Every finding on record at Thomasville Vistas of Journey LLC

Based on observations and staff interviews, the facility failed to ensure that 17 Residents (R) (R2, R4, R5, R7, R8, R9, R10, R11, R12, R13, R14, R15, R16, R17, R18, R19, R20) call lights were within reach while the residents were in their bed. This deficient practice had the potential to cause delayed assistance, potential for falls and unmet needs. The facility census is 49 residents. Findings include: All observations on 06/02/2026 and 06/08/2026 were made in the presence of the Maintenance Director during call light functional checks and verification of nonfunctional call lights. 1. Review of the admission Record revealed R2 was admitted to the facility with diagnoses including but not limited to chronic combined systolic congestive and diastolic congestive heart failure, type 2 diabetes mellitus, protein-calorie malnutrition, and hypertension. Review of the care plan dated 12/31/2025 revealed R2 has an Activities of Daily Living (ADL) self-care performance deficit and is at risk for not having needs met in a timely manner. One intervention directs staff to encourage the resident to use the call light to request assistance before attempting ADLs that cannot be performed independently.Observations revealed the following:On 06/02/2026 at 2:06 PM, R2 was in room [ROOM NUMBER]-A. The call light was draped over the bed rail and hanging above the floor. The call light was not within the resident's reach.On 06/03/2026 at 2:23 PM, R2 was lying in bed with eyes closed. The call light was not within reach of the resident.On 06/08/2026 at 12:19 PM, R2 was lying in bed. The call light was attached to the bed frame and was not within reach of the resident.2. Review of the admission Record revealed R4 was admitted to the facility with diagnoses including, but not limited to, type 2 diabetes mellitus, cardiomyopathy, hypertension, and thyrotoxicosis. Review of the care plan dated 05/22/2024 revealed R4 requires assistance with ADL care related to decreased mobility, surgical wound, disease process and generalized weakness. An intervention directs staff to encourage the resident to use call light to request assistance before ADLs that cannot be performed independently. Observations revealed the following:On 06/02/2026 at 2:32 PM, R4 was in room [ROOM NUMBER]-B lying in bed. The call light was hanging from the lower bed frame with the call button facing the floor. The call light was not within reach of the resident.On 06/03/2026 at 2:27 PM, the call light was observed on the floor and was not within reach of the resident.3. Review of the admission Record revealed R5 was admitted to the facility with diagnoses including, but not limited to, type 2 diabetes mellitus, hypertension, protein-calorie malnutrition, and atrial fibrillation. Review of the care plan dated 08/21/2025 revealed R5 has an ADL self-care performance deficit and is at risk for not having needs met in a timely manner. An intervention directs staff to encourage the resident to use call light to request assistance before attempting ADLs that cannot be performed independently. An observation on 06/08/2026 at 12:09 PM of room [ROOM NUMBER]-B revealed a new call light hanging on the wall with the plastic wire still attached. The call light was not within reach of the resident. 4. Review of the admission Record revealed R7 was admitted to the facility with diagnoses including, but not limited to, Alzheimer's disease, vascular dementia, type 2 diabetes mellitus, and diverticulosis of the intestine. Review of the care plan dated 04/22/2025 revealed R7 has an ADL self-care performance deficit and is at risk for not having needs met in a timely manner. Interventions include providing a safe environment by ensuring the call light is within reach, adequate low glare lighting is available, and the bed is in the lowest position with wheels locked. Observation on 06/02/2026 at 1:48 PM, R7 was lying in bed in room [ROOM NUMBER]-B. The call light was attached to the lower bed frame behind the headboard and was not within reach of the resident. 5. Review of the admission Record revealed R8 was admitted to the facility with diagnoses including but not limited to, rhabdomyolysis, Parkinson's disease, and hypertension. Review of the care plan dated 10/23/2025 revealed R8 has an ADL self-care performance deficit and is at risk for not having needs met in a timely manner. Interventions include providing a safe environment by ensuring the call light is within reach and encouraging the resident to use the call light to request assistance before attempting ADLs that cannot be performed independently. Observation on 06/02/2026 at 1:57 PM, revealed R8 was lying bed in 103-A. The call light was not within reach of the resident. 6. Review of the admission Record revealed R9 was admitted to the facility with diagnoses including, but not limited to, hypertension, peripheral vasculare disease, and protein-calorie malnutrition Review of the care plan dated 08/28/2024 revealed R9 has an ADL self-care performance deficit and is at risk for not having needs met in a timely manner. An intervention directs staff to ensure a safe environment by keeping the call light within reach. Observations revealed the following:On 06/02/2026 at 2:19 PM, R9 was lying in bed in room [ROOM NUMBER]-A. The call light was located under the head of the bed and was not within reach of the resident.On 06/03/2026 at 2:26 PM, the call light was observed on top of the three-drawer bedside cabinet and was not within reach of the resident.7. Review of the admission Record revealed R10 was admitted to the facility with the diagnoses including, but not limited to, Parkinson's disease, type 2 diabetes mellitus, osteomyelitis, vascular dementia, and hypertension. Review of the care plan dated 08/19/2024 revealed R10 has an ADL self-care performance deficit related to cognitive impairment, functional limitations in range of motion or decreased mobility and pain. Interventions include providing a safe environment by ensuring the call light is within reach, the bed in lowest position, and the wheels locked.Observations revealed the following:On 06/02/2026 at 1:42 PM, R10 was in room [ROOM NUMBER]-B. No call light was observed at the bedside. A bell was present on the bedside table; however, it was not within reach of the resident. The resident was unable to ring the bell.On 06/08/2026 at 12:14 PM, a flat call light was observed on the bedside table next to the head of the bed. The call light was not within reach of the resident. 8. Review of the admission Record revealed R11 was admitted to the facility with diagnoses including, but not limited to, hypertension, depression, and cerebral infarction. Review of the care plan dated 01/16/2026 revealed R11 has an ADL self-care performance deficit and is at risk for not having needs met in a timely manner. Interventions include providing a safe environment by ensuring the call light is within reach, the bed is in the lowest position, and the wheels are locked.Observations revealed the following:On 06/02/2026 at 2:10 PM, R11 was lying in bed in room [ROOM NUMBER]-A. The call light was observed on the floor underneath the bed and was not within reach of the resident.On 06/08/2026 at 12:06 PM, R11 was observed lying in bed. The call light was on the floor and was not within reach of the resident. 9. Review of the admission Record revealed R12 was admitted to the facility with the following diagnoses that included but are not limited to type 2 diabetes mellitus, retention of urine, history of falling, and vascular dementia.9. Review of the admission Record revealed R12 was admitted with diagnoses including, but not limited to, type 2 diabetes mellitus, urinary retention, history of falls, and vascular dementia. Review of the care plan dated 12/5/2024 revealed R12 has an ADL self-care performance deficit and is at risk for not having their need met in a timely manner. Interventions include providing a safe environment by ensuring the call light is within reach, the bed is in the lowest position, and the wheels are locked.Observations revealed the following:On 06/02/2026 at 2:08 PM, R12 was seated in a wheelchair at the foot of the bed in room [ROOM NUMBER]-A. The call light was observed on the floor behind the headboard and was not within reach of the resident.On 06/03/2026 at 2:25 PM, R12 was seated in a wheelchair at the foot of the bed. The call light was not within reach of the resident. The call light was draped over the head of the bed with the call button hanging toward the floor. 10. Review of the admission Record revealed R13 was admitted to the facility with diagnoses including, but are not limited to, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, peripheral vascular disease, Alzheimer's disease, and gastrostomy. An observation on 06/02/2026 at 2:03 PM revealed lying in bed in room [ROOM NUMBER]-A. The call light was on the floor next to the wall and was not within reach of the resident. 11. Review of the admission Record revealed R14 was admitted to the facility with diagnoses including, but not limited to, hypertension, obstructive sleep apnea, gastro-esophageal reflux disease, coronary angioplasty status and thrombocytopenia. An observation on 06/02/2026 at 2:36 PM, revealed R14 in room [ROOM NUMBER]-B. The call light was on the floor and was not within reach of the resident. 12. Review of the admission Record revealed R15 was admitted to the facility with diagnoses including, but not limited to dementia, disorder of lung, and history of transient ischemic attach (TIA) and cerebral infarction An observation on 06/02/2026 at 2:03 PM revealed R15 in room [ROOM NUMBER]-B. The call light was on the floor and not within reach of the resident. 13. Review of the admission Record revealed R16 was admitted to the facility with diagnoses including, but not limited to, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, ventricular tachycardia, and hypertension. Review of the care plan dated 07/18/2024 revealed R16 has an ADL self-care performance deficit and is at risk for not having needs met in a timely manner. Interventions include providing a safe environment by ensuring the call light is within reach and bed is in the lowest position with wheels locked. Observations revealed the following:On 06/02/2026 at 1:36 PM, R16 was lying in bed in room [ROOM NUMBER]-B. The call light was not within reach of the resident.On 06/08/2026 at 12:17 PM, the call light was observed on the floor underneath the bed and was not within reach of the resident.14. Review of the admission Record revealed R17 was admitted to the facility with the following diagnoses including but not limited to, hypertensive heart disease, asthma and chronic cough.Review of the care plan dated 12/20/2025 revealed R17 has an ADL self-care performance deficit and is at risk of not having needs met in a timely manner. Interventions include providing a safe environment by ensuring the call light is within reach and the bed is in the lowest position with wheels locked. Observation on 06/08/2026 at 12:13 PM, R17 was observed lying in bed in room [ROOM NUMBER]-A. The call light was on the floor and was not within reach of the resident. 15. Review of the admission Record revealed R18 was admitted to the facility with diagnoses including, but not limited to, Alzheimer's disease, hypertension, dementia, and atherosclerotic heart disease of native coronary artery. Review of the care plan dated 7/2/2024 revealed R18 has an ADL self-care performance deficit and is at risk for not having needs met in a timely manner. Interventions include providing a safe environment by ensuring the call light is within reach and the bed is in the lowest position with wheels locked. An observation on 06/08/2026 at 12:15 PM, R18 was observed in room [ROOM NUMBER]-B. The wall-mounted call light system had been removed. A bell was present; however, it was not within reach of the resident. 16. Review of the admission Record revealed R19 was admitted to the facility with diagnoses including, but not limited to, hemiplegia and hemiparesis following cerebral infraction affecting the right dominant side, cerebral infarction, urinary retention, and hypertension. Review of the care plan dated12/21/2024 revealed R19 is at risk for falls related to impaired balance and history of falls. Inventions include placing the resident's call light within reach and encouraging the resident to use the call light to request assistance as needed. An observation on 06/08/2026 at 12:18 PM R19 was observed in room [ROOM NUMBER]-A. The call light was on the floor on the left side of the bed and was not within reach of the resident. 17. Review of the admission Record revealed R20 was admitted with diagnoses including, but not limited to, hypertension, radiculopathy lumbar region, cerebral infarction, and need for assistance with personal care. Review of the care plan dated 06/02/2026 revealed R20 has an alteration in musculoskeletal status related to radiculopathy, other signs and symptoms involving musculoskeletal system. Interventions include anticipating and meeting the resident's needs, ensuring the call light is within reach, and responding promptly to requests for assistance. On 06/08/2026 at 12:18 PM, R20 was observed lying in bed in room [ROOM NUMBER]-A. The call light was on the floor and was not within reach of the resident.During an interview on 6/8/2025 at 12:01 pm, the Maintenance Director revealed that he saw the call lights that were on the floor or below the bed frames and not within the residents' reach. He continued to state that he had put a few call lights back in reach of the resident but not all of them. And that a vendor will be here today to repair the call lights. During an interview on 6/8/2026 at 3:30 pm, the Director of Nursing (DON) revealed that the call lights should be within reach of the residents. Housekeeping, maintenance director or anyone (staff) who enters the room can put the call light within reach. If a call light is not within reach that means rounds are not being done. And CNAs or nurses making rounds can put the call light within reach of the resident and the call light should be in reach at all times. During an interview on 6/8/2026 at 3:40 pm, the Administrator revealed that he expects any staff who enters a residents' room and the call light is not in reach, should put the call light within reach. Staff need education.

Based on staff interviews and observations, the facility failed to ensure that call light communication system was functioning to allow the residents to call for assistance in four out of 25 residents' rooms (114A, 109B, 112B, 201A). Findings include:During an observation on 06/02/2026 at 1:28 PM, with the Maintenance Director, each residents' room call lights were checked and the following lights were non-operative and did not respond when the call light button was pressed for the following rooms. Observation on 06/02/2026 at 1:34 PM, revealed that the call light in room [ROOM NUMBER]-A was not functioning. When activated, the light above the resident's door did not illuminate to indicate a request for assistance. An observation on 06/02/2026 at 1:38 PM revealed that the call light in room [ROOM NUMBER]-B was not functioning. No alternative method for the resident to request assistance was observed.Observation on 06/02/2026 at 1:42 PM revealed that room [ROOM NUMBER]-B did not have a functioning call light cord. A broken plug without a cord was observed in the wall-mounted call light panel. A bell was present on the bedside table; however, it was not within the resident's reach. The resident was unable to use the bell to request assistance.During the observation, the Assistant Maintenance Director brought a replacement call light cord into the room and provided it to the Maintenance Director. After the replacement cord was installed, the call light system remained nonfunctional.Observation on 06/02/2026 at 2:10 PM revealed that the call light in room [ROOM NUMBER]-A did not illuminate outside the resident's room when activated, preventing staff from knowing the resident had requested assistance.Observation on 06/08/2026 at 12:15 PM revealed that the wall-mounted call light device in room [ROOM NUMBER]-B had been removed. A bell was present; however, it was not within the resident's reach. During an interview on 06/08/2025 at 12:01 PM, the Maintenance Director revealed that a vendor scheduled to repair the call light system that day.At the time exit on 06/08/2026, the call lights system had not been repaired.

Based on observations, staff interviews, and review of the facility's policy titled Food safety requirements the facility failed to label, store, prepare and discard food under sanitary conditions. In addition, the facility failed to ensure cleanliness of the kitchen floors and equipment used for residents. The deficient practices created an unsanitary kitchen environment that increased the potential for cross contamination and foodborne illness for 43 of 47 residents receiving oral diets.Findings include:Review of the facility's policy titled, Food safety requirements, implemented on 4/1/2025 documented under Policy Explanation and Compliance Guidelines number 3- iv. Labeling, dating, and monitoring refrigerated food, including, but not limited to leftovers so it is used by its use by date or frozen discarded. Documented under 7.e Hairnets should be worn when cooking, preparing, or assembling food, such as stirring pots or assembling the ingredients of a salad.During the initial observation tour of the kitchen on 12/16/2025 beginning at 8:55 am with the Registered Dietician (RD) and [NAME] (C) II, the following concerns were identified and confirmed:-A stand-up fan with the blades and grill were covered in dirt and dust.-The kitchen floor under the sinks was missing tiles with grease and dirt built up in addition to a sticky substance covering the floor in that area.-Freezer one contained a bag of hashbrowns without a date or label. -Freezer two contained an opened package of hot dogs wrapped in plastic wrap without a date or label and one cheese pizza without a date or label. -Freezer three contained an opened clear plastic bag of fries without a date or label; one opened plastic bags of what appeared to be breaded cheese sticks without a date or label; five frozen cheese pizzas without a date or label; a pullout drawer with a sticker dated 10/9/2024 that contained a plastic bag of what appeared to be chicken tenders that were not dated or labeled and two clear bags of hashbrowns that were not dated or labeled.-Cooler one contained cheese slices wrapped in plastic wrap without a date or label and a bowl of coleslaw with an expiration date of 12/12/2025.-Cooler two contained a clear bag with four heads of cabbage that were wilted with patches of yellow leaves with black spots without a label or date and two bags of greens with a use by date of 12/5/2025. -A shelf located across from the three stand up freezers contained a plastic tote with various opened bags of expired pasta; a bag of macaroni with a use by date of 12/10/2025; a bag of pasta with a use by date of 10/16/2025; a bag of pasta with an expiration date of 12/5/2025; a bag of pasta not labeled or dated, and a bag of pasta with a use by date of 11/30/2025.- CII and other dietary aids were observed without hair coverings.During the tour, RD confirmed and verified all identified concerns and revealed the staff need a lot of education on labeling, dating, and discarding items. RD removed most of the items and discarded them as they were identified. She stated the kitchen was due for a deep cleaning and did not know when it was last cleaned. She confirmed the dirty fan, the sticky floor with dirt and grease build up and missing tiles. CII confirmed she did not have a hair covering on along with the other aids but put them on as soon as the surveyor entered the kitchen. Observation and interview on 12/17/2025 at 11:40 am with RD revealed the ice machine located in break room off the dining room that is used for the residents contained a black/brown substance on the inside ceiling and was also dripping water. RD verified there was a dark substance and the water dripping from the inside ceiling of the ice maker.Interview on 12/17/2025 at 11:48 am with the Administrator revealed she did not know when the ice maker was last cleaned. The Administrator shut down the ice machine and got it cleaned/corrected during the survey. She confirmed the concerns identified in the kitchen from 12/16/2025. She stated it was her expectation that the kitchen staff follow policy and maintain the cleanliness of the kitchen, wear hair coverings, label, date, and discard items appropriately.

Based on observations, staff interviews, and the facility policy, Disposal of Garbage and Refuse the facility failed to ensure the outdoor garbage and refuse area was maintained in a sanitary manner, creating the potential for harboring pests and insects. The facility census was 47.Findings include:A review of the facility policy titled, Disposal of Garbage and Refuse last revised on 3/26/2025 documented: 7. Refuse containers and dumpsters kept outside the facility shall be designed and constructed to have tightly fitting lids, doors, or covers. Containers and dumpsters shall be kept covered when not being loaded. Surrounding area shall be kept clean so that accumulation of debris and insect/rodent attractions are minimized.Observations on 12/16/2025 at 10:06 am, 12/17/2025 at 8:38 am, and 12/18/2025 at 8:45 am revealed trash scattered on the ground outside of the dumpster including paper, plastic, and food container waste products. In addition, there were wooden pallets leaning against the wooden fence surrounding the dumpster. Interview on 12/18/2025 at 10:01 am with the Administrator confirmed the presence of trash on the ground in the dumpster area and the wooden pallets leaning against the wooden fence surrounding the dumpster. The Administrator revealed trash is picked up three times a week and trash gets spilled. She stated the trash company will not dispose of the wooden pallets and that the Maintenance Director leans them against the dumpster fence and discards them himself.

Based on observations, staff interviews, record review, and review of the facility's policy titled Resident Self Administration of Medications, the facility failed to ensure unauthorized medications were not stored at the bedside for four residents (R) (R5, R21, R36 and R45) of 40 sampled residents. The deficient practice had the potential for other residents and visitors to access unsecured medications stored in the residens' rooms. Findings include: A review of the facilities policy titled, Resident Self-Administration of Medication, dated 2024 revealed that a resident may only self-administer medications after the facility's interdisciplinary team (IDT) has determined which medications may be self-administered safely. Guideline number 4. reveals that results of the IDT assessment are recorded on the Medication Self-administration assessment form and placed in resident's medical record. Bedside medication storage is permitted if it does not present a risk to other residents and stored in a manner that prevents access by other residents. 1.A review of the most recent Quarterly Minimum Data Set (MDS) dated [DATE] revealed Section C (Cognitive Patterns) that R36 has a Brief Interview for Mental Status (BIMS) score of 14 that indicated little to no cognitive impairment. Section I (Active Diagnosis) revealed diagnosis of but not all-inclusive diabetes melitis (DM), depression, knee pain, digestive surgery, atrial fibrillation, and hypertension. A record review revealed that R36 did not have an IDT self-administration assessment or physician order to self-administer medications. An observation on 12/16/2025 at 10:01 am in room [ROOM NUMBER] where R36 resided revealed that Flonase (prescription nasal spray) was on the bedside table within view of other residents/visitors. A second observation on 12/17/2025 at 10:32 am revealed that the Flonase remained on bedside table and zinc oxide over the counter (OTC) cream was on the table within view of other residents/visitors. An observation and interview on 12/17/2025 at 10:54 am with LPN GG verified that Flonase nasal spray and zinc oxide were on the bedside table belonging to R36. She confirmed that he was not assessed to self-administer medications and that he should not store medication at the bedside. An interview with the Director of Nursing on 12/17/2025 at 2:21 pm confirmed that residents should be assessed to allow them to self-administer medications. She stated the resident should be care planned to self-administer. She revealed that no one is to self-administer medications in the facility. She confirmed that medication should not be stored at the bedside. 2.Observation and interview with R45 on 12/16/2025 at 11:58 pm who resided in room [ROOM NUMBER]A revealed a bottle of OTC nasal spray sitting on the resident's bedside stand within view of other residents and/or visitors entering the room. R45 stated the medication was being used without the supervision of staff. Review of the electronic health record (EHR) for R45 revealed the following diagnoses that included but not limited to paroxysmal atrial fibrillations and respiratory infections. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] for R45 revealed in Section C (Cognitive Patterns) a Brief Interview Mental Status Score (BIMS) of 14, which indicated little to no cognitive impairment. Review of the active physician orders as of 12/17/2025 for R45 revealed there was no documented order for the nasal spray. Additionally, there was no order for the self-administration of medications. Review of the electronic health record (EHR) for R45 revealed there was no self-administration assessment or care plan regarding self-administering medications. During an observation and interview on 12/17/2025 at 9:37 am with Unit Nurse Supervisor-Register Nurse (RN) and Director of Nursing (DON), both confirmed the medication was in the room. They reported being unaware of the nasal spray in the room. 3. Observation on 12/16/2025 at 1:54 pm of room [ROOM NUMBER] belonging to R21 revealed the following medication and medication products sitting on her bedside rolling table: zinc oxide creams and cough drops. Review of the electronic health record (EHR) for R21 revealed the following diagnoses that included but not limited to hypertension and atherosclerotic heart disease of native artery without angina pectoris. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] for R21 revealed in Section C (Cognitive Patterns) a Brief Interview Mental Status Score (BIMS) of 13, which indicated little to no cognitive impairment. Review of the active physician orders as of 12/16/2025 for R21 revealed there was no documented order for the self-administration of medications. Review of the electronic health record (EHR) for R21 revealed there was no self-administration assessment or care plan regarding self-administering medications. Observation and interview on 12/20/2025 at 10:51 pm with the DON confirmed the medications were in the room and immediately removed the medication. She stated the resident was not assessed to self-administer medications. 4. Observation on 12/16/2025 at 11:44 pm of room [ROOM NUMBER] assigned to R5 revealed the following OTC medication products: zinc oxide cream, jar of vapor rub, and package of cough drops within open view of residents/visitors entering the room. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] for R5 revealed in Section C (Cognitive Patterns) a Brief Interview Mental Status Score (BIMS) of 11, which indicated moderate cognitive impairment. Review of the physician orders dated 12/23/2025 for R5 revealed there was no documented active order for the observed OTC medications. Additionally, there was no active order for the self-administration of medications. Review of the electronic health record (EHR) for R5 revealed there was no self-administration assessment or care plan regarding self-administering medications. During an observation and interview on 12/17/2025 at 10:03 am with the DON and Nurse Supervisor, both confirmed the medications should not be stored in the resident's room and removed the medications.

Based on observations, interviews, record review, and review of the facility's policy titled Comprehensive Care Plans, the facility failed to develop and/or implement a comprehensive person-centered care plan related to nail care and pain management for three of 40 sampled residents (R) (R24, R35 and R42). The deficient practice had the potential to affect the quality of life for the residents.Findings include: A review of the facility policy titled, Comprehensive Care Plans, dated 2/2/2025 documented that the facility was to Develop and implement comprehensive person-centered care plan for each resident, consistent with resident rights, than includes measurable objectives and time frames to meet a residents' medical, nursing, mental, and psychosocial needs and all services that are identified in the residents' assessment and meet professional standards of quality. 1. A review of the electronic medical record (EMR) revealed that R35 was admitted to the facility with diagnoses that included but not limited to hemiplegia and hemiparesis following cerebral infarction effecting left non-dominant side encounter for attention to gastrostomy essential (primary) hypertension, anxiety disorder, unspecified peripheral vascular disease, Alzheimer's, and major depressive disorder. A review of the annual Minimum Data Set (MDS) assessment dated [DATE] for R35 revealed Section C (Cognitive Patterns) Brief Interview for Mental Status (BIMS) score of six, which indicated severe cognitive impairment. In addition, Section GG (Functional Abilities and Goals) revealed the resident was dependent on staff for personal hygiene. A review of the care plan dated 8/18/2025 documented an intervention that included but not limited to Staff to provide shower and nail care per schedule and when needed. Observation with interview on 12/16/2025 at 11:00 am with R35 revealed his fingernails were long with a black substance underneath the tips of the nails. R35 was able to verbally express he wanted his nails trimmed and cleaned. Observation on 12/17/2025 at 9:05 am with R35 revealed his fingernails were long with a black substance underneath the tips of the nails. Observation with interview on 12/18/2025 at 12:06 pm with R35 revealed his fingernails were long with a black substance underneath the tips of his nails. R35 was able to verbally express he wanted his nails trimmed and cleaned. Interview on 12/18/2025 at 12:23 pm with the Director of Nursing (DON) confirmed that R35's nails were long and had a black substance underneath. She stated that Certified Nurse Assistants' (CNA) should follow the care plan interventions by cleaning and trimming nails. She confirmed the care plan was not being implemented. Interview on 12/18/2025 at 1:43 pm with the MDS Coordinator verified R35's care plan included interventions to address nail care; specifically for fingernails to be cleaned and trimmed. MDS Coordinator confirmed that staff were not providing care according to the care plan as evidenced by R35's nails being long and dirty with a black substance under the tip of the nail. 2. A review of the electronic medical record (EMR) for R42 revealed the most recent Quarterly Minimum Data Set (MDS) dated [DATE] Section C (Cognitive Patterns) that R42 has a Brief Interview for Mental Status (BIMS) score of seven indicated severe cognitive impairment. Section I (Active Diagnosis) revealed diagnosis of but not all-inclusive amputation of right great toe, neuromuscular dysfunction of bladder, protein-calorie malnutrition, depression, urethritis, depressive disorder, stage four pressure ulcer of sacrum, type two diabetes mellitus. A review of the care plan dated 12/8/2025 revealed that R42 had a focus statement regarding activities of daily living (ADL) self-care performance deficit at risk of not having needs met in a timely manner. An observation and interview with R42 on 12/16/2025 at 9:29 am revealed that R42 had long and dirty fingernails. R42 was able to verbally express she did not want her nails that long and wanted them cut. An observation and interview with R42 on 12/17/2025 at 10:34 am revealed R42 fingernails remain long and dirty and she would like her fingernails cut. An interview with Director of Nursing (DON) on 12/18/2025 at 12:32 pm confirmed that staff should follow the care plan. An interview with MDS Coordinator on 12/18/2025 at 1:45 pm confirmed that staff are to provide care according to the care plan. 3. A review of the admission Record for R24 revealed an admission date of 11/20/2025 with primary diagnosis: multiple fractures of ribs, left side, subsequent encounter for fracture with routine healing. A record review revealed that R24 had a physician order dated 12/5/2025 for tramadol HCL [hydrochloride] oral tablet 50mg (Milligrams) give one tablet by mouth every eight hours as needed [PRN] for pain. A review of the Comprehensive Care Plan dated 11/20/2025 and revised 11/24/2025 for R24 revealed there is no problem or interventions documented to address pain management or controlled medication use on the Comprehensive Care Plan and according to physician orders. An interview with MDS Coordinator on 12/18/2025 at 1:45 pm confirmed that staff are to provide care according to the care plan and Interdisciplinary Team, Infection Preventionist, Unit Manager and/or Director of Nursing can update the care plan for changes.

Based on observations, interviews, record review, and review of the facility's policy titled Activities of Daily Living, the facility failed to ensure that Activities of Daily Living (ADL) care services were provided for two of 40 sampled residents (R) (R35 and R42) related to nail care. This failure placed the residents at risk for diminished quality of life. Findings include: A Review of the facility's policy revised on 1/14/2025 titled Activities of Daily Living documented Care and services will be provided for the following activities of daily living: 1. Bathing, dressing, grooming and oral care. Under policy explanation and compliance guidelines 3. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. 1. A review of the electronic medical record (EMR) revealed that R35 was admitted to the facility with diagnoses that included but not limited to hemiplegia and hemiparesis following cerebral infarction effecting left non-dominant side encounter for attention to gastrostomy essential (primary) hypertension, anxiety disorder, unspecified peripheral vascular disease, Alzheimer's, and major depressive disorder. A review of the annual Minimum Data Set (MDS) assessment dated [DATE] for R35 Section C (Cognitive Patterns) revealed a Brief Interview for Mental Status (BIMS) score of six, which indicated severe cognitive impairment. In addition, Section GG (Functional Abilities and Goals) revealed the resident was dependent on staff for personal hygiene. A review of the care plan dated 8/18/2025 for R35 documented an intervention that included but not limited to Staff to provide shower and nail care per schedule and when needed. Observation with interview on 12/16/2025 at 11:00 am with R35 revealed his fingernails were long with a black substance underneath the tips of the nails. R35 was able to verbally express he wanted his nails trimmed and cleaned. Observation on 12/17/2025 at 9:05 am with R35 revealed his fingernails were long with a black substance underneath the tips of the nails. Observation with interview on 12/18/2025 at 12:06 pm with R35 revealed his fingernails were long with a black substance underneath the tips of his nails. R35 was able to verbally express he wanted his nails trimmed and cleaned. Interview on 12/18/2025 at 12:15 pm with Certified Nurse Aid (CNA) HH stated that she does not like to cut resident nails, so she asks the wound care nurse to complete nail care. She revealed nails are cleaned at bath time which is every other day or everyday if the resident prefers. She revealed she was the CNA who last gave R35 a bath on 12/17/2025. She stated she cleaned R35's nails and knew they were long but confirmed she did not trim his nails or ask the wound nurse to trim his nails. Interview on 12/18/2025 at 12:20 pm with the wound care nurse revealed that she does not normally cut resident nails. She revealed that no one has recently asked her to trim any residents' nails including R35's but that she would do it if asked. Interview during observation rounding on 12/18/2025 at 12:23 pm with the Director of Nursing (DON) confirmed R35's nails were long and had a black substance underneath the tips of the nails. She stated that CNAs should be cleaning nails on bath days, which is every other day and should trim nails when needed or everyday according to resident preferences. 2. A review of the electronic medical record (EMR) for R42 revealed the most recent Quarterly Minimum Data Set (MDS) dated [DATE] Section C (Cognitive Patterns) that R42 has a Brief Interview for Mental Status (BIMS) score of seven indicated severe cognitive impairment. Section I (Active Diagnosis) revealed diagnosis of but not all-inclusive amputation of right great toe, neuromuscular dysfunction of bladder, protein-calorie malnutrition, depression, urethritis, depressive disorder, stage four pressure ulcer of sacrum, type two diabetes mellitus. A review of the care plan dated 12/8/2025 revealed that R42 had a focus statement regarding activities of daily living (ADL) self-care performance deficit at risk of not having needs met in a timely manner. An observation and interview with R42 on 12/16/2025 at 9:29 am revealed that R42 had long and dirty fingernails. R42 was able to verbally express she did not want her nails that long and wanted them cut. An observation and interview with R42 on 12/17/2025 at 10:34 am revealed R42 fingernails remain long and dirty and she would like her fingernails cut. An observation and interview with Certified Nurse Assistant (CNA) BB confirmed that R42 had long and dirty fingernails. CNA BB stated that nurses and CNAs are responsible for cutting fingernails. An observation and interview with the Wound Care Nurse (WCN) on 12/18/2025 at 10:34 am revealed that R42's fingernails were long and dirty. She confirmed they need to be cleaned and cut. WCN stated the Certified Nurse Assistants are responsible for cutting residents' fingernails. An observation and interview with the Unit Manager on 12/18/2025 at 11:24 am confirmed that R42's fingernails were long and that R42 would like her fingernails cut. An interview with the DON on 12/18/2025 at 12:32 pm revealed that CNA staff are responsible for maintaining fingernails during bath time. She confirmed that there was no reason for R42's fingernails to be so long and dirty and that staff should have addressed R42's fingernails.

Based on observations, interviews and review of policy titled, Controlled Substance Administration and Accountability, the facility failed to reconcile controlled narcotic medications for one resident (R) (R24) out of 40 sampled residents. This deficient practice had the potential to place residents at risk of clinical complications and drug diversion. Findings include:Review of the facility's policy titled, Controlled Substance Administration and Accountability dated 2024 documented: the facility promotes safe, high quality patient care, compliant with state and federal regulations regarding monitoring the use of controlled substances. Documented under General Protocols: (F) All controlled substances are accounted for obtained from a non-automated medication cart or cabinet are recorded on the designated usage form.the dose noted on the usage form or entered into the automated dispensing system must match the dose recorded on the Medication Administration Record (MAR), Controlled Drug Record, or other facility specified form and placed in the patient's medical record.A review of the most recent Quarterly Minimum Data Set (MDS) dated [DATE] for R24 revealed Section C (Cognitive Patterns) Brief Interview for Mental Status (BIMS) score of eight indicating moderate cognitive impairment. Section I (Active Diagnosis) revealed diagnoses of but not all-inclusive hypertension, renal insufficiency, multiple fractures of ribs, and motor vehicle accident.A review of care plan dated 11/20/2025 for R24 revealed there is no problem or interventions documented to address pain management or controlled medication use. A record review revealed that R24 had a physician order dated 12/5/2025 for tramadol HCL [hydrochloride] oral tablet 50mg (Milligrams) give one tablet by mouth every eight hours as needed [PRN] for pain.An observation and interview with Licensed Practical Nurse (LPN) DD on 12/17/2025 revealed that the narcotic count on the reconciliation form for R24 did not match the number of tablets remaining in the medication card. LPN DD stated that the night shift nurse told her during shift-to-shift report that she administered PRN medication at 12:30 am on 12/17/2025 to R24. The controlled substance form revealed that the last dose administered was 12/15/2025. LPN DD confirmed that there was no documentation of a dose administered during night shift in the narcotic control book, medication administration record (MAR), or progress note.An interview with the Unit Manager on 12/17/2025 at 3:56 pm revealed that the controlled substance count was wrong. The night shift LPN did not record the dose of tramadol on the narcotic log or MAR but wrote on shift-to-shift communication report that she gave the medication last night.An interview with the Director of Nursing (DON) on 12/17/2025 at 2:11 pm confirmed there was a narcotic discrepancy for the tramadol belonging to R24. She stated that pharmacy started the narcotic count sheet when the medication is delivered. She stated that each nurse on each shift must verify the count every shift. The nurses are to document the time they give a narcotic to a resident. When a count is wrong, they are to notify the DON and Administrator that the controlled substance count was wrong. She stated the oncoming nurse should not take the keys if the controlled substance count was wrong.An interview with the Administrator on 12/17/2025 at 2:20 pm confirmed there was a controlled substance discrepancy and that they consulted the pharmacist for next steps. An interview with the Pharmacist Consultant on 12/18/2025 at 11:54 am revealed that he was not notified of the narcotic discrepancy. He stated that the manifest (reconciliation form) was sent with the medication and each nurse is to document the administration of controlled medications.

Based on observations, staff interviews, and facility policy titled, Medication Administration, the facility failed to ensure a medication error rate of less than five percent (%). A total of 36 medication opportunities were observed, with three errors for one resident (R) (R23) by one nurse giving medications resulting in an 8.33% medication error rate. This deficient practice has the potential to place residents at risk of clinical complications and diminished quality of life. Findings include:A review of the policy titled Medication Administration, dated 2025 documented the principles of medication administration include the right resident, right medication, right dosage, right route, right time, and right documentation. Review medication administration record (MAR) and compared to medication source (bubble pack, vial, etc.) with medication administration record (MAR) to verify resident name, medication name, form, dose, route, and time.A review of physician orders for R23 revealed:-Buspirone HCL [hydrochloride] oral table give 20mg [milligrams] by mouth three times a day for anxiety disorder.-Sertraline HCL oral tablet 100mg give two tablets by mouth one time a day related to major depressive disorder.-Sucralfate 1GM [gram] tablet give 1 [one] tablet by mouth two times a day related to gastro-esophageal reflux disease without esophagitis.A review of the medication card for R23 Sucralfate revealed special directions to give on an empty stomach.An observation of LPN GG on 12/17/2025 at 7:49 am during a medication pass revealed that R23 received sucralfate 1 GM tablet along with the other medications while eating breakfast. Additional observation revealed that buspirone HCL medication card contained 10mg tablets, the directions documented buspirone (anxiety medication) give 20 mg three times a day; R23 received one 10 mg tablet but should have received two tablets. Finally, during the same observation, R23 received one tablet of sertraline HCL 100mg, but should have received two tablets. An interview with LPN GG on 12/17/2025 at 10:57 am confirmed that R23 did not receive sucralfate on an empty stomach, received one tablet of 10mg buspirone, and one tablet of sertraline 100mg. LPN GG confirmed she did not administer the medications according to the MAR and medication card directions, which resulted in three errors.An interview with the Medical Director on 12/17/2025 11:42 am revealed residents should receive medication as ordered. He confirmed that R23 should have received two tablets, each of sertraline and buspirone. The expectation is that the nurses will follow the written orders listed on the MAR.An interview with the Pharmacist Consultant on 12/18/2025 at 11:54 am revealed that the nurse should have given two tablets each of sertraline and buspirone. He confirmed that the timing of the sucralfate should be on an empty stomachAn interview with the Director of Nursing (DON) on 12/18/2025 at 12:32 pm revealed that sucralfate was to be administered on an empty stomach. She confirmed the nurses are to administer medication the right way, right dose, right amount, right person, and right time.

Based on observations, staff interviews, record review and the facility policies titled, Infection Prevention and Control Program, Hand Hygiene, and Transmission Based Precautions, the facility failed to follow safe and appropriate infection control practices for two of five residents (R) (R 16 and R 31) reviewed for infection control and one room (room [ROOM NUMBER]) on one of three hallways observed for Transmission based precautions. These deficient practices have the potential to place residents and staff at risk for cross-contamination and the spread of infections.Findings include:Review of the facility policy titled, Infection Prevention and Control Program, dated 8/1/2025 documented under policy statement the facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to prevent the development and transmission of communicable disease and infections. In addition, regarding linens on page four documented solid linen shall be collected at the bedside and placed in linen bag .soiled linen shall not be kept in resident's room or bathroom.Review of the facility policy titled Hand Hygiene, dated 1/14/2025 documented that all staff will perform hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations of the building. This includes after handling contaminated objections, between resident contacts, before applying and after removing personal protective equipment (PPE), including gloves.Review of the facility policy titled, Transmission Based precautions, dated 4/1/2024 documented the facility is to take appropriate precautions to prevent transmission of pathogen's mode of transmission. residents have a private room accommodation and will wear a fit tested N95 or higher-level respirator and other appropriate PPE while delivering care to the resident.1. An observation and interview on 12/16/2025 at 10:35 am revealed a Housekeeper (HK) KK applied a gown, gloves and surgical mask and entered room [ROOM NUMBER]. On the outside door was a sign reflecting the resident was under Airborne Precautions. An interview with HK KK confirmed she was wearing a gown, gloves, and surgical mask instead of the recommended N95 mask (mask rated to help protect against airborne organisms.)An observation of LPN DD on 12/16/2025 at 11:51 am revealed she donned a gown, gloves and surgical mask before entering room [ROOM NUMBER]. During the medication pass LPN DD left the room door open to the hallway while she prepared medications on the med cart located outside the room. The sign located on the outside part of the door read Airborne Precautions and to keep the door closed. LPN DD exited out the door of the adjoining room [ROOM NUMBER] creating potential contamination between the two rooms.An observation and interview of CNA JJ on 12/17/2025 at 8:18 am revealed CNA JJ entered room [ROOM NUMBER] wearing a gown, gloves, and a surgical mask. CNA JJ revealed that airborne precautions require mask, gown, and gloves and confirmed that she was wearing a surgical mask and should wear an N95 mask.An interview with UM on 12/17/2025 at 3:56 pm revealed the resident in room [ROOM NUMBER] was on transmission based Airborne Precautions related to chicken pox. UM stated airborne precautions mean the staff should keep door closed, good hand washing, dispose of items and wear a surgical mask, gloves, and gown. The UM stated she was unaware of the N95 mask requirement, until she reviewed the policy. An interview with Director of Nursing on 12/18/2025 at 12:32 pm revealed for the residents under airborne precautions, the staff must wear a gown, N95 mask, gloves and possibly a face shield. She confirmed the resident in 303 is considered a private room and the door should always remain closed. She confirmed staff should not be wearing surgical masks for airborne precautions. 2. An observation of Wound Care Nurse (WCN)/Infection Preventionist on 12/17/2025 at 8:40 am revealed that during wound care for R 31 she changed gloves without using hand sanitizer between glove changes. After completion of wound care for R31, she moved over to provide a dressing change to g-tube site for R16 who resided in the same room. She did not clean her hands after removing the gloves and did not change the gown. She changed gloves and did not disinfect hands before applying new gauze around gastrostomy tube site.An interview with WCN/Infection Preventionist on 12/17/2025 at 9:10 am revealed she did not disinfect her hands between glove changes and between residents. She confirmed the hand sanitizer was not on the bedside table but across the room on the dresser. She confirmed the gown was not changed between residents and acknowledged it should have been changed.

Based on resident interviews, staff interviews, and record review, the facility failed to ensure two of 11 sampled residents (R) (R4 and R5) were not served identified food allergens. The deficient practice had the potential to place R4 and R5 at risk for medical complications, unmet needs, and a diminished quality of life. Findings include: 1. Review of R4's Admission Record revealed diagnoses that included, but were not limited to, gastro-esophageal reflux disease and vitamin deficiency. The Admission Record revealed shellfish products listed in the allergies section. Review of R4's quarterly Minimum Data Set (MDS) assessment, dated 3/6/2025, revealed Section C (Cognitive Patterns) documented a Brief Interview for Mental Status (BIMS) of 15 (indicating little to no cognitive impairment). Review of R4's Order Summary Report active orders as of 12/1/2024 revealed an allergy to shellfish products. Review of R4's Progress Notes revealed an entry dated 12/10/2024 that the resident did not have any reactions or issues during this shift. An entry dated 12/11/2024 noted that R4 had no shortness of breath or edema. Review of a Facility Incident Report Form dated 12/10/2024 revealed a Certified Nursing Assistant (CNA) reported R4 received seafood from the dietary department, and the resident took one bite and refused to eat more. The report documented that the physician, family member, and dietary manager were notified. The resident was assessed and showed no signs of allergic reaction throughout a shift. Review of the monthly menu revealed that fish products were served once a week. During an interview on 3/26/2025 at 3:58 pm, R4 revealed that she had been served fish and had asked the CNA what it was. R4 stated that the CNA told her that she didn't know what it was. R4 stated that she took one bite and realized it was a crab cake. She stated that she spit out the fish and rinsed her mouth with water. She stated she was allergic to fish, shellfish, clams, and oysters. During an interview on 3/31/2025 at 9:44 am, the Certified Dietary Manager (CDM) confirmed R4 had been served a crab cake on a meal tray. The CDM stated that the nurses and CNAs determined that the resident had received the wrong tray, and the resident was served an alternate meal after the discovery. During an interview on 3/31/2025 at 12:28 pm, Licensed Practical Nurse (LPN) II revealed that everyone had received an in-service to check the resident meal tickets. LPN II stated that CNAs, nurses, and dietary staff were responsible for checking food allergens. 2. Review of R5's Admission Record revealed diagnoses that include, but are not limited to, adult failure to thrive. The Admission Record revealed fish was listed in the allergies section. Review of R5's admission MDS assessment, dated 1/23/2025, revealed Section C (Cognitive Patterns) documented a BIMS of 13 (indicating little to no cognitive impairment). Review of R5's Order Summary report dated 2/1/2025 through 3/31/2025 revealed fish allergy was listed in the allergies section. During an interview on 3/24/2025 at 2:42 pm, R5 revealed that he received fish every time it was on the menu and he sent it back. During an interview on 3/31/2025 at 2:56 pm, CNA KK revealed that R5 told her he was allergic to fish, and she saw it on his meal card. She stated that R5 had been served a meal with fish and that she took the entire tray back to dietary and obtained another tray for the resident. During an interview on 3/31/2025 at 9:44 am, the CDM revealed that the Dietary [NAME] was to ensure that residents with food allergies were not served the food allergens and that the nursing staff should check the meal trays as well. During an interview on 3/31/2025 at 3:29 pm, the Director of Nursing (DON) revealed that the staff was responsible for checking meal trays for allergens and that residents should not be served foods they were allergic to.

Based on observations, staff interviews, record review, and review of the facility policy titled, Enhanced Barrier Precautions, the facility failed to ensure staff followed infection control processes during wound care for one of one residents (R) (R3) observed for wound care from a sample of 11 residents. The deficient practice increased the risk of staff spreading infection to other residents in the facility. Findings include: Review of the facility policy titled, Enhanced Barrier Precautions, dated 4/1/2024, revealed the Policy section included, It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms. 3. Implementation of Enhanced Barrier Precautions: 3a. Make gowns and gloves available immediately near or outside of the resident's room. Noted: face protection may also be needed if performing activity with risk of splash or spray (i.e., wound irrigation, tracheostomy care). 3b. PPE for enhanced barrier precautions is only necessary when performing high-contact care activities and my not need to bed donned prior to entering their resident's room. 4. High-contact resident care activities include: a. Dressing b Bathing c. Transferring d. Providing hygiene e. Changing linens f. changing briefs or assisting with toileting g. device care or use: central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes h. Wound care: any skin opening requiring a dressing. Review of R3's Quarterly Minimum Data Set (MDS) assessment, dated 2/27/2025, revealed Section M (Skin Condition) documented the resident had one unstageable pressure ulcer. An observation on 3/24/2025 at 3:10 pm in R3's room revealed Certified Nursing Aide (CNA) AA providing perineal care to R3. Observation revealed CNA AA providing direct care to remove the dirty incontinent brief and was not wearing a protective barrier gown. An observation on 3/24/2025 at 3:31 pm revealed Licensed Practical Nurse (LPN) BB provided wound care to R3's right heel. Observations during the wound care procedure revealed that LPN BB did not wear a gown during the procedure. Further observations revealed LPN BB placed the wound care supplies on a bedside table without sanitizing the surface of the table or placing a barrier on the table. During an interview on 3/31/2025 at 10:46 am, CNA EE stated that the facility had not had any gowns available for the past month. She further stated that gowns should be worn when providing care to residents with urinary catheters, infections, bloody urine, and feces when the facility had gowns. During an interview on 3/31/2025 at 11:48 am, Registered Nurse (RN) HH/Infection Preventionist (IP) stated that staff should wear a barrier gown when providing care to residents who were on enhanced barrier precautions (EBP) and further stated she was unsure why staff were not wearing gowns. Observation on 3/31/2025 at 12:03 pm with RN HH IP revealed a supply of protective gowns in the supply room on 300 Hall.

Based on staff interviews and record review, the facility failed to ensure laboratory orders were obtained as ordered by the physician for one of 13 residents (R) (R21). This failure resulted in actual harm on 9/19/2023 when R21 was admitted to the local hospital and required a blood transfusion after the facility failed to obtain ordered labs for March 2023 and June 2023 facility received lab results on September 19, 2023, indicating R21 had a hemoglobin level of 5.9 g/dl (grams per deciliter) normal range was 13.5 - 17.5 g/dl. Findings: Record review revealed R21 was admitted to the facility with the diagnosis of but not limited to, Idiopathic gout, cerebral infarction, aphasia, hemiplegia, Diabetes mellitus, chronic systolic congestive heart failure, hypertensive heart disease, hypercholesterolemia, angina pectoris, major depressive disorder, and epilepsy. Physician order dated 3/7/2023 indicated to collect labs CBC (complete blood count) w (with) diff Q (every) three months March/June/September/December. There was no indication the ordered labs were obtained for March 2023 and June 2023. Review of the laboratory results dated [DATE] revealed a CBC was obtained with a result of Hemoglobin (HGB) 5.9 g/dl. Review of R21 progress notes dated 9/19/2023 revealed resident has a critical lab with a hemoglobin of 5.9 (--) on call for Medical Director (MD) wanted to send to emergency room (ER) notified family member and called report to ER was transported by Emergency Medical Service (EMS). Interview on 8/10/2024 at 2:37 pm with Unit Manager revealed that R21 received the diagnosis of Iron Deficiency anemia after he was admitted to the hospital and received two units of blood for a hemoglobin of 5.9. The order to collect the CBC was a routine blood draw that the facility physician would order for all residents. The results for the CBC that was ordered for March 2023 and June 2023 were not completed, and results were unable to be located in the electronic Laboratory system or in the R21 medical record.

Based on record review, staff interviews, and review of the Payroll-Based Journal (PBJ) Staffing Data Report [NAME] Report 1705D Fiscal Year (FY) Quarter 2 2024 (January 1 - March 31), the facility failed to provide Registered Nurse (RN) coverage for 8 hours within a 24-hour period on 1/7/2024, 1/21/2024, 2/4/2024, 2/18/2024, 3/3/2024, 3/17/2024 and 3/31/2024. The facility census was 40 residents. Findings include: Review of the most recent PBJ Staffing Data Report CASPER Report 1705D FY Quarter 2 2024 (January 1 - March 31) revealed the facility triggered for No RN Hours which indicated four or more days within the Quarter with no RN hours for the following dates: 1/7/2024, 1/21/2024, 2/4/2024, 2/18/2024, 3/3/2024, 3/17/2024 and 3/31/2024. Review of the form titled, [Facility Name] Daily Nursing Sheet, dated 1/7/2024 revealed, there was not a registered nurse scheduled on the 1st, 2nd, or 3rd shifts. Further review revealed on 1/21/2024, 2/4/2024, 2/18/2024, 3/3/2024, 3/17/2024, and 3/31/2024 there was RN coverage eight hours on 1st shift. Review of the form titled, Daily Staffing Schedule dated 1/7/2024, 1/21/2024, 2/4/2024, 2/18/2024, 3/3/2024, 3/17/2024 and 3/31/2024 revealed, RN HH was scheduled to work on 1st shift. Review of the payroll Timecard Report for RN HH revealed, the total number of hours worked on 1/7/2024 (7.67 hours),1/21/2024 (8.22 hours), 2/4/2024 (7.55 hours), 2/18/2024 (7.47 hours), 3/3/2024 (7.80 hours), 3/17/2024 (7.43 hours) and 3/31/2024 (7.68 hours). Interview on 8/10/2024 at 10:05 am with the Business Office Manager (BOM) revealed, she was responsible for human resources and payroll. She confirmed there was no RN coverage for eight full hours for the following dates (1/7/2024, 1/21/2024, 2/4/2024, 2/18/2024, 3/3/2024, 3/17/2024 and 3/31/2024) indicated on the PBJ report. The BOM revealed they had RN coverage scheduled on those days however the time clock system automatically deducted 30 minutes for lunch. She stated they were aware that RN HH who worked on those dates did not work the full eight hours and that this had been addressed with the Administrator. She reported they try to staff at least two RNs daily to meet the requirements. Interview on 8/10/2024 at 2:00 pm with the Administrator revealed, she was aware of the discrepancy with the RN hours indicated on the PBJ report. She revealed that she knew it would potentially trigger the report. She revealed the facility staff are required to take 30 minute lunch breaks and two 15 minute breaks during an eight hour period. She revealed she had discussed this with corporate so that they could produce a resolution. She reported she was aware that there should be RN coverage a full eight hours within a 24 hour period. Interview on 8/10/2024 at 3:22 pm with Licensed Practical Nurse (LPN) Unit Manager revealed, that she was responsible for staffing RN coverage for eight hours per day. She reported that the new time clock system automatically clocks them out regardless of whether the nurse took the lunch or not. LPN Unit Manager stated her expectations of the RNs was to work at least 8.5 hours to ensure a full eight hours daily as required.

Based on observation, staff interviews, and review of facility documents, the facility failed to ensure recipe for puree carrots and chicken were followed to preserve nutritional value of food for residents receiving a pureed diet. The facility also failed to ensure residents consuming a puree diet were served the recommended three ounces (oz) of protein during meal service. Findings: Review of the untiled document submitted by the Dietary Manager with scoop number, diameter capacity (in ounces) and color (color of scoop handle) revealed the number 16 scoop that was used to measure the puree foods had the following: Number 16 -Diameter 2 1/4 inches/5.72 cm (Centimeters), Capacity - 2 3/4 0z. The number 16 scoop did not provide the needed three ounces of protein per resident. Review of the document titled, Quantified Recipe (Recipe #220) for baked chicken revealed the following: portion size: number 8 scoop, serving utensil #8 scoop, baked chicken 30z SCR. 1. Prepare according to ground recipe. Stock Chicken/soup base for thinning. Recipe #249 Seasoned carrots, portion size #16 scoop (1/2 cup), serving utensil #16 scoop.1. Prepare according to regular recipe. There was no indication to add any type of liquids during the puree process Puree observation on 8/10/2024 at 10:45 am revealed [NAME] AA poured measured carrots into food processor and began blending food. During blending staff member went over to the vegetable sink next to blending station and retrieved tap water from the sink faucet and proceeded to add to the carrots during the mixing process. This step was repeated one more time until desired consistency was met. After carrots were completed [NAME] AA proceeded to prepare the diced chicken for the puree residents in the same manner of adding water to the mixture until desired consistency was met. Interview on 8/10/2024 at 11:00 am with [NAME] AA revealed that the facility currently had three residents that were on puree diets. It was reported that the recipe for pureeing foods is in the menu book that is kept on the shelf above the milk cooler. During the interview staff member was asked how many ounces (oz) of protein should each resident on a puree diet receive and staff member was unable to verbalize the amount needed for each resident to receive to ensure the appropriate nutritional value was met. [NAME] AA stated, The puree residents have a divided plate and I just make sure that one of the squares is full when I scoop the food into the plate, and sometimes I will put a little more in it. Further interview also revealed that [NAME] AA stated that she uses the number 16 scoop to measure the portions before pureeing the food but was unable to verbalize what the measurement of the scoop used was. Interview on 8/10/2024 at 11:30 am with the Dietary Manager revealed that there are recipes that are to be followed that are located in the kitchen, but the staff that is currently working in the kitchen have been there for a while and are aware of which scoop to use for measuring foods to ensure nutritional value is met. During interview, the Dietary Manager was asked how the staff know which scoop to use and she stated that the scoops are color coded and there use to be a guide posted on the wall in the kitchen that indicates the amount in ounces of each scoop by the color of the handle. Further interview also revealed that sometimes during the puree process the cooks will add water or milk to ensure the right consistency is obtained. Dietary Manager confirmed the scoop used by [NAME] AA was not the correct scoop to obtain the recommended three ounces of vegetables and protein for residents consuming a puree diet.

Based on observations, staff interviews, and review of the facility policy titled, Used By Dating Guideline, the facility failed to ensure food items were properly labeled and dated, failed to discard expired foods by expiration date, and failed to ensure ice machine was kept clean and free of lime and calcium buildup. The deficient practice had the potential to affect 36 of 40 residents receiving an oral diet. Findings: Review of the facility policy titled, Used By Dating Guideline Dated [DATE] revealed under Section 1: foods that have been mixed with other ingredients, prepared in any way, or portioned out include, but are not limited to juices, thickened beverages, canned fruit, unused portions, prepared salads, cut fruits/vegetables, roasted/sliced meats use by date-three days after preparation. Observation on [DATE] at 7:50 am revealed in the reach in cooler located to the right of the main kitchen a small steamtable pan of tuna salad that was unlabeled and dated, a bag of cooked macaroni noodles that were not label or dated, 16 oz (ounce) bottle of opened Zesty Italian dressing that was not labeled or dated, 22 oz bottle of opened strawberry syrup not labeled or dated. Observation on [DATE] at 7:51 am revealed on the steel table at the back of the main kitchen in a large gray plastic container was an opened half bag of brown sugar that was not labeled or dated, a bag of unknown substance that was wrapped in plastic wrap unlabeled and undated, a opened half bag of fried onions with a use by date of [DATE]. Observation on [DATE] at 7:53 am revealed in the reach in cooler located to the left of the kitchen by the steam table a large chef salad unlabeled with no expiration date, chef salad in a small white bowl unlabeled and not dated, medium size steamtable pan of macaroni salad with the expiration date of [DATE], half a bag of shredded white cheese not labeled or dated, half a bag of opened cheese cubes unlabeled and undated. Observation on [DATE] at 11:10 am revealed the facility ice machine located in the staff break area there were white chalky streaks noted streaming down the back, front and side of the machine, there was also a thick layer of white chalky substance that was noted in right upper crevices on the front side of the machine. Observation on the inside of the ice machine also revealed a thin layer of black substance on the plastic white panel on the inside of the machine. Interview on [DATE] at 11:15 am with the Administrator revealed the ice machine should be cleaned by the dietary staff daily and maintenance cleans the filter and the motor parts quarterly. A further interview also revealed that the expectation is that the machine is cleaned at least monthly. Interview on [DATE] at 11:25 am with Dietary Manager revealed that she will wipe down the ice machine daily but has been on vacation for the last week. Maintenance is responsible for cleaning the inside of the machine to include the white plastic panel on the inside of the machine. Further interview also revealed that all foods should be labeled and dated when put in the cooler and any leftover food should be discarded after three days. The Dietary Manager also confirmed all unlabeled and expired foods as well as the ice machine that were observed during the initial tour. Interview on [DATE] at 11:57 am with the Maintenance Director revealed that he was responsible for cleaning the ice machine quarterly and the last time it was cleaned was in [DATE]. A further interview revealed that the last quarter's cleaning was not completed, and the machine is currently being cleaned. During the interview it was also revealed that when the machine is cleaned the ice bin is emptied, the filters are cleaned, and the outside of the machine is de limed.

Based on observations, staff interviews, record review, and review of the facility's policy titled, Promoting/Maintaining Resident Dignity, the facility failed to promote, maintain, and protect residents' dignity for two of three residents (R11, R20) with an indwelling urinary catheter. Findings include: Review of the facility's undated policy titled, Promoting/Maintaining Resident Dignity under the section titled Policy revealed, It is the practice of this facility to protect and promote residents rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident's quality of life by recognizing each resident's individuality. 1. Review of R11's Face Sheet revealed diagnoses that included but not limited to, cerebral infarction, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant, retention of urine, disorders of urinary system, and obstructive and reflux uropathy. Review of R11's Quarterly Minimum Data Set (MDS) dated [DATE] revealed Section C-Cognition: Brief Interview of Mental Status (BIMS) score of 11 indicating moderate cognitive impairment; Section GG-Functional Status: resident requires total assistance with all Activities of Daily Living (ADL's); Section H-Bowel and Bladder: resident had indwelling urinary catheter and was always incontinent of bowel; Section M-Skin: resident is at risk for pressure ulcers and had an diabetic foot ulcer. Review of R11's Physician's orders included but not limited to an order dated 8/10/2024 for [Name of catheter] catheter care every shift every eight hours and an order dated 1/19/2024 to change [Name of catheter] cath #20 French on the 19th of each month in the morning starting on the 19th and ending on the 19th every month. Review of R11's Care Plans revealed, a plan in place dated 6/14/2024 that indicated [R1 Name] has a urinary catheter and is at risk for urinary tract infections and injury. Urinary catheter related to obstructive uropathy with urine retention. An observation of R11 on 8/9/2024 at 8:20 am revealed, the resident had an indwelling urinary catheter attached to a urinary catheter bag with yellow urine noted inside. The catheter bag was not covered and was visible from the door. An observation of R11 on 8/9/2024 at 9:26 am revealed the resident had an indwelling urinary catheter attached to a urinary catheter bag with yellow urine noted inside. The catheter bag was not covered and was visible from the door. An observation and interview on 8/10/2024 at 8:38 am with Registered Nurse (RN) BB in R11's room revealed, the resident had an indwelling urinary catheter attached to a urinary catheter bag with yellow urine noted inside. The catheter bag was not covered and was visible from the door. RN BB immediately pulled the dignity bag over the catheter bag down and confirmed the catheter bag should have been covered because it was a dignity issue. An interview on 8/10/2024 at 10:57 am with Licensed Practical Nurse, Unit Manager CC stated her expectations of staff was to ensure catheter bags were covered and not visible at all times. She stated the Certified Nursing Assistants should be doing this when rounding and as needed. 36377 2. Record review of R20's medical record revealed the following diagnoses but not limited to chronic kidney disease Stage 3, and diabetes. Record review revealed a physician order dated 8/10/2024 for [Name of catheter] catheter care every shift every 8 hours. There was no active order for an indwelling catheter. The Significant Change MDS date 7/24/2024 assessed a BIMS score of unable to detect (which indicates severe cognition impairments) and an assessment for indwelling catheter use. Record review of the care plan created on 7/12/2024 stated that R20 has a urinary catheter and is at risk for urinary tract infections. Urinary catheter related to neurogenic bladder with urine retention and open wounds. The following intervention listed stated: Provide urinary catheter care per facility practice. An observation on 8/9/2024 revealed R20 lying in bed with the room door open. Continue observation revealed an indwelling catheter attached to a urinary catheter bag with yellow color urine noted inside. The catheter bag was not covered and was visible from the door. An observation on 8/9/2024 at 2:44 pm revealed R20 sitting upright in a Geriatric chair in his room with an indwelling catheter attached to a urinary catheter bag with yellow color urine noted inside. The catheter bag was not covered and was visible from the door. An observation on 8/10/2024 at 9:50 am revealed that R20 had an indwelling catheter attached to a urinary catheter bag with yellow color urine noted inside. R20 was observed lying in bed in his room with the room door open. The catheter bag was not covered. Interview on 8/10/2024 at 9:59 am, RN DD confirmed that the catheter bag was not covered with a dignity bag. She confirmed that this was a dignity issue for the resident. Interview on 8/10/2024 at 9:59 am, RN DD confirmed that the catheter bag was not covered with a dignity bag. She confirmed that this was a dignity issue for the resident.

Based on record review and staff interviews, the facility failed to obtain a concurring Physician's signature on a Do Not Resuscitate (DNR) order for one resident (R) (R29) of two residents reviewed for DNR. Findings include: Record review of R29's medical record revealed the following diagnoses but not limited to Alzheimer 's Disease, paranoid schizophrenia, and hyperlipidemia. Record review revealed that R29's original admitted to the facility was 5/4/2022 and Re-admitted was 11/22/2023. R29's face sheet and medical record revealed that resident did not have a Power of Attorney (POA) or Legal Guardian listed. The Quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview Mental Status Score (BIMS) of four which indicated severe cognitive impairment. The most recent Annual MDS assessment dated [DATE] indicated a BIMS score of two which also indicated severe cognitive impairment. Review of copy of Do Not Resuscitate Order (DNR) indicated the signature of an Authorized Person was a guardian over R29. This document was signed on 5/4/2022 by the Authorized Person and signed by one Physician on 5/7/2022. Further review of the medical record did not indicate any documentation that anyone served as Guardian, Power of Attorney (POA), or any other type of healthcare agent for R29. Interview on 8/10/2024 at 10:53 am with Family Member A of R29's, revealed that neither herself nor any other member of the family of R29 had legal guardianship or had been appointed as POA. She stated R29 's preference would be to remain a DNR. Interview on 8/10/2024 at 11:01 am with Unit Manager Registered Nurse (RN) BB and Unit Manager Licensed Practical Nurse (LPN) CC who confirmed that there was no evidence that R29 had a healthcare agent and R29's code status was changed to Full Code. Surveyor was unable to reach Family Member B of R29 to determine her POA or Guardianship status for R29.

Based on observations and staff interviews, the facility failed to ensure a consistent home-like environment free from missing floor tiles, peeling paint on walls, rust on resident equipment (raise toilet seats), and an odor-free environment in which odors were consistently present where residents resided on one of two halls (room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], and shower room on 300 hall) . Findings include: 1.Observation of room [ROOM NUMBER]'s bathroom on 8/9/2024 at 8:26 am and 2:00 pm and 8/10/2024 at 8:13 am and 2:00 pm revealed the frame of a raised toilet seat coated with dark brown substances. 2. Observation of room [ROOM NUMBER]'s bathroom on 8/9/2024 at 8:27 am and 8/10/2024 at 8:14 am revealed the frame of a raised toilet seat coated with dark brown substances. Continued observation revealed missing shower fixture (missing shower head) protruding from the wall with ragged edges, stained tiles covered with dark sticky brown substances on the tile around the commode. A strong urine odor was observed in bathroom and the smell overflowed into the resident room. 3. Observation of room [ROOM NUMBER] on 8/9/2024 at 8:26 am and 8/10/2024 at 8:12 am revealed peeling paint on the wall above Bed A. 4. Observation of room [ROOM NUMBER] on 8/10/2024 at 8:14 am revealed dark grayish and brown color substances on the ceiling tile above Bed A. 5. Observation of room [ROOM NUMBER]'s bathroom on 8/9/2024 at 8:33 am and 3:10 pm, 8/10/2024 at 8:16 am and 2:11 pm, and 8/11/2024 at 9:37 am revealed a strong urine odor, stained tiles, missing paint on the ceiling and walls, and light fixture cover coated with dark yellowish and dark grayish colors. 6. Observation of one of two shower rooms on 8/9/2024 at 9:30 am, 8/10/2024 at 11:00 am, and 8/11/2024 at 10:23 am revealed missing tiles on the floor by the shower bed revealing an overlayer of dark brownish substances on the floor. There was a shower chair with a hard white substance coating, buildup of dirt, and brown substances coating the frame and the back rest of the shower chair. The environmental tour began on 8/11/2024 at 9:36 am on the 300 hall with the Registered Nurse Supervisor (RN) BB, the Maintenance Director, and Housekeeper Supervisor. All staff acknowledged the odor and identified odor as urine. RN Supervisor BB reported that the urine smell in the bathroom and resident rooms were offensive to residents and visitors. She stated that no residents should have to smell a strong urine odor. The Maintenance Supervisor and Housekeeper Supervisor confirmed that odor was embedded in the bathroom tiles and the tiles should be replaced. The Maintenance Supervisor reported any needed repairs should be completed on a maintenance repair form and the forms are located at the nurse stations. He stated that he was unaware of the needed repairs with the bathroom tiles. RN Supervisor BB confirmed the bath shower chair was covered with dirt and had calcium buildup. She stated that the chair should be replaced. All staff confirmed the brown substances on the raised toilet seat frame and shower chair as rust. Maintenance Director reported that he would try to remove the rust off of the resident equipment.

Based on observations, record review, staff interviews, and review of the facility's policy titled, Hemodialysis, the facility failed to provide evidence of ongoing monitoring and care of a dialysis access site and failed to ensure ongoing communication and collaboration with the dialysis center for one of one resident (R) (R31) reviewed for dialysis services. This deficient practice had the potential to place R31 at risk for medical complications, unmet needs, and a diminished quality of life. Findings include: A review of the facility's policy titled Hemodialysis, dated 2/12/2022, under the section titled Policy revealed, This facility will provide the necessary care and treatment, consistent with professional standards of practice, physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences, to meet the special medical, nursing, mental and psychosocial needs of residents receiving hemodialysis. Under the section titled Purpose revealed, The facility will assure that each resident receives care and services for the provision of hemodialysis consistent with professional standards of practice. This will include: The ongoing assessment of the resident's condition and monitoring for complications before and after dialysis treatments received at a certified dialysis facility Ongoing communication and collaboration with the dialysis facility regarding dialysis care and services. Under the section titled Compliance Guidelines revealed, number 8. The nurse will monitor and document the status of the resident's access site(s) upon return from the dialysis treatment to observe for bleeding or other complications. Review of R31's Face Sheet revealed diagnoses that included but not limited to type two diabetes mellitus with other diabetic kidney complication, end stage renal disease, and anemia in chronic kidney disease. Review of R31's quarterly Minimum Data Set (MDS) dated [DATE] revealed Section O (Special Treatments and Programs) documented that R31 received hemodialysis while a resident. Review of R31's Electronic Medical Record (EMR) revealed a physician's order dated 9/5/2023 that read, Resident will have dialysis with [Name of dialysis facility] M/W/F (Monday, Wednesday, and Friday). Further review of physician orders revealed there were no orders for ongoing monitoring and care for R31's dialysis access site. Review of R31's Administration Record dated 8/1/2024 - 8/31/2024 revealed, there were no orders for ongoing monitoring and care for R31's dialysis access site. Review of the R31's Progress Notes from 9/5/2023 through 8/9/2024 revealed, the lack of consistent documentation and proof of ongoing monitoring for R31's dialysis access site in addition to not communicating and collaborating with the dialysis center on the resident's scheduled dialysis days. During an interview on 8/10/2024 at 8:31 am with Registered Nurse (RN) DD and Licensed Practical Nurse (LPN) EE R31's medical records were reviewed, which revealed there were no physician orders that addressed the monitoring and care for the resident's dialysis access site. RN DD revealed that she and the charge nurses were responsible for monitoring the dialysis site each shift ensuring that it remained dry and intact. LPN EE revealed the dialysis staff access R31's dialysis port, and should the facility nurses need to do anything with it they would call the doctor and get an order. During an interview on 8/10/2024 at 8:36 am with RN BB, R31's medical records were reviewed. RN BB verified there were no orders that addressed nursing care and monitoring for the resident's dialysis port. RN BB stated that it was the responsibility of the nurses at the facility to ensure the dressing at the dialysis access site was dry and intact every shift and as needed. Observation on 8/10/2024 at 8:40 am with RN BB of R31 revealed the resident had a dialysis port that was intact to the right chest wall with a dry dressing covering it. RN BB confirmed there should have been dialysis orders written to address monitoring and care for the dialysis port. Interview on 8/10/2024 at 10:58 am with LPN Unit Manager (UM), CC revealed that her expectations of nurses were to make sure orders were in place for dressing changes and to monitor dialysis access sites for residents on dialysis. During an interview on 8/11/2024 at 8:30 am with RN BB, a record review of the Dialysis Communication Sheets for R31 that was kept in the book at the nurses' station revealed missing and incomplete dialysis communication sheets ranging from 9/11/2023-8/2/2024. RN BB confirmed some of the dialysis communication sheets were missing and/or were not completed. She revealed that the facility nurses were to complete the pre-dialysis information and send the form with R31 to dialysis and that the dialysis staff were to complete the post dialysis information and send it back with the resident, but they had not been sending this information back. She reported that most of the time, the facility nurse would call the dialysis center to get a report on the resident. When questioned why the post dialysis information reported from the dialysis center was not documented, she stated she was not sure why. She reported receiving training on dialysis care and understands the importance of communication and collaboration between the facility and dialysis staff. Interview on 8/11/2024 at 9:07 am with LPN Unit Manager (UM), CC stated her expectations of nurses were to complete the dialysis communications sheet and to make sure that R31 returned with the dialysis communication sheet with the post dialysis information completed. She revealed if the post-dialysis sheet was not returned or completed, they were to call and get a report and document this on the communication sheet and/or nurse notes.

Based on staff interview and record review, it was determined the facility failed to ensure that staff provided assistance, in conformance with the care plan, during the transfer of one (1) resident (#4), of four (4) residents with a history of falls, from a total sample of five (5) residents. This failure resulted in actual harm, a scalp wound, as Resident #4 experienced a fall during transfer. Findings include: Please cross refer to F323 for more information regarding Resident #4. Record review for Resident #4 revealed that the care plan identified the resident to be at risk for falls. The care plan included an intervention, originally dated 1/4/13, for nursing staff to transfer the resident with the assistance of two (2) nursing staff members. However, further record review for Resident #4 revealed a Nurse's Notes entry of 06/03/2013 at 5:45 a.m. which documented that the resident was noted on the floor, having a laceration to the right posterior scalp, and that the resident was transferred to the emergency room for treatment. A subsequent Nurse's Notes entry of 06/03/2013 documented that Resident #4 had received three (3) staples to the scalp wound. The incident report for Resident #4's 06/03/2013 fall referenced above documented that, during the transfer and subsequent fall, the appropriate number of staff were not present. The Director of Nursing (DON) acknowledged, during an interview on 6/14/13 at 1:15 p.m., that during the transfer, the CNA had transferred the resident alone, and had required additional training on providing care in accordance with the care plan.

Based on staff interview, record review, and facility incident report review, the facility failed to ensure that staff provided two-person assistance as required during a transfer for one (1) resident (#4), of four (4) residents with a history of falls, from a total sample of five (5) residents. This failure resulted in actual harm for Resident #4, as the resident experienced a fall during a transfer and sustained a scalp wound. Findings include: Record review for Resident #4 revealed a May 2013 Minimum Data Set (MDS) assessment which documented that the resident was admitted into the facility in October of 2006. This MDS also documented that the resident's [DIAGNOSES REDACTED]. Resident #4 had a care plan since 12/13/11 for being at risk for falls. The care plan was updated on 1/4/13 to include that she was lowered to the floor by a Certified Nursing Assistant (CNA) while being transferred from the bed to the chair. A new intervention, also dated 1/4/13, to prevent further falls instructed nursing staff to transfer Resident #4 with the assistance of two nursing staff members. The CNA Assignment Sheet also documented that Resident #4 needed the assistance of two staff for transfers. Further record review for Resident #4 revealed a Nurse's Notes entry of 06/03/2013 at 5:45 a.m. which documented that nursing staff had been called to the resident's room by a CNA, who stated that the resident was on the floor. This Notes entry documented that the resident was noted to have a laceration to the right posterior scalp. This Notes entry also documented that the physician was consulted, and an order was received for the resident to be transferred to the emergency room for evaluation and treatment. A subsequent Nurse's Notes entry of 06/03/2013, with no noted time, documented that facility staff had received a report from hospital staff indicating that Resident #4 had received 3 staples to the scalp wound, and that a Computerized Tomography scan had revealed clear results. The incident report which referenced Resident #4's 06/03/2013 fall documented that the resident had fallen on that date during a transfer to a wheelchair, and that the appropriate number of staff had not been utilized during the transfer. The Director of Nursing (DON) stated during an interview on 6/14/13 at 1:15 p.m. that the CNA who transferred Resident #4 on 06/03/2013 had transferred the resident alone, without the assistance of a second staff person.