Every finding on record at The Center at Parmer

Based on observation, interviews and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights and that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 8 sampled residents (R#68). The facility failed to develop a care plan that described the respiratory care/services R#68 would receive for her shortness of breath per her physician's orders made on 10/25/25. This failure could place residents at risk of receiving the wrong oxygen flow, interruptions in therapy, delayed emergency response, respiratory distress, life-threatening hypoxia or complications from oxygenation. Review of R#68's admission record, dated 01/29/26, showed she was admitted to the facility on [DATE] with medical diagnosis that included shortness of breath.Review of R#68's admission MDS, dated [DATE], showed she had a BIMS score of 13/15, which indicated she was cognitively intact. Section O reflected that she required oxygen therapy on admission and while she was a resident. Review of R#68's order summary report, dated 01/28/26, reflected a verbal order made on 10/25/25 to change nebulizer mask and oxygen tubing every Sunday HS and PRN, oxygen to be on at (1-5) liters per minute continuously, delivered through NC, may titrate to greater than or equal to 88% every shift and PRN, okay for therapy to titrate PRN for SOB/decreased O2 saturation or every shift for SOB. The order started on 10/26/25. Review of R#68's care plan, completed 01/17/26, showed she would get shortness of breath. There were no interventions documented regarding her verbal order made on 10/25/25. During an observation of and interview with R#68 on 01/28/26 at 11:18 a.m., her oxygen machine was on in her room. Her NC was on her lap. She stated she was receiving oxygen therapy for her shortness of breath at the time of the interview, every shift and daily. She stated she did not observe and did not know if staff changed her oxygen tubing and nebulizer masks when she did not use the equipment. During an interview with CNA E on 01/30/26 at 1:34 p.m., she stated the NP reviewed and revised residents' care plans.During an interview with CNA F on 01/30/26 at 1:58p.m., she stated the Case Manager reviewed and revised residents' care plans. During an interview with CNA G on 01/30/26 at 2:23 p.m., CNA O on 01/30/26 at 3:09 p.m. and LPN L on 01/30/26 at 4:03 p.m., they stated they did not know who reviewed and revised residents' care plans. During an interview with LVN H on 01/30/26 at 2:51 p.m., she stated the nurses and IDT team reviewed and revised residents' care plans. She also stated she did not know who oversaw and ensured the nurses and IDT team reviewed and revised residents' care plans. During an interview with the Weekend Supervisor on 01/30/26 at 3:24 p.m., she stated the case manager and IDT team reviewed and revised residents' care plans.During an interview with LPN J on 01/30/26 at 3:51 p.m., she stated the ADON and DON reviewed and revised residents' care plans.During a interview with RN M on 01/30/26 at 4:12 p.m., she stated nurses reviewed and revised care plans. She also stated the ADON and DON oversaw and ensured nurses reviewed and revised residents' care plans.During an interview with the DON on 01/30/26 at 4:43 p.m., she stated MDS Coordinator C and D reviewed and revised residents' care plans. She also stated her or the ADON oversaw and ensured MDS Coordinator reviewed and revised residents' care plans by reviewing orders and 24 hour reports. The surveyor attempted to call MDS Coordinator C on 01/30/26 at 5:05 p.m The surveyor left a voicemail and call back number. MDS Coordinator C did not return the surveyor's call before exit. During an interview with MDS Coordinator D on 01/30/26 at 5:07 p.m., she stated the IDT team reviewed and revised residents' care plans. She stated she knew it was important to review and revise residents' care plans and said, Because the plan of care could change. Resident could be at risk of death, risk of falls, injuries, metabolic, cardiac, endo, kidney, etc. During an interview with the ADM on 01/30/26 at 5:17 p.m., he stated the IDT team reviewed and revised residents' care plans. He also stated he knew it was important to review and revise residents' care plans and said, It keeps residents health status up to date and what their status is. Review of the facility's care plan policy and procedure, revised 02/08/21, reflected, Policy: It is the policy of the facility to promote seamless interdisciplinary care for our residents by utilizing the interdisciplinary plan of care based on assessment, planning, treatment, service and intervention. It is utilized to plan and manage resident care as evidenced by documentation from admission through discharge for each resident.The care plan will identify priority problems and needs to be addressed by the interdisciplinary team, and will reflect the patient's strengths, limitations, and goals. The care plan will be specific and appropriate to the individual needs for each resident. The interdisciplinary care plan will be developed through collaborative efforts of the IDT and other health care professionals. The care plan will be patient centered emphasizing the resident's and/or family's goals.Procedure:The facility will develop, implement, and provide care in accordance with a comprehensive person-centered care plan for the resident consistent with regulatory requirements. The care plan is to include measurable objectives and timeframes to meet a resident's medical, nursing, psycho-social, and functional needs identified with completion of the comprehensive assessment.The interdisciplinary team members will contribute towards the interventions and approaches needed to obtain the resident's desired and expected outcomes.The care plans will be modified when needed to meet the resident's current needs, problems, and goals. Any revision, additions, or deletion to the plan of care will be dated.Revisions involving the care of other disciplines are done through consultative and collaborative efforts.All residents are discussed with the Interdisciplinary Team to provide continued updates, revisions, and discontinuation of interventions based on the resident's goals, care needs, and discharge planning.

Based on observations, interviews and record review, the facility failed to develop a comprehensive care plan within 7 days after completion of the comprehensive assessment for 1 of 8 sampled residents (R#63). The facility failed to revise R#63's care plan to reflect all fall risk interventions recommended by the PCP after his unwitnessed fall on 01/13/26. This failure could place residents at risk of falls, injuries or hospitalization. Review of R#63's admission record, dated 01/29/26, showed he was admitted to the facility on [DATE] with medical diagnoses including wedge compression fracture, low back pain and altered mental status. Review of R#63's 5-Day MDS assessment, dated 01/15/26, showed he had a BIMS score of 7/15, which indicated he had severe cognitive impairment. Section J reflected he had no falls since admission/reentry. Review of R#63's progress notes showed RN K created a note on 01/13/26 at 8:00 a.m. that reflected she notified the PCP of his change in condition evaluation for fall on 01/13/26. The PCP recommended increasing frequent monitoring, place fall mats, educate him on importance of using call light to prevent falls and keeping his bed low to the ground after fall. Review of R#63's care plan, initiated 01/09/26, showed he was a high risk faller and had a fall on 01/13/26. Interventions include call don't fall signs in his room to remind him to call for assistance, safety rounds by all staff, fall mats at bedside, have adequate lighting, and transfer and change positions slowly. Interventions did not include the PCP's recommendation of lowering bed to the ground. During an observation and interview of R#63 on 01/28/26 at 11:47 a.m., he was lying in bed with FAM sitting next to him. Fall mats were on each side of his bed. Call don't fall sign was in his room. There was adequate lighting. A female CNA left his room after finishing resident care on him. The female CNA did not lower his bed to the ground before leaving his room. The surveyor attempted to interview R#63, but he did not answer any of the surveyor's questions. R#63's FAM stated he fell on the ground at the facility. They also stated staff did not lower his bed to the ground before leaving his room and they often had to remind staff. During an interview with CNA E on 01/30/26 at 1:34 p.m., she stated the NP reviewed and revised residents' care plans. During an interview with CNA F on 01/30/26 at 1:58 p.m., she stated the Case Manager reviewed and revised residents' care plans. During an interview with CNA G on 01/30/26 at 2:23 p.m., she stated she did not know who reviewed and revised residents' care plans. During an interview with LVN H on 01/30/26 at 2:51 p.m., she stated the nurses and IDT team reviewed and revised residents' care plans. She stated she did not know who oversaw and ensured the nurses and IDT team reviewed and revised residents' care plans. During an interview with CNA O on 01/30/26 at 3:09 p.m., she stated she did not know who reviewed and revised residents' care plans. During an interview with the Weekend Supervisor on 01/30/26 at 3:24 p.m., she stated the Case Manager and IDT team reviewed and revised residents' care plans. During an interview with LPN J on 01/30/26 at 3:51 p.m., she stated the ADON and DON reviewed and revised residents' care plans. During an interview with LPN L on 01/30/26 at 4:03 p.m., she stated she did not know who reviewed and revised residents' care plans. During an interview with RN M on 01/30/26 at 4:12 p.m., she stated the nurses reviewed and revised residents' care plans. She also stated the ADON and DON oversaw and ensured residents' care plans were reviewed and revised. During an interview with the DON on 01/30/26 at 4:43 p.m., she stated MDS Coordinator C and D reviewed and revised residents' care plans. She also stated she or the ADON oversaw and ensured residents' care plans were reviewed and revised by reviewing residents' orders and 24 hour reports. The surveyor attempted to call MDS Coordinator C on 01/30/26 at 5:05 p.m the surveyor left a voicemail and call back number. MDS Coordinator C did not return the surveyor's call before exit. During an interview with MDS Coordinator D on 01/30/26 at 5:07 p.m., she stated she, MDS Coordinator C and the IDT team were responsible for reviewing and revising residents' care plans. She also stated she knew it was important to review and revise residents' care plans and said, Because the plan of care could change. Resident could be at risk of death, falls, injuries, metabolic, cardiac, endo, kidney, etc. During an interview with the ADM on 01/30/26 at 5:17 p.m., he stated the IDT team reviewed and revised residents' care plans. He stated he knew it was important to review and revise residents' care plans and said, It keeps residents health status up to date and what their status is. Review of the facility's care plan policy and procedure, revised 02/08/21, reflected, Policy: It is the policy of the facility to promote seamless interdisciplinary care for our residents by utilizing the interdisciplinary plan of care based on assessment, planning, treatment, service and intervention. It is utilized to plan and manage resident care as evidenced by documentation from admission through discharge for each resident.The care plan will identify priority problems and needs to be addressed by the interdisciplinary team, and will reflect the patient's strengths, limitations, and goals. The care plan will be specific and appropriate to the individual needs for each resident. The interdisciplinary care plan will be developed through collaborative efforts of the IDT and other health care professionals. The care plan will be patient centered emphasizing the resident's and/or family's goals.Procedure:The facility will develop, implement, and provide care in accordance with a comprehensive person-centered care plan for the resident consistent with regulatory requirements. The care plan is to include measurable objectives and timeframes to meet a resident's medical, nursing, psycho-social, and functional needs identified with completion of the comprehensive assessment.The interdisciplinary team members will contribute towards the interventions and approaches needed to obtain the resident's desired and expected outcomes.The care plans will be modified when needed to meet the resident's current needs, problems, and goals. Any revision, additions, or deletion to the plan of care will be dated.Revisions involving the care of other disciplines are done through consultative and collaborative efforts.All residents are discussed with the Interdisciplinary Team to provide continued updates, revisions, and discontinuation of interventions based on the resident's goals, care needs, and discharge planning. Review of the facility's fall prevention policy, revised 07/24/23, reflected, PROCEDURE:Any patient deemed to be high risk by nursing and/or therapy staff will have the following interventions at least considered: .Low bed (or lower our standard bed to its lowest position).Post fall Procedure::.Determine what interventions need to be implemented to prevent further falls. Complete orders and/or tasks for fall prevention and for skin injuries if indicated.

Based on observation, interviews and record review, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 8 sampled residents (R#63). The facility failed to conduct neurological monitoring for R#63 after his unwitnessed fall on 01/13/26. These failures could place residents at risk of delayed treatment adjustments or potential health complications. Review of R#63's admission record, dated 01/29/26, showed he was admitted to the facility on [DATE] with medical diagnoses including wedge compression fracture, low back pain and altered mental status. Review of R#63's 5-Day MDS assessment, dated 01/15/26, showed he had a BIMS score of 7/15, which indicated he had severe cognitive impairment. Section J reflected he had no falls since admission/reentry. Review of R#63's care plan, initiated 01/09/26, showed he was a high risk faller and had a fall on 01/13/26. Interventions include call don't fall signs in his room to remind him to call for assistance, safety rounds by all staff, fall mats at bedside, have adequate lighting, and transfer and change positions slowly. Review of R#63's progress notes showed:- RN K created a note on 01/13/26 at 8:00 a.m. that reflected she notified the PCP of his change in condition evaluation for fall on 01/13/26. The PCP recommended increasing frequent monitoring, place fall mats, educate him on importance of using call light to prevent falls and keeping his bed low to the ground after fall.-Physician A signed an encounter note on 01/15/26 at 10:08 p.m. that reflected, Chief Complaint / Nature of Presenting Problem: Staff reports patient had a fall. History Of Present Illness: .Patient seen and examined at bedside. According to the staff patient was found on the floor at bedside this morning. Patient says he was trying to get out of bed independently and landed on his back. Denies any pain, and no signs of injury noted. Neurologically at his baseline. Denies nausea, HA, vision changes. Will continue to monitor. Stable vitals. Labs reviewed with family.Review of R#63's Change in Condition Evaluation, dated 01/13/26 at 8:00 a.m. showed he had a fall on 01/13/26 in the morning time, had previous falls at home and surgical interventions, notified his PCP and FAM on 01/13/26 at 8:00 a.m. and the PCP recommended increase frequent monitoring, place fall mats, educate patient on importance of using call light to prevent falls and keep the bed low to the ground.Review of R#63's Post-Fall Evaluation, created by RN K on 01/13/26 at 3:18 p.m., showed he had an unwitnessed fall in his room on 01/13/26, was found lying on his back directly next to the bed, had no new skin issues, bleeding or bumps, denied complaints of pain to his head and having used his call light at the time, his call light was not on at the time, and stated he was trying to go out to his lawn to walk, hit his head during the fall and did have pain regarding his chronic back pain. Neurological checks were initiated per facility protocol. Review of R#63's evaluations showed there was no record of neurological evaluations completed after his unwitnessed fall on 01/13/26. Review of R#63's documents showed there was no record of neurological evaluations completed after his unwitnessed fall on 01/13/26. During an observation and interview of R#63 on 01/28/26 at 11:47 a.m., he was lying in bed with FAM sitting next to him. Fall mats were on each side of his bed. Call don't fall sign was in his room. There was adequate lighting. A female CNA left his room after finishing resident care on him. The female CNA did not lower his bed to the ground before leaving his room. The surveyor attempted to interview R#63, but he did not answer any of the surveyor's questions. R#63's FAM stated he fell on the ground at the facility. They also stated staff did not lower his bed to the ground before leaving his room and they often had to remind staff. The surveyor attempted to call MD R on 01/29/26 at 4:05p.m. The surveyor left a voicemail and call back number. MD R did not return the surveyor's call before exit. During an interview with MD Q on 01/29/26 at 4:06 p.m., he stated he worked with R#63. He stated he expected staff to notify the MD, assess the resident for injury, determine if there was a head injury, review residents' medications to determine if any brain bleed and would send the resident out to the hospital if a resident had an unwitnessed fall. He stated he would expect staff to initiate neurological monitoring within the first 24 hours if there was a suspected head injury and medications the resident took that could cause brain bleed. He stated he knew it was important to initiate neurological monitoring after an unwitnessed fall and said, Well because if there were any changes after a fall, it could attribute to an intercranial bleed if there was a head injury. The surveyor attempted to call RN K on 01/30/26 at 4:01 p.m The surveyor left a voicemail and call back number. RN K did not return the surveyor's call before exit. During an interview with the DON on 01/30/26 at 4:43 p.m., she stated she expected the frequency of neurological monitoring to take place in accordance with the neurological flow sheet form she provided the surveyor. She stated the nurses documented neurological monitoring on the flow sheets form and uploaded it to residents' electronic health records later on. She stated she oversaw and ensured nurses conducted neurological monitoring. She knew it was important to initiate neurological monitoring after an unwitnessed fall and said, To make sure there was not a change in condition or to make sure the neurological status did not change. Residents could be at risk of a lot of things. During an interview with the ADM on 01/30/26 at 5:17 p.m., he stated he expected staff perform neurological monitoring immediately after an unwitnessed fall and follow the frequency. He stated the nurses documented neurological monitoring on the flow sheet forms and uploaded it to residents' electronic health records later on. He stated the DON oversaw and ensured nurses conducted neurological monitoring. He stated he knew it was important to initiate neurological monitoring after an unwitnessed fall and said, To check for any change in condition of the residents and to see what the next immediate step would be. Residents could be at risk of having a change of condition missed. Review of the facility's neurological flow sheet form reflected staff were required to check on level of consciousness, range of motion, hand grasp, speech and pupil reaction once every 15 minutes x4, once every 30 minutes x2, once every hour x4, once every four hours x6, and once every shift x4. Review of the facility's fall prevention policy, revised 07/24/23, reflected, Post fall Procedure::If unwitnessed fall, perform neurological assessment using the neurological flow sheet.Determine what interventions need to be implemented to prevent further falls. Complete orders and/or tasks for fall prevention and for skin injuries if indicated.The surveyor requested the DON and ADM provide a copy of the facility's quality of care policy and procedure on 01/30/26 at 2:39 p.m. and was not provided with the record before exit.

Based on observations, interviews and record review, the facility failed to ensure that a resident who needs respiratory care is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences for 2 of 8 sampled residents (R#11 and R#68). 1.The facility failed to bag R#11 and R#68's NCs, CPAP masks, and tubing when not in use.2. The facility failed to document oxygen liters in R#11 and R#68's TARs per their physician's orders. This failure could place residents at risk of respiratory infection. Review of R#11's admission record, dated 01/28/26, showed she was admitted to the facility on [DATE] with medical diagnoses including acute respiratory failure, asthma, pneumonia and COVID-19. Review of R#11's admission MDS, dated [DATE], showed she had a BIMS score of 13/15, which indicated she was cognitively intact. Section O reflected that she also required oxygen therapy while a resident. Review of R#11's care plan, completed 01/19/26, showed staff were required to administer oxygen as ordered and PRN, monitor pulse every shift if less than 88%, start oxygen at 1-5 liters per minute continuously, deliver oxygen through NC, may titrate oxygen to greater than or equal to 88% every shift and prn, and okay for therapy to titrate.Review of R#11's order summary report, dated 01/29/26, showed she had a verbal order for oxygen to be on at (1-5) liters per minute (continuously), delivered through (NC) may titrate to greater than or equal to 88% every shift and PRN and okay for therapy to titrate every shift and PRN for SOB/decreased saturation started on 12/26/25. Review of R#11's MAR/TAR for January 2026 showed staff did not document liters she received per minute on the night of 01/02/26, morning and night of 01/16/26, night of 01/17/26, 01/21/26 and 01/22/26, morning and night of 01/24/26, 01/26/26 and 01/27/26 and the morning of 01/28/26, which indicated there were 13 entries that were not documented with the amount of liters she received during those shifts. Review of R#11's progress notes reviewed on 01/28/26 showed no notes related to amount of liters not documented in MAR/TAR. Review of R#68's admission record, dated 01/29/26, showed she was admitted to the facility on [DATE] with medical diagnosis including shortness of breath. Review of R#68's admission MDS, dated [DATE], showed Section C reflected she had a BIMS score of 13/15, which indicated she was cognitively intact. Section O reflected she required oxygen therapy on and while admitted at the facility. Review of R#68's care plan, completed 01/17/26, reflected she had shortness of breath. No interventions documented related to oxygen use orders. Review of R#68's order summary report, dated 01/29/26, showed she had a verbal order for oxygen to be on at (1-5)liters per minute (continuously), delivered through (NC) may titrate to greater than or equal to 88% every shift and PRN and okay for therapy to titrate every shift and PRN for SOB/decreased saturation started on 10/25/25.Review of R#68's MAR/TAR for January 2026 showed staff did not document liters she received per minute on the morning and night of 01/01/26 through 01/15/26 and 01/17/26 through 01/28/26 and the morning of 01/16/26 and 01/29/26, which indicated there were 56 entries that were not documented with the amount of liters she received during those shifts. Review of R#68's progress notes reviewed on 01/29/26 showed no notes related to amount of liters not documented in MAR/TAR. During an observation and interview of R#68 on 01/28/26 at 11:18 a.m., she was lying in her bed in her room. Her NC was sitting on her lap. The oxygen machine was on. She stated she was receiving oxygen every shift daily and PRN for her shortness of breath. She stated she did not observe and did not know if staff changed or bagged her tubing and NC when she did not use them. During an observation and interview of R#11 on 01/28/26 at 11:26 a.m., she was lying in her bed in her room. Her NC was on the ground and the oxygen machine was on. Her CPAP mask was on her night stand next to her and the machine was off. Her NC was hanging on her wheelchair back support and the oxygen tank was off. She stated she was receiving oxygen every shift daily and PRN for her shortness of breath. She stated staff did not bag her NC and CPAP masks whenever her respiratory equipment was not in use. During an interview with CNA E on 01/30/26 at 1:34 p.m., she stated the CNAs and nurses were responsible for bagging oxygen tubing and equipment when not in use and said, If we leave it out, someone could trip. She stated she rounded and stayed on the floor to ensure oxygen equipment was stored away when not in use. She stated the nurses oversaw and ensured the CNAs stored away oxygen equipment when not in use. She stated she knew it was important to properly store away oxygen equipment when not in use and said, Because it's important, what if it falls and causes a fire or resident gets hurt. Residents could be at risk of respiratory infection. She also stated the nurses documented amount of oxygen liters in residents' TAR. She also stated the DON and management team oversaw and ensured nurses documented amount of oxygen liters in residents' TAR. She stated she knew it was important to document amount of oxygen liters and said, Because that's how you determine how much you need. If they don't get the appropriate amount, they might not be able to breathe right. During an interview with CNA F on 01/30/26 at 1:58 p.m., she stated the CNAs checked and ensured oxygen equipment was stored away when not in use every morning and notified the nurse when oxygen equipment was not in use. She also stated the nurses were responsible for bagging oxygen tubing and equipment when not in use. She stated the maintenance staff and nurses oversaw and ensured oxygen equipment was properly stored away when not in use. She stated she knew it was important to store away oxygen equipment when not in use and said, Because we need to make sure the tubing is not damaged because sometimes it happens. She did not know what residents could be at risk of if oxygen equipment was not properly stored away when not in use. She also stated the nurses documented amount of oxygen liters in residents' TAR. She stated the ADON or DON oversaw and ensured nurses documented amount of oxygen liters in residents' TAR. She stated she knew it was important to document amount of oxygen liters and said, To make sure residents have enough to breathe. She did not know what residents could be at risk of if staff did not document amount of oxygen liters in residents' TAR.During an interview with CNA G on 01/30/26 at 2:23 p.m., she stated the CNAs or nurses were responsible for bagging oxygen tubing and equipment when not in use. She stated the CNAs and nurses checked all the time to ensure oxygen equipment was stored away when not in use and said, To make sure residents don't fall or get hurt. She stated the nurses oversaw and ensured oxygen equipment was properly stored away when not in use. She stated she knew it was important to store away oxygen equipment when not in use and said, So it's not contaminated. Residents could be at risk of infection. She also stated the nurses documented amount of oxygen liters in residents' TAR. She also stated that the ADON or DON oversaw and ensured nurses documented amount of oxygen liters in residents' TAR. She stated she knew it was important to document amount of oxygen liters and said, To make sure residents were getting right amount of oxygen they need. Residents could be at risk of suffocation. During an interview with LVN H on 01/30/26 at 2:51 p.m., she stated the nurses bagged oxygen NC and equipment when not in use and every time treatment is finished. She stated the ADON oversaw and ensured nurses stored and bagged oxygen equipment and NC when not in use. She stated she knew it was important to store away oxygen equipment when not in use and said, It could get dirty and cause an infection. She also stated the nurses documented amount of oxygen liters in residents' TAR. She also stated that the ADON or DON oversaw and ensured amount of oxygen liters were documented in residents' TAR. She stated she knew it was important to ensure oxygen liters were documented in TAR and said, Just to monitor where residents are at and might need to titrate due to oxygen orders. Residents could be at risk of getting the wrong amount of oxygen and inconsistent or lack of continuity of care. During an interview with CNA I on 01/30/26 at 3:09 p.m., she stated the CNAs or nurses were responsible for bagging oxygen tubing when not in use. She stated the CNAs and nurses checked and ensured oxygen equipment was stored away when not in use at least every two hours. She stated the HR oversaw and ensured oxygen equipment was properly stored away when not in use. She stated she knew it was important to store away oxygen equipment when not in use and said, Because it could get bacteria and residents could catch and infection. She also stated the nurses documented amount of oxygen liters in residents' TAR. She stated the MDS Coordinators oversaw and ensured nurses documented amount of oxygen liters in residents' TAR. She stated she knew it was important to document amount of oxygen liters and said, Because they might end up getting too much of what they were supposed to have. During an interview with the Weekend Supervisor on 01/30/26 at 3:24 p.m., she stated the CNAs, therapy or nurses were responsible for bagging oxygen tubing when not in use. She stated she checked whenever she did room rounds, which were at least throughout the shift, and ensured oxygen equipment was stored away when not in use. She stated all staff and night time staff oversaw and ensured oxygen equipment was properly stored away when not in use during night shifts and angel rounds. She stated she knew it was important to store away oxygen equipment when not in use and said, Infection control. So they're not picking up bugs. Residents could be at risk of respiratory infections. She also stated the nurse on shift documented amount of oxygen liters in residents' TAR. She stated her, the ADON and DON oversaw and ensured nurses documented amount of oxygen liters in residents' TAR by conducting daily audits. She stated she knew it was important to document amount of oxygen liters and said, To make sure staff were going by orders and make sure staff were giving not more or less than what residents need.During an interview with LPN J on 01/30/26 at 3:51 p.m., she stated the nurses were responsible for bagging oxygen tubing when not in use. She stated she checked throughout her shift and ensured oxygen equipment was stored away when not in use. She stated the ADM, ADON, and DON oversaw and ensured oxygen equipment was properly stored away when not in use during night shifts and angel rounds. She stated she knew it was important to store away oxygen equipment when not in use and said, For Infection control. Residents could be susceptible to respiratory infections or infections. She also stated the nurses documented amount of oxygen liters in residents' TAR. She also stated the ADON and DON oversaw and ensured nurses documented amount of oxygen liters in residents' TAR. She stated she knew it was important to document amount of oxygen liters and said, So we know as far as how much oxygen resident received. Residents could be at risk of receive respiratory failure due to not receiving enough oxygen and fall into hypoxia.During an interview with LPN L on 01/30/26 at 4:03 p.m., she stated the nurses were responsible for bagging oxygen tubing when not in use. She stated she checked throughout her shift. She stated the charge nurses, ADON, and DON oversaw and ensured oxygen equipment was properly stored away when not in use. She stated she knew it was important to store away oxygen equipment when not in use and said, For Infection control. Residents could be at risk of infection because it could fall on the floor, get dirty, and residents could become septic. She also stated the charge nurses documented amount of oxygen liters in residents' TAR. She stated the ADON and DON oversaw and ensured nurses documented amount of oxygen liters in residents' TAR. She stated she knew it was important to document amount of oxygen liters and said, Depending on what they are at with respiratory status and need to find out if need more or less and need to know if it needs to be tapered down. Residents could be at risk of staff not knowing how much oxygen the resident needed and if therapy was effective. During an interview with RN M on 01/30/26 at 4:12 p.m., she stated the nurses were responsible for bagging oxygen tubing when not in use. She stated she checked anytime she went into residents' rooms and ensured oxygen equipment was stored away when not in use. She stated the ADM and DON oversaw and ensured oxygen equipment was properly stored away when not in use. She stated she knew it was important to store away oxygen equipment when not in use and said, Uh, germs, if it falls on the floor, you must replace the tubing, and if it's in the plastic bag, it'll be okay. Residents could be at risk of falls and infection. She also stated the nurses documented amount of oxygen liters in residents' TAR. She stated the DON oversaw and ensured nurses documented amount of oxygen liters in residents' TAR. She stated she knew it was important to document amount of oxygen liters and said, Go by the order and must follow the orders. Residents could become hypoxic and shortness of breath. Residents could not be getting oxygen enough or too much.During an interview with the DON on 01/30/26 at 4:43 p.m., she stated the CNAs, therapy and nurses were responsible for bagging oxygen tubing when not in use. She stated she expected all staff to check throughout their shift and ensure oxygen equipment was stored away when not in use. She stated she knew it was important to store away oxygen equipment when not in use and said, Because we can find where it is at. So it is readily available. So that it does not get dirty and if it does it needs to be thrown away. She stated she did not believe there would be an adverse outcome to residents if oxygen equipment was not bagged when not in use. She also stated the nurses documented amount of oxygen liters in residents' TAR. She also stated she and the ADON oversaw and ensured nurses documented amount of oxygen liters in residents' TAR by conducting daily chart checks. She stated she knew it was important to document amount of oxygen liters and said, To get a baseline. She stated she did not believe there was an adverse outcome that likely could result if staff did not document amount of oxygen liters. During an interview with the ADM on 01/30/26 at 5:17 p.m., he stated he would expect staff to bag oxygen equipment and tubing when not in use. He stated angel rounds are conducted every morning by management staff to ensure oxygen equipment was stored away when not in use. He stated he knew the importance of storing away oxygen equipment when not in use and said, Because you don't want the resident to get tangled with it or have it fall on the resident. He also stated he expected staff to follow physician's orders. He stated he knew it was important to follow physician's orders and said, It's what we do. We got to follow it. If it's too much or too little, call the doctor, DON or NP and get a new order. Review of the facility's oxygen tubing policy and procedure, revised 02/09/23, reflected, Purpose:Oxygen therapy may be provided through various types of supply and delivery systems. Equipment may include the provision of oxygen through nasal cannulas, trans-tracheal oxygen catheters, oxygen canisters, cylinders, or concentrators.Procedure:For a patient receiving oxygen therapy: The Oxygen tubing may be changed monthly. Oxygen tubing may be changed when it becomes soiled. Change PRN Change Oxygen tubing if dropped on the floor.For a patient receiving oxygen therapy, the patient's record must reflect ongoing evaluation of the patient's respiratory status, response to oxygen therapy and include, at a minimum, the attending practitioner's orders, and indication for use. In addition, the record should include: The type of oxygen delivery system When to administer, such as continuous or intermittent and/or when to discontinue Equipment settings for the prescribed flow rates Monitoring of SpO2 levels and/or vital signs, as ordered; and Based upon the individual patient's risks, if applicable, monitoring for complications, such as skin integrity issues related to the use of a nasal cannula. Concentrators, Wall oxygen and portable tanks should be checked. If any defect noted, it should be replaced. The defected item needs to be tagged. If any issues noted with the wall oxygen maintenance/management should be notified as soon as the problem is noted.

Based on observations, interviews and record reviews, the facility failed to ensure that each resident receives adequate supervision and assistive devices to prevent accidents for 1 of 8 sampled residents (R#63). CNA A failed to lower R#63's bed per physician's orders after performing resident care and exiting his room on 01/28/26 at 11:47 a.m. This failure could place residents at risk of falls, injuries and hospitalization. Review of R#63's admission record, dated 01/29/26, showed he was admitted to the facility on [DATE] with medical diagnoses including wedge compression fracture, low back pain and altered mental status. Review of R#63's 5-Day MDS assessment, dated 01/15/26, showed he had a BIMS score of 7/15, which indicated he had severe cognitive impairment. Section J reflected he had no falls since admission/reentry. Review of R#63's progress notes showed:- RN K created a note on 01/13/26 at 8:00 a.m. that reflected she notified the PCP of his change in condition evaluation for fall on 01/13/26. The PCP recommended increasing frequent monitoring, place fall mats, educate him on importance of using call light to prevent falls and keeping his bed low to the ground after fall.-Physician A signed an encounter note on 01/15/26 at 10:08 p.m. that reflected, Chief Complaint / Nature of Presenting Problem: Staff reports patient had a fall. History Of Present Illness: .Patient seen and examined at bedside. According to the staff patient was found on the floor at bedside this morning. Patient says he was trying to get out of bed independently and landed on his back. Denies any pain, and no signs of injury noted. Neurologically at his baseline. Denies nausea, HA, vision changes. Will continue to monitor. Stable vitals. Labs reviewed with family.Review of R#63's care plan, initiated 01/09/26, showed he was a high risk faller and had a fall on 01/13/26. Interventions include call don't fall signs in his room to remind him to call for assistance, safety rounds by all staff, fall mats at bedside, have adequate lighting, and transfer and change positions slowly. Interventions did not include the PCP's recommendation of lowering bed to the ground. Review of R#63's Change in Condition Evaluation, dated 01/13/26 at 8:00 a.m. showed he had a fall on 01/13/26 in the morning time, had previous falls at home and surgical interventions, notified his PCP and FAM on 01/13/26 at 8:00 a.m. and the PCP recommended increase frequent monitoring, place fall mats, educate patient on importance of using call light to prevent falls and keep the bed low to the ground. During an observation and interview of R#63 on 01/28/26 at 11:47 a.m., he was lying in bed with FAM sitting next to him. Fall mats were on each side of his bed. Call don't fall sign was in his room. There was adequate lighting. A female CNA left his room after finishing resident care on him. The female CNA did not lower his bed to the ground before leaving his room. The surveyor attempted to interview R#63, but he did not answer any of the surveyor's questions. R#63's FAM stated he fell on the ground at the facility. They also stated staff did not lower his bed to the ground before leaving his room and they often had to remind staff. During an interview with CNA E on 01/30/26 at 1:34 p.m., she stated all staff were responsible for ensuring residents' fall interventions were implemented. She stated nurses oversaw and ensured all staff ensured residents' fall interventions were put in place and implemented. She stated she knew the importance of ensuring fall interventions were implemented and said, Because we don't want another injury or for them to get hurt again. Residents could be at risk of accident, fall and develop an injury. During an interview with CNA F on 01/30/26 at 1:58 p.m., she stated the CNAs, nurses and DON were responsible for ensuring residents' fall interventions were implemented. She also stated nurses oversaw and ensured fall interventions were implemented. She stated she knew the importance of implementing fall interventions and said, Because to prevent resident injuries. Residents could be at risk of accident and could fall while trying to reach the call light to bring it closer to the resident.During an interview with CNA G on 01/30/26 at 2:23 p.m., she stated the CNAs and nurses were responsible for ensuring residents' fall interventions were implemented. She stated she did not know who oversaw and ensured fall interventions were implemented. She stated she knew the importance of implementing fall interventions and said, So residents don't break another hip, leg or arm.During an interview with the DON on 01/30/26 at 2:38 p.m., she stated the facility did not have an accidents and supervision policy and procedure. During an interview with LVN H on 01/30/26 at 2:51 p.m., she stated the nurses oversaw and ensured residents' fall interventions were implemented and checked at least every 30 minutes or one hour to ensure the interventions were in place. She stated she knew the importance of implementing fall interventions and said, To prevent further injuries. During an interview with CNA O on 01/30/26 at 3:09 p.m., she stated the CNAs and nurses were responsible for ensuring residents' fall interventions were implemented. She stated nursing staff oversaw and ensured fall interventions were implemented. She stated she knew the importance of implementing fall interventions and said, Because residents could fall, bump their head, or break a bone. Residents could get injured really bad or worse if the bed were higher than lower.During an interview with the Weekend Supervisor on 01/30/26 at 3:24 p.m., she stated the CNAs and nurses were responsible for ensuring residents' fall interventions were implemented. She explained residents' 24 hour reports, plan of care and staff communication were used to oversee and ensure fall interventions were implemented. She stated she knew the importance of implementing fall interventions and said, Safety for the resident. Resident could be at risk of harm if proper measures were not in place. During an interview with LPN J on 01/30/26 at 3:51 p.m., she stated the nurses were responsible for ensuring residents' fall interventions were implemented. She stated the IDT team, ADON, MDS Coordinators, and DON oversaw and ensured fall interventions were implemented. She also stated she knew the importance of implementing fall interventions and said, Safety. To make sure residents don't get injured and to make sure resident safety is on the same page for everyone. During an interview with LPN L on 01/30/26 at 4:03 p.m., she stated the IDT team were responsible for ensuring residents' fall interventions were implemented. She stated she knew the importance of implementing fall interventions and said, To prevent injuries. During an interview with RN M on 01/30/26 at 4:12 p.m., she stated the nurses implemented residents' fall interventions. She stated the ADON and DON oversaw and ensured fall interventions were implemented. She stated she knew the importance of implementing fall interventions and said, Safety measurements. During an interview with the DON on 01/30/26 at 4:43 p.m., she stated the nurses oversaw and ensured fall preventative devices were put in place and implemented. She stated she knew the importance of implementing fall interventions and said, So residents do not have another fall . During an interview with the ADM on 01/30/26 at 5:17 p.m., he stated the IDT team ensured that fall preventative devices were put in place. He stated he knew it was important to implement fall interventions and said, For safety and to prevent injury. Review of the facility's fall prevention policy, revised 07/24/23, reflected, PROCEDURE:Any patient deemed to be high risk by nursing and/or therapy staff will have the following interventions at least considered: .Low bed (or lower our standard bed to its lowest position).Post fall Procedure:.Determine what interventions need to be implemented to prevent further falls. Complete orders and/or tasks for fall prevention and for skin injuries if indicated.

Based on interviews and record review, the facility failed to comprehensively assess within 14 days after the facility determined, or should have determined, that there has been a significant change in resident's physical or mental condition for 1 of 8 sampled residents (R#7). 1.The facility failed to complete a significant change assessment within 14 days of determining R#7 had 5% or more significant weight loss. 2. The facility failed to document R#7's weekly weights per her physician's order. This failure could place residents at risk of inadequate care planning or not receiving appropriate care.Review of R#7's admission record, reviewed on 02/28/26, showed she was admitted to the facility on [DATE] with medical diagnoses that included Parkinson's disease (a chronic, progressive neurological disorder where brain neurons slowly break down), cognitive communication deficit, protein-calorie malnutrition and dementia. Review of R#7's admission MDS, dated [DATE], showed she had a BIMS score of 7/15, which indicated she had severe cognitive impairment. Section I reflected she had malnutrition as an active diagnosis in the last 7 days. Review of R#7's assessments reviewed on 01/28/26 showed there was no significant change in condition MDS assessment completed.Review of R#7's care plan, completed 01/17/26, showed she was at risk for inability to maintain nutrition. Staff created a note on 12/05/25 that she had a diagnoses on 12/01/25 of severe malnutrition. Interventions included monitor and record weight per facility guidelines. Review of R#7's order summary report, dated 01/28/26, showed she had a verbal order on 12/21/25 for daily weights every day shift every Sunday that started on 12/28/25.Review of R#7's MAR/TAR for January 2026 showed staff weighed her on 01/18/26 at 121.1lbs. Review of R#7's progress notes showed Physician A created a note on 12/31/25 that reflected her weight was 130lbs on 12/28/25. Physician B created a note on 01/05/25 that reflected her weight was 121lbs on 01/04/26. Review of R#7's weight summary showed staff documented she weighed 130lbs on 12/28/25. Staff documented she weighed 121lbs on 01/04/26, which triggered a warning notification of 5% or more weight change. There were no subsequent documented weights. During an interview with CNA E on 01/30/26 at 1:34 p.m., she stated CNAs weighed residents every Sunday, notify the nurse of residents' weights and sometimes documented weights in residents' TAR. She also stated nurses mostly documented weights in residents' TAR and oversaw and ensured residents' weekly weights were documented. She stated she knew it was important to weigh residents and said, It's very important because we need to make sure the resident is getting healthier and declining. Staff would not know how resident is doing if weights were not documented. During an interview with CNA F on 01/30/26 at 1:58 p.m., she stated CNAs weighed residents every Sunday. She stated the CNAs have not been able to document residents' weights in the last 2 months because the system was down. She stated she would notify the nurse whenever she could not document residents' weights. She also stated nurses documented weights in residents' TAR and oversaw and ensured weekly weights were documented. She stated the ADON, DON and ADM were aware of the system being down. She stated she knew it was important to weigh residents and said, It's very important because there were residents who did not eat and to prevent residents from getting sick or developing wounds. During an interview with CNA G on 01/30/26 at 2:23 p.m., she stated CNAs weighed residents. She also stated nurses documented weights in residents' TAR. She stated the DON oversaw and ensured nurses documented weights in TAR. She stated she knew it was important to weigh residents and said, To make sure residents were not retaining fluids and gaining or losing too much weight. During an interview with LVN H on 01/30/26 at 2:51 p.m., she stated CNAs weighed residents. She also stated nurses documented weights in residents' TAR. She stated the ADON and DON oversaw and ensured nurses documented weights in residents' TAR. She stated she knew it was important to weigh residents and said, To see if residents were getting adequate nutrition and diets. Residents could be at risk of malnutrition. During an interview with CNA I on 01/30/26 at 3:09 p.m., she stated CNAs weighed residents and documented weights in residents' TAR weekly. She also stated nurses documented residents weights monthly. She stated the DON oversaw and ensured nurses documented weights in residents' TAR. She stated she knew it was important to weigh residents and said, Because you want to make sure residents were not losing too much weight. During an interview with the Weekend Supervisor on 01/30/26 at 3:24 p.m., she stated CNAs weighed residents. She also stated the nurses documented weights in residents' TAR and notified the DON and NP of any weight changes. She stated the Dietician, ADON and DON oversaw and ensured nurses documented weights in residents' TAR. She stated she knew it was important to weigh residents and said, Because residents could have CHF, they could stop eating and you want to make sure you're reporting any loss in weight. During an interview with LPN J on 01/30/26 at 3:51 p.m., she stated CNAs weighed residents. She also stated nurses documented weights in residents' TAR and notified the dietician and NP of weight changes. She stated the Dietician, Wound Care, ADON, and DON oversaw and ensured nurses documented weights in residents' TAR. She stated she knew it was important to weigh residents and said, Malnutrition. Obesity. To make sure residents does not have a change in condition worsen. The surveyor attempted to call RN K on 01/30/26 at 4:01 p.m The surveyor left a voicemail and call back number. RN K did not return the surveyor's call before exit. During an interview with LPN L on 01/30/26 at 4:03 p.m., she stated CNAs weighed residents. She also stated nurses documented weights in residents' TAR. She stated the Dietician, ADON, and DON oversaw and ensured nurses documented weights in residents' TAR. She stated she knew it was important to weigh residents and said, To keep track and make sure there was no significant weight loss. During an interview with RN M on 01/30/26 at 4:14 p.m., she stated nurses documented weights in residents' TAR. She also stated the ADON and DON oversaw and ensured nurses documented weights in residents' TAR. She stated she knew it was important to weigh residents and said, We need to report and make sure residents weight is stable, lost or gained or to add more nutrition. During an interview with the DON on 01/30/26 at 4:43 p.m., she stated MDS Coordinator C and D reviewed and revised residents' MDS assessments. She also stated she or the ADON oversaw and ensured residents' MDS assessments were reviewed and revised by reviewing orders and 24 hour reports daily. She also stated the nurses weighed residents and documented weights in residents' TAR once a week and on admission. She also stated her and the ADON oversaw and ensured nurses weighed and documented weights in residents' TAR by conducting morning meetings on the weights. She stated she knew it was important to weigh residents and said, To make sure residents do not lose any more weight.The surveyor attempted to call MDS Coordinator C on 01/30/26 at 5:05 p.m The surveyor left a voicemail and call back number. MDS Coordinator C did not return the surveyor's call before exit. During an interview with MDS Coordinator D on 01/30/26 at 5:07 p.m., she stated the IDT team reviewed and revised MDS assessments. She explained the ADON and DON identify changes in residents' condition and determine if a significant change in status assessment must be completed. She stated she knew it was important to review and revise MDS assessments and said, Because the plan of care could change. Resident could be at risk of death, risk of falls, injuries, metabolic, cardiac, endo, kidney, etc. During an interview with the ADM on 01/30/26 at 5:17 p.m., he stated the IDT team reviewed and revised residents' MDS assessments. He knew it was important to review and revise residents' MDS assessments and said, It keeps residents health status up to date and what their status is. He also stated the ADON or DON oversaw and ensured nurses documented weights by conducting morning meetings on the weights. He also stated he knew it was important to weigh residents and said, To see where the resident was at in condition and or to document if refused or allowed weight to be scaled. Review of the facility's MDS policy and procedure, revised 02/08/21, reflected, All staff members will be responsible for completion of the MDS and transmission processes in accordance with the MDS RAI instruction manual.The MDS coordinator is responsible for ensuring that appropriate edits are made prior to transmitting MDS data and that feedback and validation reports from each transmission are maintained for historical purposes and for tracking. The policy did not reflect the regulatory timeframes for completing the significant change in condition assessment.

Based on interviews and record reviews, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one (Resident #1) of five residents reviewed for quality of care. The facility delayed Resident #1's catheter care for approximately 2.50 hours on 09/02/25 resulting in Resident #1 having discomfort and pain. This failure could place residents at risk of discomfort and pain, a decrease in their quality of life, quality of care, and dignity.Findings included:Record review of Resident #1's face sheet, dated 09/13/25, revealed a forty-one-year-old male who was admitted to the facility on [DATE]. His admitting diagnoses included paraplegia (damage to the spinal cord, the bundle of nerves that connects the brain to the lower body), major depressive disorder (a common mental health condition characterized by persistent feelings of sadness, hopelessness, and loss of interest or pleasure in activities), and ankylosing spondylitis of multiple sites in spine (an inflammatory disease that, over time, can cause some of the bones in the spine, called vertebrae, to fuse).Record review of Resident #1's care plan revealed a focus dated 01/03/25 of self-catheter (a way for you to empty your own bladder) and intervention dated 01/03/25 monitor and document intake and output. Record review of Resident #1's MDS (clinical assessment to determine resident's strength and needs) Quarterly Assessment Section C - Cognitive Patterns dated 04/09/25 revealed a score of 15, indicating he was cognitively intact.Review of Resident #1's orders reflected in and out catheter (flexible tube called a catheter was inserted to drain fluids from the body) every 6 hours four times a day start date 01/05/2025 4:00 am, 10:00 am, 4:00 pm, and 10:00 pm. Review of Resident #1's MAR dated 09/02/25 for in and out catheter every 6 hours four times a day reflected Resident #1 received catheter care at 4:00 am with a urine output of 1100 ml, 10:00 am with a urine output of 900 ml, no entry for 4:00 pm, and 10:00 pm with urine output of 1500 ml.Interview on 09/13/25 at 12:06 pm with the ED reflected Resident #1 had an in and out catheter but Resident #1 did not like to do his own catheter care. The facility did it for them. The facility staff were trying to get him as independent as possible. Interview on 09/13/25 at 11:00 am with Resident #1 reflected the facility did not provide catheter care on 09/02/25 for about 2.5 hours after it was scheduled and he was in massive pain. He said it hurt until 4:00 am and they had to give him a pain pill. He said he heard someone in the hallway tell the ADON that he needed to have his catheter care, but the ADON said she would get to it when she had a chance. He said he asked two times to have his catheter emptied but no one came until about 2 hours later. He said he hurt so bad he had to ask for a pain pill. He said he felt that because they did not provide the catheter care on 09/02/25, it caused him to have a urinary tract infection. Interview on 09/13/25 at 3:41 pm with the NP reflected the facility told her that Resident #1 did not receive catheter care until approximately 6:00 pm on 09/02/25. Resident #1 refused to do catheter care on his own. Resident #1 told her on 09/02/25 he did not receive catheter care until approximately 2 hours later than he was supposed to have received catheter care and this caused a urinary tract infection. She said when he was tested a day or so after 09/02/25 (date of test unknown) he was positive for a urinary tract infection. The NP said the positive urinary tract infection cannot be directly related to the not being tapped (bladder stimulation by tapping to help empty the bladder) on 09/02/25 approximately 2 hours after it was scheduled. She was not sure when he was last catheterized prior to the approximately 6:00 pm catheterization. She said a bladder can retain urine and enlarge but when they were able to catheterize him approximately 2 hours later than he was usually catheterized, there was not a great deal of urine in his bladder. She said a full bladder was 600 ml to 650 ml and up and that was way too much for one bladder. She could not recall how much urine was in Resident #1's bladder when they catheterized him at approximately 6:00 pm. She said Resident #1 told him the story of the late cauterization the next day, 09/03/25, but he did not seem to be too upset about it and Resident #1 told her everything had improved, and everything was better. She said Resident #1 did not complain to her he was having symptoms of pain or discomfort. She said she had no concerns about his care at the facility. She said Resident #1 was afraid to do the in and out catheter self-care. She said he was not harmed at all by the situation of him getting catheterized approximately 2 hours late on 09/02/25 and she was not concerned at all about the nursing care treatment Resident #1 received at the facility. Interview on 09/13/25 at 5:35 pm with LVN A reflected Resident #1 had an in and out catheter and nursing staff had to assist him with his catheter. He said Resident #1 was care planned for a self-catheter, but the nurses had to make sure the catheter tubing went in the proper place. He said a nurse had to be there to guide the catheter tubing.Interview on 10/02/2025 at 2:29 pm with the ADON reflected she was told on 09/02/25 that Resident #1 asked for his catheter care to be done but she was in another resident's room because that resident had pain. She said it took about 40 minutes to handle the pain situation for that resident and then she was told by a family member of another resident that their family member was in pain. The ADON said that Resident #1 did not get his catheter taken care of until about 6:30 pm. The ADON said she never saw Resident #1 on 09/02/25 because another nurse took care of Resident #1's catheter care. She said no staff member told her Resident #1 was in pain and that he wanted her to go to him and do his in and out catheter care. She said it would have taken less than 5 minutes to do his in and out catheter care. The ADON was not aware of another nurse who could have helped Resident #1 with his in-and-out catheter care. She said maybe the facility placed other residents' needs before his, but there were 2 other residents who were in pain that had to be handled. Interview on 10/02/2025 at 4:16 pm with CNA B reflected Resident #1 did not complain of any pain when she assisted him to lay down at bedtime at approximately 10:00 pm on 09/02/25. CNA B said Resident #1 did not say he was miserable, and he needed someone to help him because he was uncomfortable. Interview on 10/02/25 at 4:24 pm with LPN A reflected she assisted Resident #1 with his catheter care at approximately 6:30 because he asked her to do it. She said the ADON never informed her Resident #1's catheter care was not done and Resident #1 said he had discomfort, so she catheterized Resident #1. She said Resident #1 was unable to straight catheterize himself. She said Resident #1 complained about having pain and Resident #1 said he felt better after he was catheterized. LPN A said Resident #1 normally did not complain and for him to say he was in pain, she knew something was wrong. She said Resident #1 said he hurt because he had not received catheter care. She said the ADON did not tell LPN A in the nurse's report when LPN A came on for duty that Resident #1 had not received his catheter care. Interview on 10/02/25 at 5:17 pm with the ED reflected LPN A did not document that she provided the catheter care to Resident #1 at approximately 6:30 pm instead of the 10:00 pm reflected in Resident #1 09/02/25 MAR. The ED said that Resident #1 probably felt his stomach was very full and he felt a little better after the catheter care was provided at approximately 6:00 pm on 09/02/25. The ED said depending on the situation he would have expected his staff to have done Resident #1's catheter care on 09/02/25 but if a resident was coding that resident would be the priority. He said two other residents were in pain and the ADON addressed their pain and the staff was addressing the most emergent situation, residents who were in pain. The Administrator said Resident #1 confirmed he received catheter care at 6:30 pm but LPN A did not document the catheter care as a late entry for approximately 6:00 pm but documented that the catheter care was provided at 10:00 pm. Interview on 10/02/25 at 6:20 pm with the DON, who did not work at the facility until after 09/02/25, reflected she did not think that Resident #1 would have been uncomfortable if he received catheter care approximately 2.50 hours late. She said that 1500 ml was an average amount of urine output. She said if he said he was uncomfortable, it could describe a large range of what was uncomfortable. She said that if there was an order to follow, staff needed to follow the order. She said she could not give an answer to the possible negative side effects of not giving him catheter care when it was ordered because there were too many possibilities. She said she visited Resident #1 when she began working at the facility and asked him if there was anything she could do for him and she asked about the staff and if he had any concerns. She said Resident #1 stated everyone had been great and he had no issues and no problems.Interview on 10/02/25 at 6:40 pm with the RN E reflected she had done a lot of resident catheter care and if there was an order for the in and out catheter, staff had an hour before and hour after the order to provide the care but there were circumstances when it did not happen at those times. She said that if a resident received catheter care approximately 2.5 hours later than the catheter time was ordered the resident could become uncomfortable and verbalize that he was uncomfortable. 1500 ml of urine output might be a lot, but it would depend on the medication the residents had been taking and what the resident had been drinking. The possible negative effects of catheterizing the resident after a scheduled order were the resident could be uncomfortable and might experience pain or distention (enlargement or swelling of a hollow organ or structure due to increased pressure or fluid accumulation within it). The resident could be upset or angry. It was the ultimate responsibility of the nurse taking the hall that day to make sure that this was taken care of. It was the responsibility of the nurse who was in charge of the resident to delegate the task. Interview on 10/02/25 at 6:56 pm with RN C reflected she did a lot of resident catheter care. She said if a resident did not receive catheter care according to the order it could be a problem, and multiple things could happen with the resident. She said the resident might be in pain and might be frustrated. She said orders should be followed and if you cannot follow the orders a nurse needed to get someone to assist or someone to follow up. She said it was the responsibility of the resident's nurse to have made sure catheter care was done. She said 1500 ml was a lot of urine output, but compared to Resident #1's average output, it looked normal. Review of facility policy for Dignity dated 04/02/2024 reflected Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality. Staff shall promote dignity and assist residents as needed by promptly responding to the resident's request for toileting assistance.

Based on interviews and record review the facility failed to ensure the medical record on each resident was complete and accurately documented for one (Resident #1) of five residents reviewed for accurate medical records. The facility documented in Resident #1's MAR that he received catheter care at 10:00 pm on 09/02/25 when Resident #1 stated he received catheter at approximately 6:30 pm on 09/02/25.This failure could place residents at risk of misdiagnosis, incorrect treatment, and poor quality of life.Findings included:Record review of Resident #1's face sheet, dated 09/13/25, revealed a forty-one-year-old male who was admitted to the facility on [DATE]. His admitting diagnoses included paraplegia (damage to the spinal cord, the bundle of nerves that connects the brain to the lower body), major depressive disorder (a common mental health condition characterized by persistent feelings of sadness, hopelessness, and loss of interest or pleasure in activities), and ankylosing spondylitis of multiple sites in spine (an inflammatory disease that, over time, can cause some of the bones in the spine, called vertebrae, to fuse).Record review of Resident #1's care plan revealed a focus dated 01/03/25 of self-catheter (a way for you to empty your own bladder) and intervention dated 01/03/25 monitor and document intake and output. Record review of Resident #1's MDS (clinical assessment to determine resident's strength and needs) Quarterly Assessment Section C - Cognitive Patterns dated 04/09/25 revealed a score of 15, indicating he was cognitively intact.Review of Resident #1's orders reflected in and out catheter (flexible tube called a catheter was inserted to drain fluids from the body) every 6 hours four times a day start date 01/05/2025 4:00 am, 10:00 am, 4:00 pm, and 10:00 pm. Review of Resident #1's MAR dated 09/02/25 for in and out catheter every 6 hours four times a day reflected Resident #1 received catheter care at 4:00 am with a urine output of 1100 ml, 10:00 am with a urine output of 900 ml, no entry for 4:00 pm, and 10:00 pm with urine output of 1500 ml. Interview on 09/13/25 at 12:06 pm with the ED reflected Resident #1 had an in and out catheter but Resident #1 did not like to do his own catheter care. The facility did it for them. The facility staff were trying to get him as independent as possible. Interview on 09/13/25 at 11:00 am with Resident #1 reflected the facility did not provide catheter care on 09/02/25 for about 2.5 hours after it was scheduled and he was in massive pain. He said it hurt until 4:00 am and they had to give him a pain pill. He said he heard someone in the hallway tell the ADON that he needed to have his catheter care, but the ADON said would get to it when she had a chance. He said he asked two times to have his catheter emptied but no one came until about 2 hours later. He said he hurt so bad he had to ask for a pain pill. He said he felt that because they did not provide the catheter care on 09/02/25, it caused him to have a urinary tract infection. Interview on 09/13/25 at 3:41 pm with the NP reflected the facility told her that Resident #1 did not receive catheter care until approximately 6:00 pm on 09/02/25. Resident #1 refused to do catheter care on his own. Resident #1 told her on 09/02/25 he did not receive catheter care until approximately 2 hours later than he was supposed to have received catheter care and this caused a urinary tract infection. She said when he was tested a day or so after 09/02/25 (date of test unknown) he was positive for a urinary tract infection. The NP said the positive urinary tract infection cannot be directly related to the not being tapped (bladder stimulation by tapping to help empty the bladder) on 09/02/25 approximately 2 hours after it was scheduled. She was not sure when he was last catheterized prior to the approximately 6:00 pm catheterization. She said a bladder can retain urine and enlarge but when they were able to catheterize him approximately 2 hours later than he was usually catheterized, there was not a great deal of urine in his bladder. She said a full bladder was 600 ml to 650 ml and up and that was way too much for one bladder. She could not recall how much urine was in Resident #1's bladder when they catheterized him at approximately 6:00 pm. She said Resident #1 told him the story of the late cauterization the next day, 09/03/25, but he did not seem to be too upset about it and Resident #1 told her everything had improved, and everything was better. She said Resident #1 did not complain to her he was having symptoms of pain or discomfort. She said she had no concerns about his care at the facility. She said Resident #1 was afraid to do the in and out catheter self-care. She said he was not harmed at all by the situation of him getting catheterized approximately 2 hours late on 09/02/25 and she was not concerned at all about the nursing care treatment Resident #1 received at the facility. Interview on 09/13/25 at 5:35 pm with LVN A reflected Resident #1 had an in and out catheter and nursing staff had to assist him with his catheter. He said Resident #1 was care planned for a self-catheter, but the nurses had to make sure the catheter tubing went in the proper place. He said a nurse had to be there to guide the catheter tubing.Interview on 10/02/2025 at 2:29 pm with the ADON reflected she was told on 09/02/25 that Resident #1 asked for his catheter care to be done but she was in another resident's room because that resident had pain. She said it took about 40 minutes to handle the pain situation for that resident and then she was told by a family member of another resident that their family member was in pain. The ADON said that Resident #1 did not get his catheter taken care of until about 6:30 pm. The ADON said she never saw Resident #1 on 09/02/25 because another nurse took care of Resident #1's catheter care. She said no staff member told her Resident #1 was in pain and that he wanted her to go to him and do his in and out catheter care. She said it would have taken less than 5 minutes to do his in and out catheter care. The ADON was not aware of another nurse who could have helped Resident #1 with his in-and-out catheter care. She said maybe the facility placed other residents' needs before his, but there were 2 other residents who were in pain that had to be handled. Interview on 10/02/2025 at 4:16 pm with CNA B reflected Resident #1 did not complain of any pain when she assisted him to lay down at bedtime at approximately 10:00 pm on 09/02/25. CNA B said Resident #1 did not say he was miserable, and he needed someone to help him because he was uncomfortable. Interview on 10/02/25 at 4:24 pm with LPN A reflected she assisted Resident #1 with his catheter care at approximately 6:30 because he asked her to do it. She said the ADON never informed her Resident #1's catheter care was not done and Resident #1 said he had discomfort, so she catheterized Resident #1. She said Resident #1 was unable to straight catheterize himself. She said Resident #1 complained about having pain and Resident #1 said he felt better after he was catheterized. LPN A said Resident #1 normally did not complain and for him to say he was in pain, she knew something was wrong. She said Resident #1 said he hurt because he had not received catheter care. She said the ADON did not tell LPN A in the nurse's report when LPN A came on for duty that Resident #1 had not received his catheter care. Interview on 10/02/25 at 5:17 pm with the ED reflected LPN A did not document that she provided the catheter care to Resident #1 at approximately 6:30 pm instead of the 10:00 pm reflected in Resident #1 09/02/25 MAR. The ED said that Resident #1 probably felt his stomach was very full and he felt a little better after the catheter care was provided at approximately 6:00 pm on 09/02/25. The ED said depending on the situation he would have expected his staff to have done Resident #1's catheter care on 09/02/25 but if a resident was coding that resident would be the priority. He said two other residents were in pain and the ADON addressed their pain and the staff was addressing the most emergent situation, residents who were in pain. The Administrator said Resident #1 confirmed he received catheter care at 6:30 pm but LPN A did not document the catheter care as a late entry for approximately 6:00 pm but documented that the catheter care was provided at 10:00 pm. Interview on 10/02/25 at 6:20 pm with the DON, who did not work at the facility until after 09/02/25, reflected she did not think that Resident #1 would have been uncomfortable if he received catheter care approximately 2.50 hours late. She said that 1500 ml was an average amount of urine output. She said if he said he was uncomfortable, it could describe a large range of what was uncomfortable. She said that if there was an order to follow, staff needed to follow the order. She said she could not give an answer to the possible negative side effects of not giving him catheter care when it was ordered because there were too many possibilities. She said she visited Resident #1 when she began working at the facility and asked him if there was anything she could do for him and she asked about the staff and if he had any concerns. She said Resident #1 stated everyone had been great and he had no issues and no problems.Interview on 10/02/25 at 6:40 pm with the RN E reflected she had done a lot of resident catheter care and if there was an order for the in and out catheter, staff have an hour before and hour after the order to provide the care but there were circumstances when it did not happen at those times. She said that if a resident received catheter care approximately 2.5 hours later than the catheter time was ordered the resident could become uncomfortable and verbalize that he was uncomfortable. 1500 ml of urine output might be a lot, but it would depend on the medication the residents had been taking and what the resident had been drinking. The possible negative effects of catheterizing the resident after a scheduled order were the resident could be uncomfortable and might experience pain or distention(enlargement or swelling of a hollow organ or structure due to increased pressure or fluid accumulation within it). The resident could be upset or angry. It was the ultimate responsibility of the nurse taking the hall that day to make sure that this was taken care of. It was the responsibility of the nurse who was in charge of the resident to delegate the task. Interview on 10/02/25 at 6:56 pm with RN C reflected she did a lot of resident catheter care. She said if a resident did not receive catheter care according to the order it could be a problem, and multiple things could happen with the resident. She said the resident might be in pain and might be frustrated. She said orders should be followed and if you cannot follow the orders a nurse needed to get someone to assist or someone to follow up. She said it was the responsibility of the resident's nurse to have made sure catheter care was done. She said 1500 ml was a lot of urine output, but compared to Resident #1's average output, it looked normal. Review of facility policy for Dignity dated 04/02/2024 reflected Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality. Staff shall promote dignity and assist residents as needed by promptly responding to the resident's request for toileting assistance.

Based on interview and record review the facility failed to, in response to allegations of abuse, neglect, exploitation, or mistreatment, ensure that all alleged violations are reported to the state survey agency immediately but not later than 2 hours after the allegation is made if the events that cause the allegation involve abuse for one (1) of five (5) residents reviewed for abuse and neglect. (Resident #1).The facility failed to report an alleged abuse incident reported by Resident #1 on 06/19/2025 to the State Agency when Resident#1 alleged CNA B pushed her. This deficient practice placed all residents at risk of harm from abuse due to not having a thorough investigation done for an alleged abuseFindings Include: Record review of Resident #1's face sheet, dated 07/15/2025, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included hypertension (high blood pressure), fall on the same level from slipping, muscle weakness, unsteady to the feet, history of falling, traumatic subdural Hemorrhage (a type of traumatic brain injury (TBI) where blood collects under the dura mater, the outer membrane covering the brain, due to a head injury) without loss of consciousness subsequent encounter. Record review of Resident #1's Quarterly MDS dated [DATE] revealed Resident #1 had a BIMS score of 10 indicating moderate cognitive impairment. Review of Resident #1's care plan initiated 05/30/2025 reflected Resident #1 had actual/potential decline in her ability to perform her activities of daily living, bowel/bladder incontinence, and need for assistance with transfers/toileting related to impaired mobility secondary to weakness and debility (physical weakness, especially as a result of illness.Most of the cases presented with general debility, muscle weakness, and weight loss.)Review of CNA B's written statement dated 06/19/2025 reflected: June 19, 2025 3:47 am Patient in [xx] had call light on upon entering the room the patient was sitting in her wheelchair and asked if I could help her unlock her brakes. I asked her why she didn't call before she transferred to the chair. She stated that she's not a 2-year-old and should not have to ask for permission to go to the bathroom. I explained to her the safety issue of calling before she transferred to her chair. She then stated that you've been a bitch since day one and won't let me do anything on my own. I proceeded to help her with her brakes and take her to the restroom, she refused to let me help her toilet. I explained to her that her chair is not locked and it's not safe for her to do this alone. I locked her chair and let her toilet herself while I stood outside of the restroom. I noticed she was struggling to pull up her underwear so I asked her if I could help with that, she then yelled at me to get away from her she does not need my help. She then accused me of throwing her up against the wall. I then exited the room and alerted the nurse of what the patient was saying. [room #] Statement [CNA B].Review of LVN A's written statement dated 06/19/2025 reflected: To: Abuse Coordinator Re: Statement regarding patient allegation Patient: [Resident #1]6/19/25 This date 6/19/25 this nurse called into the patient's, [Resident #1] room by [CNA B]. This nurse entered room, observed [CNA B] standing by restroom door, and patient [Resident #1] awake, sitting in her wheelchair by the bed, no s/s of distress. [CNA B] informed this nurse that patient stated CNA had pushed her. This nurse asked CNA B to leave room, then asked patient to tell me what happened. Patient verbalized that while transferring to the toilet from the wheelchair, CNA B pushed her left shoulder against the wall. This nurse asked if I may check her for injury, patient agreeable. No visible sign of injury noted to back, shoulders or face. ROM per baseline, patient denied pain. This nurse reassured patient that the CNA would not return to room, and assisted patient back into bed safely, bed placed in low position, fall precautions in place, call light within reach. This nurse immediately notified abuse coordinator and spoke with DON. [LVN A]During an interview on 07/15/2025 at about 2:20 pm, the DON stated there was an allegation incident of abuse regarding Resident #1. The DON stated CNA B went to assist Resident #1 in her room on the overnight shift, CNA B did not touch Resident #1, and Resident #1 accused CNA B of pushing her. The DON stated LVN A notified her and both LVN A and CNA B left written statements.During an interview on 07/15/2025 at about 2:32 pm, LVN A stated on the morning of 06/19/2025 Resident #1 alleged that CNA B pushed her. LVN A stated CNA B called her [LVN A] to inform her that Resident #1 alleged she had pushed her. LVN A said she asked the CNA to leave the room while she spoke with Resident #1. LVN A stated Resident #1 stated CNA B had pushed her. LVN A stated she assessed Resident #1 and there was no evidence of injuries. LVN A stated she helped Resident #1 out of the restroom. LVN A stated she and CNA B wrote statements for the abuse coordinator, and she reported the incident immediately. During an interview on 07/15/2025 at about 3:13 pm the Administrator stated he had just found out about the incident today 07/15/2025 regarding Resident #1 when the State Surveyor asked due to him being on vacation at the time of the incident. The Administrator stated he would have interviewed Resident #1, if there was an allegation of abuse, and he would have reported it to the state. The Administrator stated in his absence, the DON was responsible to report to the state all allegations of abuse and neglect. The Administrator stated, when a Resident alleged abuse, it was reportable to the state. During an interview on 07/15/2025 at about 3:33 pm, the DON stated she attempted to interview Resident #1 and Resident #1 was dismissive, so she [DON] did nothing else regarding the allegation. The DON stated she did not document her attempt to interview Resident #1. The DON stated the Administrator was on vacation at the time and so she made contact with the Administrator's Boss and told him about the incident. The DON stated she did not report the incident to the State Agency. The DON stated allegations of abuse and neglect were reportable to the State Agency.During an interview on 7/15/2025 at 3:45 pm, CNA B stated on the morning of 06/19/2025, she went to assist Resident #1 and Resident #1 was already in the wheelchair. CNA B stated she was trying to explain to Resident #1 that she had to call for help before getting out of bed. CNA B stated she never got to help Resident #1, she did not touch Resident #1 when Resident #1 accused her [CNA B] of pushing her. CNA B said she immediately walked out of the room and notified LVN A. CNA B stated LVN A went to Resident #1 and assessed her. CNA B stated LVN A called the Administrator, but she [CNA B] told LVN A that the Administrator was not available, so LVN A called the DON. CNA B said she wrote a statement and gave to LVN A.Review of facility's policy titled Abuse and Neglect Prohibition revised 10/12/2022 reflected: PolicyEach resident has the right to be free from abuse, neglect, mistreatment, injuries of unknown origin, misappropriation of resident property, exploitation, corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. The facility does not allow involuntary seclusion. Any observations or allegations of abuse, neglect or mistreatment must be immediately reported to the Administrator.Abuse Prevention Coordinator The facility administrator is the Abuse Prevention Coordinator. Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse, including abuse facilitated or enabled through the use of technology. Injuries of unknown origin may occur as a result of abuse. Alleged violation is a situation or occurrence that is observed or reported by staff, resident, relative, visitor, another health care provider, or others but has not yet been investigated and, if verified, could be noncompliance with the Federal requirements related to mistreatment, exploitation, neglect, or abuse, including injuries of unknown source, and misappropriation of resident property.PreventionReporting and ResponseSTATE REPORTING OBLIGATIONS: The facility will report all allegations and substantiated occurrences of abuse, neglect, exploitation, mistreatment including injuries of unknown origin, and misappropriation of property to the administrator, State Survey Agency, and law enforcement officials and adult protective services (where state law provides for jurisdiction in long-term care). What to Report1. All alleged violations of abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property2. The results of all investigations of alleged violationsWho is Required to Report----The FacilityWhen to Report the Incident----2 hours if the alleged violation involves abuse or results in serious bodily injury.

Based on interview and record review the facility failed to, in response to allegations of abuse, neglect, exploitation, or mistreatment, have evidence that all alleged violations are thoroughly investigated and report the results of all investigations to the state survey agency within five working days of the incident for one (1) of five (5) residents reviewed for abuse and neglect. (Resident #1).The facility failed to thoroughly investigate an alleged abuse incident reported by Resident #1 on 06/19/2025 when Resident #1 alleged being pushed by CNA B. This deficient practice placed all residents at risk of harm from abuse due to not having a thorough investigation done for an alleged abuse.Findings Include: Record review of Resident #1's face sheet, dated 07/15/2025, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included hypertension (high blood pressure), fall on the same level from slipping, muscle weakness, unsteady to the feet, history of falling, traumatic subdural Hemorrhage (a type of traumatic brain injury (TBI) where blood collects under the dura mater, the outer membrane covering the brain, due to a head injury) without loss of consciousness subsequent encounter. Record review of Resident #1's Quarterly MDS dated [DATE] revealed Resident #1 had a BIMS score of 10 indicating moderate cognitive impairment. Review of Resident #1's care plan initiated 05/30/2025 reflected Resident #1 had actual/potential decline in her ability to perform her activities of daily living, bowel/bladder incontinence, and need for assistance with transfers/toileting related to impaired mobility secondary to weakness and debility (physical weakness, especially as a result of illness.Most of the cases presented with general debility, muscle weakness, and weight loss.)Review of CNA B's written statement dated 06/19/2025 reflected: June 19, 2025 3:47 am Patient in [xx] had call light on upon entering the room the patient was sitting in her wheelchair and asked if I could help her unlock her brakes. I asked her why she didn't call before she transferred to the chair. She stated that she's not a 2-year-old and should not have to ask for permission to go to the bathroom. I explained to her the safety issue of calling before she transferred to her chair. She then stated that you've been a bitch since day one and won't let me do anything on my own. I proceeded to help her with her brakes and take her to the restroom, she refused to let me help her toilet. I explained to her that her chair is not locked and it's not safe for her to do this alone. I locked her chair and let her toilet herself while I stood outside of the restroom. I noticed she was struggling to pull up her underwear so I asked her if I could help with that, she then yelled at me to get away from her she does not need my help. She then accused me of throwing her up against the wall. I then exited the room and alerted the nurse of what the patient was saying. [room #] Statement [CNA B].Review of LVN A's written statement dated 06/19/2025 reflected: To: Abuse Coordinator Re: Statement regarding patient allegation Patient: [Resident #1]6/19/25 This date 6/19/25 this nurse called into the patient's, [Resident #1] room by [CNA B]. This nurse entered room, observed [CNA B] standing by restroom door, and patient [Resident #1] awake, sitting in her wheelchair by the bed, no s/s of distress. [CNA B] informed this nurse that patient stated CNA had pushed her. This nurse asked CNA B to leave room, then asked patient to tell me what happened. Patient verbalized that while transferring to the toilet from the wheelchair, CNA B pushed her left shoulder against the wall. This nurse asked if I may check her for injury, patient agreeable. No visible sign of injury noted to back, shoulders or face. ROM per baseline, patient denied pain. This nurse reassured patient that the CNA would not return to room, and assisted patient back into bed safely, bed placed in low position, fall precautions in place, call light within reach. This nurse immediately notified abuse coordinator and spoke with DON. [LVN A]During an interview on 07/15/2025 at about 2:20 pm, the DON stated there was an allegation incident of abuse regarding Resident #1. The DON stated CNA B went to assist Resident #1 in her room on the overnight shift, CNA B did not touch Resident #1, and Resident #1 accused CNA B of pushing her. The DON stated LVN A notified her and both LVN A and CNA B left written statements.During an interview on 07/15/2025 at about 2:32 pm, LVN A stated on the morning of 06/19/2025 Resident #1 alleged that CNA B pushed her. LVN A stated CNA B called her [LVN A] to inform her that Resident #1 alleged she had pushed her. LVN A said she asked the CNA to leave the room while she spoke with Resident #1. LVN A stated Resident #1 stated CNA B had pushed her. LVN A stated she assessed Resident #1 and there was no evidence of injuries. LVN A stated she helped Resident #1 out of the restroom. LVN A stated she and CNA B wrote statements for the abuse coordinator, and she reported the incident immediately. During an interview on 07/15/2025 at about 3:13 pm the Administrator stated he had just found out about the incident today 07/15/2025 regarding Resident #1 when the State Surveyor asked due to him being on vacation at the time of the incident. The Administrator stated he would have interviewed Resident #1, if there was an allegation of abuse, and he would have reported it to the state. The Administrator stated in his absence, the DON was responsible to report to the state all allegations of abuse and neglect. The Administrator stated, when a Resident alleged abuse, it was reportable to the state. During an interview on 07/15/2025 at about 3:33 pm, the DON stated she attempted to interview Resident #1 and Resident #1 was dismissive, so she [DON] did nothing else regarding the allegation. The DON stated she did not document her attempt to interview Resident #1. The DON stated the Administrator was on vacation at the time and so she made contact with the Administrator's Boss and told him about the incident. The DON stated she did not report the incident to the State Agency. The DON stated allegations of abuse and neglect were reportable to the State Agency.During an interview on 7/15/2025 at 3:45 pm, CNA B stated on the morning of 06/19/2025, she went to assist Resident #1 and Resident #1 was already in the wheelchair. CNA B stated she was trying to explain to Resident #1 that she had to call for help before getting out of bed. CNA B stated she never got to help Resident #1, she did not touch Resident #1 when Resident #1 accused her [CNA B] of pushing her. CNA B said she immediately walked out of the room and notified LVN A. CNA B stated LVN A went to Resident #1 and assessed her. CNA B stated LVN A called the Administrator, but she [CNA B] told LVN A that the Administrator was not available, so LVN A called the DON. CNA B said she wrote a statement and gave to LVN A.Abuse Prevention Coordinator The facility administrator is the Abuse Prevention Coordinator. Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse, including abuse facilitated or enabled through the use of technology. Injuries of unknown origin may occur as a result of abuse. Alleged violation is a situation or occurrence that is observed or reported by staff, resident, relative, visitor, another health care provider, or others but has not yet been investigated and, if verified, could be noncompliance with the Federal requirements related to mistreatment, exploitation, neglect, or abuse, including injuries of unknown source, and misappropriation of resident property.Prevention3. Facility supervisors will immediately investigate and correct reported or identified situations in which abuse, neglect, injuries of unknown origin, or misappropriation of resident property is at risk for occurring.4. Staff will be instructed to report any signs of stress from employees, family and other individuals involved with the resident that may lead to abuse, neglect, injuries of unknown origin, or misappropriation of resident property, and to intervene as appropriate.Investigation1. The facility will timely conduct an investigation of any alleged abuse/neglect, exploitation,mistreatment, injuries of unknown origin, or misappropriation of resident property in accordance with state law.2. Any employee alleged to be involved in an instance(s) of abuse and/or neglect will be interviewed and suspended immediately, and will not be permitted to return to work unless and until suchallegations of abuse/neglect are unsubstantiated.

Based on interviews and record reviews, the facility failed to notify the resident and resident's representative(s) of the discharge, reasons for the move, and right to appeal in writing and in a language and manner they understand and send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman for 1 (Resident #1) of 6 residents reviewed for discharge planning. 1. The facility failed to notify Resident #1 and Resident #1's RP of Resident #1's discharge, reasons for the move, and right to appeal in writing, in a language and manner they understand, and at least 30 days before Resident #1 was discharged from the facility on 06/11/25. 2. The facility failed to send a copy of the notice to the facility's Ombudsman before Resident #1 was discharged from the facility on 06/11/25. This failure could place residents at risk of being discharged without alternative placement, discharge options, their rights to appeal and access to advocacy services. Findings included: Review of Resident #1's Profile, dated 06/23/25, reflected she was a [AGE] year old female who was admitted to the facility on [DATE] and discharged from the facility on 06/11/25. Review of Resident #1's Medical Diagnoses Report, dated 06/23/25, reflected she had diagnoses of hemiplegia (complete paralysis of one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (stroke) affecting the left dominant side, dysphagia following cerebral infarction (difficulty swallowing), age-related physical debility (a state of weakness and reduced physical strength), generalized muscle weakness, unsteadiness on feet, other lack of coordination, anxiety disorder, anorexia (an eating disorder causing people to obsess about weight and what they eat) and depression. Review of Resident #1's admission MDS, dated [DATE], reflected she had a BIMS score of 6 out of 15, which indicated severe cognitive impairment. Resident #1 also always needed help with health literacy (assistance with reading written material related to health) and was dependent on assistance with her functional cognition (assistance with planning regular tasks). Review of Resident #1's Care Plan, initiated on 03/03/25, reflected she wanted to establish goals for herself and be involved in her discharge planning process. Staff were also required to communicate with Resident #1 and/or her family related to progress, goals and plans, contact appropriate community agencies as needed when Resident #1 was ready to discharge, continue to encourage Resident #1 to make an effort toward achieving their goals, and Resident #1 wanted to go home when she discharged . Review of Resident #1's Progress Notes, from 03/03/25 through 06/23/25, reflected there were no notes related to a written notice of discharge and reasons for the move given to Resident #1, Resident #1's RP, and the facility's Ombudsman. Review of Resident #1's Electronic Health Records on 06/23/25 reflected there was no written notice of discharge and reasons for the move given to Resident #1, Resident #1's RP, and the facility's Ombudsman. Review of Resident #1's IDT Discharge Summary, created by CM on 06/10/25 at 1:07 p.m., reflected she was discharged on 06/11/25 at 12:00 p.m. with hospice, a wheelchair and a mechanical lift, would continue physical therapy and medication management, and transported in a private vehicle to her home. The section of the summary in which the discharge instructions were to be reviewed with Resident #1 or Resident #1's RP in a language they understand was not signed and not dated by Resident #1, Resident #1's RP, and CM or discharging nurse. An attempt to contact the facility's Ombudsman was made on 06/23/25 at 9:50 a.m. The facility's Ombudsman did not return the surveyor's attempted contact before exit. During an interview on 06/23/25 at 9:54 a.m., Resident #1's RP stated the facility did not provide her and Resident #1 with a written 30-day notice that they were discharging Resident #1 on 06/11/25. Resident #1's RP stated she learned that Resident #1 was discharging from the facility by a medical equipment provider who called her on 06/06/25. Resident #1's RP stated she called the CM on 06/06/25 and the CM told her that Resident #1 was being discharged from the facility on 06/11/25 because she was coming up to her 100 days of covered stay at the facility. Resident #1's RP stated she informed the CM and ADM about her concerns of not being notified of Resident #1's discharge in advance on unknown date . Resident #1's RP also stated the facility did not inform her and Resident #1 of Resident #1's right to appeal the discharge and the appeal process. During an interview on 06/23/25 at 1:23 p.m., the ADON stated the CM was responsible for notifying residents, residents' RPs and the Ombudsman in writing of residents' discharge from the facility. The ADON stated she spoke with the facility's Corporate team and learned that the facility was required to send a written discharge notice to residents, residents' RPs and the Ombudsman within 30 days of discharge per the facility's policy. The ADON stated she did not know the facility was required to send a written 30-day notice of discharge to residents, RPs and Ombudsman because the facility's policy was vague. The ADON stated the facility did not comply with the regulation for providing a written 30-day notice of discharge to residents, residents' RPs, and the Ombudsman. During an interview on 06/23/25 at 1:56 p.m., Resident #1's RP stated Resident #1 was unable to answer the surveyor's questions due to her severe cognitive impairment. Resident #1's RP also stated the Administrator told her that she did not have to be informed of Resident #1's discharge three days before Resident #1's discharge. During an interview on 06/23/25 at 2:28 p.m., the CM said she was responsible for issuing a formal written notice of discharge to residents, residents' RPs, and the Ombudsman. The CM stated she did not provide Resident #1, Resident #1's RP, and the Ombudsman with a written notice of discharge because she did not know she had to provide a formal written notice of discharge to the resident, residents' RP, and Ombudsman within 30 days of a resident's discharge from the facility. The CM also stated she did not inform Resident #1 and Resident #1's RP of Resident #1's right to appeal the discharge and the appeal process for unknown reasons. The CM stated she knew it was important to provide a notice of discharge in writing to the resident, representative and Ombudsman at least 30 days before a resident is discharged and said, So residents' families knew when, where, why and how the resident was discharging from the facility. So the Ombudsman was aware of the resident's discharge. The CM stated she knew it was important to inform the resident and residents' RPs of residents' right to appeal their discharge and the appeal process and said, Because residents must know their right to appeal. The CM stated the ADM was responsible for overseeing and ensuring the discharge process was correctly completed. The CM stated the ADM was out of the country at the time of the interview. During an interview on 06/23/25 at 2:59 p.m., the DON stated Resident #1 had a low BIMS and could not make decisions for herself. The DON stated the CM was responsible for initiating the notice of discharge to the resident, resident's RP, and Ombudsman. The DON stated the CM did not provide a written notice of discharge to Resident #1, Resident #1's RP, and the Ombudsman. The DON stated she knew it was important to provide a written notice of discharge to residents, residents' RPs, and the Ombudsman within 30 days of a resident's discharge from the facility and said, You have to notify the appropriate parties to ensure the resident discharge safely and to be able to follow-up with necessary agencies and make sure resident was safe and provided continued care from the facility when transitioning back to home and so family was equipped when receiving the resident. And so the Ombudsman could ensure and had a role in resident being well taken care of and it was important for continuity of care for the resident and to make sure to communicate all discharge plans and interventions the resident needed for the resident's welfare. The DON stated the ADM was responsible for overseeing and ensuring the CM correctly completed the discharge process. Review of the facility's Transfers and Discharges policy, undated, reflected, .Any transfer or discharge not meeting regulatory standards or that places the resident at risk is considered inappropriate and is strictly prohibited .Discharges are inappropriate and unlawful if they occur under any of the following conditions: .2. Failure to provide written notice: Not giving the required 30-day written notice to the resident and their representative .Procedure for Transfer or discharge: .Notice Requirements: The facility must provide 30 days written notice of discharge to the resident and their legal representative .Notice must include: Reason for discharge, effective date, location to which the resident is being transferred, contact information for: state long-term care ombudsman, state survey agency, appeal rights and process, resources for assistance .5. Residents and their representatives must be informed of their right to appeal a discharge .6. Involuntary Discharges: .The Ombudsman program must be notified before the discharge is initiated .Staff Responsibilities: Admissions and Social Services: Ensure that transfers and discharges are carried out in accordance with this policy, providing support and proper documentation .Administrator: .inform the Ombudsman . Review of the facility's Resident Rights policy, undated, reflected, .Social Services: The Center must provide you with any needed medically-related social services, including .discharge planning .You can't be sent to another nursing home or be made to leave The Center .You (and your representative) have a right to be notified before you are transferred or discharged from The Center .Your rights include: .The right to remain in the facility: The right to not be transferred or discharged .and to be given 30 days advance notice .

Based on observations, interviews, and record review, the facility failed to implement a comprehensive care plan to meet the medical and nursing needs and the services to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being of 3 (Resident #235, Resident #242, and Resident #289) of 6 residents reviewed for care plans. The facility failed to complete an accurate comprehensive care plan for Resident #235, Resident #242, and Resident #289 by not including assistance required during transfer. This failure could place residents at risk of not having their care and treatment needs assessed to ensure necessary care and services were provided during transfers leading to falls and hospitalization s. Resident #235 Record review of Resident #235's undated face sheet reflected he was a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses that included nondisplaced fracture of the base of neck of right femur (right hip fracture), malaise (weakness), muscle weakness, and unsteadiness on feet. Record review of Physical Therapy Progress Report dated 10/10/2024 reflected resident #235 had a weight bearing status precaution (restrictions) on his right lower extremity of 10-20% related to his right femoral neck fracture. Record review of Resident #235's Comprehensive Care Plan dated 10/09/2024 reflected resident #235 needed assistance with transfers/toileting related to impaired mobility secondary to weakness and debility. Interventions on the care plans did not indicate how much assistance was needed. Record review of Resident #235's Admission MDS dated [DATE] reflected he had a BIMS score of 10 indicating he had cognitive impairment. Resident #235 required substantial assistance with activities of daily living such as dressing and grooming. He was dependent for transfers meaning to complete the activity the helper does all the effort, and the resident does none of the effort. Or the assistance of 2 (two) or more helpers was required for the resident to complete the activity. In an interview on 10/29/2024 at 10:04 AM with Resident #235, he stated he was able to get into his wheelchair with assistance of 1 staff but could not stand too long or put weight on his hip and knee. Resident #235 stated he was very weak when standing. Resident #242 Record review of Resident #242's face sheet dated 10/30/2024 reflected she was an [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses that included hemiplegia and hemiparesis following cerebral infarction affecting left non dominant side (paralysis after a stroke), facial weakness following cerebral infarction (stroke), muscle weakness, and history of falling. Record review of Baseline Care plan dated 10/08/2024 reflected resident #242 required 2-person assistance with transfers. Transfer status with the use of the Hoyer (mechanical lift) was not marked. Record review of Resident #242's Comprehensive Care Plan dated 10/08/2024 reflected resident #242 needed assistance with transfers/toileting related to impaired mobility secondary to weakness and debility. Interventions on the care plan did not indicate how much assistance was needed. Record review of Physical Therapy evaluation and plan of treatment dated 10/09/2024 reflected resident #242 was total dependence for transfer status. Record review of Resident #242's Admission MDS dated [DATE] reflected she had a BIMS score of 12 indicating she had moderate cognitive impairment. Resident #242 required substantial assistance with activities of daily living such as dressing and grooming. She was dependent for transfers meaning to complete the activity the helper did all the effort, and the resident did none of the effort. Or the assistance of 2 (two) or more helpers was required for the resident to complete the activity. The MDS also reflected Resident #242 required the use of a wheelchair for mobility and had limited range of motion with impairments on one side of both her upper and lower extremities. In an observation and interview on 10/29/2024 at 10:34 AM with Resident #242, she was observed lying in bed on top of a lift sling. Resident #242 stated the staff were going to get her up. She stated the staff used the sling to transfer her with a lift. Resident #289 Review of Resident #289's face sheet, dated 10/31/2024, reflected an [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included sepsis due to methicillin resistant staphylococcus aureus (a contagious bacterial infection that starts on the skin and is resistant to most common antibiotics. MRSA can spread through cuts, scrapes, and skin-to-skin contact), acute congestive heart failure, type 2 diabetes, acute respiratory failure with hypoxia (a dangerous condition that occurs when the body does not have enough oxygen, which can lead to low oxygen levels in the body's tissues), unsteadiness on feet, and other lack of coordination. Review of Resident #289's initial MDS assessment, dated 10/17/2024, reflected no information regarding resident activities of daily living assistance transfer needs. Review of Resident #289's BIMS assessment dated [DATE] reflected a score of 14, indicating intact cognition . Review of Resident #289's care plan dated 10/17/2024 reflected a focus of, I need assistance with transfers/toileting related to impaired mobility secondary to weakness and debility with a goal dated 10/17/2024, I will cooperate in toileting efforts through the review date and interventions dated 10/17/2024, check frequently and assist with toileting as needed and keep call light within reach and remind me to call for assistance. In an interview on 10/31/2024 at 11:33 AM Resident #289 stated he had been helped from his bed to his wheelchair and from his wheelchair to his bed and to the toilet by sometimes one staff member or sometimes two staff members. He said a male staff member sometimes helped him alone, but pretty much he had two people helping him and he had not felt unsafe when he was transferred. Observation on 10/30/2024 at 9:02 AM revealed two staff members were present during an attempted transfer of Resident #289 from his bed to his wheelchair. Resident #289 stood up from the bed with a staff member on either side of him each with their hands on one of his arms, but after he achieved a standing position, he said he was in too much pain to be moved to his wheelchair. The staff members held his arms and lowered him to a sitting position on the bed and helped him lay back on his bed. In an interview on 10/30/2024 at 9:03 AM CNA D and CNA E each stated Resident #289 was always a two-person transfer. In an interview on 10/31/2024 at 11:47 AM CNA F stated that Resident #289 was usually a two-person transfer, but at times he had assisted Resident #289 by himself. In an interview on 10/31/2024 at 10:50 AM LVN C stated staff can obtain transfer status by reviewing the care plan. She stated if the care plan just states assistance with transfers then she would assume that would be a 1-person transfer. She stated staff have a beginning of shift verbal report with the nursing assistants and they let them know how much assistance a resident will need with transfers. She stated the nursing assistants should be communicating transfer status in shift report between each other and in the care plan. LVN C stated negative effects for not establishing a transfer status within the care plan would be residents falling. In an interview on 10/31/2024 at 11:00 AM the DON stated transfer status should be on the task bar. The DON stated the nursing assistants get transfer status information in report verbally. The DON stated ultimately the therapist established the transfer status and communicated it to the nurses and nursing assistants. He stated the nurses were responsible for updating the care plan along with the MDS coordinator. He stated the negative effects for not having transfer status on the care plan were that the resident could fall. In an interview on 10/31/2024 at 11:19 AM the ADM stated the facility liked to have therapy evaluate and communicate the transfer status of a resident to the team. Once transfer status was determined it was communicated verbally to the nurses and nursing assistants. The nursing staff pass this information in verbal report. They walk the halls giving bedside report to each other on the residents' status. Within the electronic medical records transfer status should be in the care plan and specialty equipment needed if used. The negative effects of not listing a transfer status would be a resident fall. In an interview on 10/31/2024 at 12:22 PM MDS Coordinator B stated the ADON and the DON will update the care plans with transfer status. She stated use of mechanical lifts, limitations in weight bearing status, and transfer assistance needed would be documented under task bar. She stated the MDS Coordinator has not been defining assistance needed by staff in the care plan. She stated negative effects for the resident may include the nursing assistants may have a problem with the transfer or will have to ask someone for the amount of assistance needed. Record review of facility policy titled Care Plan dated 3/14/24 reflected The center will develop, implement, and provide care in accordance with a comprehensive person-centered care plan for the resident consistent with regulatory requirements. The care plan is to include measurable objectives and timeframes to meet a resident's medical, nursing, psycho-social, and functional needs identified with completion of the comprehensive assessment. To the extent that is practical, the resident and/or family will be involved in the development of their care plan. The care plans will be modified when needed to meet the resident's current needs, problems, and goals. Any revision, additions, or deletion to the plan of care will be dated and initialed. Revisions involving the care of other disciplines are done through consultative and collaborative efforts.

Based on interviews and record review, the facility failed to transmit a resident assessment within the required time frame for 1 of 4 discharged residents (Resident #61) reviewed for data encoding and transmission. in that: Resident #61's Discharge MDS was not encoded or transmitted as of 07/22/2024. This failure affected residents who have been discharged in the last 30 days at risk of not having their assessments transmitted timely. The findings included: Record review of Resident #61's face sheet revealed the resident admitted to the facility on [DATE] and discharged on [DATE] home. Resident #61's admitting diagnoses included intervertebral disc disorder with radiculopathy in the lumbar region (symptoms that occur when a spinal nerve root is compressed) other lower back pain, and hypo-osmolality and hyponatremia (a condition of having low levels of electrolytes (including sodium), proteins, and nutrients). Record review of Resident #61's EMR revealed the resident's Admission MDS was completed and accepted, but the Discharge MDS assessment was not initiated to where the assessment would be visible, coded, or transmitted as of 07/26/2024. Record review of the RAI (Resident Assessment Instrument) Manual OBRA Assessment Summary, dated October 2023, revealed OBRA Discharge assessments -Return Not Anticipated (A0310F = 10) Must be completed when the resident is discharged from the facility and the resident is not expected to return to the facility within 30 days. Must be completed (item Z0500B) within 14 days after the discharge date (A2000 + 14 calendar days). Must be submitted within 14 days after the MDS completion date (Z0500B + 14 calendar days. In an interview on I0/30/2024 at 2:39 PM the MDS coordinator stated she was out for personnel reasons and Resident #61's Discharge MDS was not encoded or timely transmitted as of 07/22/2024. The MDS coordinator said she was responsible for the encoding of this record in a timely manner. Facility MDS policy dated 02/08/2021 reflected it is the policy of this facility that MDS assessments, discharge and reentry records will be completed and electronically encoded into our facilities MSDS information system and appropriate assessments will be transmitted to CMS. Procedures: 1. All staff members will be responsible for completion of the MSDS and transmission process in accordance with the MDS RAI instruction manual. 2. MDS electronic submissions shall be conducted in accordance with current OBRA regulation governing the transmission of such data. 3. The MDS coordinator is responsible for ensuring that appropriate edits are made prior to transmitting MDS data and that feedback and validation reports from each transmission are maintained for historical purposes and for tracking.

Based on interviews and record review, the facility failed to provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community for 3 residents of 24 residents (Resident #11, Resident #18, and Resident #285) reviewed for activities. 1. Residents #11, Resident #18, and Resident #285 were not engaged in a person-centered activity programs and said they were bored. 2. The group activity calendar for the month of September 2024 listed an entry of books, puzzles, and TV Time for each day, no other activities listed. 3. The group activity calendar of the month of October 2024 listed 16 days of AM (morning) news, puzzles, and books. These failures placed residents at risk of boredom, depression, and a diminished quality of life. Findings included: Review of Resident #11's face sheet, dated 10/31/2024, reflected an [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included acute respiratory failure with hypoxia (a dangerous condition that occurs when the body does not have enough oxygen which can lead to low oxygen levels in the body's tissues), acute congestive heart failure, morbid obesity due to excess calories, and unsteadiness on feet. Review of Resident #11's initial MDS assessment, dated 09/17/2024, section F0500 interview for activity preferences reflected: o How important is it to you to have books, newspapers, and magazines to read - very important o How important is it to you to listen to music you like? - very important o How important is if for you to be around animals such as pets? - very important o How important is it to you to keep up with the news? - very important o How important is it to you to do thing with groups of people? - very Important o How important is it to you to do your favorite activities? - very important o How important is it to you to go outside to get fresh air when the weather is good? - Very important o How important is it to you to participate in religious services or activities? - very important Review of Resident #11's 09/11/2024 BIMS reflected a score of 13, indicating intact cognition. Review of Resident #11's care plan dated 09/13/2024 reflected a focus of My Preferences dated 09/13/2024, Goal dated 09/13/2024 - my preferences will be met during my stay. Intervention dated 09/13/2024 - preferred time to wake up between 8:00 AM and 9:00 AM and dated 09/16/2024 intervention permission given to wake up to administer medications, therapy or other services dated 09/13/2024. Review of Resident #18's face sheet, dated 10/31/2024, reflected an [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses that included atrial fibrillation (a common heart arrhythmia that causes the upper chambers of the heart to beat irregularly and often rapidly), muscle weakness, and steadiness on feet, and need for assistance with personal care. Review of Resident #18's initial MDS assessment, dated 09/20/2024, section F0500 interview for activity preferences was not completed. Review of Resident #18's 09/11/2024 BIMS reflected a score of 13, indicating intact cognition. Review of Resident #18's care plan dated 09/15/2024 reflected a focus of My Preferences dated 09/15/2024, Goal dated 09/15/2024 - my preferences will be met during my stay. Intervention dated 09/15/2024 - preferred time to wake up between 8:00 AM and 9:00 AM, and permission given to wake up to administer medications, therapy, or other services. Review of Resident #285's face sheet, dated 10/31/2024, reflected an [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses that included metabolic encephalopathy (a brain disorder caused by a chemical imbalance in the blood that affects brain function), convulsions, acute kidney failure, and unsteadiness on feet. Review of Resident #285's initial MDS assessment, dated 10/16/2024, section F0500 interview for activity preferences reflected: o How important is it to you to have books, newspapers, and magazines to read - very important o How important is it to you to listen to music you like? - very important o How important is if for you to be around animals such as pets? - very important o How important is it to you to keep up with the news? - very important o How important is it to you to do thing with groups of people? - very Important o How important is it to you to do your favorite activities? - very important o How important is it to you to go outside to get fresh air when the weather is good? - Very important o How important is it to you to participate in religious services or activities? - very important Review of Resident #285's 10/13/2024 BIMS reflected a score of 12, indicating moderate cognitive impairment. Review of Resident #285's care plan dated 10/12/2024 reflected a focus of My Preferences dated 10/12/2024, Goal dated 10/13/2024 - my preferences will be met during my stay. Intervention dated 10/12/2024 - preferred time to wake up between 8:00 AM and 9:00 AM, and permission given to wake up to administer medications, therapy, or other services. Review of Resident #11's Activity Initial Evaluation dated 09/17/2024 reflected: o Activity Involvement preferences - afternoon o Activity Involvement Preferences - group activities o How important is it to you to have books, newspapers, and magazines to read? - very important o How important is it to you to have music you like to listen to? - very important o How important is if for you to be around animals such as pets? - very important o How important is it to you to keep up with the news? - very important o How important is it to you to do thing with groups of people? - very Important o How important is it to you to do your favorite activities? - very important o How important is it to you to go outside to get fresh air when the weather is good? - Very important o How important is it to you to participate in religious services or activities? - very important o Indicate respondent for daily activities and preferences - resident Review of Resident #18's Activity Initial Evaluation dated 09/20/2024 reflected: o Activity Involvement preferences - morning o Activity Involvement Preferences - Individual activities o Issues, concerns, problems or needs that may affect involvement or engagement in leisure activity included - prefers to stay in own room o Additional Individual Interests - Watching TV/Movies o Group Activities - social (socials, entertainment, games, moves, pet visits) o How important is it to you to have books, newspapers, and magazines to read? - very important o How important is it to you to have music you like to listen to? - very important o How important is if for you to be around animals such as pets? - very important o How important is it to you to keep up with the news? - very important o How important is it to you to do thing with groups of people? - very Important o How important is it to you to do your favorite activities? - very important o How important is it to you to go outside to get fresh air when the weather is good? - Very important o How important is it to you to participate in religious services or activities? - very important o Indicate respondent for daily activities and preferences - resident Review of Resident #285's Activity Initial Evaluation dated 10/14/2024 reflected: o Activity Involvement preferences - no specific preference o Activity Involvement Preferences - individual activities and group activities o How important is it to you to have books, newspapers, and magazines to read? - very important o How important is it to you to have music you like to listen to? - very important o How important is if for you to be around animals such as pets? - very important o How important is it to you to keep up with the news? - very important o How important is it to you to do thing with groups of people? - very Important o How important is it to you to do your favorite activities? - very important o How important is it to you to go outside to get fresh air when the weather is good? - very important o How important is it to you to participate in religious services or activities? - very important o Indicate respondent for daily activities and preferences - resident In an interview on 10/30/24 at 4:02 PM Resident #11 stated she did not receive an activity calendar; she had not been offered a manicure or pedicure as an activity. She stated she did not know the facility had activities and she was extremely bored, and she was bored over the weekend. She stated there was nothing to do on the weekend. She said that not having had activities affected her attitude and got her down. In an interview on 10/29/2024 at 10:52 AM Resident #18 stated the staff had not given her the opportunity to demonstrate her intelligence or ability and she had not been given the opportunity to show people that she is not a potato. When asked what she meant by potato, she said she had been regarded an object that just laid there. She stated the only thing she had been out to do was walk with a walker. She stated she did not have enough stimulation. In an interview on 10/31/2024 at 9:38 AM Resident #18 stated she did not recall receiving an activities calendar. She stated she is bored. She stated she stayed in bed all day yesterday because there was, not a damn thing to do otherwise. She did not tell the staff she is bored because she was not a complainer. Resident #18 felt activities should be offered based on the individual needs of each resident and she felt she had been lumped into a category and it had been difficult to express herself. In an interview on 10/31/24 at 9:13 AM Resident #285 stated she had never seen an activity calendar and she was absolutely bored and asked, what the hell is there to do here? When asked how she felt being bored, she replied that that was a stupid question and how would you feel if you were bored? She said she was invited to Bingo, but she did not know one person at the facility. Observation on 10/31/24 at 9:13 AM revealed, the state surveyor, with the permission Resident #285, looked for an activity calendar in the papers in her room and no activity calendar was located in her room. In an interview on 10/31/2024 at 10:15 AM the Activities Director stated she began the job as the activity's director the second week of October 2024. She stated the first thing she began doing was working on the activity calendar. She stated she tried to make sure residents had activities because she wanted them to get out of their rooms and get them motivated. She stated that if residents were closed in their rooms they got depressed. She set up puzzles in a room on the third floor and books were in the library. AM (morning) news was for residents who want to get up and watch the news. She stated she felt an activity was something to get residents active and to get residents to use their hands and feet. She said most residents liked Bingo. She stated an activity assessment was done with each resident. She stated she went to the residents' rooms a little bit after breakfast and explained the activities to them. They currently did not have any religious offerings. She explained the night receptionist was supposed to turn on the TV before she left for the evening. She stated she had been spending time visiting with the residents. She stated she thought residents could get depressed and bored and her goal was to keep them motivated because they were already down and sad. She stated the resident council meeting, and the beauty parlor information should have been on the activity calendar. In an interview on 10/31/2024 at 10:27 AM the Administrator stated resident activities were both for group and individual. Residents were provided with an activity assessment and the facility had activity rooms on both floors that provided coloring books, puzzles, games, and books. The facility was without an activity director from September 2024 until about two weeks ago and no one was acting as an activity director. He stated they did Bingo with residents. He said additional activities were provided to the residents that were not reflected on the September 2024 and October 2024 activity calendar. He said activities could be described as an ongoing patient centered activity program that incorporated the patient's hobbies and culture preferences and he felt like the books, the AM (morning) news, and coloring partially met this description. He stated they could have provided more activates but it was hard when there was not someone in the role as activity director. He said it was the responsibility of the Administrator to make sure that the residents had activities and if residents do not have activities, it was possible they could decline. He stated the lack of activities could affect their mental health, but he did not know how much it would affect them because the facility was a rehabilitation skilled nursing facility and residents do not live at the facility long term. A review of the facility September 2024 activity calendar reflected: 09/01/2024 through 09/30/2024 - books, puzzles, and TV time. A review of the facility October 2024 activity calendar reflected: 10/01/2024 through 10/12/2024 - AM (morning) news, puzzles 3rd floor, and books, 10/13/2024 AM (morning) news, Sunday Night Football, 10/14/2024 through 10/17/2024 - AM (morning) news, puzzles 3rd floor, and books, 10/198/2024 Bingo 1:30 PM - 3:30 PM, 10/19/2024 - AM (morning) news and college football, 10/20/2024 AM (morning) news and Sunday Night Football, 10/21/2024 Bingo 1:30 PM - 3:30 PM, 10/22/2024 Movie Night 7:00 PM, 10/23/24 Quartet 1:30 PM - 3:30 PM, 10/24/2024 Fall [NAME], 10/25/2024 Bingo 1:30 PM - 3:30 PM and Central Texas Rehabilitation Hospital, 10/26/2024 AM (morning) news and College Football, 10/29/2024 Arts & Crafts, Halloween bags 1:30 PM - 3:30 PM, 10/30/2024 Bingo 1:30 PM - 3:30 PM, 10/31/2024 Halloween Party staff/patient. Review of facilities activities policy dated 02/08/2021 reflected the patient has the right to choose activities and participate in activities, including social, religious, and community activities that do not interfere with the rights of other patients in the facility. The center will ensure and implement an ongoing patient centered activity program that incorporates the patient's hobbies and cultural preferences, which is integral to maintaining and or improving a patient's physical, mental, and psychosocial well-being and independence. The facility will support and create meaningful life by supporting his/her domain of Wellness. The patient will make choices about the activities they would like to participate in. The activity calendar will be provided to all patients. Activities will be provided seven days a week on days and evening. Activity room will have self-directed activities 24 hours a day available to the patient. The patient's interests will be reviewed by activity director with patient. Activities of daily living such as manicures and pedicures and hair styling may be part of an activity program. Validating and respecting patients right to refuse an activity. Promoting one to one visits in patient room as needed. Engagements of exercise and movement. Hands on activities such as crafts, games, etcetera.

Based on observations, interviews, and record review, the facility failed to ensure respiratory care was provided consistent with professional standards of practice for 1 of 1 Residents (Resident #73) reviewed for tracheostomy care. The facility failed to ensure Resident #73 used aseptic technique (a procedure that healthcare providers use to prevent the spread of germs that cause infection. Placing barriers, using sterile equipment, and following strict guidelines that help create an environment free of germs.) during tracheostomy care. The facility further failed to ensure that Resident #73's tracheostomy tube was free from secretions to ensure a patent airway prior to inserting his inner cannula. This failure could place residents who use respiratory equipment and have tracheostomies at risk for respiratory infections and respiratory distress. Findings included: Review of Resident #73's face sheet dated 10/30/2024 reflected he was admitted on [DATE] with the following diagnoses encephalopathy (a medical term used to describe a disease that affects brain structure or function. It causes altered mental state and confusion.), human immunodeficiency virus, (a virus that attacks cells that help the body fight infection, making a person more vulnerable to other infections and diseases.), and tracheostomy status (a surgically created opening in the neck leading directly to the trachea (the breathing tube). It is maintained open with a hollow tube called a tracheostomy tube.). Review of Resident #73's Admission MDS dated [DATE] reflected he was assessed to have a BIMS score of 14 indicating he was cognitively intact. Resident #73 was assessed to be independent in all areas of ADL assistance. Resident #73 was assessed to have a multidrug-resistant organism, to receive antibiotics, and to receive tracheostomy care and suctioning. Review of Resident #73's comprehensive care plan reflected a focus area dated 09/19/2024 Antibiotic therapy related infection gangrenous necrosis (is death of body tissue due to a lack of blood flow or a serious bacterial infection.) and acute osteomyelitis of the mandible . Further review reflected a focus area dated 10/29/2024 Tracheostomy interventions included suction as needed. The plan of care did not address tracheostomy care or frequency of care. Review of Resident #73's consolidated physician orders reflected an order dated 09/18/2024 Trach care: Stoma: cleanse peri area with normal start at 12 o'clock to 9am, 3 pm to 6pm, and 12am to 3am. Apply new drain sponge secure in place with new trach tie. Monitor for signs and symptoms of breakdown around stoma as needed. Observation on 10/30/2024 at 11:05 AM LVN F entered Resident #73's room to provide tracheostomy care. LVN F gathered her supplies and opened the sterile trach care kit. LVN F then opened the sterile trach inner cannula and dropped the inner cannula into the trach care kit. LVN F had an unopened bottle of normal saline. LVN F then donned gloves and removed Resident #73's old trach gauze from around his trach stoma and she removed his inner cannula. LVN F sanitized her hands and donned she donned sterile gloves. LVN F then opened the non- sterile normal saline and poured into the sterile tray. Resident #73 was observed coughing as she cleaned around the trach stoma producing mucus. Resident #73 continued to cough and was observed to have a mucus plug visible at the opening of the tracheostomy tube. LVN F then, without clearing the airway inserted the inner cannula through the mucus plug. In an interview on 10/30/2024 at 11:20 am LVN F stated she should have opened the normal saline and placed it in the trach care tray prior to donning the sterile gloves. She stated by not doing so she contaminated her sterile field. She stated should have suctioned Resident #73 or made sure his airway was clear prior to inserting the inner cannula. In an interview on 10/30/2024 at 11:30 AM the DON stated he excepted trach care to be done as an aseptic procedure and LVN F did cross contaminate when she used sterile gloves to open the normal saline which was not sterile to prevent infections. He further stated the resident's airway should be clear prior to inserting an inner cannula to prevent blockage of the airway. Review of the facility's policy Tracheostomy care dated 10/10/2019 reflected Purpose: The purpose of this procedure is to guide tracheostomy care and the cleaning of reusable tracheostomy cannulas. 1. Aseptic technique must be used: (Aseptic technique is a procedure that healthcare providers use to prevent the spread of germs that cause infection. Placing barriers, using sterile equipment, and following strict guidelines help create an environment free of germs that can make you sick.) a. During cleaning and sterilization of reusable tracheostomy tubes; b. During all dressing changes until the tracheostomy wound has granulated (healed), and c. During tracheostomy tube changes, either reusable or disposable. 2. Gloves must be used on both hands during any or all manipulation of the tracheostomy. Sterile gloves must be used during aseptic procedures 5. Tracheostomy care should be provided as often as needed, at least once daily for old, established tracheostomies, and at least every eight hours for residents with unhealed tracheostomies . A suction machine, supply of suction catheters, exam and sterile gloves, and flush solution, must be available at the bedside at all times . Review of the website: https://nurseslabs.com/tracheostomy/#h-providing-tracheostomy-care for nursing procedure dated 05/26/2024 reflected .5. Establish the sterile field. Open other sterile supplies as needed, including sterile applicators, a suction kit, and a tracheostomy dressing. 6. Suction the tracheostomy tube, if necessary. Put a clean glove on your nondominant hand and a sterile glove on your dominant hand (or put on a pair of sterile gloves). Suction the full length of the tracheostomy tube to remove secretions and ensure a patent airway. Rinse the suction catheter, wrap it around your hand, and peel the glove off so that it turns inside out over the catheter. 7. Remove the inner cannula. Unlock the inner cannula with the gloved hand. Gently pull it out in line with its curvature and place it in the soaking solution. This moistens and loosens secretions. 8. Remove the soiled dressing. Place the soiled tracheostomy dressing in your gloved hand and peel the glove off so that it turns inside out over the dressing. Discard the glove and the dressing. 9. Put on sterile gloves. Keep your dominant hand sterile during the procedure. Clean the inner cannula. Remove the inner cannula from the soaking solution. 10. Clean the lumen and entire inner cannula thoroughly using the brush or pipe cleaners moistened with sterile normal saline. Inspect the cannula for cleanliness by holding it at eye level and looking through it into the light. Rinse the inner cannula thoroughly in the sterile normal saline. After rinsing, gently tap the cannula against the inside edge of the sterile saline container. Use a pipe cleaner folded in half to dry only the inside of the cannula, leaving a film of moisture on the outer surface to lubricate the cannula for reinsertion. This removes excess liquid and prevents aspiration. 11. Replace the inner cannula, securing it in place. Insert the inner cannula by grasping the outer flange and inserting the cannula in the direction of its curvature. Lock the cannula in place by turning the lock (if present) to secure the flange of the inner cannula to the outer cannula. 12. Clean the incision site and tube flange. Using sterile applicators or gauze dressings moistened with normal saline, clean the incision site. Handle the sterile supplies with your dominant hand and use each applicator or gauze dressing only once. Hydrogen peroxide may be used (usually in a half-strength solution mixed with sterile normal saline) to remove crusty secretions. Thoroughly rinse the cleaned area using gauze squares moistened with sterile normal saline. This avoids contaminating a clean area and ensures thorough cleaning without irritating the skin. 13. Apply a sterile dressing. Use a commercially prepared tracheostomy dressing or open and refold a 4x4-inch gauze dressing into a V shape. Place the dressing under the flange of the tracheostomy tube while ensuring the tube is securely supported to avoid irritation from excessive movement .

Based on observations, interviews, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections and follow accepted national standards for one of one resident reviewed for tracheotomy care (Resident #73). The facility failed to ensure LVN F used aseptic technique during tracheotomy care for Resident #73. These failures could place residents at risk for developing wound and upper respiratory infections. Findings included: Review of Resident #73's face sheet dated 10/30/2024 reflected he was admitted on [DATE] with the following diagnoses encephalopathy (A medical term used to describe a disease that affects brain structure or function. It causes altered mental state and confusion.), human immunodeficiency virus, (a virus that attacks cells that help the body fight infection, making a person more vulnerable to other infections and diseases.), and tracheostomy status (a surgically created opening in the neck leading directly to the trachea (the breathing tube). It is maintained open with a hollow tube called a tracheostomy tube.). Review of Resident #73's Admission MDS dated [DATE] reflected he was assessed to have a BIMS score of 14 indicating he was cognitively intact. Resident #73 was assessed to be independent in all areas of ADL assistance. Resident #73 was assessed to have a multidrug-resistant organism, to receive antibiotics, to receive tracheostomy care and suctioning. Review of Resident #73's comprehensive care plan reflected a focus area dated 09/19/2024 Antibiotic therapy related infection gangrenous necrosis (is death of body tissue due to a lack of blood flow or a serious bacterial infection.) and acute osteomyelitis of the mandible . Further review reflected a focus area dated 10/29/2024 Tracheostomy interventions included suction as needed. The plan of care did not address tracheostomy care or frequency of care. Review of Resident #73's consolidated physician orders reflected an order dated 09/18/2024 Trach care: Stoma: cleanse peri area with normal start at 12 o'clock to 9am, 3 pm to 6pm and 12am to 3am. Apply new drain sponge secure in place with new trach tie. Monitor for signs and symptoms of breakdown around stoma as needed. Observation on 10/30/2024 at 11:05 AM LVN F entered Resident #73 room to provide tracheostomy care. LVN F gathered her supplies and opened the sterile trach care kit. LVN F then opened the sterile trach inner cannula and dropped the inner cannula into the trach care kit. LVN F had an unopened bottle of normal saline. LVN F then donned gloves and removed Resident #73 old trach gauze from around his trach stoma and she removed his inner cannula. LVN F sanitized her hands and donned she donned sterile gloves. LVN F then opened the non- sterile normal saline and poured into the sterile tray. Resident #73 was observed coughing as she cleaned around the trach stoma producing mucus. Resident #73 continued to cough and was observed to have a mucus plug visible at the opening of the tracheostomy tube. LVN F then, without clearing the airway inserted the inner cannula through the mucus plug. In an interview on 10/30/2024 at 11:20 am LVN F stated she should have opened the normal saline and placed it in the trach care tray prior to donning the sterile gloves. She stated by not doing so she contaminated her sterile field. In an interview on 10/30/2024 at 11:30 AM the DON stated he excepted trach care to be done as an aseptic procedure and the LVN F did cross contaminate when she used to sterile gloves to open the normal saline which was not sterile to prevent infections. Review of the facility's policy Tracheostomy care dated 10/10/2019 reflected Purpose: The purpose of this procedure is to guide tracheostomy care and the cleaning of reusable tracheostomy cannulas. 1. Aseptic technique must be used:( Aseptic technique is a procedure that healthcare providers use to prevent the spread of germs that cause infection. Placing barriers, using sterile equipment, and following strict guidelines help create an environment free of germs that can make you sick.) a. During cleaning and sterilization of reusable tracheostomy tubes; .Sterile gloves must be used during aseptic procedures 5. Tracheostomy care should be provided as often as needed, at least once daily for old, established tracheostomies, and at least every eight hours for residents with unhealed tracheostomies . Review of the website: https://nurseslabs.com/tracheostomy/#h-providing-tracheostomy-care for nursing procedure dated 05/26/2024 reflected .5. Establish the sterile field. Open other sterile supplies as needed, including sterile applicators, a suction kit, and a tracheostomy dressing. 6. Suction the tracheostomy tube, if necessary. Put a clean glove on your nondominant hand and a sterile glove on your dominant hand (or put on a pair of sterile gloves) .8. Remove the soiled dressing. Place the soiled tracheostomy dressing in your gloved hand and peel the glove off so that it turns inside out over the dressing. Discard the glove and the dressing. 9. Put on sterile gloves. Keep your dominant hand sterile during the procedure . Using sterile applicators or gauze dressings moistened with normal saline, clean the incision site. Handle the sterile supplies with your dominant hand and use each applicator or gauze dressing only once .Thoroughly rinse the cleaned area using gauze squares moistened with sterile normal saline. This avoids contaminating a clean area and ensures thorough cleaning without irritating the skin. 13. Apply a sterile dressing.

Based on interviews and record reviews, the facility failed to develop a comprehensive care plan within seven days after completion of the comprehensive assessment for 4 (Residents #1, 2, 3, and 4) of 6 residents reviewed for comprehensive care plans, in that: The facility failed to complete a comprehensive person-centered care plan to address Residents #1, 2, 3, and 4's needs within seven days after the comprehensive MDS assessment were completed. This deficient practice could place residents at risk of not having their individual care needs met in a timely manner or diminished quality of life. Findings included: Record review of Resident #1's face sheet, dated 02/12/24, reflected a [AGE] year-old male who was admitted to the facility on [DATE], readmitted on [DATE], and was his own RP. Record review of Resident #1's medical diagnoses report, dated 02/12/24, reflected he had diagnoses including encounter for surgical aftercare following digestive system surgery, acute cholecystitis (inflammation of the gallbladder, a small, digestive organ beneath the liver), acute on chronic systolic (congestive) heart failure, influenza due to other identified influenza virus with other respiratory manifestations, essential (primary) hypertension (a condition in which the force of the blood against the artery walls is too high), uncomplicated alcohol dependence and cocaine abuse, long term (current) use of opiate analgesic (pain relieving drug), unspecified nutritional anemia (a condition in which the blood doesn't have enough healthy red blood cells and hemoglobin, a protein found in red blood cells, to carry oxygen all through the body), and unspecified and subsequent encounter of open wound of right wrist. Record review of Resident #1's comprehensive MDS assessment, dated 11/11/23, reflected a BIMS score of 13, indicating he was cognitively intact. Resident #1 was independent with eating, required set-up/clean-up assistance with oral and personal hygiene, supervision/touching assistance with toileting, bed mobility and transfers, and partial/moderate assistance with showering/bathing. Record review of Resident #1's clinical record reflected the comprehensive care plan was started on 11/28/23. There was no completion date, indicating the care plan was not completed. Record review of Resident #2's face sheet, dated 02/12/24, reflected a [AGE] year-old female who was admitted to the facility on [DATE] and was her own RP. Record review of Resident #2's medical diagnoses report, dated 02/12/24, reflected she had diagnoses including cellulitis of right lower limb, non-pressure chronic ulcer of other part of right foot with unspecified severity, unspecified rheumatoid arthritis (a chronic inflammatory disorder usually affecting small joints in the hands and feet), chronic pain syndrome, dependence on wheelchair, long term (current) use of opiate analgesic, long term (current) use of antibiotics, unspecified low back pain, and unspecified insomnia. Record review of Resident #2's comprehensive MDS assessment, dated 12/22/23, reflected a BIMS score of 15, indicating she was cognitively intact. Resident #2 required supervision/touching assistance with eating, partial/moderate assistance with oral hygiene, substantial/maximal assistance with showering, personal hygiene, bed mobility and transfers, and dependent on toileting. Record review of Resident #2's clinical record reflected the comprehensive care plan was started on 12/22/23. There was no completion date, indicating the care plan was not completed. Record review of Resident #3's face sheet, dated 02/12/24, reflected a [AGE] year-old female who was admitted to the facility on [DATE] and was her own RP. Record review of Resident #3's medical diagnoses report, dated 02/12/24, reflected she had diagnoses including COVID-19, unspecified hypothyroidism (a condition in which the thyroid gland doesn't produce enough thyroid hormone), unspecified depression, morbid (severe) obesity due to excess calories, unspecified insomnia, weakness, unspecified edema (swelling caused by too much fluid trapped in the body's tissues), pain in left shoulder, pneumonia due to coronavirus disease, unspecified anxiety disorder, unsteadiness on feet, other lack of coordination, long term (current) use of anticoagulants, overactive bladder, and history of falling. Record review of Resident #3's comprehensive MDS assessment, dated 02/07/24, reflected a BIMS score of 15, indicating she was cognitively intact. Resident #3 required supervision/touching assistance with eating and oral hygiene, partial/moderate assistance with personal hygiene, substantial/maximal assistance with showering/bathing and bed mobility dependent on toileting and transfers. Record review of Resident #3's clinical record reflected the comprehensive care plan was started on 02/08/24. There was no completion date, indicating the care plan was not completed. Record review of Resident #4's face sheet, dated 02/13/24, reflected a [AGE] year-old male who was admitted to the facility on [DATE], discharged on [DATE], and was his own RP. Record review of Resident #4's medical diagnoses report, dated 02/12/24, reflected he had diagnoses including wedge compression fracture of T11-T12 vertebra subsequent encounter for fracture with wound healing, fall (on) (from) other stairs and steps subsequent encounter, other hypoglycemia, other postprocedural complications and disorders of digestive system, unspecified nausea with vomiting, type 2 diabetes mellitus without complications, unspecified asthma, generalized muscle weakness, essential (primary) hypertension, unspecified depression and anxiety disorder. Record review of Resident #4's comprehensive MDS assessment, dated 12/17/23, reflected no BIMS score was documented. Resident #4 was independent with bed mobility, required set-up/clean up assistance with eating and oral hygiene, supervision with personal hygiene, substantial/maximal assistance with showering, dependent on toileting, and did not attempt to demonstrate transfer functional status due to medical conditions. Record review of Resident #4's clinical record reflected the comprehensive care plan was started on 01/04/24. There was no completion date, indicating the care plan was not completed. During an interview on 02/12/24 at 11:35 a.m., the ADM revealed comprehensive care plans were completed and updated daily. The ADM also revealed the MDS nurse was responsible for preparing residents' comprehensive care plans. During an interview on 02/12/24 at 11:46 a.m., MDS Nurse A revealed she started working for the facility on either 01/28/24 or 01/30/24. MDS Nurse A also revealed residents' comprehensive care plans were completed by the MDS nurse. MDS Nurse A explained residents' comprehensive care plans were completed within 14-21 days after the MDS assessment was completed. MDS Nurse A revealed she knew the facility was behind with completing residents' comprehensive care plans and she was helping with catching them up. MDS Nurse A did not know why the facility fell behind. MDS Nurse A revealed she knew MDS Nurse B and her back-up, who were both part-time, were both sick for some time. MDS Nurse A did not know when and for how long MDS Nurse B and her back-up were sick or if there was a second back-up who worked on residents' comprehensive care plans. MDS Nurse A revealed she was able to reach out to MDS Nurse B if she needed additional assistance and training. MDS Nurse A also revealed departments (dietary, physical therapy, nursing, and social services) signed after they reviewed and revised their sections of the residents' comprehensive care plans. MDS Nurse A explained she followed-up with the assigned department personnel by email to ensure they finished reviewing their section of the residents' comprehensive care plans. MDS Nurse A did not know why department personnel were not assigned to review their sections of Residents #1, 2, 3, and 4's comprehensive care plans. MDS Nurse A revealed residents could not be at risk of any adverse outcomes if their comprehensive care plans were not completed in a timely manner. During an interview on 02/12/24 at 12:05 p.m., MDS Nurse B revealed she started working at the facility full-time at the end of August 2021 and became PRN status at the end of January 2024. MDS Nurse B also revealed residents' comprehensive care plans were completed by the MDS nurse. MDS Nurse B also revealed MDS Nurse A was responsible for ensuring residents' comprehensive care plans were completed within the required timeframes. MDS Nurse B explained residents' comprehensive care plans were completed within seven days after the MDS assessment was completed. MDS Nurse B did not know why Residents #1, 2, 3,and 4's comprehensive care plans were not completed with a completion date indicated. MDS Nurse B explained MDS Nurse A might have forgotten to indicate a completion date on Residents #1, 2, 3, and 4's comprehensive care plans. MDS Nurse B revealed departments who completed their review of their sections in residents' comprehensive care plan should be indicating with a date when their review was completed. MDS Nurse B also revealed residents might be at risk if their comprehensive care plans were not completed in a timely manner because of their condition. Record review of the undated MDS Coordinator's job description reflected the following, Purpose of job position: The primary purpose of this position is to conduct and coordinate the development and completion of the RAI, that is, the MDS, CAAs and care plan in accordance with state and federal requirements. The MDS Coordinator participates as part of the facility IDT in the systems and processes to manage patients receiving skilled services as assigned. Essential Functions: Coordinates the IDT in timely completion of the assessments. Completes care plan items and attends care plan meetings as assigned. Provides teaching and training for MDS item completion to IDT members that have responsibility for MDS item completion. Record review of the facility's care plan policy and procedure, revised 02/08/21, reflected the following, Policy: It is the policy of the facility to promote seamless interdisciplinary care for our residents by utilizing the interdisciplinary plan of care based on assessment, planning, treatment, service, and intervention. It is utilized to plan and manage resident care as evidenced by documentation from admission through discharge for each resident. The care plan will identify priority problems and needs to be addressed by the interdisciplinary team, and will reflect the patient's strengths, limitations, and goals. The interdisciplinary care plan will be developed through collaborative efforts of the IDT and other health care professionals. It is our purpose to ensure that each resident is provided with individualized, goal-directed care, which is reasonable, measurable, and based on resident needs. Procedure: The Centers will develop, implement, and provide care in accordance with a comprehensive person-centered care plan for the resident consistent with regulatory requirements. The interdisciplinary team members will contribute towards the interventions and approaches needed to obtain the resident's desired and expected outcomes. The care plans will be modified when needed to meet the resident's current needs, problems, and goals. Any revision, additions, or deletion to the plan of care will be dated. All residents are discussed with the Interdisciplinary Team to provide continued updates, revisions, and discontinuation of interventions based on the resident's goals, care needs, and discharge planning.

Based on interview and record review, the facility failed to include as part of its QAPI program, mandatory training that outlined and informed staff of the elements and goals of the facility's QAPI program, for 11 of the 11 staff members reviewed for mandatory training, in that: All eleven staff members reviewed for mandatory training had not received training regarding the facility's QAPI program. This failure could place residents at risk of receiving inadequate care from staff who are unfamiliar with the facility's QAPI program. The findings included: Record review of employee files reflected the following employees had not received training regarding the QAPI program: -ADM was hired on 05/09/2023 -DON hired on 02/17/2022 -RN E, hired on 10/27/2022 -LVN F, hired on 06/02/2022 -LVN G, hired on 06/17/2021 -DM, hired on 08/21/2023 -DOR, hired on 03/01/2022 -CNA H, hired on 02/09/2023 -CNA I, hired on 07/11/2023 -CNA J, hired on 01/30/2020 -CNA K, hired on 06/16/2022 Interview 08/31/2023 at 5:08 PM, the HRD stated she was not aware of staff being required to be trained in any manner related to QAPI and could not find training related to QAPI for any staff. The HRD stated corporate assigned training to the facility staff based on job code and staff completed training based on their corporate-assigned training plan. Interview on 09/01/2023 at 3:57 PM, the ADM stated he was the QA point-of-contact and was not aware any staff members, himself included, were required to be trained on QAPI and only receives training that is assigned to him from corporate. The ADM stated he believed the QA plan and associated processes related to QAPI were helpful to staff. The ADM stated he did not understand the risk associated with staff being untrained on QAPI.

Based on observation, interview, and record review the facility failed to ensure their medication error rate was not 5 percent or greater and had a medication error rate of 30.77% percent with 26 medications administration opportunities observed with 8 errors for 2 of 5 residents (Residents #39 and #195) and 1 of 2 staff (RN A) reviewed for medication administration, in that: 1. RN A administered the incorrect dosage of diltiazem to Resident #39. 2. RN A administered 4 medications to Resident #39 with no physician orders. 3. RN A crushed all of Resident #39's medications in the same bag, 2 medications were extended release (Do NOT Crush) and administered them to Resident #39. 4. RN A did not observe administration of 1 medication for Resident #195. 5. RN A allowed Resident #195 to self-administer a medication when the order did not allow for self-administration. These deficient practices could place residents at risk of not receiving therapeutic effects from their medications as intended by the prescribing physician order. The findings include: 1. Record review of Resident #39's faceshet, dated 8/31/23, revealed he was admitted on [DATE] with diagnoses which included acute kidney failure, syncope and collapse, and hypertensive emergency. Record review of Resident #39's admission MDS assessment, dated 7/31/23, revealed a BIMS score of 13 which indicated no cognitive impairment. Record review of Resident #39's orders, dated 08/31/23, revealed a physician order for, diltiazem HCl Oral Tablet 60 MG, give 1 tablet by mouth one time a day for HTN Hold for SBP <125, order date 08/30/23, start date 08/31/23, and no end date. An observation on 08/31/23 at 8:31 a.m. RN A dispensed (1) 120 mg tablet of diltiazem to Resident #39 and not the 60 mg prescribed. 2. Record review of Resident #39's orders, dated 08/31/23, revealed a physician order for Potassium Chloride ER Oral Tablet Extended Release 10 MEQ (Potassium Chloride) Give 1 tablet by mouth one time a day for Hypokalemia, with an order date of 07/27/23, a start date of 07/28/23, no end date, and an order status of DISCONTINUED. Record review of Resident #39's orders, dated 08/31/23, revealed a physician order for Lisinopril Oral Tablet 10 MG (Lisinopril) Give 1 tablet by mouth one time a day for Blood Pressure HOLD FOR SYSTOLIC BLOOD PRESSURE <110 OR HR <60, with an order date of 07/27/23, a start date of 07/28/23, no end date, and an order status of DISCONTINUED. Record review of Resident #39's orders, dated 08/31/23, revealed a physician order for Furosemide Oral Tablet 20 MG (Furosemide) Give 1 tablet by mouth one time a day for Edema, with an order date of 07/27/23, a start date of 07/28/23, no end date, and an order status of DISCONTINUED. Record review of Resident #39's orders, dated 08/31/23, revealed a physician order for hydralazine HCl Oral Tablet 50 MG (Hydralazine HCl) Give 1 tablet by mouth every 8 hours for HTN Hold for B/P less than 110/70, with an order date of 08/24/23, a start date of 08/24/23, no end date, and an order status of DISCONTINUED. Record review of Resident #39's orders, dated 08/31/23, revealed a physician order for hydralazine HCl Oral Tablet 50 MG (Hydralazine HCl) Give 1 tablet by mouth three times a day for HTN Hold for B/P less than 120/70, with an order date of 08/25/23, a start date of 08/29/23, no end date, and an order status of DISCONTINUED. An observation on 08/31/23 at 8:31 a.m. RN A dispensed (1) 10 mEq ER tablet of potassium chloride (medication to treat and prevent low blood potassium), (1) 10 mg tablet of lisinopril (medication to treat high blood pressure), (1) 20 mg tablet of furosemide (This medication is known as a diuretic (like a water pill). It helps your body get rid of extra water by increasing the amount of urine you make. Getting rid of extra water decreases the strain on your heart and blood vessels, thereby lowering high blood pressure), and (1) 50 mg tablet of hydralazine (medication to treat high blood pressure) to Resident #39. 3. Record review of Resident #39's orders, dated 08/31/23, revealed a physician order for Pantoprazole Sodium Oral Tablet Delayed Release (designed to delay release of a drug in the body (as through the use of enteric coatings) usually until it passes through the stomach into the small intestine) 40 MG (Pantoprazole Sodium) Give 1 tablet by mouth two times a day for GERD (Gastroesophageal reflux disease), with an order date of 07/27/23, a start date of 07/27/23, no end date, and an order status of ACTIVE. Record review of Resident #39's orders, dated 08/31/23, revealed a physician order for Potassium Chloride ER Oral Tablet Extended Release (designed to slowly release a drug in the body over an extended period of time especially to reduce dosing frequency) 10 MEQ (Potassium Chloride) Give 1 tablet by mouth one time a day for Hypokalemia, with an order date of 07/27/23, a start date of 07/28/23, no end date, and an order status of DISCONTINUED. An observation on 08/31/23 at 8:31 a.m. RN A removed Tamsulosin capsule 0.4 mg, potassium chloride extended-release tablet 10 meq, midodrine tablet 5 mg, diltiazem tablet 120 mg, lisinopril tablet 10 mg, pantoprazole tablet 40 mg delayed release, furosemide tablet 20 mg, and hydralazine tablet from their packages. RN A then placed all the pills in the same bag and crushed them all together. RN A then took the crushed pills, mixed them with apple sauce, and administered them to Resident #39. 4. Record review of Resident #195, dated 8/31/23, revealed she was admitted to the facility on [DATE] with diagnoses which included hyperkalemia, displaced trimalleolar fracture of left lower leg, and unspecified asthma with acut exacerbation. Record review of Resident #195's orders, dated 08/31/23, revealed a physician order for, Polyethylene Glycol 3350 Powder (Polyethylene Glycol 3350 (Bulk)) Give 1 tsp by mouth one time a day for Constipation Mix with 4 oz of juice or water, order date 08/30/23, start date 08/31/23, and no end date. During an observation on 08/31/23 at 8:42 a.m. RN A mixed 1 cap (about 3.5 tsp) full of polyethylene glycol powder with a cup of water. RN A entered Resident #195's room and placed the cup on the counter across the room from Resident #195's bed. RN A administered other medications to Resident #195 and left the room. This surveyor asked RN A if he was done administering medications to Resident #195 and RN A stated yes. This surveyor asked about the polyethylene glycol mixture and RN A stated he forgot. RN A reentered Resident #195's room and moved the cup onto the Resident's bedside table and left the room. 5. Record review of Resident #195's orders, dated 08/31/23, revealed a physician order for, Fluticasone Propionate Nasal Suspension 50 MCG/ACT (Fluticasone Propionate (Nasal)) 2 sprays in each nostril one time a day for Nasal congestion, order date 08/26/23, start date 08/27/23, and no end date. During an observation on 08/31/23 at 8:42 a.m. RN A handed Resident #195 a bottle of Fluticasone Propionate Nasal spray and Resident #195 self-administered 2 sprays into each nostril. During an interview on 08/31/23 at 11:54 a.m. RN A stated he looks at the electronic medication administration record to verify medications when administering medications to residents. RN A then looked at the MAR and the physician orders and stated he could not find all the orders. RN A stated the potassium chloride he administered to Resident #39 was not an active order and that he should not crush extended-release pill or administered it. RN A stated he was trying to rush because he was being observed and did not check the medication orders. RN A stated when he checked Resident #39's blood pressure, it was good, so he administered the medication. RN A stated they do not hold the lisinopril when the residents blood pressure is good. RN A stated the resident cannot swallow the pills. RN B stated he crushed all the pills together because the resident would complain if he had to swallow an extended-release pill whole or if RN B crushed 10 pills separately. RN B stated you should not crush extended-release pills because it changes the absorption. RN B stated he spoke with the prescribing nurse practitioner, and they had discontinued the furosemide and lisinopril or all the blood pressure medications because they wanted to monitor the Resident's blood pressure but because the blood pressure was excellent, he did not need to hold the medications. RN A stated he forgot to give Resident #195 her polyethylene glycol powder with a cup of water, but he went back in the room and observed her taking it. During an interview on 08/31/23 at 12:12 p.m. the DON stated staff is expected to verify any medications against the MAR or TAR, verify the identity of the patient, and they should be able to see the active medication orders. The DON stated staff is expected to remove any medication that have been discontinued and dispose of them. The DON stated she was not sure why Resident #39's medications had been discontinued and administering medication without an active physician's order could cause the resident to have adverse effects. During an observation on 08/31/23 at 1:52 p.m. a nurse took Resident 39's blood pressure. The blood pressure reading was 106/54. During an interview on 08/31/23 at 2:24 p.m. NP C stated they had discontinued Resident #39's blood pressure medications because he was having issues with hypotension. The NP stated she was notified discontinued medications were administered to Resident #39. The NP stated she instructed nursing staff to alert her if his systolic (top number) blood pressure dropped below 100. The NP stated since the resident had a history of a brain bleed she wanted the systolic blood pressure to stay under 140. During a follow up interview on 09/01/23 at 10:47 a.m. the DON stated Resident #39 had his medications discontinued because he had been hypotensive (low blood pressure). The DON stated symptoms of hypotension could be dizziness, flush feeling, pale, and tachycardia (fast heart rate). The DON stated if a resident could self-administer medications, they put the order in and do a self-medication evaluation. The DON stated Resident #195 could not self-administer the nasal spray. The DON stated staff can leave medication at the bedside only If there is an order stating they can leave it at the bedside. Record review of the facility's policy titled Medication Administration, dated 02/02/21, stated policy : it is the policy of the facility that medications are to be administered as prescribed by the attending physician. Procedures: 1. only licensed medical and nursing personnel or other lawfully authorized staff members may prepare, administer, and record medications. 2. Medications must be administered in accordance with the written orders of the attending physician. 3. All current drugs and dosage schedules must be recorded on the patient's medical administration record (MAT and TAR) .6. The staff administering the medication must record the administration on the patient's MAR/TAR. 7. Should a drug be withheld, refused, or given other than at a scheduled time it should be appropriately documented as such on the MAR.

Based on record review and interview, the facility failed to complete an assessment which accurately reflected the resident's status for 1 of 24 (Resident #7) residents reviewed, in that: Resident #7's use of antipsychotics were not included in the resident's admission MDS assessments. This failure could result in inadequate care due to an incomplete assessment of her psychological condition. The findings included: Record review of Resident #7's face sheet, dated 09/01/2023, reflected the resident was admitted to the facility on [DATE] with a diagnoses including Alzheimer's Disease, Unspecified (A progressive disease that destroys memory and other important mental functions.) Record review of Resident #7's Admission MDS, dated [DATE], revealed a BIMS score of 12 which indicated moderate cognitive impairment. Further review of the initial medication assessment, completed by the Corporate LVN, reflected an answer of 5 days for question N0410A with regard to the question Indicate the number of days the resident received the following medications by pharmacological classification, not how it is used, during the last 7 days or since admission/entry or reentry if less than 7 days. Following this question and answer, the question N0450 was answered with No - Antipsychotics were not received to the question Did the resident receive antipsychotic medications since admission/entry or reentry or the prior OBRA assessment, whichever is more recent? Record review of Resident #7's order summary, dated, 09/01/2021, reflected an order for the medication Risperidone (an antipsychotic medication that can be used to treat Alzheimer's Disease) with a start date of 07/25/2023. Interview with the MDS Coordinator on 09/01/2023 at 10:46 AM, the MDS Coordinator stated Resident #7's Admission MDS was completed by a corporate LVN who supports her when her workload is too large. The MDS Coordinator stated she completed an audit of Resident #7's Admission MDS today and confirmed question N0450 was completed incorrectly and during the look-back period that this MDS is based on the antipsychotic was taken. The MDS Coordinator stated she was unaware why the Corporate LVN completed the MDS question N0450 incorrectly. Interview on 09/01/2023 at 11:10 AM, the DON stated the MDS assessments are completed either by herself or by the RN's of the facility and confirmed Resident #7 received an antipsychotic since admission and during the look-back period Resident #7 was taking the antipsychotic then as well. The DON stated it is her expectation that assessments were reflected in the MDS appropriately. Interview on 09/01/2023 at 3:57 PM, the ADM stated it was his expectation that the MDS for any resident is completed thoroughly and corrected based on the resident assessment tool. Record review of the facility policy, Minimum Data Set (MDS) Policy for MDS Assessment Data Accuracy, undated, reflected, The purpose of the MDS policy is to ensure each resident receives and accurate assessment by qualified staff to address the needs of the resident who are familiar with his/her physical, mental and psychological well-being.

Based on observation, interview, and record review the facility failed to ensure that pain management was provided to residents who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one of six residents reviewed (Resident #1) for pain management, in that Resident #1 had uncontrolled pain when she did not receive hydrocodone-acetaminophen 10-325 mg PRN as prescribed and requested for three days, due to it not being available in the building. This failure allowed Resident #1 to experience unnecessary pain and placed other residents at risk of uncontrolled pain and diminished quality of life. Findings included: Review of the undated face sheet for Resident #1 reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of encounter for surgical aftercare following surgery on the skin and subcutaneous tissue, type two diabetes mellitus, hypertension (high blood pressure), depression, insomnia, hyperlipidemia (high cholesterol), history of methicillin resistant staphylococcus aureus infection (a bacterial infection resistant to antibiotics), urge incontinence (a strong, sudden need to urinate that is difficult to delay), presence of left artificial hip joint, gastroesophageal reflux disease (heartburn), chronic pain syndrome, history of other infectious and parasitic diseases, muscle weakness, and long-term use of insulin. Review of the care plan for Resident #1 dated 11/06/22 and revised on 11/13/22 reflected the following: I have acute/chronic pain r/t surgical wound to sacrum post skin flap secondary to pressure ulcer. I will have effective pain control over next 90 days. Acknowledge presence of pains and discomfort. Listen to patient's concerns as needed. Administer pain medications per physician order and note effectiveness. Implement non-pharmacological interventions when able such as: positioning/support, exercise/stretching, ice packs/moist hot pack application, relaxation. Monitor for pain every shift and as needed. Notify physician as needed of any changes. It also reflected the following, dated 11/08/22: I am taking Opioid medication for pain relief. I had a surgical procedure of a surgical flap closure on the sacrum. I will be free of any discomfort or adverse side effects from opiod pain medication through the review date. Monitor for side effect of dependence, somnolence, nausea, vomiting, constipation, itching, slowed reaction, respiratory depression and addiction. Review of the admission MDS for Resident #1 dated 11/12/22 Section C Cognitive Patterns reflected a BIMS score of 15, indicating little or no cognitive impairment. Review of Section J Health Conditions reflected she had received scheduled pain medications, PRN pain medications, and non-medication intervention for pain in the five-day lookback period prior to the assessment. Review of physician orders for Resident #1 reflected the following: -Hydrocodone-acetaminophen 10-325 mg Give one tablet by mouth as needed every 8 hours for pain 7-10 started 12/09/22. -TraMADol HCl Oral Tablet 50 MG (Tramadol HCl) Give 2 tablet by mouth every 6 hours as needed for pain rating of 5-10 dated 12/10/22 -Evaluation pain q shift and document. every shift for Routine Screening; Pain; dated 11/05/22 Review of the December 2022 MAR for Resident #1 reflected the following administrations: -Hydrocodone-Acetaminophen 10-325 mg (Norco) given on 12/10/22 at 8:08 a.m. with an associated pain scale of 5. Follow up pain scale for this administration was listed as 0 out of 10. It was given on 12/10/22 at 7:18 p.m. with an associated pain scale of 7. Follow up pain scales for both administrations were 0 out of 10. -Tramadol HCl 50 mg given on 12/11/22 at 7:42 p.m. with an associated pain scale of 6 out of 10. Follow up pain scale for this administration was listed as a 2 out of 10. Administered again on 12/13/22 at 6:42 p.m. with a pain scale of 6. Follow up undetermined. Review of the controlled substances log for Resident #1 on 12/14/22 reflected that Tramadol was counted as give on 12/13/22 at 9:00 a.m. and signed by RN B. Hydrocodone-Acetaminophen had not been signed out at all on the log. Review of pain evaluations for Resident #1 dated 12/11/22 to 12/13/22 reflected the following: -Day evaluation 12/11/22 2 out of 10 -Evening evaluation 12/11/22 0 out of 10 -Day evaluation 12/12/22 2 out of 10 -Evening evaluation 12/12/22 2 out of 10 -Day evaluation 12/13/22 6 out of 10 Review of skilled nurse's notes for Resident #1 reflected each note included a pain assessment. These pain assessments were documented as follows: -12/11/22 11:32 p.m. pain was 7 out of 10 -12/12/22 8:29 p.m. pain was 7 out of 10 During interview on observation on 12/13/22 at 3:10 p.m., Resident #1 stated she was still waiting for a pain medication. Resident #1 stated she was supposed to get Norco, but they kept telling her that the pharmacy had not sent it. Resident #1 stated they have not had the medication in the building for three days, and in the meantime, they have only offered her Tramadol. Resident #1 stated Tramadol was what they prescribed for menstrual cramps in the 60s, and it was not effective for her. Resident #1 stated she accepted it once, but she has not bothered to take it again, because it did not help her pain. Resident #1 stated she was in pain during the interview. Resident #1 did not exhibit any outward signs of pain such as wincing, sweating, or grimacing. During an interview on 12/13/22 at 5:32 p.m., LVN A stated he had worked with Resident #1 the day prior, on 12/12/22. LVN A stated he thought she asked for Hydrocodone-Acetaminophen, but he did not have any to give her at that time. LVN A stated he offered Tramadol, but she did not accept and said it was not effective for her. LVN A stated she told him she was in pain, but she asked for the Hydrocodone-Acetaminophen with a flat affect. LVN A stated he assessed her for pain, and she was a at a 2 of 10. LVN A stated if she had indicated she was in more pain, he would have contacted the pharmacy for access to obtain a Hydrocodone-Acetaminophen from the facility emergency kit. During an interview on 12/13/22 at 6:06 p.m., RN B stated she worked 6:00 a.m. to 6:00 p.m. at the facility. RN B stated she had administered a Tramadol to Resident #1 that evening (12/13/22). RN B stated Resident #1's Hydrocodone-Acetaminophen was not in the building, because it had not been delivered to the pharmacy. RN B stated she had not spoken to the DON about the medicine not being available and was not entirely sure of the protocol for alerting the DON when a medication was not received from the pharmacy, but normally she would report to the DON. When asked why she did not report the situation to the DON, RN B did not have an answer. RN B stated Resident #1 preferred the Hydrocodone-Acetaminophen but was willing to take the Tramadol sometimes if her pain was too bad. During an interview on 12/13/22 at 6:10 p.m., RN C stated he worked the 6:00 p.m. to 6:00 a.m. shift. RN C stated Resident #1 had not reported any pain during his shifts. When asked about the skilled nursing notes in her chart that indicated her pain was at a 7 of 10, RN C stated they must have been entered by the other overnight nurse, RN E. RN C stated Resident #1 did not ask for any pain medication on his shift. RN C stated usually she did ask for pain medication one time first thing in the morning, and she wanted her Hydrocodone-Acetaminophen and would not take the Tramadol. RN C stated she always said her pain was 10 out of 10. RN C stated his understanding about the Hydrocodone-Acetaminophen was that it was supposed to have arrived the night before, 12/12/22, and should now arrive by tonight 12/13/22. RN C stated he had not talked to the DON or ADON about the missing medication and did not know if they were aware. An attempt was made on 12/13/22 at 7:03 p.m. to interview RN E by telephone, but she did not answer and did not return contact prior to exit. During an interview and observation on 12/14/22 at 8:08 a.m., RN D stated she was just about to administer Hydrocodone-Acetaminophen to Resident #1 who was complaining of pain at a scale of 7 out of 10. RN D stated the medication had arrived at the facility the night before, but this was the first time it had been administered. RN D pulled the blister pack out of the medication cart and presented it. Observation on 12/14/22 at 8:30 a.m. revealed DON called RN B on speaker phone and asked why the narcotic logbook listed an administration of Tramadol at 9:00 a.m. on 12/13/22 while the MAR had it listed as administered on 12/13/22 at 6:42 p.m. RN B told the DON the medication was administered at 9:00 a.m. but she did not document in the MAR until later, and the time in the MAR was incorrect. The DON asked RN B to correct the time. RN B stated that Resident #1's pain was at a 2 when it was reassessed after that administration of Tramadol. During an interview on 12/14/22 at 7:19 a.m., DON stated Resident #1 had a sacral flap (a surgery in which a piece of tissue is taken from a donor site and moved to another site with an intact blood supply) and she was very concerned about her pain medication. DON stated she was not sure exactly what the pain medication regimen was for the resident, but she tended to want Hydrocodone-Acetaminophen all the time regardless of what her pain scale was. DON stated Resident #1 told them the tramadol did not work for her, and the only medication she said worked for her pain was two Hydrocodone-Acetaminophen. DON stated that sometimes there was a delay in receiving medication from the pharmacy when they were waiting for a provider to send a triplicate (a special form required for writing prescriptions for certain narcotic medication). DON stated it was her understanding that the nurse began calling the NP for a refill on the order for Resident #1's Hydrocodone-Acetaminophen on 12/08/22 and the issue with the medication was the NP did not send the triplicate form. DON stated one of her staff had made her aware that the medication had not arrived at around noon the day before, 12/13/22. DON stated she spoke to Resident #1 and confirmed she was not in too much pain for the pain to be addressed by Tramadol, and they reached out again to the provider to ensure the prescription would be sent. When asked why a stronger pain medication had not been pulled from the emergency kit to give to Resident #1, DON stated staff were assessing her pain, and it was not in the range that required the Hydrocodone-Acetaminophen. DON stated her nurses were telling her that the Tramadol was reducing her pain to a 2 out of 10 when Resident #1 was willing to take it, and yet she was refusing. When asked if she felt they did not need to provide the stronger medication because they considered Resident #1 to be drug seeking, DON stated that did not play a role in their decision. DON stated if the resident was ordered a medication and wanted the medication, it should be administered when the resident wanted it. DON stated usually, they were able to get in touch with the provider and get the triplicate sent to the pharmacy. When asked what the procedure should have been if they could not get the triplicate sent in, and DON stated she would escalate to her boss to have her boss escalate it to the NP's boss. When asked why it was not escalated in that way in this situation, DON stated the nurses were assessing the resident, and she assessed the resident herself, and Resident #1 was not reporting a pain level to them that warranted offering the Hydrocodone-Acetaminophen. DON stated when she assessed Resident #1, she determined the resident's pain was a level six of ten, and the resident was amenable to the fact they were working very hard to provide her with her desired medication. DON stated that she was responsible for ensuring residents' pain was controlled. DON stated she did not think she had done any specific in-servicing on what to do if a medication had not arrived at the facility, but she felt the staff knew to reach out to her. During an interview on 12/14/22 at 8:19 a.m., NP stated she was not aware that Resident #1's Hydrocodone-Acetaminophen was not available from 12/11/22 to 12/13/22. NP stated the resident had been on a pain regimen for quite some time and had been ordered the Hydrocodone-Acetaminophen as needed every six hours. NP stated that she had reduced the frequency of the pain medication from every six to every eight hours on 12/09/22, and so the prescription probably required a new triplicate form to be provided to the pharmacy, but no one had reached out to her to ask for it. NP stated Resident #1 had experienced pain chronically and had been on Hydrocodone-Acetaminophen for many weeks. NP stated it was time to back the medication off slowly. NP stated the staff usually contacted her if there was an issue with a prescription at the pharmacy, but no one had called her about this. During an interview on 9:13 a.m., ADM stated Resident #1 should have had her medication available to her as it was ordered. ADM stated the DON was responsible for overseeing the program to ensure that residents had their pain medications and their pain was properly controlled. ADM stated that process was also monitored when the DON did a weekly review of the system which was sent to a clinical consultant for their company. When asked what negative impact not having a prescribed narcotic pain medication could have on a resident, ADM stated it could cause Resident #1 to be in pain and lower her quality of life. Review of facility policy dated 02/02/21 and titled Analgesia Policy & Procedure reflected the following: PURPOSE Pain is a medical problem that we face on a daily basis in our facility. Frequently patients arrive from the hospital with acute pain secondary to being transferred and transported to (facility name). This protocol should help with alleviating any delays in our attempts at controlling pain. POLICY Upon admission, all patients will be evaluated for pain. Pain level will also be evaluated every shift. Once a patient expresses the perception of pain or makes a request for pain medication, patient will be provided with a dose of analgesic pain medication or non-pharmacological intervention will be initiated. RESPONSIBLE AREAS: Nursing Staff PROCEDURE: -It is the responsibility of the individual staff member that heard the complaint to follow up and make sure that some intervention (pharmacological or otherwise) is initiated. -If a patient has an order for a pain medication from the hospital or one of our physicians, please use that order. Any scheduled pain medications should be given as close as time stated in MAR. -If there is no order and the patient is experiencing pain, contact the physician immediately to obtain an order for analgesia. -If no response is received timely, please call the Medical Director to obtain an order for analgesia. -In the interim, attempt non-pharmacological modalities for pain control such as repositioning, touch therapy, biofeedback, distraction (TV, conversation etc.).