Every finding on record at The Rehab Center at Bristol

Based on observation, record review, interview, and facility document and policy review, the facility failed to provide adequate supervision to prevent accidents for 1 (Resident #101) of 4 residents reviewed for falls. Specifically, the facility failed to provide the appropriate level of supervision for Resident #101 during bathing. The resident was left unsupported on a shower bench while a staff member stepped away to retrieve a towel. As a result, the resident fell from the shower chair and hit their head, causing a head injury that required hospitalization. Findings included:A facility policy titled Falls-Clinical Protocol, revised 03/2018, indicated, 1. The physician will help identify individuals with a history of falls and risk factors for falling. The policy also specified, 5. The staff will evaluate and document falls that occur while the individual is in the facility, for example, when and where they happen, any observations of the events, etc. [et cetera]. The policy also included a section titled, Cause Identification that specified, 1. For an individual who has fallen, the staff and practitioner will begin to try to identify possible causes within 24 hours of the fall; a. Often, multiple factors contribute to a falling problem; 2. If the cause of a fall is unclear, or if a fall may have significant medical cause such as a stroke or an adverse drug reaction (ADR), or if the individual continues to fall despite attempted interventions, a physician will review the situation and help further identify causes and contributing factors and, 3. The staff and physician will continue to collect and evaluate information until either the cause of the falling is identified, or it is determined that the cause cannot be found or is not correctable. An admission Record revealed the facility admitted Resident #101 on 03/06/2025. According to the admission Record, the resident had a medical history that included diagnoses of transient cerebral ischemic attack, unspecified symptoms and signs involving cognitive functions following other cerebrovascular disease, muscle weakness, difficulty in walking and need for assistance with personal care. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/10/2025, revealed Resident #101 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident had moderate cognitive impairment. The MDS indicated the resident required substantial/maximal assistance to shower/bathe self and for upper body dressing and was dependent for lower body dressing. According to the MDS, the resident was not assessed for tub/shower transfers during the assessment period. The MDS indicated the resident had functional limitation in range of motion in the upper extremity on one side and the lower extremities on both sides. Resident #101's Care Plan Report included the following: - A focus area, initiated on 03/11/2025, indicated the resident was at risk for falls related to deconditioning. Interventions directed staff to anticipate and meet the resident's needs and be sure the resident's call light was within reach, encourage the resident to use the call light for assistance, and provide prompt response to all requests for assistance. - A focus area, initiated on 03/11/2025, indicated the resident had a cerebral vascular accident which affected the resident's left side. Interventions directed staff to assist the resident with activities as tolerated, get the resident out of bed into a chair if tolerated, give medications as ordered by the physician, and observe for side effects and effectiveness. - A focus area, initiated on 03/11/2025, indicated the resident was on anticoagulation therapy. Interventions directed staff to administer anticoagulant medication as ordered by the physician, observe for medication side effects, and observe/report adverse reactions of anticoagulant therapy, to include blood-tinged or red blood in urine, black tarry stools, dark or bright red blood in stools, sudden severe headaches, nausea, vomiting, diarrhea, muscle joint pain, lethargy, bruising, blurred vision, shortness of breath, loss of appetite, sudden changes in mental status, and significant or sudden changes in vital signs. - A focus area, initiated on 03/11/2025, indicated the resident had an ADL self-care performance deficit related to activity intolerance and stroke. Interventions directed staff to encourage the resident to participate to the fullest extent possible with each interaction and encourage the resident to use a bell to call for assistance. The interventions did not address the level of care or number of staff required to assist the resident with bathing or other ADLs. A Fall Risk Evaluation, dated 03/06/2025 at 1:31 PM, indicated Resident #101 was at high risk for falls. The Fall Risk Evaluation indicated the resident was chairbound, had a change of condition in the last 14 days, and had a recent hospitalization in the last 30 days. The evaluation indicated an assessment of the resident's gait and balance could not be performed. A Baseline Care Plan, dated 03/06/2025 and completed by Licensed Practical Nurse (LPN) #27, indicated Resident #101 was assessed to require two or more persons' physical assistance for bathing. The Baseline Care Plan did not indicate the resident utilized a mobility device. An undated MDS Kardex Report (used to communicate residents' care needs to CNA staff) revealed Resident #101 required the extensive physical assistance of two people for bed mobility, transfers, and toilet use. The level of assistance or number of staff required for bathing was not addressed on the Kardex Report. Resident #101's Physical Therapy PT Therapy Progress Report with service dates from 04/18/2025 to 04/30/2025 indicated on 04/30/2025, Resident #101's dynamic sitting ability was at a fair-minus level, and the resident required moderate assistance with transfers. Resident #101's Physical Therapy (PT) Discharge Summary with service dates from 03/07/2025 to 05/02/2025, indicated upon discharge from therapy services on 05/02/2025, Resident #101's ability for dynamic sitting balance remained at a fair-minus level and the resident continued to require moderate assistance with transfers. An undated facility document titled, Sitting Balance Grades defined fair-minus as indicating the resident was able to sit unsupported for short periods but may lose balance easily without support; was able to sit with upper extremity support; could not perform dynamic tasks safely; could reach to the ipsilateral side (same side of the body); and was unable to weight shift. A Physiatry Progress Note dated 04/30/2025 at 8:01 PM indicated Resident #101 had decreased muscle strength in their left lower extremity and had a flaccid tone in the left upper extremity, which was supported with the use of a sling. A nursing Discharge Summary Note, dated 05/04/2025 at 9:40 AM, revealed Resident #101 was sent to the emergency room for radiological studies of the head on the left side. The nursing Discharge Summary Note revealed Resident #101 had slipped and fallen in the shower and experienced bleeding from the eyebrow with the presence of two small cuts and a lump that developed over their left eye. A late entry nursing Progress Note, dated 05/04/2025 at 10:37 AM and written by LPN #24, revealed CNA #1 provided Resident #101 a shower, during which the resident slipped off the shower seat and fell to the floor while being dried by CNA #1. The note indicated when the writer arrived to the resident's room, the resident was lying on the floor on their left side and was determined to have hit their forehead on the floor. The note indicated during an assessment, Resident #101 denied injury, but due to bleeding of the left eye, the resident's use of blood-thinning medications, elevated blood pressure, and the resident striking their head on the floor, the resident was transferred to the local hospital for evaluation. A nursing Progress Note dated 05/04/2025 at 1:10 PM, revealed Resident #101 was admitted to the hospital after the resident's blood pressure was unable to be stabilized after their transfer to the hospital. A review of a statement, handwritten by CNA #1, dated 05/07/2025, indicated on 05/04/2025 about 9:45 AM, the CNA was giving the resident a shower. The resident told the CNA that it was the first shower the resident had received since she had been admitted to the facility. The CNA indicated the resident was sitting in [the] shower and CNA #1 turned around to get a towel off the sink. The CNA wrote that the resident just went off [the] shower seat in the floor. She described the resident as having a hematoma on the left upper side of the resident's head, above their eye. A late entry Post Fall Evaluation note dated 05/04/2025 at 10:40 AM identified CNA #1 as a direct witness to Resident #101's fall. During a telephone interview on 09/25/2025 at 3:14 PM, CNA #1 stated she recalled providing Resident #101 a shower on 05/04/2025. CNA #1 stated following the resident's shower, the resident was sitting on the shower bench. The CNA turned around to get a towel from the nearby sink, and the resident fell to the floor. CNA #1 stated when she turned around, Resident #101 just leaned over and fell. CNA #1 stated she alerted the nurse, and she and the nurse transferred Resident #101 into the wheelchair, then CNA #1 dressed the resident. CNA #1 stated following the fall, the resident had a spot over their eye. CNA #1 stated she thought Resident #101 may have struck their head on a nearby commode during the fall. She stated the resident remained highly alert at the time of transfer to the hospital. Attempts to contact LPN #24, who was identified as the nurse on duty at the time of Resident #101's fall, were unsuccessful during the survey.A review of a statement, dated 05/04/2025 and handwritten by LPN #24, indicated she was called to the resident's room by CNA #1, who said the resident was on the floor. CNA #1 stated she gave the resident a shower and the resident slipped in the floor. LPN #24 entered the resident's bathroom to see the resident lying flat on the floor, facedown, on the resident's left side. The LPN wrote that the resident had a small knot forming over the left eyebrow and was bleeding from the area over the left eyebrow. Vital signs were obtained, and the resident's blood pressure was 179/108. Emergency medical services (EMS) was called and the resident was sent to the hospital. LPN #24 further wrote in her statement that she had called the emergency department to obtain an update on Resident #101 and was informed the resident would be admitted because they were unable to get the resident's blood pressure down. During an interview on 09/25/2025 at 3:02 PM, Physical Therapist (PT) #2 stated Resident #101 was able to sit and perform some reaching activities but needed physical support. During a follow-up interview on 09/26/2025 at 9:55 AM, PT #2 stated Resident #101 was able to sit in a wheelchair without falling to the side because the wheelchair had armrests. He stated the resident was able to sit, but if the resident reached for anything, the resident was likely to fall over. PT #2 stated it would not have been safe for staff to turn their back to Resident #101 while providing care because the resident was at risk of falling over quickly and easily. During an interview on 09/26/2025 at 2:28 PM, Registered Nurse (RN) #12 stated she remembered the incident with Resident #101 happened over the weekend, but she did not have firsthand knowledge of what happened. RN #12 stated that she knew Resident #101 leaned some, but she could not say if the resident needed one or two people for assistance with bathing. During an interview on 09/26/2025 at 2:28 PM, the Assistant Director of Nursing (ADON) stated she was aware Resident #101 had fallen. She said she recalled the resident's fall occurred in the shower on a weekend day. The ADON stated while CNA #1 was providing the resident a shower, CNA #1 turned around to retrieve a towel to dry the resident off and the resident fell. She said the resident was transferred to the hospital and did not return to the facility. The ADON stated CNAs were expected to know each resident's mobility needs by using the Kardex system. She stated if Resident #101 did not have the Kardex available, the CNA should have asked the nurse. The ADON stated she was unable to determine the number of staff members required to provide bathing assistance for Resident #101 on 05/04/2025. The ADON stated she expected CNA #1 to have knowledge of each resident's transfer status, physical ability, and limitations and if the resident had any safety concerns with transfers. During an interview on 09/27/2025 at 10:40 AM, Therapy Staff #29 stated she had limited knowledge of Resident #101 and recalled that the resident received physical therapy and occupational therapy and was very motivated in their treatment plan. She stated Resident #101 had hemiparesis on one side and needed maximal assistance for mobility. Therapy Staff #29 stated Resident #101 was extensively evaluated for their mobility and the assistance they required. She said the physical and occupational therapists were expected to communicate the level of care needed for each resident to the nursing staff. She indicated she would consider moderate assistance to be assistance of one person and maximal assistance times two (x 2) would have indicated the resident required the assistance of two people. During an interview on 09/27/2025 at 4:20 PM, LPN #3 stated she recalled Resident #101. She stated the resident had weakness on the left side and sometimes was observed to lean to the left side while seated in the wheelchair. LPN #3 stated she occasionally had to prop the resident up in the wheelchair. LPN #3 stated Resident #101 required the assistance of two staff members for bed mobility. LPN #3 stated she was trained that moderate assistance indicated the resident required one-person physical assistance, and maximal assistance indicated the resident required the assistance of two people to perform care. During an interview on 09/28/2025 at 9:21 AM, CNA #34 stated she knew how much assistance a resident needed by looking at the print-outs at the nurses' station. She stated these documents were printed by the night shift nurse and were kept at the nurses' station. She walked over to the nurses' station and provided a copy from a drawer and stated, They are shredded at the end of the day and that they were a working document, so there are no old copies. During an interview on 09/28/2025 at 9:41 AM, RN #12, the Unit Manager for the Rehab Unit, stated she was unsure if the staff had a report sheet that they used to communicate resident care needs. During an interview on 09/28/2025 at 11:23 AM, MDS Coordinator #11 stated residents' Kardex information was derived from the information he entered into the MDS assessments. He reviewed the Kardex Report for Resident #101 and acknowledged the section for bathing was blank. He stated he thought the resident would have required two people to transfer to the shower and one person to perform the shower. During an interview on 09/28/2025 at 11:48 AM, the ADON reviewed the Kardex for Resident #101. She acknowledged Resident #101's Kardex contained a section designated to address bathing assistance but that this section was blank; therefore, she was unsure how much assistance was required to provide bathing assistance for Resident #101. She was unable to explain how staff would have been able to determine the number of staff required to assist the resident with bathing. The ADON indicated she was unfamiliar with Resident #101 but stated if a resident leaned in their wheelchair, the resident was at risk to fall if not supported on that side of their body. During an interview on 09/28/2025 at 12:00 PM, the Administrator (ADM) stated she was not on duty at the time of Resident #101's fall. The ADM stated when she returned to work after that weekend, both she and the Director of Nursing (DON) spoke with CNA #1, who told them Resident #101 fell when she turned away to retrieve a towel. When asked what steps were taken to investigate the fall, the ADM stated she obtained written witness statements from CNA #1 and LPN #24 and determined that the fall was an accident. The ADM stated the fall was not reported to the state agency because it was not an incident/injury of unknown origin. Review of the facility's investigation documentation for Resident #101's fall revealed the investigation consisted only of obtaining witness statements from CNA #1 and LPN #24. The facility's investigation contained no evidence that the facility reviewed Resident #101's need for assistance or support while sitting and did not identify that CNA #1 turning her back, and leaving the resident unsupported on their weak/flaccid side created a situation in which the resident was at risk for experiencing a fall. As a result, the resident experienced a fall that resulted in a head injury requiring hospitalization.

Based on facility policy review, record review, facility document review, and interview, the facility failed to have evidence that allegations of abuse were thoroughly investigated for 4 (Residents #13, #92, #52, and #98) of 8 residents reviewed for abuse/neglect prohibition. The facility also failed to implement interventions to prevent further potential abuse/neglect while an investigation was in progress for 1 (Resident #98) of 8 residents reviewed for abuse/neglect prohibition.Findings included: A facility policy titled, “Abuse, Neglect, Exploitation or Misappropriation – Reporting and Investigating,” revised September 2022, revealed, “All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported.” The policy further revealed “Investigating Allegations” included “1. All allegations are thoroughly investigated. The administrator initiates investigations,” “2. Investigations may be assigned to an individual trained in reviewing, investigating and reporting such allegations,” “3. The administrator provides supporting documents and evidence related to the alleged incident to the individual in charge of the investigation,” “5. The administrator ensures that the resident and the person(s) reporting the suspected violation are protected from retaliation or reprisal by the alleged perpetrator, or by anyone associated with the facility,” “6. Any employee who has been accused of resident abuse is placed on leave with no resident contact until the investigation is complete,” and “7. The individual conducting the investigation as a minimum,” which included “a. reviews the documentation and evidence;” “b. reviews the resident's medical record to determine the resident's physical and cognitive status at the time of the incident and since the incident;” “c. observes the alleged victim, including his or her interactions with staff and other residents;” “d. interviews the person(s) reporting the incident;” “e. interviews any witnesses to the incident;” “f. interviews the resident (as medically appropriate) or the resident's representative;” “g. interviews the resident's attending physician as needed to determine the resident's condition;” “h. interviews staff members (on all shifts) who have had contact with the resident during the period of the alleged incident;” “i. interviews the resident's roommate, family members, and visitors;” “j. interviews other residents to whom the accused employee provides care or services;” “k. reviews all events leading up to the incident; and” “l. documents the investigation completely and thoroughly.” 1. An “admission Record” revealed the facility admitted Resident #13 on 03/20/2025. According to the admission Record, the resident had a medical history that included diagnoses of rheumatoid arthritis, pain in the right hip, depression, anxiety disorder, long term (current) use of anticoagulants (blood thinners), muscle weakness (generalized), and the need for assistance with personal care. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/08/2025, revealed Resident #13 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident had moderate cognitive impairment. The MDS indicated that the resident was dependent on staff to provide toileting hygiene and to roll left and right in bed. The MDS also indicated that the resident took antiplatelet medications during the assessment look-back period. Resident #13's “Care Plan Report” included a focus area initiated 03/24/2025, that indicated the resident was on anticoagulant therapy. Interventions directed staff to observe the resident for side effects and effectiveness (initiated 03/24/2025). The Care Plan Report included a focus area initiated on 03/24/2025, that indicated the resident had an activity of daily living (ADL) self-care performance deficit related to the need for assistance with personal care. Interventions directed staff to encourage the resident to discuss their feelings about the self-care deficit (initiated 03/24/2025). A “Facility Reported Incident Investigation and conclusion,” dated 04/06/2025 to 04/11/2025, revealed that on 04/06/2025, Resident #13 reported to a day shift certified nursing assistant (CNA), CNA #14, that an overnight CNA, CNA #22, was “rough” when changing Resident #13's brief and “pulled” on the resident's leg. The investigation revealed the resident pointed to the location where the CNA pulled on the resident, and there was bruising present. Per the investigation, the resident reported that they thought the CNA was aggravated, and that the CNA stated she had difficulty cleaning feces off the resident. According to the Facility Reported Incident Investigation and conclusion, CNA #22 was suspended during the investigation. The facility concluded that there was no harm intended to the resident; however, the facility decided that CNA #22 would not provide care to the resident during the remaining days of the resident's stay, unless there was an emergency. The investigation revealed no documented evidence that the facility interviewed/assessed other residents to whom the accused employee (CNA #22) provided care. The facility's investigation included written statements from CNA #22 and Licensed Practical Nurse (LPN) #21. Per their statements, they were providing incontinence care for Resident #13 when CNA #22 noticed “a small sore” and redness to the resident's “bottom.” According to LPN #21's statement, after they noticed the reddened area, the CNA got wipes to clean the resident because she thought wipes would be softer on the resident's skin. Per the investigation, CNA #22 and LPN #21 also reported that Resident #13 made no complaints and that they had a “pleasant” and “polite” conversation with the resident while they provided care. A typed statement dated 04/07/2025, signed by Registered Nurse (RN) #12, who was also a unit manager, revealed she spoke to Resident #13 regarding the allegation and observed the bruising to the resident's thigh. RN #12's statement revealed that she interviewed other residents who resided in the hall about their care on the night of 04/05/2025, and no one had any complaints of anyone being rough or rude with them. During an interview on 09/25/2025 at 8:58 A.M, RN #12 stated that once she learned of Resident #13's allegation, she initiated an investigation. She stated she and the Social [NAME] Director (SSD) interviewed Resident #13, and they each interviewed some of the residents who lived on the same hallway. RN #12 stated that she thought she documented the resident interviews that she conducted. Per RN #12, she and the SSD also talked to residents or families of residents who were not alert and oriented. She stated that if they felt like more than one resident was affected or if another resident had a concern, they would conduct skin assessments for all residents on the floor. RN #12 stated they gave all their information to the Administrator (ADM) and that she, the ADM, the Director of Nursing (DON), and the SSD concluded the allegation. During an interview on 09/25/2025 at 9:37 AM, the SSD stated that she and RN #12 interviewed Resident #13 and CNA #22. She stated that she also interviewed residents to determine whether CNA #22 was rough with them but did not remember which residents she spoke with. The SSD stated that the residents who were not cognitively intact were not interviewed; however, she stated they would know if nonverbal residents were abused because the families kept an eye on them, and therapy staff were very involved in the residents' care. During an interview on 09/25/2025 at 3:51 PM, the ADM stated she did not speak to Resident #13 about the incident because the DON was responsible for the investigation of the 04/06/2025 incident. The ADM revealed that for nonverbal residents, they assessed the potential risk for abuse by asking nearby residents or staff members if they had noticed any changes in residents; however, the ADM stated there was no documentation of resident interviews. The ADM stated that the ADM and DON were responsible for monitoring the investigative process, and the expectation was for a thorough investigation to be conducted. 2. An “admission Record” revealed the facility admitted Resident #92 on 10/03/2022. According to the admission Record, the resident had a medical history that included diagnoses of depression, anxiety, other chronic pain, muscle weakness, difficulty in walking, a need for assistance with personal care, and unspecified osteoarthritis. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/12/2025, revealed Resident #92 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident had intact cognition. The MDS revealed Resident #92's vision and hearing were adequate. The MDS indicated the resident did not exhibit any behavioral symptoms, hallucinations, or delusions during the assessment look-back period. Resident #92's “Care Plan Report” included a focus area initiated 04/27/2023, that indicated the resident had bladder incontinence and impaired mobility. Interventions directed staff to observe and report signs and symptoms of a urinary tract infection (UTI), such as altered mental status and changes in behavior (initiated 04/27/2023). An “admission Record” revealed the facility admitted Resident #52 on 03/01/2024. According to the admission Record, the resident had a medical history that included diagnoses of major depressive disorder, unspecified dementia, and unspecified hearing loss. A quarterly MDS, with an ARD of 09/08/2025, revealed Resident #52 had a BIMS score of 7, which indicated the resident had severe cognitive impairment. The MDS revealed the resident had adequate vision. The MDS indicated the resident was always incontinent of bowel and bladder and was dependent on staff to provide toileting hygiene. Resident #52's “Care Plan Report” included a focus area initiated 12/05/2024, that indicated the resident had a psychosocial well-being problem related to dementia. Interventions directed staff to explain all procedures and treatments (initiated 12/05/2024). A “Facility Reported Incident Investigation and conclusion,” dated 05/06/2025, revealed Resident #92 reported that Certified Nursing Assistant (CNA) #15 kicked the resident's leg when it was hanging off the resident's bed, and also kicked the resident's hairbrush across the floor when the resident asked the CNA to pick it up for them. The document indicated that Resident #92 also reported that CNA #15 had gotten into bed with Resident #52, Resident #92's roommate. Per the report, Resident #92 felt the relationship between Resident #52 and CNA #15 was inappropriate and “sexual” in nature because the CNA was on their knees on Resident 52's bed while the resident was in bed. Per the facility investigation, Resident #52 stated that no one had ever been inappropriate towards them and denied having any sexual relationships. According to the investigation, the facility concluded that there was no evidence to suggest that either resident was physically or sexually abused, assaulted, or exploited. The report revealed that CNA #15 was suspended and although abuse could not be proven, the facility felt it would be best for “all involved” if CNA #15 were no longer employed at the facility. Per the report, CNA #15's employment would be terminated. The investigation revealed no documented evidence that the facility staff interviewed or obtained statements from staff members who had contact with the residents during the period of the alleged incident; family members/visitors, or other residents to whom the accused employee provided care or services. There was also no documented evidence that the facility staff assessed Resident #52 or Resident #92 for injury. During an interview on 09/26/2025 at 9:55 AM, Registered Nurse (RN) #13, who was also a unit manager, stated that the 05/06/2025 allegation was the first allegation that she had investigated, and she was still learning at that time. RN #13 stated she interviewed Resident #92, who initially stated that CNA #15 kicked a hairbrush, and the brush hit the resident's leg, but did not say anything about Resident #52. RN #13 stated she thought the Administrator (ADM) and Therapy Staff #29 talked to Resident #92, which was when the resident told them that CNA #15 had their knees on the side of Resident #52's bed. She stated she assessed Resident #92's leg and there was no bruising or redness. RN #13 stated that she also assessed Resident #52 and there was no bruising or bleeding. According to RN #13, staff assessed the skin of all residents that CNA #15 had worked with to ensure there were no issues but was not sure whether they documented the assessments. Per RN #13, the ADM told her to interview everyone that was cognitively intact on the floor where Resident #52 and Resident #92 resided and ask the residents how CNA #15 and other staff were doing and if there was anything they would like to talk about. RN #13 stated that she did not remember whether she documented what the residents said. RN #13 also stated she thought she obtained staff statements but did not recall who the statements were from. Further, RN #13 stated staff interviewed CNA #15 via speaker phone, and the CNA denied the allegations. During an interview on 09/26/2025 at 10:33 AM, the ADM stated that she and Therapy Staff #29, who was the Director of Rehabilitation and an administrator in training, conducted the investigation together. She stated that they were interviewing Resident #52 about being kicked when the resident said they saw CNA #15 with their knees on the side of Resident #52's bed. The ADM stated Resident #92 told them the curtain was pulled, and the resident did not know what was going on but felt that it was sexual in nature. She stated they interviewed Resident #52, who stated that no one had touched them inappropriately. Per the ADM, Resident #52's family member did not want to send the resident to the hospital for evaluation. The ADM also stated that they interviewed the CNA who was taking care of the residents, and the CNA said there were no issues. She stated they also spoke with CNA #15, who denied the allegations. The ADM stated she did not document which staff were interviewed or obtain statements. During a follow-up interview on 09/25/2025 at 3:51 PM, the ADM stated that she and the Director of Nursing (DON) were responsible for monitoring the investigation process, and the expectation was for a thorough and fair investigation to be conducted. 3. An “admission Record” indicated the facility admitted Resident #98 on 12/11/2024 and readmitted the resident on 12/27/2024. According to the admission Record, the resident had a medical history that included diagnoses of anemia; acute embolism and thrombosis of unspecified deep veins of an unspecified lower extremity; anxiety disorder; long term (current) use of anticoagulants (blood thinning medication); depression; edema; muscle weakness; and difficulty in walking, not elsewhere classified. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/17/2024, revealed Resident #98 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. Resident #98's “Care Plan Report” included a focus area initiated 12/12/2024, that indicated the resident had a deep vein thrombosis (DVT; a blood clot) of the lower extremity, was on anticoagulant therapy, and had edema. Interventions initiated 12/12/2024 directed staff to assess the resident's fingers and toes for warmth and color, obtain the resident's vital signs, and notify the medical doctor of significant abnormalities. A facility document titled, “Facility Reported Incident (FRI),” dated 01/14/2025, revealed Resident #98 alleged that on 12/18/2024, a physical therapist “aggressively messaged” behind the resident's knee, “cutting off blood flow” to the resident's leg, and resulted in the resident going to the hospital. Per the FRI, the resident made the allegation on 12/31/2024 to an occupational therapist. The FRI indicated that concerns were addressed with the facility providers, who stated that treatment could not have caused numbness or pain. The FRI indicated that the pain was related to a blood clot and hematoma for which the resident was previously admitted to the hospital. The FRI indicated that it was explained to the resident's family member, there was no further discussion, and the team felt everything was okay until Resident #98 complained again to the SSD on 01/13/2025. The FRI indicated that the facility completed a grievance form; however, the resident then stated that they felt neglected. The “Employee action initiated or taken” section of the document indicated that Physical Therapist (PT) #8 “has not treated [Resident #98] since [their] return from the hospital.” The facility's investigation revealed no evidence that other residents were interviewed regarding the treatment they received from PT #8 or interventions implemented to protect other residents from abuse from PT #8 during the investigation. During an interview on 09/26/2025 at 9:17 AM, PT #8 stated Physical Therapy Aide (PTA) #6 voiced concerns about Resident #98's leg and asked him to look at the resident. PT #8 stated that he assessed the resident and assessed the resident again upon readmission from the hospital, which was when the resident made an allegation of abuse. According to PT #8, he was not suspended from work but did not treat Resident #98 during the investigation. During an interview on 09/26/2025 at 11:58 AM, Therapy Staff #29, who was the Director of Rehabilitation, stated PT #8's employment was not suspended during the investigation, and she could not recall how they protected Resident #98 or other residents from further potential abuse during the investigation. During an interview on 09/26/2025 at 12:48 PM, the Assistant Director of Nursing (ADON) stated she would have to review the facility's policy to determine whether PT #8 should have been suspended because she did not know the whole situation. During an interview on 09/26/2025 at 1:49 PM, the Administrator (ADM) revealed that Resident #98 alleged that PT #8 caused them to go to the hospital. The ADM stated that she was not sure if any other residents were interviewed. According to the ADM, PT #8 was not suspended pending the investigation but was removed from Resident #98's assignment and did not take care of the resident anymore.

Based on facility policy review, Centers for Disease Control and Prevention (CDC) guidance review, record review, observation, and interview, the facility failed to implement enhanced barrier precautions (EBP) for 1 (Resident #4) of 21 sampled residents. Specifically, the facility failed to post signage to communicate with staff about the need for EBP.Findings included: A facility policy titled, Policies and Practices-Infection Control, revised 10/2018, revealed, This facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary and comfortable environment and to help prevent and manage transmission of disease and infections. The policy revealed, 2. The objectives of our infection control policies and practices are to, which included c. establish guidelines for implementing isolation precautions, including standard and transmission-based precautions. CDC guidance titled, Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs), updated 07/12/2022, revealed Enhanced Barrier Precautions expand the use of PPE and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. The guidance revealed, Nursing home residents with wounds and indwelling medical devices are at especially high risk of both acquisition of and colonization with MDROs. Per the guidance, The use of gown and gloves for high-contact resident care activities is indicated, when Contact Precautions do not otherwise apply, for nursing home residents with wounds and/or indwelling medical devices regardless of MDRO colonization as well as for residents with MDRO infection or colonization. Implementation revealed, When implementing Contact Precautions or Enhanced Barrier Precautions, it is critical to ensure that staff have awareness of the facility's expectations about hand hygiene and gown/glove use, initial and refresher training, and access to appropriate supplies. The guidance revealed, To accomplish this included Post clear signage on the door or wall outside of the resident room indicating the type of Precautions and required PPE (e.g. [exempli gratia; for example], gown and gloves). The guidance continued, For Enhanced Barrier Precautions, signage should also clearly indicate the high-contact resident care activities that require the use of gown and gloves. The guidance continued, Make PPE, including gowns and gloves, available immediately outside of the resident room. An admission Record revealed the facility admitted Resident #4 on 08/18/2025 with a recent readmission on [DATE]. According to the admission Record, the resident had a medical history that included diagnoses of dementia, urinary tract infection, and need for assistance with personal care. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/24/2025, revealed Resident #4 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS indicated the resident had an indwelling urinary catheter. Resident #4's Order Summary Report, with active orders as of 09/24/2025, contained an order, dated 09/15/2025, for an indwelling urinary catheter. Resident #4's Progress Note, dated 09/15/2025 at 6:23 PM, revealed Resident #4 had an indwelling urinary catheter at the time of admission. Observations on 09/23/2025 at 8:49 AM and 09/25/2025 at 9:06 AM revealed the door to Resident #4's room contained no posted signage to indicate the resident was on EBP nor was PPE readily available in or around the resident's room. During an interview on 09/25/2025, at 12:28 PM, Licensed Practical Nurse (LPN) #5 stated that any resident who had an indwelling urinary catheter should be placed on EBP. LPN #5 stated that staff used signage posted on resident doors to determine what PPE was required to be worn for providing care. LPN #5 stated she did not think Resident #4 was currently on EBP, but acknowledged the resident had an indwelling urinary catheter. During an interview on 09/26/2025 at 2:05 PM, the Assistant Director of Nursing stated that any resident who had an indwelling urinary catheter needed to be placed on EBP. During an interview on 09/27/2025 at 1:15 PM, the Administrator stated she referred her expectation of EBP to her clinical team.

Based on facility policy review, record review, observation, and interview, the facility failed to ensure respiratory care and services were provided in accordance with professional standards of practice for 2 (Resident #2 and Resident #49) of 5 residents reviewed for respiratory therapy. Specifically, the facility failed to change oxygen tubing weekly according to physician orders for Resident #2 or Resident #49.Findings included: A facility policy titled, Departmental (Respiratory Therapy) - Prevention of Infection, revised November 2011, revealed, 7. Change the oxygen cannulae [sic] [a flexible tubing used to deliver oxygen through the nostrils] and tubing every seven (7) days, or as needed. 1. An admission Record revealed the facility originally admitted Resident #2 on 09/12/2024 and most recently readmitted the resident on 06/25/2025. According to the admission Record, the resident had a medical history that included diagnoses of malignant neoplasm of the breast (breast cancer), and weakness. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/03/2025, revealed Resident #2 had a Brief Interview for Mental Status (BIMS) score of 11, which indicated the resident had moderate cognitive impairment. Resident #2's Order Summary Report, with active orders as of 09/22/2025, contained an order, dated 09/09/2025, for the use of supplemental oxygen at 2 liters per minute (L/min) continuously via nasal cannula. The Order Summary Report also included an order, with a start date of 09/14/2025, for the oxygen tubing to be changed weekly on the night shift. Resident #2's September 2025 Medication Administration Record [MAR] indicated staff documented that Resident #2's oxygen tubing was changed on 09/21/2025. An observation on 09/22/2025 at 11:13 AM revealed Resident #2's oxygen tubing was dated 09/15/2025. On 09/23/2025 at 11:41 AM, Licensed Practical Nurse (LPN) #17 observed Resident #2's oxygen tubing and stated the resident's tubing was dated 09/15/2025. LPN #17 stated that the nightshift nurses were responsible for changing the oxygen tubing, and Registered Nurse (RN) #13 checked to ensure the night nurses changed the tubing. During an interview on 10/01/2025 at 7:56 AM, LPN #18, whose initials matched the initials of the staff member who documented changing Resident #2's oxygen tubing on the MAR, stated that oxygen tubing was supposed to be changed every Sunday night. LPN #18 stated there was no reason the tubing would not be changed, and the tubing should be labeled every time it was changed. LPN #18 stated she must have missed Resident #2 when she was changing oxygen tubing. 2. An admission Record, revealed the facility admitted Resident #49 on 06/02/2025. According to the admission Record, the resident had a medical history that included diagnoses of chronic obstructive pulmonary disease (COPD), shortness of breath, and dependence on supplemental oxygen. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/17/2025, revealed Resident #49 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS indicated Resident #49 received oxygen therapy during the assessment timeframe. Resident #49's Care Plan Report included a focus area, initiated 07/22/2025, that indicated the resident was at risk for impaired gas exchange. Interventions directed staff to administer supplemental oxygen as ordered (initiated 07/22/2025). Resident #49's Order Summary Report, with active orders as of 09/22/2025, contained an order, dated 07/18/2025, for the use of supplemental oxygen at 3 liters per minute (L/min) as tolerated via nasal cannula. The Order Summary Report also contained an order, dated 07/18/2025, that indicated oxygen tubing should be changed weekly on every Sunday nightshift. Resident #49's, September Medication Administration Record [MAR] revealed staff documented that Resident #49's oxygen tubing was changed on 09/21/2025. An observation on 09/22/2025 at 11:32 AM revealed Resident #49's oxygen tubing was dated 09/01/2025. An observation on 09/23/2025 at 11:25 AM revealed Resident #49's oxygen tubing was dated 09/01/2025. On 09/23/2025 at 11:27 AM, Licensed Practical Nurse (LPN) #17 observed Resident #49's oxygen tubing and stated that the resident's oxygen tubing was dated 09/01/2025. During an interview on 10/01/2025 at 7:56 AM, LPN #18, whose initials matched the initials of the staff member who documented changing Resident #18's oxygen tubing on the MAR, stated oxygen tubing was supposed to be changed every Sunday night. LPN #18 stated there was no reason the tubing would not be changed, and the tubing should be labeled every time it was changed. LPN #18 stated she must have missed Resident #49 when she was changing oxygen tubing. During an interview on 09/24/2025 at 2:13 PM, Registered Nurse (RN) #13 stated oxygen tubing was supposed to be changed every Sunday night, and she checked each room to ensure the oxygen tubing was changed. During an interview on 09/24/2025 at 2:20 PM, the Assistant Director of Nursing (ADON) stated that the unit managers were responsible for monitoring that oxygen tubing was changed. The ADON stated that she expected oxygen tubing to be changed weekly. During an interview on 09/26/2025 at 11:39 AM, the Administrator (ADM) stated the unit managers were responsible for monitoring to ensure that oxygen tubing was changed, and the charge nurses were expected to change the tubing.

Based on facility policy review, record review, facility document review, and interview, the facility failed to ensure an allegation of abuse was reported within two hours, which affected 1 (Resident #98) of 8 residents reviewed for abuse or neglect prohibition. Findings included: A facility policy titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, revised 09/2022, revealed All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. The policy revealed, 1. If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. The policy revealed, 3. 'Immediately' is defined as, which included a. within two hours of an allegation involving abuse or result in serious bodily injury. An admission Record indicated the facility admitted Resident #98 on 12/11/2024 and readmitted the resident on 12/27/2024. According to the admission Record, the resident had a medical history that included diagnoses of anemia; acute embolism and thrombosis of unspecified deep veins of an unspecified lower extremity; anxiety disorder; long term (current) use of anticoagulants (blood thinning medication); depression; edema; muscle weakness; and difficulty in walking, not elsewhere classified. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/17/2024, revealed Resident #98 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. Resident #98's Care Plan Report, included a focus area initiated 12/12/2024, that indicated the resident had a deep vein thrombosis (DVT; a blood clot) of the lower extremity, was on anticoagulant therapy, and had edema. Interventions initiated 12/12/2024 directed staff to assess the resident's fingers and toes for warmth and color, obtain the resident's vital signs, and notify the medical doctor of significant abnormalities. Resident #98's hospital Discharge Summary, dated 12/27/2024 at 12:21 PM, indicated the residents' admission diagnoses included swelling and anemia and discharge diagnoses included a right thigh hematoma. Per the summary, a repeat sonogram of the lower extremity did not show any DVTs. A Grievance Form dated 01/13/2025, completed by the Social Services Director (SSD), revealed Resident #98 reported a grievance regarding concerns with therapy staff. The document indicated that the resident expressed that a recent hospitalization was allegedly due to a therapist, who attempted to manipulate the resident's knee. The form also indicated that according to the resident, on one occasion when therapy staff assisted the resident out of bed, they removed the resident's sheets and instructed the certified nursing assistants (CNAs) to not make the bed until the resident remained seated in a chair for an extended period of time. Per the form, Resident #98 felt they were neglected by therapy staff and was getting minimal time with them. The Nature of Resolution section of the Grievance Form indicated that on 12/31/2024, Therapy Staff #29 was notified of the concern related to the resident's blood clots. The form revealed no documented evidence that staff notified the Administrator or the state survey agency (SSA) of the resident's allegation at the time of the grievance. A facility document titled, Facility Reported Incident (FRI) indicated that the facility reported an allegation of neglect involving Resident #98 to the SSA. The FRI indicated that the resident was complaining of their leg being numb and painful, and alleged that a blood clot was dislodged by a therapist, causing the resident to be hospitalized . Per the FRI, Resident #98 alleged that on 12/18/2024, a physical therapist aggressively messaged behind the resident's knee, cutting off blood flow to the resident's leg, and resulted in the resident going to the hospital. Per the FRI, the resident made the allegation on 12/31/2024 to an occupational therapist. The FRI indicated that concerns were addressed with the facility providers, who stated that treatment could not have caused numbness or pain. The FRI indicated that the pain was related to a blood clot and hematoma for which the resident was previously admitted to the hospital. The FRI indicated that it was explained to the resident's family member, there was no further discussion, and the team felt everything was okay until Resident #98 complained again to the SSD on 01/13/2025. The FRI indicated that the facility completed a grievance form; however, the resident then stated that they felt neglected. Per the FRI, the Incident date was 12/18/2024, and the report date was 01/14/2025. A Facility Reported Incident Fax Cover Sheet indicated that the facility submitted an initial report for an allegation of neglect to the SSA on 01/14/2025 at 8:14 PM, a day after Resident #98 voiced allegations of abuse/neglect and the SSD completed the Grievance Form. A typed statement signed by Physical Therapist (PT) #2, dated 01/15/2025, indicated that he evaluated Resident #98 after their return from the hospital on [DATE]. Per the statement, Resident #98 told PT #2 that my boss was the reason they had to go to the hospital, claiming that he squeezed the resident's leg hard. The statement indicated that the resident described the staff member who squeezed their leg as PT #8 on one occasion, and a nurse practitioner on another. The facility's investigation related to the allegation revealed no documented evidence that PT #2 reported the resident's allegation to the Administrator or that a report was made to the SSA at the time the resident made the allegation to PT #2. During an interview on 09/26/2025 at 9:55 AM, PT #2 stated he evaluated Resident #98 when they came back from the hospital but stated that he could not remember exactly what the resident said. A typed statement signed by Therapy Staff #29, who was also the Director of Rehabilitation, dated 01/14/2025, revealed that on 12/31/2024, Occupational Therapist (OT) #31 notified her that Resident #98 had concerns that a physical therapist caused the resident to go to the hospital. Per the statement, Resident #98 claimed that PT #8 aggressively massaged their leg, specifically behind their knee, resulting in pain and hospitalization. Therapy Staff #29's statement revealed that she asked the therapy team for statements and discussed the resident's claims with the interdisciplinary team (IDT). According to the statement, Therapy Staff #29 also spoke with the resident's nurse practitioner, who stated that it was very unlikely that PT #8's assessment caused any issues with the resident's lower extremity. The statement also revealed that it was not unusual for physical therapy staff to conduct that type of assessment when a blood clot was suspected. Therapy Staff #29's statement revealed that she received a grievance form regarding Resident #98's allegations, on 01/14/2025. The facility's investigation related to the allegation revealed no documented evidence that Therapy Staff #29 reported the allegation from staff on 12/31/2024 to the Administrator or that a report was made to the state SSA at the time of the allegation. During an interview on 09/26/2025 at 11:58 AM, Therapy Staff #29 stated that on 12/31/2024, OT #31 reported that Resident #98 had voiced concerns that a physical therapist caused the resident to go to the hospital. She stated that OT #31 did not mention anything about a staff member being aggressive; subsequently, she did not think abuse was being discussed. She stated that on 12/30/2024, Resident #98 had also told PT #2 that a therapist had squeezed their leg, hard; however, Therapy Staff #29 did not know whether she was notified of the concern or if she saw PT #2's statement. Per Therapy Staff #29, she spoke with staff and Resident #98's family member. She stated she was not aware there were any further concerns until the SSD gave her a grievance form on 01/14/2025. During an interview on 09/28/2025 at 12:06 PM, the Administrator stated Resident #98's concerns were brought to her attention on 01/14/2025, during a 10:00 AM morning meeting after the grievance was filed, and she then notified the SSA of the allegations via fax. She stated that the time on the Facility Reported Incident Fax Cover Sheet was the time she notified the appropriate agencies. During a follow-up interview on 09/26/2025 at 1:49 PM, the Administrator stated that when she saw the grievance and the team reported what happened, they decided it would be better to make a report to the SSA rather than a completing a grievance because the resident was making an accusation against the therapist. She stated that allegations of abuse should be reported within two hours.

Based on facility policy review, record review, interview, and observation, the facility failed to develop and implement comprehensive person-centered care plans for 5 (Residents #2, #4, #7, #34, and #45) of 21 sampled residents. Specifically, the facility failed to develop care plans to address indwelling urinary catheters, intravenous (IV) catheters, or oxygen therapy.Findings included: A facility policy titled, Care Plans, Comprehensive Person-Centered, revised March 2022, indicated, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The policy revealed, 11. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. A facility policy titled, Oxygen Administration, revised October 2010, revealed, Preparation included, 2. Review the resident's care plan to assess for any special needs of the resident. 1. An admission Record revealed the facility admitted Resident #7 on 01/30/2025. According to the admission Record, the resident had a medical history that included a diagnosis of cerebral infarction (a stroke). A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/14/2025, revealed Resident #7 had a Brief Interview for Mental Status (BIMS) score of 6, which indicated the resident had severe cognitive impairment. The MDS indicated the resident had an indwelling urinary catheter. Resident #7's Order Summary Report, with active orders as of 09/29/2025, contained an order, dated 09/09/2025, for an indwelling urinary catheter. Resident #7's Care Plan Report revealed it did not include a focus area or interventions related to the resident having an indwelling urinary catheter. 2. An admission Record revealed the facility admitted Resident #4 on 08/18/2025. According to the admission Record, the resident had a medical history that included diagnoses of dementia, dependence on supplemental oxygen, blindness in the right eye, muscle weakness, difficulty in walking, and need for assistance with personal care. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/24/2025, revealed Resident #4 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS indicated that the resident had an indwelling urinary catheter. The MDS indicated Resident #4 received oxygen therapy. The MDS Care Area Assessment (CAA) Summary indicated that the Urinary Incontinence and Indwelling Catheter care area triggered and indicated that a care plan decision was made. Resident #4's Order Summary Report, with active orders as of 09/24/2025, contained an order, dated 09/15/2025, for an indwelling urinary catheter. The Order Summary Report also contained an order, dated 09/15/2025, for continuous oxygen at two liters per minute (L/min) via nasal cannula (flexible tubing to deliver oxygen directly to the nostrils). Resident #4's nursing Progress Note, dated 09/15/2025 at 6:23 PM, revealed that upon admission to the facility, Resident #4 received oxygen therapy and had an indwelling urinary catheter. Observations on 09/23/2025 at 8:49 AM and on 09/25/2025 at 9:06 AM revealed Resident #4 received supplemental oxygen. Resident #4's Care Plan Report revealed it did not include a focus area or interventions related to the resident's indwelling urinary catheter. The Care Plan Report revealed that it also did not include a focus area or interventions related to the resident receiving supplemental oxygen. 3. An admission Record revealed the facility admitted Resident #34 on 08/01/2019. According to the admission Record, the resident had a medical history that included diagnoses of dementia, peripheral vascular disease, and type 2 diabetes mellitus. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/29/2025, revealed Resident #34 had a Brief Interview for Mental Status (BIMS) score of 0, which indicated the resident had severe cognitive impairment. Resident #34's Order Summary Report, with active orders as of 09/30/2025, contained an order, dated 09/17/2025, for a midline IV catheter to administer IV antibiotics. Resident #34's Care Plan Report revealed it did not include a focus area or interventions related to the resident's midline IV catheter. 4. An admission Record revealed the facility admitted Resident #45 on 05/15/2025. According to the admission Record, the resident had a medical history that included diagnoses of benign prostatic hyperplasia without lower urinary tract symptoms and dependence on supplemental oxygen. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/13/2025, revealed Resident #45 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident had intact cognition. The MDS indicated Resident #45 received oxygen therapy. The MDS indicated the resident had an indwelling urinary catheter. The MDS Care Area Assessment (CAA) Summary indicated that the Urinary Incontinence and Indwelling Catheter care area triggered and indicated that a care plan decision was made. Resident #45's nursing Progress Note, dated 09/29/2025 at 1:25 AM, revealed the resident's indwelling urinary catheter was changed. During an observation on 09/26/2025 at 1:04 PM, Resident #45 received supplemental oxygen. Resident #45's Care Plan Report revealed it did not include a focus area or interventions related to the resident's indwelling urinary catheter. The Care Plan Report revealed that it also did not include a focus area or interventions related to the resident receiving supplemental oxygen. 5. An admission Record revealed the facility originally admitted Resident #2 on 09/12/2024 and most recently readmitted the resident on 06/25/2025. According to the admission Record, the resident had a medical history that included diagnoses of malignant neoplasm of the breast (breast cancer), and weakness. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/03/2025, revealed Resident #2 had a Brief Interview for Mental Status (BIMS) score of 11, which indicated the resident had moderate cognitive impairment. Resident #2's Order Summary Report, with active orders as of 09/22/2025, contained an order, dated 09/09/2025, for the use of supplemental oxygen at 2 liters per minute (L/min) continuously via nasal cannula (a flexible tubing used to deliver oxygen through the nostrils). Resident #2's September 2025 Medication Administration Record [MAR] included a transcription of the physician's order, dated 09/09/2025, for supplemental oxygen at 2 L/min via nasal cannula. An observation on 09/22/2025 at 11:13 AM revealed Resident #2 received supplemental oxygen. Resident #2's Care Plan Report revealed that it did not include a focus area or interventions related to the resident's use of oxygen. During an interview on 09/24/2025 at 2:13 PM, Registered Nurse (RN) #13 stated that the MDS nurses were responsible for ensuring the care plans were updated to include the use of supplemental oxygen. During an interview on 09/26/2025 at 9:44 AM, MDS Coordinator #11 stated that the use of supplemental oxygen needed to be care planned, and he was in the process of updating all the care plans. During an interview on 09/26/2025 at 12:10 PM, MDS Coordinator #11 stated that comprehensive care plans began to be developed upon a resident's admission to the facility. He stated that when the MDS was completed, the care plan was updated with any additional information identified through the MDS assessment. MDS Coordinator #11 stated that care plans were updated following clinical meetings and risk meetings, if needed. He stated that if he was not informed of a change in a resident's care or condition, then he would not know to update the care plan. During an interview on 09/24/2025 at 2:20 PM, the Assistant Director of Nursing (ADON) stated she expected that care plans were updated and accurate. The ADON stated oxygen use should have been care planned. During an interview on 09/26/2025 at 2:05 PM, the ADON stated that if a resident had an indwelling catheter, then it should be addressed in the resident's care plan. During an interview on 09/26/2025 at 11:39 AM, the Administrator (ADM) stated that the Director of Nursing (DON), unit managers, and MDS nurses were responsible for ensuring the care plans were updated. The ADM stated she expected care plans to meet regulatory requirements and to be updated to provide a guide for the residents' care. During an interview on 09/27/2025 at 1:15 PM, the ADM stated she expected care plans to be updated as needed.

Based on facility policy review, record review, and interview, the facility failed to develop and implement a baseline care plan for 1 (Resident #97) of 21 sampled residents.Findings included:A facility policy titled, Care Plans - Baseline, revised 03/2022, revealed A baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident within forty-eight (48) hours of admission. Resident #97's admission Record indicated the facility admitted the resident on 08/05/2025. According to the admission Record, the resident had a medical history that included diagnoses of noninfective gastroenteritis and colitis. The admission Record indicated the resident discharged home on [DATE]. A Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/11/2025, revealed Resident #97 had a Brief Interview for Mental Status (BIMS) score of 0, which indicated the resident had severe cognitive impairment. The MDS indicated the resident was dependent on staff for all activities of daily living (ADLs) and mobility. Resident #97's Care Plan Report indicated, no data found.During an interview on 09/26/2025 at 10:22 AM, Certified Nursing Assistant (CNA) #9 stated that a baseline care plan was needed for her to review what kind of care the resident required.During an interview on 09/26/2025 at 10:25 AM, Registered Nurse (RN) #10 stated the nurses were responsible for initiating baseline care plans. RN #10 stated the unit manager also checked to see if the baseline care plans were completed.During an interview on 09/26/2025 at 12:28 PM, MDS Coordinator #11 stated nursing staff should complete baseline care plans within 24 hours of admission and were handled by unit managers specifically.During an interview on 09/26/2025 at 12:33 PM, RN #12 stated she was the unit manager on the first floor. RN #12 stated baseline care plans should be completed within 24 hours of admission by the charge nurse. She stated the baseline care plan included the resident's name, the resident's representative, and code status. RN #12 stated the baseline care plan included the resident's ADL care needs prior to admission. She stated she reviewed every new admission the day after they came in.During an interview on 09/26/2025 at 12:54 PM, RN #13 stated she was the unit manager on the second floor. RN #13 stated the baseline care plan should be completed within 24 hours after admission, and they entailed what kind of care residents needed. She stated that when a new resident was admitted , she completed the admission assessment. RN #13 stated the day shift nurse went through and put orders in, and the night shift nurse double checked and made sure all assessments were completed. RN #13 stated she triple checked and made sure the assessments and orders were in. RN #13 stated she was on vacation during the week Resident #97 was admitted .During an interview on 09/26/2025 at 1:39 PM, the Assistant Director of Nursing (ADON) stated baseline care plans were completed for new admissions by MDS coordinators within the first 24 hours of admission. The ADON stated the baseline care plan was a basic initial plan of care.During an interview on 09/24/2025 at 9:49 AM, the Administrator (ADM) stated she could not find a baseline care plan for Resident #97.During a follow-up interview on 09/26/2025 at 1:47 PM, the ADM stated baseline care plans should be completed on admission. The ADM stated she would have to look at the regulations but believed baseline care plans should be completed within 24 hours. The ADM stated the admissions nurses and unit managers oversaw the process and stated that the unit manager at the time of Resident #97's admission was on vacation.

Based on staff interview and clinical record review, the facility staff failed to provide notice of rights and services prior to or upon admission for 1 of 6 residents, Resident #1. The findings include. The facility staff failed to provide Resident #1 with a notice of rights and services upon their admission to the facility or prior to admit. This paperwork was not provided to Resident #1 until 3 days after their admission to the facility. This was a closed record review. Resident #1's diagnoses included, but were not limited to, atrial fibrillation, traumatic brain injury, epilepsy, and anxiety disorder. Section C (cognitive patterns) of Resident #1's admission minimum data set (MDS) assessment with an assessment reference date (ARD) of 10/22/24 included a brief interview for mental status (BIMS) score of 5. Per the MDS manual a score of 5=severe impairment in cognitive skills for daily decision making. Resident #1 had been admitted to the facility on a Friday. The clinical record included signed copies of Resident #1's admission paperwork to include, resident rights and responsibilities. Resident #1 signed and dated these documents on the Monday three days after their admission to the facility. On 02/25/25 at 11:30 a.m., during an interview with the admissions staff, this staff stated they worked Monday-Thursday and Resident #1 was not provided their admission paperwork until the Monday after their admission on the previous Friday. On 02/25/25 at 4:10 p.m., during a meeting with the Administrator, Director of Rehab, Director of Nursing, and Assistant Director of Nursing the Administrator stated they had resident rights posted throughout the facility. No further information regarding this issue was provided to the survey team prior to the exit conference.

Based on staff interview and clinical record review, the facility staff failed to provide evidence that they had obtained a provider ordered laboratory test for 1 of 6 residents, Resident #1. The findings include. The facility staff failed to provide evidence that they had obtained the provider ordered laboratory test urinalysis (UA). This was a closed record review. Resident #1's diagnoses included, but were not limited to, atrial fibrillation, traumatic brain injury, epilepsy, and anxiety disorder. Section C (cognitive patterns) of Resident #1's admission minimum data set (MDS) assessment with an assessment reference date (ARD) of 10/22/24 included a brief interview for mental status (BIMS) score of 5. Per the MDS manual a score of 5=severe impairment in cognitive skills for daily decision making. Section GG (functional abilities) was coded to indicate a toilet transfer was not attempted with this resident due to medical conditions or safety concerns. Section H (bladder/bowel) was coded to indicate this resident was always incontinent of urine. Resident #1's comprehensive care plan included the focus area has an activities of daily living self-care performance deficit. The clinical record included a provider progress note with a date of service of 10/24/24 that included the following documentation .seen today at the request of the facility .has complaints today of dysuria and recently finished her antibiotics. Vital signs stable and no fever reported. Staff without any other acute concerns to report today .Orders for this Visit UA C/S [culture and sensitivity] send out .DIAGNOSES .Urinary tract infection, site not specified . The clinical record included an order summary report that included the order UA C/S for confusion. The order date was documented as 10/25/24 and the order status read completed. During the clinical record review, the surveyor was unable to find the results of the UA. The clinical record included documentation on 10/24/24, 10/25/24, and 10/26/24 by the nursing staff that Resident #3 was continent of bladder, their urine was clear yellow, and the resident denied any urinary complaints. The nursing staff also documented on 10/25/24 that the resident was incontinent of urine, urine yellow in color, no urinary complaints, and the resident uses adult briefs. On 02/25/25 at 2:55 p.m., during an interview with Registered Nurse (RN) #4 this staff was asked the procedure for collecting a UA. RN #4 stated they would put the order in the computer, complete the lab slip, attempt to collect the urine sample, if unable to collect report it to the oncoming shift, and if still unable to collect notify the provider. RN #4 stated if the staff were unable to collect the urine sample they would expect to see a progress note. On 02/25/25 at 3:00 p.m., the surveyor interviewed RN #3 regarding the collection of a urine sample. RN #3 stated if the resident was continent, they would supply them with a urine collection device hat or use a specimen cup provided by the laboratory company. If someone was incontinent, they would reach out to the provider for an order for a straight catheterization, hydrate the resident, once the specimen was obtained it was put in the refrigerator, and the courier called. On 02/25/25 at 5:35 p.m., during a meeting with the Administrator, Director of Nursing, Assistant Director of Nursing and Director of Rehab the issue with the missing UA results was reviewed. The Administrative staff stated the resident was sent out per the spouse's request either prior to the UA being collected or it may have been tossed out once the resident had been sent out. When the surveyor stated the status beside the UA order said completed the Administrator stated the urine may have been collected but the laboratory company that they were using went out of business and there was no one to contact. No further information regarding this issue was provided to the survey team prior to the exit conference.

Based on staff interview, clinical record review, and facility document review, the facility staff failed to follow the providers orders for 2 of 6 residents in the survey sample, Resident #1 and #3. The findings include. 1. For Resident #1, the facility nursing staff failed to transcribe an order for the seizure medication Lamictal onto the residents admission paperwork from the discharge instructions from the admitting hospital. This was a closed record review. Resident #1's diagnoses included, but were not limited to, epilepsy, atrial fibrillation, traumatic brain injury and anxiety disorder. Section C (cognitive patterns) of Resident #1's admission minimum data set (MDS) assessment with an assessment reference date (ARD) of 10/22/24 included a brief interview for mental status (BIMS) score of 5. Per the MDS manual a score of 5=severe impairment in cognitive skills for daily decision making. Resident #1's comprehensive care plan included the focus area has a seizure disorder. Interventions included, give seizure medication as ordered. Resident #1's hospital discharge instructions/summary with a discharge date of 10/18/24 included an order for Lamictal 100 mg take 11 tablets a day. A review of Resident #1's clinical record revealed that this order had not been transcribed into the clinical record upon admission. The clinical record did include provider orders for this medication dated the day after admission. During an interview with the physician on 02/25/25 at 1:45 p.m. the physician stated the Lamictal was probably missed on the admission paperwork. On 02/25/25 at 2:00 p.m., the interview with the physician was shared with the Director of Nursing (DON). The DON stated the missing Lamictal order was probably caught on a chart review. The clinical record included Lamotrigine (Lamictal) laboratory tests results dated 10/22/24. The results of this laboratory test were documented as 12.7 the reference range was 2-20. The surveyor did not find any information to indicate this resident had any seizures during their stay at the facility. No further information regarding this issue was provided to the survey team prior to the exit conference. 2. For Resident #3, the facility staff failed to follow provider orders for Seroquel and failed to apply provider ordered geri-sleeves. This was a closed record review. Resident #3's diagnoses included, but were not limited to, Alzheimer's disease, dementia, anemia, hypertension, anxiety, and restlessness and agitation. Section C (cognitive patterns) of Resident #3's quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of 10/17/23 included a brief interview for mental status (BIMS) score of 00. Per the MDS manual a score of 00=severe impairment in cognitive skills for daily decision making. Resident #3's comprehensive care plan included the focus areas at risk for falls potential side effects of psychotropic medications. Uses antipsychotic medications related to behaviors. Risk for impaired skin integrity, comfort sleeves to arms as skin preventative. Resident #3's clinical record included a provider order for Seroquel 12.5 mg one time a day for mood for 7 days. Date of order 07/13/23. On 07/18/23 Licensed Practical Nurse (LPN) #7 revised the Seroquel order. Under reason the nursing staff had added hold for sedation. A review of the medication administration records (MARs) indicated this medication was scheduled to be administered beginning on 07/14/23 at 8:00 p.m. The nursing staff documented they had administered this medication on 07/14/23 and 07/17/23. For 07/15/23 and 07/16/23 the facility nursing staff documented a 9. Per the preprinted code on the MAR a 9=other/see progress notes. For both these dates the nursing staff documented not given due to family's request. When the order was revised on 07/18/23 the nursing staff blocked out 7 additional days on the MARs for the administration of the Seroquel indicating there was an opportunity for Resident #3 to be administered 11 doses of Seroquel and not 7 as ordered by the provider. For 07/18/23 and 07/19/23 the nursing staff documented a 9. On 07/18/23 the nursing staff documented hold for sedation and on 07/19/23 they documented held at family request. The nursing staff documented they had administered this medication at 8:00 p.m. from 07/20/23-07/24/23. LPN #7 no longer worked at the facility and could not be interviewed. On 02/25/25 at 4:10 p.m., during a meeting with the Administrator, Director of Nursing (DON), Director of Rehab and Assistant Director of Nursing the issue with the Seroquel being available for 11 administrations instead of 7 as ordered by the provider was reviewed. The DON stated Resident #3 should have received the 12.5 mg dose of Seroquel for 7 days. Resident #3's clinical record included a provider order dated 09/26/23 for geri-sleeves to arms as tolerated. A review of the treatment administration records (TARs) for 10/01/23-01/12/24 revealed that for day shift on October 10, 19, and 24, November 24 and 25, December 5, 19, and 22-26, and January 6, 2024, there was no documentation to indicate the geri-sleeves had been applied. The TAR included codes the nursing staff should have used if the resident had refused to wear the geri-sleeves. The facility policy titled, Charting and Documentation read in part, All services provided to the resident .shall be documented in the resident's medical record . No further information regarding these issues were provided to the survey team prior to the exit conference.

Based on staff interview, clinical record review and facility document review the facility staff failed to ensure the required documentation related to hospital transfer was included in the clinical record for 2 of 6 residents, Resident #2 and Resident #6. The findings included: 1. For Resident #2 the facility staff failed to document what paperwork was sent with resident, failed to document who was contacted at the emergency department, and failed to document name of facility being transferred to. Resident #2's clinical record listed diagnoses which included but not limited to acute and chronic respiratory failure with hypoxia, acute and chronic respiratory failure with hypercapnia, obstructive sleep apnea, and chronic obstructive pulmonary disease. Resident #2's most recent minimum data set with an assessment reference date of 10/14/24 assigned the resident a brief interview for mental status score of 14 out of 15 in section C, cognitive patterns. This indicates that the resident was cognitively intact. Resident #2's comprehensive care plan was reviewed and contained a plan for Resident is at risk for complications r/t (related to) Asthma, Chronic Respiratory Failure, seasonal allergies, pulmonary HTN (hypertension), COPD (chronic obstructive pulmonary disease) and OSA (obstructive sleep apnea). Resident #2's progress notes were reviewed and contained a note which read in part, 1/2/2025 18:47 This nurse was called to this resident's room when the cna (certified nurse's aide) went to room she found resident unresponsive and foaming at the mouth nasal cannula off cna stated she tried sternum rub and resident still didn't respond; this nurse told the cna to go get help while this nurse got the resident on the side and called the DON (director of nursing) told her that we were calling 911 then after calling 911 called family and then the ER (emergency room) to give report; when the ambulance arrived the resident was still unresponsive. Surveyor spoke with the DON on 02/25/24 at 12:55 pm regarding what should be documented when a resident is transferred to the hospital. DON stated, Some nurses chart well, some don't. DON stated that all information from the facility Transfer to Hospital Checklist should be documented in the clinical record. Surveyor requested and was provided with a facility document entitled Transfer to Hospital Checklist which read in part, Bed Hold Policy sent to Hospital with resident. Transfer Observation. Careplan printed and sent out with patient. Print MAR/TAR (medication/treatment administration record). Print Facesheet. Send Copy of DNR (do not resuscitate) form. Make sure you call report to ER with exactly why you are sending the patient to ER. Document who you called report to at the hospital in your progress note. Make a Progress Note and include why the resident is being transferred out of facility, include that all of the above was sent with resident to hospital such as (bed hold policy, transfer form, SBAR, MAR). Time that symptoms occurred and family and doctor notification. Include what hospital resident is being transferred to. The concern of not ensuring proper documentation was included in the clinical record related to a hospital transfer was discussed with the administrator, DON, assistant director of nursing and director of rehabilitation services on 02/25/25 at 4:10 pm. No further information was provided prior to exit. 2. For Resident #6 the facility staff failed to include required documentation related to a hospital transfer in the resident's clinical record. Resident #6's clinical record listed diagnoses which included but not limited to essential primary hypertension, dementia, and other chronic pain. Resident #6's most recent minimum data set with an assessment reference date of 12/12/24 assigned the resident a brief interview for mental status score of 6 out of 15 in section C, cognitive patterns. This indicates that the resident is severely cognitively impaired. Resident #6's comprehensive care plan was reviewed and contained a plan for Resident has a potential for cardiovascular complications r/t (related to) HTN (hypertension) and Hyperlipidemia. Resident #6's nurse's progress notes were reviewed and contained a note which read in part, 12/29/2024 08:15 Resident c/o (complaint of) crushing chest pain requested to go to ER for evaluation and treatment. Daughter notified. 911 notified. Surveyor could not locate any other documentation related to hospital transfer. Surveyor spoke with the DON on 02/25/24 at 12:55 pm regarding what should be documented when a resident is transferred to the hospital. DON stated, Some nurses chart well, some don't. DON stated that all information from the facility Transfer to Hospital Checklist should be documented in the clinical record. Surveyor requested and was provided with a facility document entitled Transfer to Hospital Checklist which read in part, Bed Hold Policy sent to Hospital with resident. Transfer Observation. Careplan printed and sent out with patient. Print MAR/TAR (medication/treatment administration record). Print Facesheet. Send Copy of DNR (do not resuscitate) form. Make sure you call report to ER with exactly why you are sending the patient to ER. Document who you called report to at the hospital in your progress note. Make a Progress Note and include why the resident is being transferred out of facility, include that all of the above was sent with resident to hospital such as (bed hold policy, transfer form, SBAR, MAR). Time that symptoms occurred and family and doctor notification. Include what hospital resident is being transferred to. The concern of not ensuring proper documentation was included in the clinical record related to a hospital transfer was discussed with the administrator, DON, assistant director of nursing and director of rehabilitation services on 02/25/25 at 4:10 pm. No further information was provided prior to exit.

Based on staff interview, clinical record review, and facility document review, the facility staff failed to notify the responsible party (RP) of a change in a residents antipsychotic medication for 1 of 6 residents in the survey sample, Resident #3. The findings include. The facility staff failed to notify the RP when Resident #3's antipsychotic medication Seroquel was discontinued. This was a closed record review. Resident #3's diagnoses included, but were not limited to, Alzheimer's disease, dementia, anemia, hypertension, anxiety, and restlessness and agitation. Section C (cognitive patterns) of Resident #3's quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of 10/17/23 included a brief interview for mental status (BIMS) score of 00. Per the MDS manual a score of 00=severe impairment in cognitive skills for daily decision making. Resident #3's comprehensive care plan included the focus areas at risk for falls potential side effects of psychotropic medications. Uses antipsychotic medications related to behaviors. Resident #3's clinical record included a provider order for Seroquel 25 mg at bedtime for psychophysiologic insomnia. Date of order 02/09/23. This medication had been discontinued on 07/06/23. During the clinical record review, the surveyor was unable to find any evidence to indicate the RP had been notified that Resident #3's Seroquel had been discontinued. On 02/24/25 at 4:50 p.m., during an interview with the Assistant Director of Nursing (ADON) this staff stated they were unable to find any documentation to indicate the RP had been notified that the Seroquel had been discontinued and it would have been the responsibility of the hall nurse to report this. On 02/24/25 at 5:35 p.m., during an interview with Registered Nurse (RN) #1 this staff stated they had not made a note regarding RP notification when the Seroquel had been discontinued, they usually made a note and always notified the RP. On 02/25/25 at 8:15 a.m., during an interview with Nurse Practitioner (NP) #3 regarding this residents Seroquel the NP stated they had reviewed their notes and per their documentation the Seroquel was discontinued due to falls. On 02/25/25 the Administrator provided the survey team with a copy of their policy titled, Resident Representative. This policy read in part, The facility treats the decisions of the resident representative as the decisions of the resident .resident representative is defined as an individual chose by the resident to act on behalf of the resident in order to support the resident in decision-making .or receive notifications . On 02/25/25 at 4:10 p.m., during a meeting with the Administrator, Director of Nursing, ADON, and Director of Rehab the issue with the RP not being notified when Resident #3's Seroquel was discontinued was reviewed. The consensus of this group was that the RP was difficult to get in touch with. No further information regarding this issue was provided to the survey team prior to the exit conference.

Based on observation, resident interview, staff interview and clinical record review, the facility staff failed to provide respiratory care consistent with the comprehensive person-centered care plan for one of six residents in the survey sample. The findings included: For resident # 1, the facility staff failed to administer oxygen as ordered by the physician and according to the residents comprehensive person-centered care plan. Resident # 1's diagnoses included but were not limited to, acute and chronic respiratory failure with hypoxia, obstructive sleep apnea, chronic obstructive pulmonary disease (COPD), morbid obesity, right heart failure unspecified, essential hypertension, pulmonary hypertension. Resident # 1's most recent minimum data set (MDS) assessment assigned the resident a brief interview for mental status score of 15 indicating intact cognition. This surveyor observed the resident in their room on 3/25/23 at 11:52 AM and noted they were on oxygen via a nasal cannula. When asked how much oxygen they required they stated, I'm on 3 liters. Surveyor noted that the oxygen concentrator setting was for 3 liters. On 3/25/24 at 4:23 PM surveyor again observed the resident and oxygen setting and noted the setting was on 3 liters. On 3/26/24 at 9:07 AM surveyor noted the oxygen setting was at 3 liters. On 3/26/24 at 10:36 AM surveyor approached Licensed Practical Nurse (LPN) # 1 who stated that they were caring for resident # 1. When asked if they knew how much oxygen resident was supposed to be getting, they stated. I think it's 2 liters. Surveyor asked them to confirm the oxygen setting. LPN # 1 checked the concentrator and stated, it's on 3 liters. I think the order is for 2 but I'll need to check to make sure. LPN # 1 checked the orders and stated, yes the order is for 2 liters, so I'll go change the setting on the concentrator. Review of the clinical record indicated that resident is oxygen dependent and there was an order for oxygen via nasal cannula at 2 liters per minute with a start date of 3/24/24. The comprehensive person centered care plan had a problem statement that read in, Resident at risk for complications r/t (related to) asthma, chronic respirtatory failure, COPD and OSA. Interventions included, Administer oxygen as ordered. This surveyor met with the Director of Nursing (DON) and the Administrator on 3/26/24 at 11:23 AM. The DON returned at 3:24 PM and stated that they had contacted the physician and got the oxygen increased to 3 liters per minute for resident # 1. No further information was presented to the survey team prior to exit.

Based on staff interview, clinical record review and facility document review, the facility staff failed to provide activities of daily living (ADL) care to one of six residents in the survey sample, resident # 5. This was a closed record review. The findings included: For resident # 5, the facility staff failed to provide scheduled bathing assistance for October 2022 through January of 2023. Resident # 5's diagnoses included but were not limited to, end stage renal disease, chronic obstructive pulmonary disease, Alzheimer's disease, muscle weakness, difficulty walking, need for assistance with personal care. Resident # 5's minimum data set (MDS) assessment with an assessment reference date of 2/17/23 assigned the resident a brief interview for mental status (BIMS) score of 00 indicating severe cognitive impairment. Resident # 5 was coded as being dependent for bathing with assistance of one staff member. Resident # 5 's comprehensive person-centered care plan had a problem statement with an effective date of 11/4/22 that read, Resident's ability to perform ADL's has declined R/T (related to) impaired vision, hx (history) of falls, weakness, medical conditions and occasional incontinence. The ADL flow sheets for resident # 5 were reviewed. Resident # 5's baths were scheduled for every Wednesday and Saturday. Complete bed baths or showers were documented on 10/13/22, 10/17/22, 10/27/22, 10/31/22, 11/16/22, 11/23/22, 11/26/22, 12/3/22, 12/10/22, 12/21/22, 12/28/22, 12/31/22, 1/4/23, 1/7/23, 1/18/23 for a total of 15 over three month period. On 3/26/24 at 2:23 PM this surveyor met with the Director of Nursing (DON) and Administrator to discuss this concern. The Administrator stated that there had been an issue or confusion between facility staff and hospice staff regarding which staff were responsible for bathing, and that could have been the problem. Review of the resident orders revealed that hospice began 2/4/23. Surveyor asked what the expectation for showers or complete bed baths for residents was, the DON stated, two per week. Two per week over three months would be 24 complete bed baths or showers expected to be given to resident # 5 rather than 15, which is what the documentation in the record reflected. The DON provided surveyor with Facility Daily Shower Lists but several of these did not have dates written on them so could not be used to verify showers for the above time period. No further information was provided prior to the exit conference.

Based on staff interview and facility document review, the facility staff failed to maintain an infection prevention and control program to include an antibiotic stewardship program. The findings included: The facility staff failed to safeguard and maintain documentation regarding the facility antibiotic stewardship program. On 10/26/22 at 12:39 pm, surveyor met with the administrator and director of nursing (DON) regarding the facility infection prevention and control program. The DON began employment with the facility on 6/27/22 and the administrator began on 9/20/22. The DON stated the previous assistant director of nursing (ADON), who also served as the Infection Preventionist, had the facility antibiotic stewardship documentation on their computer and current staff have been unable to retrieve this information following their departure from the facility. The administrator stated an FRI (Facility Reported Incident) was completed and submitted. Administrator provided a copy of an FRI dated 10/05/22 which stated in part The ADON/Infection Control, (name omitted) sent out an immediate resignation via email effective 9/19/22 at 6:35 pm . (name omitted) stated to me that (he/she) had communication with the former ADON and questioned the whereabouts of some records related to COVID, infection control, and antibiotic stewardship. (He/she) stated that it was on (his/her) personal computer. (He/she) stated that (he/she) had informed (him/her) to please send to the appropriate recipients since it was not on the share drive .(name and position omitted) .informed me that on the previous Monday, (ADON) placed (his/her) computer on the desk of the (name omitted) office, stated this was what (he/she) thought of this place, and reset the computer to factory settings and deleted all the records .As of this date, no records have been retrieved. The DON stated corrective actions have been put into place but a written plan of correction had not been developed. On 10/26/22 at 1:49 pm, the survey team met with the administrator and DON and discussed the concern of the missing antibiotic stewardship documentation. No further information regarding this concern was presented to the survey team prior to the exit conference on 10/26/22.

Based on staff interview, family interview, and facility document review the facility staff to ensure a clean, comfortable, homelike environment for 1 of 2 floors, and one of 19 residents, Resident #36. The findings included: 1. For the 2nd floor of the facility, the facility staff failed to ensure a clean environment. Throughout the course of the survey, the surveyor observed a pervasive odor of urine in the hallway of the second floor. The surveyor also observed debris in the floor, and inside the handrails. These observations were addressed with the maintenance director and housekeeping district manager on 10/26/22 at 11:10 am during a waking tour of the 2nd floor of the facility. Surveyor asked the housekeeping district manager how often the handrails were cleaned, and housekeeping district manager stated one time per week. Surveyor asked how many housekeepers were assigned to each floor and housekeeping district manager stated one on each floor. Surveyor asked how often each resident room is cleaned and housekeeping district manager stated each room should be cleaned daily. Surveyor asked what room cleaning consisted of and housekeeping district manager stated dusting, wiping of high use surfaces (overbed tables, call bell cords), damp mopping, emptying trash, and cleaning bathrooms. Surveyor spoke with CNA (certified nurse's aide) #4 on 10/226/22 at 10:45 am. Surveyor asked CNA #4 how often housekeeping cleaned resident rooms, and CNA stated they were not sure. CNA #4 stated there is only one housekeeper for the floor, and they do not clean every room, every day. Surveyor asked CNA #4 if they noticed an odor of urine, and CNA #4 stated, Oh, yeah, it's like that every day. Surveyor spoke with housekeeper on 10/26/22 at 12:25 pm. Surveyor asked housekeeper if they cleaned every resident room every day, and housekeeper replied, Depends, I can do it every day if I just do a sweep through. Surveyor asked housekeeper how long it takes to clean a room, and housekeeper stated, some take longer than others, but generally 10-15 minutes. Surveyor observed housekeeper using damp mop to sweep debris from under a resident's bed. Surveyor requested and was provided with a policy entitled Daily Patient Room Cleaning which read in part, Timing and Method-C Follow 5-step room cleaning method: 1) Empty trash Get the trash out of all rooms first thing. Wipe basket-if necessary replace liner. 2) Horizontal dusting. With a cloth & disinfectant wipe all horizontal (flat) surfaces. 3) Spot clean. With a cloth & disinfectant spot clean all vertical surfaces. 4) Dust mop floor. Use dust mop to gather all trash & debris on floor. Sweep to the door; pick up with dust pan. 5) Damp mop floor with germicide solution . and Bathroom Cleaning: Timing and Method - B. Follow 7-step Method. Dry steps: 2. Pull trash. Wipe can and if necessary replace liner. 2. Fill dispensers Soap. paper, etc. 3. Dust mop. Wet Steps: 4. Sanitize sinks, light, mirror, sink, fixtures and pipes. 5. Sanitize commode, tank, bowl & base. Use brush for inside of bowl. 6. Spot clean-Walls, partitions, light switches. 7. Damp mop. The concern of not providing a clean, comfortable environment was discussed with the administrator and director of nursing on 10/26/22 at 1:50 pm. No further information was provided prior to exit. 2. For Resident #36, the facility failed to ensure a clean, comfortable environment. Resident #36's face sheet listed diagnoses which included, but not limited to Autistic disorder, liver disease, anxiety, hypertension, hypothyroidism, disorder of urea cycle metabolism, and age-related osteoporosis. Resident #36's most recent quarterly minimum data set with an assessment reference date of 08/16/22 assigned the resident a brief interview for mental status score of 9 out of 15 in section C, cognitive patterns. This indicates that the resident is moderately cognitively impaired. Surveyor observed Resident #36 on 10/24/22 at 3:30 pm. Resident #36 was seated in wheelchair at side of bed. Surveyor introduced self to resident, and resident turned their face away from surveyor. Surveyor noticed a strong odor of urine in the room at this time. Surveyor observed Resident #36 again on 10/25/22 at 8:40 am. Resident was seated in wheelchair at side of bed. Surveyor noticed a strong odor of urine in the room. Surveyor spoke with resident's family member/sibling on 10/25/22 at 1:15 pm. Surveyor asked sibling if they had any concerns with the care the resident was receiving at the facility, and sibling stated, The biggest issue I have is with the cleanliness and smell. Surveyor observed Resident #36 on 10/26/22 at 7:45 am. Resident was seated in wheelchair at bedside. Surveyor noticed a slight odor of urine in the room at this time. Surveyor observed the resident's bathroom at this time, and noticed a brownish substance on the toilet, toilet seat and floor. Surveyor observed Resident #36's bathroom again on 10/26/22 at 10:45 am. Surveyor observed brownish substance on toilet, toilet seat and floor. Surveyor spoke with CNA #4 at this time and asked CNA #4 if the housekeeper had been in the room, and CNA #4 stated they had not yet seen housekeeping. Surveyor pointed out the brownish debris to the CNA, and CNA stated they would take care of it. The concern of not providing a clean, comfortable environment was discussed with the administrator and director of nursing on 10/26/22 at 1:50 pm. No further information was provided prior to exit.

Based on resident interview, staff interview, clinical record review, facility document review, and during a medication pass and pour observation the facility staff failed to ensure a medication error rate of less than 5%. There were 3 errors in 32 opportunities for a medication error rate of 9.38%. These medication errors affected Resident #55. The findings include: During a medication pass and pour observation the facility staff failed to ensure a medication error rate of less than 5%. The medication error rate was 9.38%. LPN #2 did not administer Resident #55's Aspercreme, Colace, or Magnesium Hydroxide. 10/25/22 beginning at approximately 7:38 a.m., the surveyor observed Licensed Practical Nurse (LPN/agency nurse) #2 prepare and administer Resident #55's morning medications. LPN #2 was observed to pick up a bottle of Magnesium Hydroxide from the cart and state it did not have the residents name on it and they would have to find out the facility procedure. LPN #2 placed the medication back into the medication cart. Resident #55's diagnoses included, but were not limited to, pain and constipation. Section C (cognitive patterns) of Resident #55's quarterly minimum data set (MDS) assessment with an ARD of 08/02/22 included a brief interview for mental status (BIMS) score of 14 out of a possible 15 points. Resident #55's clinical record included provider orders for Aspercreme apply a quarter size amount to right shoulder twice a day, Colace 100 mg 1 tab by mouth twice daily, and Magnesium Hydroxide 30 ml by mouth daily. The morning administration times on all of these medications was documented as 8:00 a.m. The surveyor did not observe these medications being administered. Resident #55's comprehensive care plan included the problem area complaints of pain. Approaches included, but were not limited to, Administer medications as ordered. 10/25/22 10:00 a.m., the Assistant Director of Nursing (ADON) provided the survey team with a copy of policy titled, Administering Medication. This policy read in part, .Medications are administered in accordance with prescriber orders, including any required time frame . 10/25/22 11:40 a.m., Resident #55 stated they did not get their Aspercreme. 10/25/22 11:44 a.m., LPN #2 stated they did not administer Resident #55's Colace or Magnesium Hydroxide. 10/25/22 4:15 p.m., during an end of the day meeting with the Administrator, Director of Nursing (DON), ADON, and Social Worker the issue with the medication pass and medication error rate was reviewed. 10/26/22 1:50 p.m., during a meeting with the Administrator and DON the DON stated they had spoken with LPN #2's agency. No further information regarding this issue was provided to the survey team prior to the exit conference.

Based on staff interview and clinical record review the facility staff failed to follow-up on pharmacist recommendations for 2 of 19 residents, Resident #36 and Resident #47 and failed to complete pharmacy reviews for 1 of 19 residents, Resident #44. The findings included: 1. For Resident #36 the facility staff failed to follow-up on pharmacist recommendations. Resident #36's face sheet listed diagnoses which included, but not limited to Autistic disorder, liver disease, anxiety, hypertension, hypothyroidism, disorder of urea cycle metabolism, and age-related osteoporosis. Resident #36's most recent quarterly minimum data set with an assessment reference date of 08/16/22 assigned the resident a brief interview for mental status score of 9 out of 15 in section C, cognitive patterns. This indicates that the resident is moderately cognitively impaired. Resident #36's comprehensive care plan was reviewed and contained care plans for Resident has liver disease, Resident has hypothyroidism and Resident is prescribed anticoagulant therapy d/t (due to) hx (history) of DVT (deep venous thrombosis [blood clot]) Interventions for these care plans included Monitor lab work as ordered. Resident #36's clinical record was reviewed and contained a pharmacy review form, which read in part Note to Attending Physician/Prescriber. MRR (medication regimen review) Date: 6/21/2022. This resident is taking the following medications: Synthroid, Cal (calcium)/Vit D, Omeprazole. If appropriate consider obtaining at next lab draw CBC (complete blood count), BMP (basic metabolic panel), TSH (thyroid stimulating hormone), Vit D, Vit B12, Magnesium to monitor the safety and efficacy of these medication(s). RESPONSE: OBTAIN THE FOLLOWING LAB WORK: Add above. Physician/Provider Response: Agree This form was signed/dated on 07/21/22. Resident #36's clinical record contained a second pharmacy review form which read in part, Note to Attending Physician/Prescriber. MRR (medication regimen review) Date: 8/19/2022. This resident is taking the following medications: Synthroid, Cal Vit D, Omeprazole, Lactulose. If appropriate consider obtaining at next lab draw CBC, BMP, TSH, Vit D, Vit B12, Magnesium, ammonia to monitor the safety and efficacy of these medication(s). RESPONSE: OBTAIN THE FOLLOWING LAB WORK: Add above. Physician/Provider Response: Agree This form was signed/dated on 08/30/22. Resident #36's clinical record contained a physician's order summary, which read in part 07/22/2022-07/22/2022 Basic Metabolic Panel; CBC (complete blood count) with Diff (differential); TSH (thyroid stimulating hormone); Vitamin B12; Other Test: (Vitamin D, Magnesium) Once-One Time; 07:00 AM-07:00 PM and 08/31/2022-08/31/2022 Basic Metabolic Panel; CBC with Diff; TSH; Vitamin B12; Other Test: (Vitamin D, Magnesium, Ammonia) Once-One Time; 07:00 AM-07:00 PM Resident's clinical record was reviewed on 10/26/22, and surveyor could not locate any laboratory reports related to the above ordered lab tests. Surveyor informed the director of nursing (DON) of the missing lab reports on 10/26/22 at 12:15 pm. DON informed the surveyor on 10/26/22 at 1:40 pm that the labs were not completed as ordered. The concern of not following up on pharmacy recommendations was discussed with the administrator and DON on 10/26/22 at 1:50 pm. No further information provided prior to exit. 28567 2. For Resident #47, the facility staff failed to follow up on a pharmacy recommendation in regards to the topical medication Diclofenac (nonsteroidal anti-inflammatory drug). Resident #47's diagnosis included, but were not limited to, chronic pain syndrome. Section C (cognitive patterns) of Resident #47's admission minimum data set (MDS) assessment with an assessment reference date (ARD) of 08/31/22 included a brief interview for mental status (BIMS) summary score of 13 out of a possible 15 points. The clinical record included a document titled, INTERIM MEDICATION REGIMEN REVIEW (IMRR). This document included the following pharmacy recommendations, in regards to the medication Diclofenac (voltaren) 1% gel 1 application topically three times daily for pain. The pharmacy consultant transcribed the following, Please clarify instructions to include dose in grams and site of application. On 09/22/22 the provider ordered Diclofenac sodium (voltaren) apply 1% apply quarter sized amount to left shoulder and lumbar area every 6 hours PRN (as needed) for pain. However, the scheduled order remained active and read apply 1 application to affected area TID (three times a day) for pain. 10/26/22 8:36 a.m., the Director of Nursing (DON) was asked for information regarding the Diclofenac pharmacy recommendation. 10/26/22 10:25 a.m., the DON stated they were going to discontinue the Diclofenac scheduled order and keep the PRN order in place. 10/26/22 1:50 p.m., during a meeting with the Administrator and DON the surveyor asked if they knew why a PRN order was written for the Diclofenac instead of addressing the current order. The DON stated they could come up with different scenarios but really had no idea. No further information regarding this issue was provide to the survey team prior to the exit conference. 47299 3. For resident #44, facility staff failed to ensure a medication regimen review (MRR) was performed for the month of February 2022. Resident #44 diagnosis list includes, but is not limited to the following: congestive heart failure, chronic pain syndrome, hypertension, atrial fibrillation, generalized anxiety disorder, major depressive disorder, polyosteoarthritis, and restless legs syndrome. The most recent quarterly minimum data set (MDS) with an assessment reference date of 8-9-22, assigned the resident a BIMS (brief interview for mental status) summary score of 10 out of 15 in section C, cognitive patterns, indicating the resident was moderately cognitively impaired. Upon review of resident #44's clinical record, surveyor was unable to locate the February 2022 medication regimen review completed by a pharmacist. On 10-26-2022 at 10:20 A.M., surveyor spoke with the Director of Nursing (DON) and the Administrator about the medication regimen review not being in the chart. DON stated that she would look for it. At 11:13 A.M., DON asked surveyor what it was that had been asked for, and again stated she would look. At 1:40 P.M. DON brought surveyor reviews for the months of June and September and stated, February's are missing. On 10-26-2022 the survey team met with the DON and Administrator, surveyor again mentioned that there is no medication regimen review for the month of February in resident #44's medical record. No further information regarding this concern was provided to the survey team prior to the exit conference.

Based on observation, resident interview, family interview, staff interview, and clinical record review, the facility staff failed to provide activities of daily living (ADL) care for 3 of 18 Residents, Resident #52, #36, and #252. The findings include: 1. Resident #52's toenails were observed to be long, thick, and jagged. Resident #52 was unable to cut/trim their toenails. Resident #52's diagnoses included but were not limited to, Alzheimer's disease and need for assistance with personal care. Section C (cognitive patterns) of Resident #52's annual minimum data set (MDS) assessment with an assessment reference date (ARD) of 08/22/22 included a brief interview for mental status (BIMS) score of 10 out of a possible 15 points. Resident #52's comprehensive care plan included the problem area Activity of Daily Living. Approaches included, but were not limited to, provide assistance for completion of ADL tasks. 10/24/22 3:20 p.m., Resident #52 was observed ambulating in room. Resident #52 was observed with open toed shoes and their toenails were observed to be long, thick, and jagged. When asked about their toenails Resident #52 stated, who do I get to cut them? Resident #52 stated they were able to cut their fingernails at times but not their toenails. 10/25/22 10:05 a.m., Resident #52 observed in room, open toed shoes, toenails remain long, thick, and jagged. 10/25/22 12:20 p.m., the Administrator provided the survey team with a copy of policy titled, Fingernails/Toenails, Care of. This policy read in part, .The purpose of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infection .Nail care includes daily cleaning and regular trimming .Trimmed and smoothed nails prevent the resident from accidentally scratching and injuring his or her skin . 10/25/22 4:15 p.m., during an end of the day meeting. The Administrator, Director of Nursing (DON), Assistant Director of Nursing (ADON), and Social Worker were made aware of the issue regarding Resident #52's toenails. 10/26/22 7:55 a.m., the DON stated they did an in house sweep of the residents regarding toenails, some toenails were trimmed, and podiatry consults were made as needed. 10/26/22, the facility staff provided the survey team with a progress note regarding Resident #52 dated 10/25/22 6:40 p.m. that read in part, .provided foot care with toenail trimmings . No further information regarding this issue was provided to the survey team prior to the exit conference. 34307 2. For Resident #36 the facility staff failed to provide activities of daily living (ADL) care in regards to facial hair. Resident #36's face sheet listed diagnoses which included, but not limited to Autistic disorder and cognitive communication deficit. Resident #36's most recent quarterly minimum data set with an assessment reference date of 08/16/22 assigned the resident a brief interview for mental status score of 9 out of 15 in section C, cognitive patterns. This indicates that the resident is moderately cognitively impaired. Section G, functional status, coded the resident as total dependence, one person physical assist, in the area of personal hygiene. This includes removal of facial hair. Resident #36's comprehensive care plan was reviewed and contained a care plan for Resident needs assist with ADL's R/T (related to) hx (history) of tendon rupture, weakness, impaired cognition and incontinence. Approaches for this care plan included provide assistance as needed for ADL's. Surveyor observed Resident #36 on 10/25/22 at 8:40 am. Resident was dressed in street clothes, seated in wheelchair at bedside. Surveyor observed that the resident had large amount of facial hair in the chin area. Surveyor asked the resident if this bothered them, but resident turned face away from surveyor and did not answer. Surveyor spoke with the resident's sibling on 10/25/22 at 1:15 pm. Surveyor asked sibling if resident's facial hair seemed to bother them, and sibling stated that resident did not like having hair on their chin, and that when they lived at home, they removed it themselves. Sibling also stated that chin hair had not been removed in 2 weeks. The concern on not providing ADL care was discussed with the administrator and director of nursing on 10/26/22 at 1:50 pm. No further information was provided prior to exit. 2. For Resident #252 the facility staff failed to provide activities of daily living (ADL) in regards to nail care. Resident #252's face sheet listed diagnoses which included but not limited to acute kidney failure, dementia, type 2 diabetes mellitus, and anxiety. Resident #252's most recent minimum data set with an assessment reference date of 0609/22 assigned the resident a brief interview for mental status score of 7 out of 15 in section C, cognitive patterns. This indicates that the resident is severely cognitively impaired. Section G, functional status, coded the resident as needing extensive assistance of one person in the area of personal hygiene. Resident #252's comprehensive care plan was reviewed and contained a care plan for . needs assistance with ADL's r/t (related to) weakness, mental health and impaired cognition. Approaches for this care plan included provide assistance with ADL's as needed. Surveyor observed Resident #252 on 10/24/22 at 3:15 pm. Resident was resting in bed. Surveyor observed resident's fingernails to be long with brownish discoloration. Surveyor asked resident if this bothered them, and they stated, they need to be cut. Surveyor requested and the administrator provided the survey team with a copy of policy entitled Fingernails/Toenails, Care of which read in part, .The purpose of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infection .Nail care includes daily cleaning and regular trimming .Trimmed and smoothed nails prevent the resident from accidentally scratching and injuring his or her skin . The concern of not providing nail care to Resident #252 was discussed with the administrator, director of nursing, assistant director of nursing and social worked on 10/25/22 at 4:15 pm. On 10/26/22 at 7:55 am, the director of nursing informed the survey team that they had completed an in-house sweep of all residents regarding nail care. Nails were trimmed and consults made as needed. No further information provided prior to exit.

Based on staff interview and facility document review, the facility staff failed to provide copies of notice of resident transfers and discharges to a representative of the Office of the State Long-Term Care Ombudsman. The findings included: The facility staff failed to provide evidence of notification of resident transfers and discharges to the Office of the State Long-Term Care Ombudsman. On 10/26/22 at approximately 12:00 pm, surveyor spoke with the administrator who stated they were unable to locate documentation of notice of resident transfers and discharges being sent to the ombudsman's office. The administrator stated they were reaching out to the ombudsman to find out when the facility last provided resident transfer and discharge information. Surveyor requested and received the facility policy entitled Notice Requirements before Transfer/Discharge which read in part: 1. Before the facility transfers or discharges a resident, the facility will: b. Notify the resident and, if known, a family member or the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. c. The facility will send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman. On 10/26/22 at 1:49 pm, the survey team met with the administrator and director of nursing and discussed the concern of the facility being unable to provide evidence of ombudsman notification regarding resident transfers and discharges. No further information regarding this concern was presented to the survey team prior to the exit conference on 10/26/22.