NAME] #7 in the dining room on the countertop observed moderate amount of a red sticky substance along backsplash and on countertop, cook #7 confirmed, reported, We need to get this cleaned and proceed to wipe the area.02/15/26 at around 10:45AM, during initial tour with [NAME] #7,In the dining room on the countertop along the wall, and in drawers with utensils, and in cabinet labeled suction machine, In drawer labeled clothing protectors. A large amount of small, dark brown-to-black, cylindrical pellets resembling grains of rice debris were observed, [NAME] #7 confirmed, reports we have had issues with mice We will get this cleaned up. 02/15/26 at around 1:00PM during tour with Account Manager the cylindrical pellets remained on the countertop along backsplash, in the cabinet, drawers with utensils and clothing protectors. Account Manager confirmed reporting, Ill inform maintenance and get the area cleaned and all items re-washed.02/15/26 at around 11:30AM,Food delivery cart observation revealed five (5) of five (5) food carts had sticky debris, food debris, on outsides of each one had sticky substances.along back and sides dried liquid substance. Aide #11 verified the carts were ready for meal, and verified the substances reported Aide #37, was supposed to clean these already, On 02/15/26 at around 4:30PM during a return observation with Account Manager the Food delivery carts continued to have dried sticky substance, food debris along outside and on edges of the carts. The account manager confirmed these were ready for meal service and that the debris and sticky substance remain. The Account Manager reported, I will get them cleaned up before meal service.02/15/26 at around 10:45AM, during initial tour with [NAME] #7,Refrigerator in dining room: doors, gaskets with sticky black substance on outer doors and bottom of area. Bottom of the refrigerator with dried substance sticky on outside. cook#7 confirmed. 02/15/26 at around 2:00PM during tour with Account Manager the debris, sticky substance on outside of the refrigerator and on gaskets and inside the refrigerator remained, Account Manager confirmed, reporting We will get this cleaned up.On 02/17/26 at around 2:00 PM during a return visit with Account Manager the items on and inside of the refrigerator were still present. The Account Manager reported, It will be cleaned today.02/15/26 at around 10:45 AM , during initial tour with [NAME] #7,a container of thickened tea was sitting on the counter near the hand wash sink. The tea was opened with no date and no use by date. Information on the container reads, Use up to 7 days after opening, best if refrigerated prior to opening. [NAME] #7 confirmed and threw the carton in the trash.02/15/26 at around 10:45 AM, during initial tour with [NAME] #7, on top of the outlet next to the refrigerator in the dining room on the wall there was an observation of a moderate amount of black sticky residue. [NAME] #7 confirmed this observation. On 02/15/26 at around 2:00 PM during a tour with the Account Manager, the black substance remained on the wall and outlet, Account Manager confirmed and said, I'll get this cleaned. 02/15/26 at around 1:00 PM, review of food temperature logs, revealed the following missing temperatures: 02/04/26 Dinner temperatures 02/05/26 Breakfast, Lunch and Dinner missing temperatures 02/06/26 Dinner temperatures 02/07/26 Breakfast and Lunch temperatures02/08/25 Breakfast, Lunch and Dinner temperatures 02/09/26 Dinner temperatures 02/10/26 Dinner temperatures02/11/26 Dinner temperatures02/12/26 Breakfast, Lunch and Dinner temperatures02/13/26 Breakfast, Lunch and Dinner temperatures 02/14/26 Dinner temperatures missing. Account manager reviewed with surveyor and confirmed missing temps02/15/26 at around 10:30 AM during initial tour with [NAME] #7,in the cabinet near the kitchen entrance, on the inside: on the shelf rails, a large amount of debris powdery in consistency, on the bottom of the cabinet, a glue trap with moderate amount of small black cylindrical pellets debris. [NAME] #7 confirmed. 02/15/26 at around 1:00 PM during tour with Account Manager debris and glue traps remained in the cabinet, Account Manager confirmed.02/15/26 at around 10:30 AM during initial tour with [NAME] #7 an observation in the cabinet under coffee maker, where a small trash can was housed revealed large amount of dried sticky substance on the outside of the trash can, and on the bottom of the cabinet, along with large amount of opened sugar packets. [NAME] #7 confirmed this observation. 02/15/26 at around 1:00 PM during the tour with Account Manager observation revealed the debris and opened sugar packets remained. Account Manager confirmed and said, I think housekeeping cleans this area. 02/16/2026 10:20 AM District manager for food and dining manager rounded with surveyor, will review policy regarding the cabinets that have excessive debris for cleaning and who is responsible. 02/16/26 at around 2:30 PM District Manager for Food and Dining reported, These cabinets have been cleaned02/15/26 at around 10:30AM during initial tour with [NAME] #7 observed, A case of disposable cups on floor. [NAME] #7 confirmed. On 02/16/2026 at 1:34 PM the case remained on the floor Dietary Aide #37 confirmed, reporting I will place it off the floor, proceeded to remove the case off the floor.02/15/26 at around 2:00 PM during tour with Account Manager observed in pantry on 400 hall missing temperatures for 2/14/26 and 2/15/26, Account manager said, They usually do these in the morning.Inside the pantry refrigerator observation revealed a dried brown substance on the door , gallons of milk on shelf in the door.02/16/26 at around 1:33 PM a dried sticky substance remained on the inside of the door on the shelf, with gallons of chocolate milk and white milk on shelf. Account Manager said, It needs to get cleaned02/15/26 at around 2:00 PM observation revealed:A carton of thicken cranberry juice with no open or use by date.A carton of thicken water with no open or use by date. Account manager said, I will review with staff to ensure dates are done upon opening02/15/26 at around 2:30 PM during walk through with Account Manager in dining room the following was observed: The trashcan at entrance to the kitchen had a dried sticky debris on lid and outside. The Account Manager said, This will be cleaned.02/16/26 at around 12:30 PM an observation of the dish room noted water spilled on floor and into kitchen area. The (District manager) reported this was from where they just finished dishes. An observation along the floorboards where tiles were against wall revealed a large amount of black flaky substance. The hand wash sink in the dish room revealed dried sticky brown debris. District Manager with surveyor, confirmed, reporting definitely needs cleaned dish machine with yellowish, off-white moderate amount debris on top of machine, along the edges, under the lid. Buildup inside. The Account Manager said it was de-limed weekly.On 02/17/26 at around 3:10 PM during another observation in the dish room revealed along the floorboards where tiles are against wall continue to have large amount of black flaky substance. The district manager confirmed the area needed cleaned. The dish machine continued to have a moderate amount of debris on top of the machine. The district manager confirmed it needed cleaned.

Based on record review and staff interview the facility failed to educate, offer and obtain declination or consent or administered for the COVID-19 2024-2025 and/or COVID-19 2025-2026 immunizations. This was true for five (5) of seven (7) Residents screened for immunizations. Resident Identifiers: #37, #49, #70, #89 and #91. Facility Census: 120.Findings Included: a) Resident #37 On 02/18/26 at 9:30 AM record review shows Resident #37 was admitted on [DATE]. Further record review showed the resident had not been administered nor consented/declination of COVID-19 vaccinations for the 2024-2025 or the 2025-2026 COVID-19 boosters. On 02/18/26 at 10:00 AM the above was confirmed with the Director of Nursing. b) Resident #49 On 02/17/26 at 9:02 AM record review of COVID-19 immunizations for Resident #49 showed this resident had received every vaccination offered to her. However, she had not received the 2024-2025 or the 2025-2026 COVID vaccination. Upon further review and interview with the Director of Nursing, Resident #49 had received the 2023-2024 SpikeVax booster but was not offered either the 2024-2025 or the 2025-2026 COVID-19 immunization. The facility Policy #IC604 for COVID-19 vaccination states Centers will provide the opportunity to receive COVID-19 vaccinations for all doses (this includes dose, 1, dose 2, additional dose, booster - not immunocompromised, and any future doses) following the Centers for Disease Control and Prevention (CDC) recommendations The purpose stated in the policy is to prevent the spread of SARs-CoV-2 infection and its complications to patients and staff. Upon confirming this with the Director of Nursing on 02/17/26 at 9:10 AM she agreed the resident/representative should have been educated, offered and either consented or declination obtained for the boosters prior to this date. c) Resident #70 On 02/18/26 at approximately 1:03 PM record review shows that Resident #70 was admitted on [DATE] and had historically received her last COVID-19 Vaccine Booster on 02/01/23. When inquiring with the Administrator for consents and/or additional vaccines relating to this resident, the Administrator stated Resident #70 had no additional consents or vaccines since 02/01/23. d) Resident #89 On 02/17/26 at 9:02 AM record review of COVID-19 immunizations for Resident #89 shows his Patient Representative consented for the COVID 2025-2026 Nuvaxovid vaccine on 01/26/26. As of this date of 02/17/26 Resident #89 had not received the vaccine. The facility Policy #IC604 for COVID-19 vaccination states Centers will provide the opportunity to receive COVID-19 vaccinations for all doses (this includes dose, 1, dose 2, additional dose, booster - not immunocompromised, and any future doses) following the Centers for Disease Control and Prevention (CDC) recommendations The purpose stated in the policy is to prevent the spread of SARs-CoV-2 infection and its complications to patients and staff. Upon confirming this with the Director of Nursing on 02/17/26 at 9:10 AM she agreed the resident should have received the vaccine immediately upon consent. e) Resident #91 On 02/17/26 at 9:02 AM record review of COVID-19 immunizations for Resident #91 shows his Patient Representative consented for the COVID 2024-2025 COVID-19 vaccine on 07/26/25. As of this date of 02/17/26 Resident #91 has not received the vaccine. The facility Policy #IC604 for COVID-19 vaccination states Centers will provide the opportunity to receive COVID-19 vaccinations for all doses (this includes dose, 1, dose 2, additional dose, booster - not immunocompromised, and any future doses) following the Centers for Disease Control and Prevention (CDC) recommendations The purpose stated in the policy is to prevent the spread of SARs-CoV-2 infection and its complications to patients and staff. Upon confirming this with the Director of Nursing on 02/17/26 at 9:10 AM she agreed the resident should have received the vaccine immediately upon consent.

Based on observation, staff interview and resident interview, facility failed to ensure an effective pest control program is in place. This was found during the Annual Long Term Care Facility Survey process. Facility census 120. Resident identifiers: #8, #21, #40, #70, #104 and #99. Findings include:a) Policy for Pest Control (received same one from Dining Services and the Facility, the facility one was last updated 02/2025)- Policy statement reads same in both policies: A program will be established for the control of insects and rodents for the Dining Services department.-Procedures review reads: (from Dining Service)1. The Dining Service Director coordinates with the Director of Maintenance to arrange pest control services on a monthly basis, or as needed.2. All food preparation, service, and storage areas will be monitored regularly for any signs of pest/vermin. The center staff will be notified immediately of any concerns.3.Where applicable, bulk foods will be removed from their original packaging and stored in containers with tight fitting lids.-Procedures review reads:(from Facility, updated)2. All food preparation, service, and storage areas will be monitored regularly for any signs of pest/vermin. The center staff will be notified immediately of any concerns verbally and in writing (e.g. facility maintenance log or TEL system.-02/15/26 at around 10:45 AM, during initial tour with [NAME] #7, in the dining room on the countertop along the wall, in drawers with utensils, and in the cabinet labeled suction machine, In the drawer labeled clothing protectors. A large amount of small, dark brown-to-black, cylindrical pellets resembling grains of rice debris were observed, [NAME] #7 confirmed reports We have had issues with mice We will get this cleaned up. 02/15/26 at around 1:00 PM during a tour with the Account Manager the cylindrical pellets remained on the countertop along backsplash, in the cabinet, drawers with utensils and clothing protectors. The Account Manager confirmed reporting, I'll inform maintenance and get the area cleaned and all items re-washed. -02/16/2026 at around 10:20 AM, during an interview with Resident #8. The resident reports rooms don't get cleaned like they should. I've seen mice before, last time was last week. Observation, food debris on floor under bed, bed linens with food debris , bathroom and around sink with debris - 02/15/2026 at around 1:55 PM, during an interview with Resident #21. The resident reports we have mice still, saw one this morning under my roommate's cabinet. Observation at around 2:00PM, along floor near wall behind the cabinet (it is a plastic one with drawers on wheels) several small dark brown-to-black, cylindrical pellets resembling grains of rice debris and on top of the cabinet large amount of debris. Certified Nursing Aide #127 confirmed, reports will inform maintenance and housekeeping.-02/15/2026 at around 1:07 PM, during an interview with Resident #40. The resident reports, there are mice here, I saw one last week they run from under the closets. Observation of bathroom, there is a hole behind the commode where the water shut off valve is. Observed small dark brown-to-black, cylindrical pellets resembling grains of rice debris on floor in corner behind commode and another hole in the wall just above the baseboard. Certified Nursing Aide #127 confirmed. Reporting I'll tell housekeeping 02/16/26 at around 3:15 PM Administrator observed holes in wall behind commode and the small dark brown-to-black, cylindrical pellets resembling grains of rice debris on floor in corner, confirmed reporting definitely needing cleaned.-02/15/2026 at around 1:20 PM, during an interview with Resident #70, reports I saw mice last week in my room, coming from bathroom and under closets Observed small dark brown-to-black, cylindrical pellets resembling grains of rice debris on the floor behind commode near the wall, a hole observed in the wall behind commode and in corner. 02/16/26 at around 3:00 PM Administrator with surveyor confirmed there were debris items on the floor. Reporting this bathroom needs cleaned-02/16/2026 at around 11:00 AM during an interview with Resident #99, reports I've seen mice in last week, they need to clean our rooms better. Nothing room clutter, and the floor with areas of dried liquid.-02/15/2026 at around 2:40 PM during an interview with Resident #104, reports seeing mice last week came out from under the wardrobe. Observation: Baseboard on wall near sink loose, hole noted behind. Glue trap under cabinet, clear. Wall behind bed with several areas of drywall having deep tore areas. 02/16/26 at around 3:00PM Administrator with surveyor observed condition of wall, confirming, reporting, our maintenance is working on repairing each room. We have a schedule.02/18/2026 9:54 AM review of QUAPI notes regarding resident rooms needing repairs to ensure homelike environment in place with schedule to correct the findings.

Based on medical record review and staff interview the facility failed to ensure they gave a resident the right to have their food preferences honored. Resident identifier: #105. Facility census: 120. a) Resident #105 The resident was first admitted to the facility on [DATE]. Resident #105 was on hospital leave on two occasions, 11/24/25 - 12/7/25 and 01/07/26 - 02/05/26. During an interview with the resident on 02/16/26 at 11:07 AM, when asked about the food at the facility, the resident stated the facility gives her oatmeal and eggs every day, and she does not want these. She further stated she was lactose intolerant. When asked if the facility had asked her about her food preferences, she stated no. Surveyor requested from Dietary Manager #31 on 02/16/26 at approximately 1:50 PM, to see this resident's dietary preferences. The Dietary Manager at 2:25 PM came back to advise the surveyor he had just visited with the resident to obtain her dietary preferences, as none were on file. A review of the resident's care plan revealed the facility had a care plan dated 12/16/25 that indicated they would honor the resident's food preferences within the meal plan. The facility had failed to implement the care plan and obtain the resident's dietary preferences.

Based upon observation, resident interview and staff interviews, the facility failed to maintain a safe, clean, comfortable homelike environment for residents. This was found to be true for four (4) of 46 residents reviewed during the long term care process. Resident identifiers: #39, #93, #17, #33. Facility census: 120. Findings included: a) Resident #17 On 02/15/26 at 11:00 AM observation found that the privacy curtain in room [ROOM NUMBER] A, which belonged to Resident #17, was missing several brackets to allow the curtain to be fastened to the overhead track. This caused the curtain to appear be drooping and as if it was about to fall off the track. On 02/15/26 at 11:30 AM the above confirmed with the Administrator. b) Resident #22 On 02/15/26 at 11:05 AM observation found that the privacy curtain in room [ROOM NUMBER]-A, which belongs to Resident #22, was dirty and had dark brown stains on it as well as a white substance. On 02/15/26 at 11:30 AM the above was confirmed with the Administrator. c) Resident #39, room [ROOM NUMBER] During the initial walk through of the facility, while interviewing Resident #39 on 02/16/2026 at approximately10:32 AM, it was observed that the wallpaper above the resident's head board had several areas where the wallpaper was torn and peeling. Additionally, as you entered the resident's room, to the lower left of the wall, the paint on the wall was removed and visible scratches could be seen. d) Resident #93, room [ROOM NUMBER] During the same visit with Resident #39, an observation of the wall above Resident #93's head board had a section of wallpaper missing, torn, and several areas of peeling wallpaper. On the same wall, toward the bottom of the wall, a wooden base trim had been scratched in several places damaging the wood. On 02/16/26 at 11:22 AM, the Surveyor asked the Nursing Home Administrator (NHA) to walk down to room [ROOM NUMBER] and we reviewed the observations of the walls, wallpaper, and wooden trim NHA noted these and said they would work on them. The NHA stated the facility had previously conducted an audit on 01/06/26 of the building for things that maintenance needed to address. All of the 700 hallway had not been started yet.

Based on record review and staff interview the facility to administer the Respiratory Syncytial Virus (RSV) vaccine as set forth by the Centers of Disease Control and Prevention (CDC) and facility Procedure and Policy #IC605. This was true for two (2) of five (5) RSV immunization records reviewed. Resident Identifiers: #89 and 91. Facility Census: 120 Findings Included: a) Resident #89 On 02/17/26 at 9:10 AM record review of facility immunizations found that Resident #89 had not been administered a Respiratory Syncytial Virus (RSV) vaccine. According to the facility policy #IC605, Respiratory Syncytial Virus (RSV) Vaccinations provided by the Director of Nursing: .The Center will provide the opportunity for patients to receive the Respiratory Syncytial Virus (RSV) immunization based on shared clinical decision making between the patient/representative and the provider. In adherence with current recommendations of the Advisory Committee on Immunizations Practices (ACIP) as set forth by the Centers for Disease Control and Prevention (CDC). The facility obtained consent by Resident #89s Health Care Decision Maker on 01/26/26 for the RSV immunization. However as or 02/17/26 the resident had not received the vaccine. When confirmed with the Director of Nursing on 02/17/26 at 9:20 AM she agreed the resident should have had the vaccine by now and she did not know why it had not been administered. b) Resident #91 On 02/17/26 at 9:10 AM record review of facility immunizations found that Resident #91 had not been administered a Respiratory Syncytial Virus (RSV) vaccine. According to the facility policy #IC605, Respiratory Syncytial Virus (RSV) Vaccinations provided by the Director of Nursing: .The Center will provide the opportunity for patients to receive the Respiratory Syncytial Virus (RSV) immunization based on shared clinical decision making between the patient/representative and the provider. In adherence with current recommendations of the Advisory Committee on Immunizations Practices (ACIP) as set forth by the Centers for Disease Control and Prevention (CDC). The facility obtained consent by Resident #89s Health Care Decision Maker on 07/31/25 for the RSV immunization. However as or 02/17/26 the resident had not received the vaccine. When confirmed with the Director of Nursing on 02/17/26 at 9:20 AM she agreed the resident should have had the vaccine by now and she did not know why it had not been administered.

Based on record review and staff interview the facility failed to ensure one (1) resident had orthotics in place for a contracture and range of motion. This was true for one (1) of three (3) residents reviewed for limited range of motion. Resident identifier: #103. Facility Census: 120. a) Resident #103 02/17/2026 3:20 PM a medical record review revealed Resident #103 was supposed to have a Left Resting Hand Splint applied daily as tolerated. The staff were supposed to attempt to get at least 2 fingers under the straps. In the care plan, it stated the resident would refuse the heel protectors but there was no mention of the resting hand splint. In a review of tasks in the care plan,there was no documentation of staff attempting to don the heel protectors. Multiple observations during the survey were performed to see if the resident was wearing any of the orthotics and those observations revealed they were not in place. Physical Therapy and Occupational Therapy evaluations and clinical notes make zero mention of using hand splint and suggests heel protectors. Two full months of tasks were printed off showing resident received no care for either splinting.During an interview with the Nursing Home Administrator on 2/18/26 at 9:25 AM the above findings were discussed and verified.

Based on record review and staff interview the facility failed to ensure the environment is free from accident hazards over which it has control. This was a random opportunity for discovery. Resident Identifier: #63 Facility Census: 120 Findings Included: a) Resident #63 On 02/16/26 at 11:48 AM while walking through the 500 hall it was observed that Resident #63 was absent from his room and his bed mattress did not have a sheet on it. At that time is was observed the mattress was a standard mattress. Upon stopping Registered Nurse (RN) #93 and asking what type of mattress she would describe on the bed, she stated, a standard mattress. The surveyor ask her if a resident is ordered a defined perimeter mattress, would it look like this? She stated, No, they are built up a little on the edges to assist in prevention of the resident falling out of the bed. At that time it was confirmed with RN #93 that Resident #63 did have an order from the Physician as a fall intervention for a defined perimeter mattress and it was not on his bed. She agreed.

Based on observations, staff and resident interviews the facility failed to maintain food items in their personal refrigerators to ensure safe and sanitary storage, handling, and consumption. This was true for five (5) of six (6) personal refrigerators observed. Resident Identifiers: #29, #46, #52, #75, #98. Facility Census: 120 Findings Include:On 02/15/26 at 11:00 AM observation of the following personal refrigerators found the temperatures had not been performed on a daily basis. Upon further observation it was found that the refrigerators were dirty, had unlabeled food items in them as well as expired food items, making them unsafe.According to the Food and Nutrition Services Refrigerator/Freezer Temperature Log that is placed on the front of each personal refrigerator in their room Resident #29's refrigerator had not had the temperature checked daily as required. According to the facility Policy #OPS192 Refrigerators: Patient In Room: .refrigeration must be labeled with the date the food was placed in the refrigerator , Food considered unsafe for consumption or beyond the expiration date will be discarded by staff , food will be held in the refrigerator for three (3) days following the date on the label and will then be discarded ,PROCESS:4.1 Nursing will observe and record temperatures of the refrigerator on a daily basis using the Refrigerator/Freezer Temperature Log.5. Housekeeping will clean refrigerators inside and out including walls, doors, and shelves and will defrost the freezer when applicable.6. Nursing will monitor food for proper labeling and date food was placed in the refrigerator.a) Resident #29On 02/15/26 at 11:00 AM observation of the refrigerator in room [ROOM NUMBER] which belongs to Resident #29, there were no temperatures obtained on 02/12-26 through 02/15/26. According to the Food and Nutrition Services Refrigerator/Freezer Temperature Log that is placed on the front of each personal refrigerator in their room Resident #29's refrigerator had not had the temperature checked daily as required. b) Resident #46On 02/15/26 at 11:10 AM observation of the refrigerator in room [ROOM NUMBER] which belongs to Resident #46, there were no temperatures obtained since 02/02/26. Upon further observation the refrigerator was extremely dirty and there were numerous items in the refrigerator that were unlabeled as well as being expired. c) Resident #52On 02/15/26 at 11:15 AM observation of the refrigerator in room [ROOM NUMBER] A which belonged to Resident #52 revealed there were no temperatures obtained since 02/13/26. Upon further observation the refrigerator was extremely dirty with a drink that and leaked and ran out of the front of the refrigerator and there were numerous items in the refrigerator that were unlabeled as well as being expired. According to the Food and Nutrition Services Refrigerator/Freezer Temperature Log that is placed on the front of each personal refrigerator in their room Resident #29's refrigerator had not had the temperature checked daily as required. d) Resident #75On 02/15/26 at 11:20 AM observation of the refrigerator in room [ROOM NUMBER] which belongs to Resident #75, there were no temperatures obtained since 02/11/26. Upon further observation the refrigerator was extremely dirty and there were numerous items in the refrigerator that were unlabeled as well as being expired. There were two containers of potato chip dip where both had expired 05/2025. According to the Food and Nutrition Services Refrigerator/Freezer Temperature Log that is placed on the front of each personal refrigerator in their room Resident #29's refrigerator had not had the temperature checked daily as required. e) Resident #98On 02/15/26 at 11:10 AM observation of the refrigerator in room [ROOM NUMBER] which belongs to Resident #98, there were no temperatures obtained since 02/11/26. Upon further observation the refrigerator was extremely dirty and there were numerous items in the refrigerator that were unlabeled as well as being expired. According to the Food and Nutrition Services Refrigerator/Freezer Temperature Log that is placed on the front of each personal refrigerator in their room Resident #29's refrigerator had not had the temperature checked daily as required. On 02/15/26 at 11:38 AM the above refrigerators concerning temperatures, cleanliness, expired food and non-existing labels were shown and discussed with the Administrator at which time she confirmed they had not been addressed as they should.

Based upon record review and staff interview, the facility failed to ensure an accurate and complete medical record related to informing the resident or resident's representative in advance, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she prefers. This was found to be true for one (1) of one (1) resident reviewed during the long term care survey process. Resident identifier: #50. Facility census: 120. Findings included: a) Resident #50 This resident has capacity to make his/her own decisions regarding the care or treatment received. A review of the medical record documents the resident to have the following mental health conditions:-ANXIETY DISORDER, UNSPECIFIED, diagnosed on [DATE] at Admission/Readmission-DEPRESSION, UNSPECIFIED, diagnosed on [DATE] at Admission/ReadmissionAdditionally, the resident had an additional diagnosis: -INSOMNIA, UNSPECIFIED, diagnosed on [DATE] at Admission/readmission For these conditions, the resident was prescribed the following medications:-Sertraline HCl Tablet 50 MGGive 1 tablet by mouth one time a day for Depression AEB: Worry / sadness over health and life of self and familyPharmacy Active 10/24/2025 -Trazadone HCl Oral Tablet (Trazodone HCl)Give 25 mg by mouth at bedtime for depression/insomniaPharmacy Active 01/28/2026 Documentation that the resident was informed of the benefits and risks of these medications was not found in the medical record.These were requested from the facility on 02/17/2026 at 9:16 AM. The facility provided consent forms for these medications, however, the resident had not signed the consent. During an interview with the Director of Nursing (DON) at approximately 10:00 AM, she stated the resident had consented to receive the medications verbally, but refused to sign the consent forms. Since a staff member had witnessed the verbal consent, the staff member signed the consent form. However, the verbal consent was not co-signed and witnessed by a second party. The DON further stated she did not think this form was a consent form. The surveyor pointed out the form documents the benefits and risks of treatment, as well as provides verification the resident has received this information. The form also contains a section entitled Informed Consent and a place for the resident to sign. The DON finally acknowledged a second person should have signed the verbal consent form.

Based on record review and staff interview the facility failed to administer the Influenza vaccine in a timely manner in order to prevent the spread of influenza and its complication. The facility failed to follow the current recommendation from the Center for Disease Prevention and Control (CDC) guidance for the Influenza vaccine. This was true for one (1) of five (5) Influenza immunization records reviewed. Resident Identifiers: #91. Facility Census: 120 Findings Included: a) Resident #91 On 02/17/26 at 9:30 AM record review for Resident #91 immunizations shows the resident was not administered an influenza immunization. According to the facility Policy #IC600 Influenza Immunization Program the .purpose of the immunization is to prevent the spread of influenza and its complications to employees and other residents.the process is to achieve the highest level of immunity during the peak of flu seasons . Record review shows Resident #91's Patient Representative consented to the influenza vaccine on 01/26/26, however as of 02/17/26 the resident had not received the vaccine. On 02/17/26 at 9:30 AM when the above was confirmed with the Director of Nursing she agreed that Resident #91 should have already been administered the influenza vaccination and she did not know why he had not.

Based on record review and staff interview, the facility failed to ensure resident had a person-centered comprehensive care plan, developed and implemented, with specific interventions of care to address the resident's medical, physical, mental, and psychosocial needs for (one) 1 of (thirteen) 13 sampled residents reviewed. Resident #120's care plan failed to address resident being assessed as high fall risk. Census: 115Findings Included: a) Resident #120On 10/21/25 a review of document titled Fall Risk Evaluation completed upon admission [DATE], effective 09/21/24 revealed the following: Resident #120 upon admission had a history of falls (past 3 months): (one)1- (two)2 falls in past (three) 3 months. Level of consciousness / mental status: Disoriented x (three) 3 at all times. Resident is chairbound / continent. Predisposing disease: 1-2 present. Resident had a change in condition in the last 14 days. Resident is prescribed medication that could put him at risk for falls. Fall Risk Score: 15.0On 10/21/25 a review of document titled Incident By Incident Type, Fall Incidents it was revealed that Resident #120 had fallen on 10/06/24On 10/21/25 upon review of resident's care plan, Fall Risk was not addressed nor interventions to prevent falls in resident's care plan until 10/07/24. An interview with Director of Nursing who acknowledged the facility did not address the fall risk for Resident #120's in his care plan.

Based on observation, record review, staff interview and resident review, the facility failed to provide liquids in the correct consistency to meet the resident's individual needs. This was true for five (5) of five (5) residents that were ordered nectar thickened liquids. This created an immediate jeopardy situation as residents could be physically harmed and suffer possible complications such as aspiration pneumonia by not receiving their liquids in the correct consistency. Resident identifiers: #73, #1, #12, #14, #62. Facility Census: 115 Findings included: a) Resident #73 During the initial resident interview process on 12/10/24 at 9:00 AM, Resident #73 reported he did not like his current diet level of soft food and thickened liquids. The resident reported, I just can't drink the water. Thin water was observed at the bedside with a straw in the cup. The cup was dated 12/2/24. The patient stated he wasn't going to drink it because it did not have ice. Nectar thickened juice was observed at the bedside. The patient reported he received thickened water with his medications. On 12/10/24 at 9:45 AM, the Surveyor interviewed the Registered Nurse (RN) #84 who, confirmed the resident was on nectar thickened liquids. RN #84 confirmed Resident #73 had thin water in a cup with a straw which was dated 12/2/24 at bedside. The RN removed the cup and disposed of the liquid. The Surveyor interviewed Resident #73, and the resident stated, I don't get anything myself. Coughing was observed throughout the interview. The Surveyor interviewed Nursing Assistant (NA) #16 at 9:30 AM concerning the amount of thickener she used in Resident #73's thickened water. Nursing Assistant #16 stated the cups were 16 oz and she used two (2) packages. When the State Surveyor asked her how much thickener to use when thickening liquids, Nursing Assistant #16 stated one package for 8 oz and two packages for 16 oz. On 12/10/24 at 11:25 AM observations by surveyors revealed Resident #73, #1, #12 and #14 were also observed to have liquids at their bedside that were not nectar consistency. Record review revealed all four (4) of these residents had orders for nectar consistency liquids. On 12/10/24 at 11:45 am, the Dietary Manager confirmed that all liquids were thickened on the floor by nursing staff utilizing the packets of thickener. The directions on the Hormel Thick and Easy packet stated for Nectar-like to Honey-like Consistency: Add one packet to 4 fl .oz. of liquid. Additional observations and interviews regarding the consistency of thickened liquids completed on 12/10/24 included: -11:23 AM Nurse Aide #11 stated, For the big white cup by the resident's bed side (16-ounce foam cup) I would use 1 packet of thickener. -11:25 AM LPN (Licensed Practical Nurse) #7 and Nurse Aide # 90 stated, For the big white cup by the resident's bedside (16-ounce foam cup) they would use 1 packet of thickener. -11:27 AM Resident #62 had a cup of thickened liquids in room that felt and appeared to be thin and not nectar thickened. -11:31 AM Nurse Aide #115 stated, For the big white cup by the resident's bedside (16-ounce foam cup) they would use 2 packets of thickener. -11:31 AM Registered Nurse (RN) #84 confirmed the liquids for Resident #62 were not thick enough stating It's the right color not the right consistency. -11:32 AM, RN #56 confirmed the liquid in the cup was probably not nectar thickened for Resident #14 and stated NO for Resident #12. The immediate jeopardy (IJ) template was given to the facility administration on 12/10/24 at 2:03 PM. The plan of correction was provided and accepted on 12/10/24 at 2:33 PM. The plan of correction stated: All residents of the facility have the potential to be affected. The Director of Nursing (DON)/designee conducted an observation round on 12/10/2024 to ensure residents who have an order for thickened liquids are receiving the correct consistency according to the manufacturer's guidelines at bedside with any corrective action immediately upon discovery. Reeducation will be provided by the Director of Nurses (DON)/designee to nursing staff on 12/10/24 regarding residents with an order for thickened liquids are receiving the correct consistency according to the manufacturer's guidelines at bedside with a posttest and return demonstration (per the attachment educational document) to validate understanding. Any nursing staff not available during this time frame will be provided reeducation, including posttest and returned demonstration by DON/designee prior to the beginning of their shift. New nursing staff will be provided education and return demonstration, including posttest during orientation by the DON/designee. The Unit Manager/designee will monitor residents who have an order for thicken liquids starting on 12/10/24 to ensure the residents are receiving the correct liquid consistency according to the manufacturer's guidelines at bedside daily for 2 weeks, including weekends and holidays, then 5 times a week for 4 weeks, then 3 times a week for 4 weeks, then randomly thereafter. Results of monitors will be reported by the Director of Nursing (DON)/designee to the Quality Improvement Committee (QIC) monthly for any additional follow-up and or in-service until the issue is resolved, then randomly thereafter as determined by the Quality The Quality Improvement Committee. The immediate jeopardy was abated at 1:03 PM on 12/11/24.

Based on observation, resident Interview and Record review the facility failed to ensure the resident environment was clean and in good repair. This was true for three (3) resident rooms on the 400 and 500 halls. Room identifiers: #404, #407, and #500. Facility census: 115. Findings Include: a) Resident Rooms During and initial tour of the facility on 12/09/24 the following issues were identified in resident rooms: room [ROOM NUMBER] - The blind had brown stains on it. The floor had a pink substance which was not able to be wiped up. The top of the toilet tank did not fit the tank appropriately and the sink was not affixed to the wall completely. room [ROOM NUMBER]- The light fixture in the bathroom was dislodged from the ceiling and was hanging down. The light fixture was also covered in dust. room [ROOM NUMBER]- Resident #24 who resided in room [ROOM NUMBER] stated she had been asking them for a year to paint over the flowers they have stuck to the wall. She stated she did not like them and wanted them covered up. She also pointed to the ceiling and stated, There are brown spots on the ceiling too. She indicated she had told them about them and she wishes they would clean them or paint over them because she is tired of looking at them. The surveyor observed the flowers on the wall and the brown spots the resident referred to. The surveyor also noted her fan which was sitting on the bed table was covered in dust. The light in the bathroom was also covered in dust. A tour with a Corporate Registered Nurse (CRN) in the afternoon of 12/11/24 confirmed the above issues. She stated, I will get these taken care of.

Based on record review, staff interview, resident interview and observation, the facility failed to provide an accurate Minimum Data Set (MDS) for five (5) of 34 residents. MDS issues were found with Resident #10's hearing assessment, Resident #99's intravenous (IV) access, a cancer diagnosis for Resident #93, the use of insulin for Resident #79 and Resident #56's dental status. Resident Identifiers: #10, #99, #93, #79 and #56. Facility Census: 115. Findings include: a) Resident #10 On 12/10/24 at approximately 11:30 AM, the resident was interviewed and found to be hard of hearing. A record review found the care plan recognized impaired communication due to impaired hearing. The MDS section B dated 12/04/24 indicated the resident's ability to hear is adequate. The medical record was found to not have any information regarding a hearing test or an assessment for hearing aids. On 12/16/24 at 5:15 PM, the Director of Nursing (DON) confirmed the resident did have impaired hearing and a hearing assessment had not been performed since admission to the facility on [DATE] . b) Resident #99 On 12/11/24 at 9:30 AM, a record review was completed for Resident #99. The review found the MDS section O dated 11/22/24 did not indicate the resident had intravenous (IV) access for antibiotic therapy. The resident was noted with an implanted right subclavian port. On 12/11/24 at 11:50 AM, the Corporate Registered Nurse (RN) #155 confirmed the resident did have an implanted right subclavian port. Corporate RN #155 confirmed the MDS was incorrect. c) Resident #93 On 12/11/24 at 10:15 AM, a record review was completed for Resident #93. The review found the MDS section I dated 11/08/24 did not indicate the resident's diagnosis of polycythemia vera (blood cancer). On 12/11/24 at 11:55 AM, the Corporate RN #155 confirmed the diagnosis of polycythemia vera was not indicated on the MDS. d) Resident #79 On 12/11/24 at 10:50 AM, a record review was completed for Resident #79. The review found the resident was noted for taking insulin for diabetes. The MDS section N dated 10/04/24 indicated the resident was receiving insulin. However, the review found the resident was prescribed Ozempic. Ozempic is a once-weekly injection used to treat diabetes as well as assist with weight loss. However, Ozempic is not an insulin. On 12/11/24 at 1:30 PM, the Corporate RN #155 confirmed the resident was not receiving insulin. 31826 e) Resident #56 During an observation of Resident #56, on 12/09/24 at 2:30 PM, during the initial phase of the Long term care survey process it was noted Resident #56 had multiple missing teeth and the teeth remaining were in poor repair. An observation completed with the Director of Nursing (DON) on 12/11/24 at 3:00 PM found the resident had multiple missing teeth but did have some teeth remaining. Review of the residents record found a dental consultation dated 04/19/24. This consult indicated the resident had the following missing teeth 1, 2, 7-10, 13-19, 21-32. This indicated teeth 3-6, 11, 12, and 20 were not missing. A review of the Minimum Data Set (MDS) with an assessment reference date (ARD) of 01/26/24 indicated Resident #56 was edentulous under section L. Dental Status. This incorrect MDS was confirmed with the Director of Nursing (DON) on 12/11/24 at 3:00 PM.

Based on record review, interviews with the resident, and interview with the physician, the facility failed to notify the physician that one sampled resident (Resident #215) did not receive pain relief for a period of approximately five hours after a failed attempt to catheterize the resident. The physician had ordered that the resident be catheterized. Findings include: Resident #215 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The resident's MDS dated [DATE] identified that the resident had the ability to express ideas and wants and could make self understood. The BIMS (brief interview for mental status) concluded that the resident scored 15 indicating the resident was cognitively intact. An interview was conducted with Resident #215 on 3/05/2013 at 10:03 am. The resident stated that he had been at the facility for a little more than two weeks and stated, "One night I couldn't pee." The resident also stated that he had gone approximately 7 hours without the nurse catheterizing him after he had notified the nurse that he was in pain and in need of a catheterization. The resident emphasized, "I was in pain for 7 hours." The resident described his pain level as a 10 on the pain scale of 1-10 with 10 being the most severe pain. He also recalled that he had not gotten pain relief that night/early morning until the 3rd shift came in and catheterized him around 3:30 am. An interview was conducted with the resident's physician on 3/06/2013, at approximately 4:15 pm. The physician stated that the Resident #215's account of the incident was accurate with a few exceptions. The physician stated, "I was actually in seeing the other resident in his room, but it was closer to 10 pm or maybe 9:30 pm, but it was not at 6:00 pm. I did palpate his bladder and it was distended. I finished up my paper work on the other resident, (Resident #215's roommate) then I wrote a progress note for Resident #215 to do Q 6 hour in-and-out-cath, but I did not write an order to do one immediately. On my way out, I told the nurse who was at the med cart when she got a chance to do a straight cath on him. Then I left and went out the door. I'm not sure what time that was. I'm sure it took me another 15 minutes to leave after I wrote notes on the resident." The physician went on to say, that the facility had not made him aware that the nurse had no success catheterizing Resident #215 or that the resident had been in pain until 4:00 am. The physician stated, "I did not hear anything else until the following day when I heard about a significant amount of return - 1200 cc's." The physician also conveyed that he had not heard back from the nurse that she had been unsuccessful with her straight cath attempt or that the resident was in severe pain until 4 am. The physician acknowledged that his progress note included the resident's distended abdomen and that the resident was in pain at the time of his assessment. The physician stated that had he been notified that the nurse's straight cath attempt was unsuccessful, he would have asked to find someone that could (straight cath him) or send him out to the ER. A review of the physician's 2/21/13 progress note failed to indicate the time that the physician had assessed the resident. The note revealed the following assessment in part, Under the section entitled "Chief Complaint/ History of Present illness": it was documented that resident #215 was complaining of decreased voiding, was drinking plenty of fluids, was not able to void, and the abdomen was full/tender... Under the section entitled " Review of system " the section for abdominal pain was checked as "positive" Under the section entitled " Physical exam " , the physician noted, "suprapubic tenderness, bladder distended". Under the section entitled " Assessment/plan " the physician had noted, "[MEDICAL CONDITION] - straight cath Q 6 hours PRN non voiding. May need GU ([MEDICAL CONDITION]) eval. Diagnosis: [REDACTED]." The facility failed to notify the physician and seek further direction regarding Resident #215's inability to urinate, staff's inability to catheterize the resident and the resident's extreme pain following the physician's visit to the facility on [DATE]. .

Based on record review, observations, resident interview, physician interview and staff interviews, the facility failed to provide care and services to manage pain for one resident (#215) and failed to provide needed care and services for one [MEDICAL TREATMENT] resident (#80) including a specified diet and assessment of shunt site. Findings include: 1. Resident #215 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. A review of the most recent admission minimum data set (MDS) assessment dated [DATE] had the resident coded as having the ability to express ideas and wants and to make self understood. Under the section entitled BIMS (brief interview for mental status) the resident was coded as having a summary score of 15 indicating the resident is cognitively intact. Additionally, the same MDS assessment also had the resident coded having pain. Under the section entitled "Pain assessment interview", the resident was coded as having pain within the last five days. The resident was coded as "rarely having pain" over the last five days, but also coded as rating his pain as a "nine" on the pain scale of 1-10 with 10 being the worst pain you could imagine. An interview was conducted with Resident #215 on 3/05/2013 at 10:03 a.m. The resident stated he had been at the facility for a little more than two weeks and stated, "One night I couldn't pee." The resident also stated that he had gone approximately 7 hours without the nurse catheterizing him after he had notified the nurse that he was in pain and in need of a catheterization. The resident emphasized, "I was in pain for 7 hours." The resident described his pain level as a 10 on the pain scale of 1-10 with 10 being the most severe pain. He also recalled that he had not gotten pain relief that night/early morning until the 3rd shift came in and catheterized him around 3:30 am. An interview was conducted with the resident's physician on 3/06/2013, at approximately 4:15 pm. The physician stated that the Resident #215's account of the incident was accurate with a few exceptions. The physician stated, "I was actually in seeing the other resident in his room, but it was closer to 10 pm or maybe 9:30 pm, but it was not at 6:00 pm. I did palpate his bladder and it was distended. I finished up my paper work on the other resident, (Resident #215's roommate) then I wrote a progress note for Resident #215 to do Q 6 hour in-and-out-cath, but I did not write an order to do one immediately. On my way out, I told the nurse who was at the med cart when she got a chance to do a straight cath on him. Then I left and went out the door. I'm not sure what time that was. I'm sure it took me another 15 minutes to leave after I wrote notes on the resident." The physician went on to say, that the facility had not made him aware that the nurse had no success catheterizing Resident #215 or that the resident had been in pain until 4:00 am. The physician stated, "I did not hear anything else until the following day when I heard about a significant amount of return - 1200 cc's." The physician also conveyed that he had not heard back from the nurse that she had been unsuccessful with her straight cath attempt or that the resident was in severe pain until 4 am. The physician acknowledged that his progress note included the resident's distended abdomen and that the resident was in pain at the time of his assessment. The physician stated that had he been notified that the nurse's straight cath attempt was unsuccessful, he would have asked to find someone that could (straight cath him) or send him out to the ER. A review of the physician's 2/21/13 progress note failed to indicate the time that the physician had assessed the resident. The note revealed the following assessment in part, Under the section entitled "Chief Complaint/ History of Present illness": it was documented that resident #215 was complaining of decreased voiding, was drinking plenty of fluids, was not able to void, and the abdomen was full/tender... Under the section entitled " Review of system " the section for abdominal pain was checked as "positive" Under the section entitled " Physical exam " , the physician noted, "suprapubic tenderness, bladder distended". Under the section entitled " Assessment/plan " the physician had noted, "[MEDICAL CONDITION] - straight cath Q 6 hours PRN non voiding. May need GU ([MEDICAL CONDITION]) eval. Diagnosis: [REDACTED]." The facility failed to notify the physician and seek further direction regarding Resident #215's inability to urinate, staff's inability to catheterize the resident and the resident's extreme pain following the physician's visit to the facility on [DATE]. A review of the care plan, dated 2/26/2013, revealed the resident was at risk for alterations in comfort related to chronic pain. The care plan stated the resident would achieve acceptable level of pain control times 90 days. The interventions included in part, Medicate resident as ordered for pain and monitor effectiveness and report to physician as indicated. Resident #215 did not have a care plan that addressed pain management prior to 2/26/2013. Review of the clinical record revealed the only medication the resident had ordered for pain was a prn (as necessary) order for [MEDICATION NAME] 5/500 mg 1 tab po (by mouth) every 6 hours. A review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. A review of the clinical record revealed a progress note dated 2/22/2013 at 4:36 a.m. The note indicated under the section entitled "Observations: distended bladder on assessment. Little to no urine output in urinal." Under the section entitled "action/nursing interventions:" was the following entry; "physician ordered straight cath every 6 hours. Patient was straight cath at 4 am. 1200 ml of urine collected". Under the section entitled "Resident's response: Relief of pain and discomfort per patient." The author of the note was the agency nurse #143. An interview was conducted with the agency Nurse #143, LPN on 3/06/2013 at approximately 4:05 p.m. She stated that she had made an unsuccessful attempt to catheterize the resident and she was unable to obtain urine. She indicated that another nurse did obtain 1200 cc of urine on a second attempt at catheterizing the resident. The nurse did not medicate the resident for pain to relieve the resident's discomfort either prior to or after the unsuccessful catheterization attempt. A review of the facility's policy on pain management dated 1/01/2004 indicated that patients will be evaluated as part of the nursing assessment process for the presence of pain upon admission/re-admission, with change in condition, or change in pain status, and as required by the state thereafter. The policy also revealed the following entry under the section entitled "Purpose," to maintain the highest possible level of comfort for patients by providing a system to identify assess, treat and evaluate pain. . 2. Resident #80 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The annual Minimum Data Set (MDS) assessment dated [DATE] indicated the resident received a mechanically altered therapeutic diet and was on [MEDICAL TREATMENT]. The most recent dietary assessment, dated 2/5/13, was completed by the dietitian and indicated the resident received a [MEDICAL TREATMENT] renal diet. The most recent care plan, dated 2/15/13 was reviewed. The care plan indicated the resident exhibited or was at risk for impaired renal function and was at risk for complications related to [MEDICAL TREATMENT]. The interventions included: monitor for blood pressure, pulses, [MEDICAL CONDITION] and report to physician as indicated, monitor [MEDICAL TREATMENT] access for positive bruit and positive thrill every shift and as needed, monitor for signs and symptoms of fluid overload and notify physician of any significant changes, monitor labs as ordered and report abnormal labs to physician, monitor skin condition around shunt, transfer to [MEDICAL TREATMENT] unit on Tuesdays, Thursdays and Saturdays for treatment. The plan of care also identified the resident to have nutritional risk related to the [DIAGNOSES REDACTED]. Interventions included: add one scoop of Prosource twice a day with food or fluid of choice for extra protein, encourage 100% consumption of all fluids, [MEDICAL TREATMENT] three times per week on Tuesdays, Thursdays and Saturdays and provide breakfast before resident leaves, resident has advanced mechanical soft diet with double entree at lunch and dinner meals, No orange juice with meals, prefers meals in his room and feeds self. The resident was re-admitted on [DATE] and the physician's orders [REDACTED]. The 3/13 physician's orders [REDACTED]. The medical record was absent of any documentation of the resident's shunt site being assessed for a positive bruit, positive thrill or skin around the shunt site by the nursing staff. Licensed Practical Nurse (LPN) #69 was interviewed on 3/6/13 at 4:15 p.m. regarding the care she provides for the resident. The LPN stated she looks at the resident's arm when he returns from [MEDICAL TREATMENT]. She stated during the interview there used to be a place to document the assessment of bruit and thrill, but if not, the documentation for assessing the [MEDICAL TREATMENT] shunt site should be in the nurses' notes or on the Treatment Administration Record's (TAR). The LPN stated there was a binder that was sent with the resident to [MEDICAL TREATMENT] when he goes. The binder contained information about the resident and was sent back to the facility when he returned. Observations of the binder contained pieces of square paper in the binder with information about the resident ( vital signs, pre [MEDICAL TREATMENT] weight, post [MEDICAL TREATMENT] weights). The pieces of paper were dated, but not consistent with all [MEDICAL TREATMENT] days. LPN #69 thought the pieces of paper came back with him from the [MEDICAL TREATMENT] center. She thought there used to be a form that was used instead of of the scraps of paper, but was not sure when or where they were located. At 5:05 p.m. Resident #80 was interviewed. The resident stated the staff listen to his shunt site on his right arm at the [MEDICAL TREATMENT] Center. He stated the nurses in the facility check it when he returns from [MEDICAL TREATMENT], but it doesn't occur every time or on every shift. The resident stated he returns to the nursing home with a dressing over his shunt site and explained that it was to provide pressure. The resident was interviewed about his diet. His meal tray was observed in front of him on the overbed table and all of the food was eaten. The resident stated he thought he had chopped up hot dogs wrapped up in a really good bread and rice pudding. The diet card indicated the resident was on a Advanced Mechanical Soft Diet. The Dietary Manager (DM) #13 was interviewed at 5:20 p.m. The DM verified the resident received two hot dogs wrapped, or pigs in a blanket, and rice pudding. On 3/7/13 at 9:40 a.m., LPN #51 was interviewed regarding the care she provided to the resident. The LPN stated she thought the shunt site, bruit and thrill were just to be checked when the resident went to [MEDICAL TREATMENT]. The LPN stated the documentation of the assessment of the shunt site would be located in the TARs. The medical record and the TARs were reviewed and there was no documentation in the medical record or on the TARs from any of the nurses of the resident's shunt site being assessed per the care plan. At 10:30 a.m., the Registered Dietitian (RD) #5001 was interviewed. The RD verified the resident was on a [MEDICAL TREATMENT] advanced mechanical soft diet. She stated the hot dogs or pigs in a blanket the resident received was not a food that was on the renal diet menu. She stated in the past the resident had diet changes that took him off the renal diet, but his current physician's orders [REDACTED]. At 11:00 a.m., the Medical Records Clerk #53 stated she had looked in Medical Records and in the electronic documentation for the past six months and was unable to find any documentation of the nurses checking the resident's shunt site for bruit, thrill or skin around the shunt site. At 2:15 p.m., DM #13 was interviewed. She stated the resident was readmitted to the facility after a hospitalization on [DATE]. When he returned he was prescribed a cardiac/renal advanced mechanical soft diet. She verified the kitchen had not provided the resident with a cardiac/renal advanced mechanical soft diet. She verified the resident received hot dogs or pigs in a blanket yesterday which was not part of a renal diet and the resident had been receiving an Advanced Mechanical Soft Diet. At 2:45 p.m., LPN #51 was interviewed. She stated that she was not sure what the pieces of paper were that were sent back in the [MEDICAL TREATMENT] binder that went with the resident on [MEDICAL TREATMENT] days. She remembered a form that was used, but did not remember how long ago it was. She did not remember sending a form with the resident and thought the [MEDICAL TREATMENT] center must have them, complete them and send the forms back with the resident when he returned to the facility after his [MEDICAL TREATMENT] treatment. The binder contained a completed form, but was dated 9/29/12. The form included pre and post [MEDICAL TREATMENT] weight, vital signs, medications, concerns, behaviors and complications. The form was signed by staff from the [MEDICAL TREATMENT] center. At 2:50 p.m., Registered Nurse (RN) #54 was interviewed. The RN stated the Weekly [MEDICAL TREATMENT] Documentation Log was developed sometime ago as a communication form for residents on [MEDICAL TREATMENT] to be completed by the [MEDICAL TREATMENT] center and returned with the resident to the facility. The RN did not know why there were scraps of paper in the binder and assumed they came from the [MEDICAL TREATMENT] center. At 3:00 p.m., the Clinical Manager of the [MEDICAL TREATMENT] Center was interviewed. She stated the facility was responsible for sending a form to be completed by her staff regarding the [MEDICAL TREATMENT] treatment. She was familiar with the binder and stated it was sent with the resident on [MEDICAL TREATMENT] treatment days and was not sure what the pieces of paper were or why there were no completed forms. She stated the forms would only be completed if the facility provided them. At 3:35 p.m., RN #54 verified the resident was re-admitted to the facility on [DATE] and the physician orders, dated 12/14/12, indicated the resident was to receive a cardiac/renal advanced mechanical soft diet. At 3:50 p.m., Minimum Data Set (MDS) Nurse #39 was interviewed. The MDS nurse verified the resident's care plan had not been revised regarding the resident's cardiac/renal advanced mechanical soft diet. The current care plan indicated the resident was to receive an Advanced Mechanical Soft Diet with double entree at lunch and dinner meals and no orange juice with meals. The MDS nurse verified the care plan should have been revised after his re-admission to the facility on [DATE] when his diet orders were changed by the physician On 3/8/13 at 7:30 a.m., RN #72 was interviewed. RN #72 stated she usually only checked the resident's shunt site on [MEDICAL TREATMENT] days. She verified she did not document her assessment of the shunt site when she did assess it on [MEDICAL TREATMENT] days. The facility policy on [MEDICAL TREATMENT]: Graft and Fistula Care was reviewed. The policy indicated to verify and specific care orders or instructions from the attending physician or [MEDICAL TREATMENT] center. Perform routine observations of access site daily and on return from [MEDICAL TREATMENT] center. Observe for signs of complications including, but not limited to: pain, swelling, redness, odor, hardness, bleeding or drainage at site, color, temperature or extremity, presence of pain or numbness in extremity, pulses distal to access site(fistula/graft), presence of bruit auscultation with stethoscope and presence of thrill (vibration) by palpation. The policy indicated documentation of the location of access site on admission assessment, status of access site in nurse notes, status of pulses to access area, color and temperature of extremity, presence of pain numbness, signs and symptoms of complications, if present, status of bruit and thrill, notification and response of physician and [MEDICAL TREATMENT] center, if needed, patient education and nursing intervention. .

Based on medical record review and staff interview, the facility failed to ensure one (1) of six (6) sampled residents received sufficient fluid intake to maintain proper hydration. Resident #202 suffered from a [MEDICAL CONDITIONS] infection with multiple watery stools and an inadequate intake of fluids necessary to maintain health. Additionally, nursing staff members failed to ensure intravenous (IV) fluids were administered in accordance with physician's orders [REDACTED]. Resident identifier: #202. Facility census: 123. Findings include: a) Resident #202 Review of the medical record found the resident was admitted to the facility on [DATE] for treatment of [REDACTED]. The resident was determined to lack the capacity to make medical decisions by the treating physician on 04/25/12 with adult protective services (APS) appointed as the resident's health care surrogate. On 05/10/12, laboratory results were positive for a [MEDICAL CONDITIONS] infection. The resident was ordered, and began receiving, [MEDICATION NAME] 500 mg tid (3 times a day) on 05/10/12. The nursing notes document loose, thin, liquid stools on 05/10/12, 05/11/12, 05/12/12, 05/13/ 12 and 05/14/12. treatment for [REDACTED]. Review of the 04/26/12 nutritional assessment, completed by the dietitian, found the resident required a daily fluid intake of 2550 cc. Review of the resident's documented intake of fluids, beginning with his treatment for [REDACTED]. -- 05/10/12 - 240 cc, -- 05/11/12 - 360 cc, -- 05/12/12 - 180 cc, -- 05/13/12 - no intake On 05/14/12, the resident was visited by the nurse practitioner who documented the resident to be lethargic and hypotensive. The nurse practitioner ordered 2000 cc of normal saline to be administered intravenously (IV). The order written at 10:20 a.m. on 05/14/12 specified a [MEDICATION NAME] of 1000 cc of normal saline for the first liter then 85 cc/hr for the second liter of fluids. Review of the nursing notes found IV access was obtained at 12:23 p.m. for administration of the first [MEDICATION NAME] liter of normal saline. Further review of the nursing notes found a 05/15/12 note written at 2:07 a.m. which documented, "Attempted IV access X 2 which was unsuccessful...". The medical record contained no documentation of what circumstances prompted nursing to again attempt IV access. A late entry note, by the nurse practitioner, on 05/15/12, documented, "nursing reports pulled out IV, received 900 ml of normal saline". The medical record contained no evidence the treating physician was notified the IV site was no longer patent, nor the resident was not receiving the ordered IV fluids. Review of the weights and vitals summary found the resident weighed 185.2 lbs. on 05/09/12 and weighed 165.6 on 05/16/12. When asked how the resident could have been weighed at the facility when he was in an acute care facility on 05/16/12, the director of nursing (DON) stated on 06/07/12 at 2:15 p.m. the resident was weighed on 05/15/12 but the weight was not entered until 05/16/12. The resident was sent to the emergency room at 1:50 p.m. on 05/15/12 with [MEDICAL CONDITION], altered mental status and [MEDICAL CONDITION]. An interview with the nurse practitioner, Employee #153 was conducted on 06/07/12 at 1:50 p.m. She stated she did not take calls after leaving the facility and nursing would have to notify the treating physician of the inability to administer the ordered IV fluids. An interview with the director of nursing (DON), Employee #121 on 06/07/12 at 2:00 p.m. verified the resident pulled out his IV at approximately 9:30 p.m. with no documented attempts by nursing staff to restart the IV fluids until 2:07 a.m. on 05/15/12. She agreed the treating physician should have been notified of the resident's condition and the inability to administer ordered IV fluids. Review of the 05/15/12 acute care admission assessment found the resident was admitted to the intensive care unit in [MEDICAL CONDITION]. The resident's blood urea nitrogen (BUN) was 272 mg/dl (normal 7 mg/dl to 20 mg/dl) , and his [MEDICATION NAME] level was 7.3 mg/dl (normal 0.5 mg/dl to 1.5 mg/dl). .

Part I -- Based on medical record review, review of facility records, staff interview, and family interview, the facility failed to provide adequate supervision and/or appropriate assistive devices, based on a comprehensive assessment of the resident, to promote the safety of one (1) of three (3) residents whose closed records were reviewed. Resident #114 sustained a total of five (5) falls between his admission date of [DATE] and [DATE], when the resident expired at the facility. A fall from the bed on [DATE] resulted in a fractured nasal bone. A fall from the bed on [DATE] resulted in a complaint of shoulder and back pain; the resident was transported to the hospital, but x-rays were negative for fractures. On [DATE], the resident had three (3) falls from a wheelchair with no injury noted. The last fall occurred on [DATE], when the resident was found on the floor by the pharmacy delivery man at 8:30 p.m. that night, having fallen out of a reclined geri-chair located at the nurses' station. The resident sustained [REDACTED]. Medical record review and an interview with the rehabilitative therapy program manager disclosed this resident had been identified as being at risk for falls upon his admission to the facility, and staff was aware the resident was constantly attempting to get out of chairs and bed. There was no evidence in his medical record to reflect the use of the reclining geri-chair with this resident had been evaluated by physical therapy, ordered by the physician, or addressed in his care plan. Interviews with nursing staff present on [DATE] confirmed the resident had been left unsupervised in a reclining geri-chair for an unknown length of time prior to his fall. Resident identifier: #114. Facility census: 113. Findings include: a) Resident #114 1. Medical record review disclosed this [AGE] year old resident was admitted to the facility from the hospital on [DATE] for skilled services and rehabilitative therapy with the possibility of returning home with family. Prior to the hospital admission, he had been living at home with his family. Review of the hospital discharge summary revealed the resident had [DIAGNOSES REDACTED]. The resident was admitted to the hospital and was treated with antibiotics for pneumonia or urosepsis. The hospital discharge summary also noted the resident had been confused, agitated, attempting to get out of bed, and occasionally combative with staff. -- 2. Review of the resident's nursing home admission record revealed Resident #114 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of his nursing home admission orders [REDACTED]. -- 3. Review of the facility's incident / accident reports revealed the following: - On [DATE] at 9:30 p.m., Resident #114 was found lying on the floor mat beside the bed with his nose bleeding. The report described the injury as "Nose Deformity /c (with) Bruising & Nose bleed". First aid was provided for the nose bleed, neuro checks were initiated because this was an unwitnessed fall, and the physician, when notified, ordered a facial x-ray. The x-ray, completed on [DATE], revealed a fracture of nasal bone. Elsewhere on the report, the author noted, under the heading "Protective Devices" that a low bed with floor mats had been ordered and were in use at the time of the incident to prevent injury. - On [DATE] at 7:10 p.m., "Called into Rm (room) by Dayshift Nurse (sic) found Resident laying on floor on (R) (right) side c/o (complained of) (L) (left) shoulder & Low Back Pain (in room) laying on landing strip." There was no discussion on the incident report as to whether this was an unwitnessed fall. The resident was sent to the hospital for evaluation, where x-rays and a CT scan were negative. Instructions from the hospital emergency room included fall precautions. - On [DATE] at 9:15 a.m., "Called to hall by other nurse, found resident lying in floor in front of w/c (wheelchair)." Neuro checks were initiated because this was an unwitnessed fall. The author indicated there were no apparent injuries. - On [DATE] at 9:00 p.m., "Resident scooted to edge of w/c (wheelchair) & then sat in floor, assessed for injury & placed back into w/c, resident stated 'I'm gonna do it again", then proceeded to scoot to edge of w/c & sit back on the floor again, attempted to redirect & explain risk of injury /s (without) success. The report indicated there was no injury noted from the two (2) falls from the wheelchair and the resident was placed in bed after the second fall. - On [DATE] at 8:30 p.m., "Was called to nurses station by pharmacy to find (resident's name) on his right side on floor next to chair. Upon assessment found his forehead bleeding. Took vitals & paged (nurse's name) to unit." Under the heading "Description of Injury" was written "2 abrasions to forehead / top of head & 1 by (R) (right) eye. Resident stated head, neck, (R) shoulder & (R) hip hurt." Under the heading "Protective Devices" the author noted a reclined geri-chair was in use at the time of the fall due to "freq. (frequent) falls". Neuro checks were initiated because this was an unwitnessed fall, and the resident was transported to the local hospital emergency department for evaluation. A nursing note, dated [DATE] at 22:00 (10:00 p.m.), revealed the resident was found in floor by the pharmacy delivery man; he notified the floor nurse, who called supervisor. This note also stated the resident's injuries were assessed and he was transferred to the hospital. A nursing note, dated [DATE] at 05:13 a.m., revealed the hospital called the facility to notify staff the resident had fractures of C1 and C2 vertebrae and the hospital was sending the resident to another hospital to see a neurosurgeon. Another nursing note, dated [DATE] at 10:02 a.m., revealed the resident had arrived back at the facility. The new order from the hospital was to keep the Miami collar on the resident's neck at all times. -- 4. During an interview on [DATE] at 7:30 p.m., a family member reported Resident #114 was very agitated with the cervical collar and continuously attempted to remove it. The family member also reported that a meeting was held at the facility with management staff, at which time the falls and the importance of keeping the cervical collar in place were discussed. The family member reported staff informed him/her this facility had a "Right to Fall Policy"; however, when the family member requested a copy of this policy, it was not provided. -- 5. Interviews were conducted with staff on duty on [DATE] as follows: On [DATE] at 9:30 a.m., an interview was conducted with a nursing assistant (Employee #24). Employee #24 reported she had assisted putting the resident in the geri-chair. She stated she could not remember the time they put him in the chair. She stated he was put in the reclining geri-chair to be close to the nurses' station for close observation. - On [DATE] at 10:45 a.m., an interview was conducted with the therapy program manager (Employee #144) who had worked with this resident and familiar with the resident's therapy plan. Employee #144 reported the resident was constantly attempting to get up and moving constantly. Resident #114 had been evaluated for the use of a wheelchair with anti-tippers for transport and while in therapy, but the use of a reclining geri-chair had not been recommended by physical therapy. - On [DATE] at 11:30 a.m., an interview was conducted with the RN manager of the unit on which Resident #114 resided (Employee #98). During this interview, Employee #98 confirmed Resident #114 had been placed in a reclining geri-chair on that weekend, and there was no physician order for [REDACTED]. The RN manager stated she did not know who was responsible for putting the resident in the geri-chair. - On [DATE] at 2:50 p.m., a telephone interview was conducted with Employee #103, the registered nurse (RN) who worked from 7:00 a.m. to 7:00 p.m. on [DATE] and was responsible for Resident #114 ' s care on that day. (Review of the resident's medical record disclosed a nursing note dated [DATE] at 22:00 (10:00 p.m.), in which this RN documented the accident and a resident assessment and signed off as the nurse supervisor.) During the interview, Employee #103 reported she did not know who put the resident into the geri-chair or at what time he was placed there on [DATE]. She stated the chair was reclined and no staff was in the area of the nurses' station at the time of the fall. She further reported she was assigned to another area and did not know much about the accident. - On [DATE] at 2:55 p.m., a telephone interview was conducted with Employee #2, an RN who worked 7:00 p.m. to 7:00 a.m. on [DATE] and was working in the area at the time of the incident. Employee #2 stated the resident was in the reclining geri-chair when she arrived at the facility at 7:00 p.m. She also stated she was giving medications to other residents on the 800 hall and was out of sight of Resident #114. She stated the nursing assistants were busy helping other residents in their rooms and there was no one at the nurses' station when Resident #114 fell . She stated she learned of the resident's fall when the pharmacy delivery man came and told her there was a man on the floor. - On [DATE] at 9:15 a.m., an interview was conducted with Employee #27, the nursing assistant who was responsible for Resident #114's care during the 7:00 a.m. to 3:00 p.m. (,[DATE]) shift on [DATE]. Employee #27 confirmed she was assigned to this resident on that day, and she acknowledged she was probably the person who put the resident in the geri-chair, but she could not recall at what time this occurred. Employee #27 stated Resident #114 was constantly moving all the time (sliding out of bed and scooting off of chairs), that a geri-chair in a reclining position was the only chair he might not fall out of, and that he was placed at the nurses' station for closer observation. According to Employee #27, when she left at the end of her shift at 3:00 p.m., the resident was still in the geri-chair. -- 6. Review of Resident #114's comprehensive care plan found the following problem statement, with an initiated date of [DATE] and reviewed / updated on [DATE] an [DATE]: "Resident is at risk for falls: (sic) cognitive loss, lack of safety awareness." The goal associated with this problem statement was: "Resident will have < (symbol for 'less than') 2 falls per day x 90 days." The interventions intended to assist the resident in achieving this goal were: "Resident likes to lay (sic) in the floor. He will often lower himself to floor and sometimes will prop his feet up on objects. Medication evaluation as needed. Therapy / Rehab - PR Treatment 5x per week. Use a mechanical lift (sic) two person for transfer. Bed in low position with right side against wall and landing strip on the left side of the bed. Provide verbal cues for safety and sequencing when needed. Provide resident / caregiver education for safe techniques. Place call light within reach at all times. Maintain a clutter-free environment in the resident's room and consistant (sic) furniture arrangement. When resident is in bed, place all necessary personal items within reach. " There was no mention of an intervention to place the resident in a reclining geri-chair and no mention of an intervention to locate the resident at the nurses' station for close observation. -- 7. Resident #114 sustained a total of five (5) falls, two (2) of which resulted in fractures. These falls occurred between his admission date of [DATE] and [DATE], when the resident expired at the facility. The last fall occurred on [DATE], when the resident was put in a reclining geri-chair at an unknown time during the ,[DATE] shift. According to the nursing assistant responsible for the resident's care on [DATE], the resident was still in the reclining geri-chair at the nursing station when she left her shift at 3:00 p.m. According to an interview with the RN who came on for her shift at 7:00 p.m., the resident was in the reclining geri-chair at the nurses' station when she arrived at work. The resident was found on the floor by the pharmacy delivery man at 8:30 p.m. that night. Medical record review and an interview with the rehabilitative therapy program manager disclosed this resident had been identified as being at risk for falls upon his admission to the facility, and staff was aware the resident was constantly attempting to get out of chairs and bed. Interviews with nursing staff present on [DATE] confirmed the resident had been left unsupervised in a reclining geri-chair prior to his fall; the use of the geri-chair with this resident had not been evaluated by physical therapy or ordered by the physician. --- Part II -- Based on medical record review, observation, resident interview, and staff interview, the facility failed to assure assistance devices to promote safety were applied as ordered by the physician for one (1) of three (3) residents reviewed. Resident #85 had a physician order, dated [DATE], for hipsters at all times except for bathing, related to falls. Observation and resident interview, on [DATE] at 10:45 a.m., found the resident dressed herself and did not have on the hipsters. Resident identifier: #85. Facility census: 113. Findings include: a) Resident #85 Medical record review, on [DATE], disclosed Resident #85 had a physician's order, dated [DATE], for hipsters to be applied at all times except for bathing due to falls. Observation of and interview with the resident, on [DATE] at 10:45 a.m., found she was not wearing the hipsters. The resident stated she had dressed herself in the morning and did not put them on. The resident also stated she could not remember the last time she had put them on. The resident was ambulating in her room during this observation, and she acknowledged having had falls in the past. Medical record review found the resident had a fall on [DATE]. This practice was brought to the attention of the interim director of nursing (DON - Employee #145) in the resident's room on [DATE] at 11:20 a.m., where it was confirmed the resident was not wearing hipsters. The DON also confirmed the nursing assistant who was assigned to this resident was responsible for ensuring the resident put the hipsters on as ordered to prevent injury due to falls.

Part I -- Based on medical record review, review of facility records, staff interview, and family interview, the facility failed to provide adequate supervision and/or appropriate assistive devices, based on a comprehensive assessment of the resident, to promote the safety of one (1) of three (3) residents whose closed records were reviewed. Resident #114 sustained a total of five (5) falls between his admission date of [DATE] and [DATE], when the resident expired at the facility. A fall from the bed on [DATE] resulted in a fractured nasal bone. A fall from the bed on [DATE] resulted in a complaint of shoulder and back pain; the resident was transported to the hospital, but x-rays were negative for fractures. On [DATE], the resident had three (3) falls from a wheelchair with no injury noted. The last fall occurred on [DATE], when the resident was found on the floor by the pharmacy delivery man at 8:30 p.m. that night, having fallen out of a reclined geri-chair located at the nurses' station. The resident sustained [REDACTED]. Medical record review and an interview with the rehabilitative therapy program manager disclosed this resident had been identified as being at risk for falls upon his admission to the facility, and staff was aware the resident was constantly attempting to get out of chairs and bed. There was no evidence in his medical record to reflect the use of the reclining geri-chair with this resident had been evaluated by physical therapy, ordered by the physician, or addressed in his care plan. Interviews with nursing staff present on [DATE] confirmed the resident had been left unsupervised in a reclining geri-chair for an unknown length of time prior to his fall. Resident identifier: #114. Facility census: 113. Findings include: a) Resident #114 1. Medical record review disclosed this [AGE] year old resident was admitted to the facility from the hospital on [DATE] for skilled services and rehabilitative therapy with the possibility of returning home with family. Prior to the hospital admission, he had been living at home with his family. Review of the hospital discharge summary revealed the resident had [DIAGNOSES REDACTED]. The resident was admitted to the hospital and was treated with antibiotics for pneumonia or urosepsis. The hospital discharge summary also noted the resident had been confused, agitated, attempting to get out of bed, and occasionally combative with staff. -- 2. Review of the resident's nursing home admission record revealed Resident #114 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of his nursing home admission orders [REDACTED]. -- 3. Review of the facility's incident / accident reports revealed the following: - On [DATE] at 9:30 p.m., Resident #114 was found lying on the floor mat beside the bed with his nose bleeding. The report described the injury as "Nose Deformity /c (with) Bruising & Nose bleed". First aid was provided for the nose bleed, neuro checks were initiated because this was an unwitnessed fall, and the physician, when notified, ordered a facial x-ray. The x-ray, completed on [DATE], revealed a fracture of nasal bone. Elsewhere on the report, the author noted, under the heading "Protective Devices" that a low bed with floor mats had been ordered and were in use at the time of the incident to prevent injury. - On [DATE] at 7:10 p.m., "Called into Rm (room) by Dayshift Nurse (sic) found Resident laying on floor on (R) (right) side c/o (complained of) (L) (left) shoulder & Low Back Pain (in room) laying on landing strip." There was no discussion on the incident report as to whether this was an unwitnessed fall. The resident was sent to the hospital for evaluation, where x-rays and a CT scan were negative. Instructions from the hospital emergency room included fall precautions. - On [DATE] at 9:15 a.m., "Called to hall by other nurse, found resident lying in floor in front of w/c (wheelchair)." Neuro checks were initiated because this was an unwitnessed fall. The author indicated there were no apparent injuries. - On [DATE] at 9:00 p.m., "Resident scooted to edge of w/c (wheelchair) & then sat in floor, assessed for injury & placed back into w/c, resident stated 'I'm gonna do it again", then proceeded to scoot to edge of w/c & sit back on the floor again, attempted to redirect & explain risk of injury /s (without) success. The report indicated there was no injury noted from the two (2) falls from the wheelchair and the resident was placed in bed after the second fall. - On [DATE] at 8:30 p.m., "Was called to nurses station by pharmacy to find (resident's name) on his right side on floor next to chair. Upon assessment found his forehead bleeding. Took vitals & paged (nurse's name) to unit." Under the heading "Description of Injury" was written "2 abrasions to forehead / top of head & 1 by (R) (right) eye. Resident stated head, neck, (R) shoulder & (R) hip hurt." Under the heading "Protective Devices" the author noted a reclined geri-chair was in use at the time of the fall due to "freq. (frequent) falls". Neuro checks were initiated because this was an unwitnessed fall, and the resident was transported to the local hospital emergency department for evaluation. A nursing note, dated [DATE] at 22:00 (10:00 p.m.), revealed the resident was found in floor by the pharmacy delivery man; he notified the floor nurse, who called supervisor. This note also stated the resident's injuries were assessed and he was transferred to the hospital. A nursing note, dated [DATE] at 05:13 a.m., revealed the hospital called the facility to notify staff the resident had fractures of C1 and C2 vertebrae and the hospital was sending the resident to another hospital to see a neurosurgeon. Another nursing note, dated [DATE] at 10:02 a.m., revealed the resident had arrived back at the facility. The new order from the hospital was to keep the Miami collar on the resident's neck at all times. -- 4. During an interview on [DATE] at 7:30 p.m., a family member reported Resident #114 was very agitated with the cervical collar and continuously attempted to remove it. The family member also reported that a meeting was held at the facility with management staff, at which time the falls and the importance of keeping the cervical collar in place were discussed. The family member reported staff informed him/her this facility had a "Right to Fall Policy"; however, when the family member requested a copy of this policy, it was not provided. -- 5. Interviews were conducted with staff on duty on [DATE] as follows: On [DATE] at 9:30 a.m., an interview was conducted with a nursing assistant (Employee #24). Employee #24 reported she had assisted putting the resident in the geri-chair. She stated she could not remember the time they put him in the chair. She stated he was put in the reclining geri-chair to be close to the nurses' station for close observation. - On [DATE] at 10:45 a.m., an interview was conducted with the therapy program manager (Employee #144) who had worked with this resident and familiar with the resident's therapy plan. Employee #144 reported the resident was constantly attempting to get up and moving constantly. Resident #114 had been evaluated for the use of a wheelchair with anti-tippers for transport and while in therapy, but the use of a reclining geri-chair had not been recommended by physical therapy. - On [DATE] at 11:30 a.m., an interview was conducted with the RN manager of the unit on which Resident #114 resided (Employee #98). During this interview, Employee #98 confirmed Resident #114 had been placed in a reclining geri-chair on that weekend, and there was no physician order for [REDACTED]. The RN manager stated she did not know who was responsible for putting the resident in the geri-chair. - On [DATE] at 2:50 p.m., a telephone interview was conducted with Employee #103, the registered nurse (RN) who worked from 7:00 a.m. to 7:00 p.m. on [DATE] and was responsible for Resident #114 ' s care on that day. (Review of the resident's medical record disclosed a nursing note dated [DATE] at 22:00 (10:00 p.m.), in which this RN documented the accident and a resident assessment and signed off as the nurse supervisor.) During the interview, Employee #103 reported she did not know who put the resident into the geri-chair or at what time he was placed there on [DATE]. She stated the chair was reclined and no staff was in the area of the nurses' station at the time of the fall. She further reported she was assigned to another area and did not know much about the accident. - On [DATE] at 2:55 p.m., a telephone interview was conducted with Employee #2, an RN who worked 7:00 p.m. to 7:00 a.m. on [DATE] and was working in the area at the time of the incident. Employee #2 stated the resident was in the reclining geri-chair when she arrived at the facility at 7:00 p.m. She also stated she was giving medications to other residents on the 800 hall and was out of sight of Resident #114. She stated the nursing assistants were busy helping other residents in their rooms and there was no one at the nurses' station when Resident #114 fell . She stated she learned of the resident's fall when the pharmacy delivery man came and told her there was a man on the floor. - On [DATE] at 9:15 a.m., an interview was conducted with Employee #27, the nursing assistant who was responsible for Resident #114's care during the 7:00 a.m. to 3:00 p.m. (,[DATE]) shift on [DATE]. Employee #27 confirmed she was assigned to this resident on that day, and she acknowledged she was probably the person who put the resident in the geri-chair, but she could not recall at what time this occurred. Employee #27 stated Resident #114 was constantly moving all the time (sliding out of bed and scooting off of chairs), that a geri-chair in a reclining position was the only chair he might not fall out of, and that he was placed at the nurses' station for closer observation. According to Employee #27, when she left at the end of her shift at 3:00 p.m., the resident was still in the geri-chair. -- 6. Review of Resident #114's comprehensive care plan found the following problem statement, with an initiated date of [DATE] and reviewed / updated on [DATE] an [DATE]: "Resident is at risk for falls: (sic) cognitive loss, lack of safety awareness." The goal associated with this problem statement was: "Resident will have < (symbol for 'less than') 2 falls per day x 90 days." The interventions intended to assist the resident in achieving this goal were: "Resident likes to lay (sic) in the floor. He will often lower himself to floor and sometimes will prop his feet up on objects. Medication evaluation as needed. Therapy / Rehab - PR Treatment 5x per week. Use a mechanical lift (sic) two person for transfer. Bed in low position with right side against wall and landing strip on the left side of the bed. Provide verbal cues for safety and sequencing when needed. Provide resident / caregiver education for safe techniques. Place call light within reach at all times. Maintain a clutter-free environment in the resident's room and consistant (sic) furniture arrangement. When resident is in bed, place all necessary personal items within reach. " There was no mention of an intervention to place the resident in a reclining geri-chair and no mention of an intervention to locate the resident at the nurses' station for close observation. -- 7. Resident #114 sustained a total of five (5) falls, two (2) of which resulted in fractures. These falls occurred between his admission date of [DATE] and [DATE], when the resident expired at the facility. The last fall occurred on [DATE], when the resident was put in a reclining geri-chair at an unknown time during the ,[DATE] shift. According to the nursing assistant responsible for the resident's care on [DATE], the resident was still in the reclining geri-chair at the nursing station when she left her shift at 3:00 p.m. According to an interview with the RN who came on for her shift at 7:00 p.m., the resident was in the reclining geri-chair at the nurses' station when she arrived at work. The resident was found on the floor by the pharmacy delivery man at 8:30 p.m. that night. Medical record review and an interview with the rehabilitative therapy program manager disclosed this resident had been identified as being at risk for falls upon his admission to the facility, and staff was aware the resident was constantly attempting to get out of chairs and bed. Interviews with nursing staff present on [DATE] confirmed the resident had been left unsupervised in a reclining geri-chair prior to his fall; the use of the geri-chair with this resident had not been evaluated by physical therapy or ordered by the physician. --- Part II -- Based on medical record review, observation, resident interview, and staff interview, the facility failed to assure assistance devices to promote safety were applied as ordered by the physician for one (1) of three (3) residents reviewed. Resident #85 had a physician order, dated [DATE], for hipsters at all times except for bathing, related to falls. Observation and resident interview, on [DATE] at 10:45 a.m., found the resident dressed herself and did not have on the hipsters. Resident identifier: #85. Facility census: 113. Findings include: a) Resident #85 Medical record review, on [DATE], disclosed Resident #85 had a physician's order, dated [DATE], for hipsters to be applied at all times except for bathing due to falls. Observation of and interview with the resident, on [DATE] at 10:45 a.m., found she was not wearing the hipsters. The resident stated she had dressed herself in the morning and did not put them on. The resident also stated she could not remember the last time she had put them on. The resident was ambulating in her room during this observation, and she acknowledged having had falls in the past. Medical record review found the resident had a fall on [DATE]. This practice was brought to the attention of the interim director of nursing (DON - Employee #145) in the resident's room on [DATE] at 11:20 a.m., where it was confirmed the resident was not wearing hipsters. The DON also confirmed the nursing assistant who was assigned to this resident was responsible for ensuring the resident put the hipsters on as ordered to prevent injury due to falls. .

Based on review of facility documents, medical record review, and staff interview, the facility failed to ensure that goods and services were provided to prevent physical harm to one (1) of eight (8) sampled residents. Facility staff failed to assure that physician-ordered landing strips (utilized to pad / cushion the floor) were placed beside Resident #81's bed and failed to assure her bed was in a low position when left unattended on 08/22/10. Resident #81 fell from the bed and sustained a [MEDICAL CONDITION] requiring surgical repair. The graduate nursing assistant (Employee #136) responsible for the resident's care on 08/22/10 denied having knowledge of the requirement to place landing strips beside the resident's bed. The facility failed to put into place a system to orient new employees and temporary agency staff to the planned / ordered interventions to be provided to each resident. Resident identifier: #81. Facility census: 118. Findings include: a) Resident #81 Review of facility documents found that, on 08/22/10 at 6:30 p.m., Resident #81 fell from her bed to the floor. Facility staff documented the resident's bed was in a high to knee-high position with no physician-ordered landing strips present to cushion the floor beside the resident's bed. The resident sustained [REDACTED]. Review of the medical record found an active physician's orders [REDACTED]. Review of the minimum data set (MDS) assessment, with an assessment reference date (ARD) of 07/05/10, found the resident was assessed as being severely cognitively impaired with impaired long and short term memory, and she required the extensive physical assistance of one (1) staff member for bed mobility, transfers, dressing eating, toilet use, and personal hygiene. The assessor also noted resident had sustained a fall in the thirty (30) days prior to the ARD. - Further review of facility information, concerning Resident #81's fall from bed on 08/22/10, found Employee #136 stated she had no knowledge that the resident was to have landing strips placed beside her bed. Review of the one-on-one education, conducted by the facility on 08/30/10, found the nurse informed the staff member: "...there are Kardex (sic) on every station. Please look at your resident's Kardex at beginning of shift to ensure you are aware of interventions in place to prevent falls and to give appropriate care." There was a lack of evidence to reflect the facility put procedures in place to inform other new staff and temporary agency staff of the care information located in the Kardex prior to providing care to assigned residents. - An interview was conducted with a nursing assistant employed by an outside temporary staffing agency (Employee #140) at 7:40 a.m. on 09/09/10. She was asked to show this surveyor where she would locate care instructions to assure that residents received appropriate care and services, such as, landing strips, bed height, splints, etc. Employee #140 walked behind the nursing station and retrieved the activity of daily living (ADL) book. When the documents were reviewed in the ADL book, it was noted that it merely contained a record of the residents' bowel movements, intake, bathing, etc. The book contained no instructions to staff concerning landing strips, bed height, splints, or other necessary care and services to be provided. When asked what a Kardex was, the aide stated that she did not know. A subsequent interview with the charge nurse on the unit (Employee #6) revealed she had not oriented the agency nurse aide as to where to locate the Kardex to access care information for residents. .

Part I -- Based on medical record review, review of facility records, staff interview, and family interview, the facility failed to provide adequate supervision and/or appropriate assistive devices, based on a comprehensive assessment of the resident, to promote the safety of one (1) of three (3) residents whose closed records were reviewed. Resident #114 sustained a total of five (5) falls between his admission date of [DATE] and [DATE], when the resident expired at the facility. A fall from the bed on [DATE] resulted in a fractured nasal bone. A fall from the bed on [DATE] resulted in a complaint of shoulder and back pain; the resident was transported to the hospital, but x-rays were negative for fractures. On [DATE], the resident had three (3) falls from a wheelchair with no injury noted. The last fall occurred on [DATE], when the resident was found on the floor by the pharmacy delivery man at 8:30 p.m. that night, having fallen out of a reclined geri-chair located at the nurses' station. The resident sustained [REDACTED]. Medical record review and an interview with the rehabilitative therapy program manager disclosed this resident had been identified as being at risk for falls upon his admission to the facility, and staff was aware the resident was constantly attempting to get out of chairs and bed. There was no evidence in his medical record to reflect the use of the reclining geri-chair with this resident had been evaluated by physical therapy, ordered by the physician, or addressed in his care plan. Interviews with nursing staff present on [DATE] confirmed the resident had been left unsupervised in a reclining geri-chair for an unknown length of time prior to his fall. Resident identifier: #114. Facility census: 113. Findings include: a) Resident #114 1. Medical record review disclosed this [AGE] year old resident was admitted to the facility from the hospital on [DATE] for skilled services and rehabilitative therapy with the possibility of returning home with family. Prior to the hospital admission, he had been living at home with his family. Review of the hospital discharge summary revealed the resident had [DIAGNOSES REDACTED]. The resident was admitted to the hospital and was treated with antibiotics for pneumonia or urosepsis. The hospital discharge summary also noted the resident had been confused, agitated, attempting to get out of bed, and occasionally combative with staff. -- 2. Review of the resident's nursing home admission record revealed Resident #114 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of his nursing home admission orders [REDACTED]. -- 3. Review of the facility's incident / accident reports revealed the following: - On [DATE] at 9:30 p.m., Resident #114 was found lying on the floor mat beside the bed with his nose bleeding. The report described the injury as "Nose Deformity /c (with) Bruising & Nose bleed". First aid was provided for the nose bleed, neuro checks were initiated because this was an unwitnessed fall, and the physician, when notified, ordered a facial x-ray. The x-ray, completed on [DATE], revealed a fracture of nasal bone. Elsewhere on the report, the author noted, under the heading "Protective Devices" that a low bed with floor mats had been ordered and were in use at the time of the incident to prevent injury. - On [DATE] at 7:10 p.m., "Called into Rm (room) by Dayshift Nurse (sic) found Resident laying on floor on (R) (right) side c/o (complained of) (L) (left) shoulder & Low Back Pain (in room) laying on landing strip." There was no discussion on the incident report as to whether this was an unwitnessed fall. The resident was sent to the hospital for evaluation, where x-rays and a CT scan were negative. Instructions from the hospital emergency room included fall precautions. - On [DATE] at 9:15 a.m., "Called to hall by other nurse, found resident lying in floor in front of w/c (wheelchair)." Neuro checks were initiated because this was an unwitnessed fall. The author indicated there were no apparent injuries. - On [DATE] at 9:00 p.m., "Resident scooted to edge of w/c (wheelchair) & then sat in floor, assessed for injury & placed back into w/c, resident stated 'I'm gonna do it again", then proceeded to scoot to edge of w/c & sit back on the floor again, attempted to redirect & explain risk of injury /s (without) success. The report indicated there was no injury noted from the two (2) falls from the wheelchair and the resident was placed in bed after the second fall. - On [DATE] at 8:30 p.m., "Was called to nurses station by pharmacy to find (resident's name) on his right side on floor next to chair. Upon assessment found his forehead bleeding. Took vitals & paged (nurse's name) to unit." Under the heading "Description of Injury" was written "2 abrasions to forehead / top of head & 1 by (R) (right) eye. Resident stated head, neck, (R) shoulder & (R) hip hurt." Under the heading "Protective Devices" the author noted a reclined geri-chair was in use at the time of the fall due to "freq. (frequent) falls". Neuro checks were initiated because this was an unwitnessed fall, and the resident was transported to the local hospital emergency department for evaluation. A nursing note, dated [DATE] at 22:00 (10:00 p.m.), revealed the resident was found in floor by the pharmacy delivery man; he notified the floor nurse, who called supervisor. This note also stated the resident's injuries were assessed and he was transferred to the hospital. A nursing note, dated [DATE] at 05:13 a.m., revealed the hospital called the facility to notify staff the resident had fractures of C1 and C2 vertebrae and the hospital was sending the resident to another hospital to see a neurosurgeon. Another nursing note, dated [DATE] at 10:02 a.m., revealed the resident had arrived back at the facility. The new order from the hospital was to keep the Miami collar on the resident's neck at all times. -- 4. During an interview on [DATE] at 7:30 p.m., a family member reported Resident #114 was very agitated with the cervical collar and continuously attempted to remove it. The family member also reported that a meeting was held at the facility with management staff, at which time the falls and the importance of keeping the cervical collar in place were discussed. The family member reported staff informed him/her this facility had a "Right to Fall Policy"; however, when the family member requested a copy of this policy, it was not provided. -- 5. Interviews were conducted with staff on duty on [DATE] as follows: On [DATE] at 9:30 a.m., an interview was conducted with a nursing assistant (Employee #24). Employee #24 reported she had assisted putting the resident in the geri-chair. She stated she could not remember the time they put him in the chair. She stated he was put in the reclining geri-chair to be close to the nurses' station for close observation. - On [DATE] at 10:45 a.m., an interview was conducted with the therapy program manager (Employee #144) who had worked with this resident and familiar with the resident's therapy plan. Employee #144 reported the resident was constantly attempting to get up and moving constantly. Resident #114 had been evaluated for the use of a wheelchair with anti-tippers for transport and while in therapy, but the use of a reclining geri-chair had not been recommended by physical therapy. - On [DATE] at 11:30 a.m., an interview was conducted with the RN manager of the unit on which Resident #114 resided (Employee #98). During this interview, Employee #98 confirmed Resident #114 had been placed in a reclining geri-chair on that weekend, and there was no physician order for [REDACTED]. The RN manager stated she did not know who was responsible for putting the resident in the geri-chair. - On [DATE] at 2:50 p.m., a telephone interview was conducted with Employee #103, the registered nurse (RN) who worked from 7:00 a.m. to 7:00 p.m. on [DATE] and was responsible for Resident #114 ' s care on that day. (Review of the resident's medical record disclosed a nursing note dated [DATE] at 22:00 (10:00 p.m.), in which this RN documented the accident and a resident assessment and signed off as the nurse supervisor.) During the interview, Employee #103 reported she did not know who put the resident into the geri-chair or at what time he was placed there on [DATE]. She stated the chair was reclined and no staff was in the area of the nurses' station at the time of the fall. She further reported she was assigned to another area and did not know much about the accident. - On [DATE] at 2:55 p.m., a telephone interview was conducted with Employee #2, an RN who worked 7:00 p.m. to 7:00 a.m. on [DATE] and was working in the area at the time of the incident. Employee #2 stated the resident was in the reclining geri-chair when she arrived at the facility at 7:00 p.m. She also stated she was giving medications to other residents on the 800 hall and was out of sight of Resident #114. She stated the nursing assistants were busy helping other residents in their rooms and there was no one at the nurses' station when Resident #114 fell . She stated she learned of the resident's fall when the pharmacy delivery man came and told her there was a man on the floor. - On [DATE] at 9:15 a.m., an interview was conducted with Employee #27, the nursing assistant who was responsible for Resident #114's care during the 7:00 a.m. to 3:00 p.m. (,[DATE]) shift on [DATE]. Employee #27 confirmed she was assigned to this resident on that day, and she acknowledged she was probably the person who put the resident in the geri-chair, but she could not recall at what time this occurred. Employee #27 stated Resident #114 was constantly moving all the time (sliding out of bed and scooting off of chairs), that a geri-chair in a reclining position was the only chair he might not fall out of, and that he was placed at the nurses' station for closer observation. According to Employee #27, when she left at the end of her shift at 3:00 p.m., the resident was still in the geri-chair. -- 6. Review of Resident #114's comprehensive care plan found the following problem statement, with an initiated date of [DATE] and reviewed / updated on [DATE] an [DATE]: "Resident is at risk for falls: (sic) cognitive loss, lack of safety awareness." The goal associated with this problem statement was: "Resident will have < (symbol for 'less than') 2 falls per day x 90 days." The interventions intended to assist the resident in achieving this goal were: "Resident likes to lay (sic) in the floor. He will often lower himself to floor and sometimes will prop his feet up on objects. Medication evaluation as needed. Therapy / Rehab - PR Treatment 5x per week. Use a mechanical lift (sic) two person for transfer. Bed in low position with right side against wall and landing strip on the left side of the bed. Provide verbal cues for safety and sequencing when needed. Provide resident / caregiver education for safe techniques. Place call light within reach at all times. Maintain a clutter-free environment in the resident's room and consistant (sic) furniture arrangement. When resident is in bed, place all necessary personal items within reach. " There was no mention of an intervention to place the resident in a reclining geri-chair and no mention of an intervention to locate the resident at the nurses' station for close observation. -- 7. Resident #114 sustained a total of five (5) falls, two (2) of which resulted in fractures. These falls occurred between his admission date of [DATE] and [DATE], when the resident expired at the facility. The last fall occurred on [DATE], when the resident was put in a reclining geri-chair at an unknown time during the ,[DATE] shift. According to the nursing assistant responsible for the resident's care on [DATE], the resident was still in the reclining geri-chair at the nursing station when she left her shift at 3:00 p.m. According to an interview with the RN who came on for her shift at 7:00 p.m., the resident was in the reclining geri-chair at the nurses' station when she arrived at work. The resident was found on the floor by the pharmacy delivery man at 8:30 p.m. that night. Medical record review and an interview with the rehabilitative therapy program manager disclosed this resident had been identified as being at risk for falls upon his admission to the facility, and staff was aware the resident was constantly attempting to get out of chairs and bed. Interviews with nursing staff present on [DATE] confirmed the resident had been left unsupervised in a reclining geri-chair prior to his fall; the use of the geri-chair with this resident had not been evaluated by physical therapy or ordered by the physician. --- Part II -- Based on medical record review, observation, resident interview, and staff interview, the facility failed to assure assistance devices to promote safety were applied as ordered by the physician for one (1) of three (3) residents reviewed. Resident #85 had a physician order, dated [DATE], for hipsters at all times except for bathing, related to falls. Observation and resident interview, on [DATE] at 10:45 a.m., found the resident dressed herself and did not have on the hipsters. Resident identifier: #85. Facility census: 113. Findings include: a) Resident #85 Medical record review, on [DATE], disclosed Resident #85 had a physician's order, dated [DATE], for hipsters to be applied at all times except for bathing due to falls. Observation of and interview with the resident, on [DATE] at 10:45 a.m., found she was not wearing the hipsters. The resident stated she had dressed herself in the morning and did not put them on. The resident also stated she could not remember the last time she had put them on. The resident was ambulating in her room during this observation, and she acknowledged having had falls in the past. Medical record review found the resident had a fall on [DATE]. This practice was brought to the attention of the interim director of nursing (DON - Employee #145) in the resident's room on [DATE] at 11:20 a.m., where it was confirmed the resident was not wearing hipsters. The DON also confirmed the nursing assistant who was assigned to this resident was responsible for ensuring the resident put the hipsters on as ordered to prevent injury due to falls.

Based on observations, the facility failed to ensure the resident environment remained as free of accident hazards as possible. A treatment cart was found unlocked and unattended on the Blue Ridge hall in the presence of mobile residents. The cart contained items that had the potential to be harmful if ingested or used in a manner other than they were intended to be used. All mobile residents on the Blue Ridge hall had the potential to be affected. Facility census: 114. Findings include: a) Treatment cart - unlocked and unattended During random observations of the facility on 08/24/10 at 7:30 a.m., the treatment cart of Blue Ridge was found sitting outside of the Blue Ridge nurses' station. The cart was not locked, and no staff was in line of sight of the cart. The cart contained a variety of treatment supplies, i.e., a container of Greer's Goo (composed of nystatin (Mycostatin) powder 4 million U, hydrocortisone powder 1.2 g, and zinc oxide paste), Nystop (an antifungal), and a large bottle of 100% Acetone. There would be a potential for adverse reactions should a resident who was sensitive / allergic to Mycostatin or Nystop have contact with the Greer's Goo and / or Nystop. Acetone (http://www.drugs.com/enc/acetone-poisoning.html) has the potential to cause cardiovascular problems (hypotension), gastrointestinal problems (nausea, abdominal pain, vomiting), the nervous system may be affected (seem as though drunk, coma), as might the respiratory system .