Every finding on record at Tower Road Post Acute, LLC

Based on observations, staff interviews, and review of the facility's policies titled, Food Storage: Cold Foods and Food Storage: Dry Goods, the facility failed to ensure opened food items in the walk-in refrigerator and dry storage area were labeled, dated, and discarded by expiration date. The deficient practice had the potential to affect residents who receive an oral diet from the kitchen.Findings include:Review of facility's policy titled, Food Storage: Cold Foods revised date February 2023 revealed in Procedures section, . 5. All food will be stored wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination. Review of facility's policy titled, Food Storage: Dry Goods revised date February 2023, revealed in Procedures section, . 6. Storage areas will be neat, arranged for easy identification, and date marked as appropriate.During the initial brief tour on 1/6/2026 at 8:44 am, with District Manager (DM) revealed a tour and inspection of the food storage pantry was conducted, focusing on labels, dating, expiration, and the past use dates of food items. The dry storage revealed a container with 60 single-count packages of saltine crackers that were neither labeled nor dated, along with 112 single-count packages of graham crackers. Additionally, there was one 1.5 lb (pound) opened package of homestyle old-fashioned biscuit gravy mix that lacked labeling and dating. Furthermore, there was one 5.31 lb opened package of mashed potatoes complete with vitamin C, which also had no labeling or date. Moreover, there was one opened 2 lb bag of cereal labeled as name brand, which was without labeling or date. Lastly, there were 100 goldfish crackers in 0.75 oz packages that were unlabeled and dated, as well as 115 packages of name brand crackers 0.75 oz. In the kitchen near the prepping table revealed seasoning and spice with expired dates. The DM confirmed the observation of two 3.33 oz bouillon cubes with expiration date October 2024. One opened 14 oz. beef flavor base without labeling.The walk-in cooler/refrigerator was inspected and revealed 13 bottles of 8 fl oz (fluid ounce) Lactose Free Dairy, with an expiration date of 12/7/2025. Additionally, there was unthawed meat marked with expiration date of 1/3/2026. The District Manager was unable to confirm whether this date was an open date or an expiration date. Furthermore, there was one open 80 oz mozzarella cheese that lacked proper labeling or any indication of an open or expiration date. Lastly, there was one opened 4 lb ham that also did not have an expiration date and was missing proper labeling or dating.Observation of 30 ceiling tiles with brown red like substance. Four vents over oven equipment revealed rust, brown like buildup. Two air vents over serving station and three compartment sinks revealed gray-black dust-like buildup. Dirty dishes were brought to washing machine area and went from dirty to clean, from washing machine to drying area, wet nesting observed by Dietary Aid. A random inspection of dry plates prepared for storage revealed the presence of water and food residues on some dishware.Interview on 1/6/2026, during initial tour at 8:44 am, with District Manager confirmed the date on the food items in dry storage area was unidentified and missing on the sighted items. DM revealed at this point we are trying our best to just get the food out.Observation on 1/7/2026 at 2:10 pm with DM revealed in the emergency food five bags of 80 oz grits with an expiration date of 12/20/2025. The current District Manager shared the previous Dietary Manager was responsible for monitoring food expiration dates in the emergency preparedness storage.An observation and interview conducted on 1/7/2026, from 11:00 am to 11:10 am, revealed that Dietary Aid (DA) EE was operating a low-temperature dishwasher, transferring dirty dishes to clean dishes without practicing hand hygiene, and stacking wet dishes directly on top of each other on the storage rack. DA EE confirmed that she was unaware of the concept of wet nesting and did not recall receiving training on this topic. DA EE mentioned that she was responsible for operating the dishwasher machine five days a week.An interview conducted on 1/7/2026 at 11:46 am, with the District Manager confirmed the wet nesting on several randomly selected dishes and also observed food substances on two dishes.

Based on observations, staff and resident interviews, record review, and review of the facility policies titled, Abuse, Neglect and Misappropriations, the facility failed to protect residents by not reporting verbal abuse to the State Agency (SA) for one of 38 sampled residents (R) (R11). The deficient practice had the potential for other residents to experience verbal abuse.Findings include:Review of the facility policy titled Abuse, Neglect and Misappropriations, revised 1/1/2025, policy statement revealed: It is the organization's intention to prevent the occurrence of abuse, neglect, exploitation, injuries of unknown origin, and misappropriation of resident property, and to assure that all alleged violations of federal or State laws which involve abuse, neglect, exploitation, injuries of unknown origin and misappropriation of resident property are investigated, and reported immediately to the Facility Administrator, the State Survey Agency, and other appropriate State and local agencies in accordance with Federal and State law. The organization will include screening, training, prevention, identification, investigation, protection, and reporting to provide protection for the health, welfare, and rights of each resident residing in the facility.The organization's policy is that the Facility Administrator, or his or her designee, will conduct a reasonable investigation of each such alleged violation unless he or she has a conflict of interest or is implicated in the alleged violation. The Facility Administrator is responsible for reporting all investigations' results to applicable State agencies as required by Federal and State law. In the case of a suspected crime as defined in the Elder Justice Act, refer to the applicable Elder Justice Act policy and procedure. The policy defines abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain, or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Verbal abuse is defined as the use of any oral, written, or gestured language that includes any threat, or any frightening, disparaging or derogatory language, to residents or their families, or within their hearing distance, regardless of age, ability to comprehend, or disability. Immediately is defined as alleged violations involving abuse, neglect, exploitation, or mistreatment are reported immediately, but no later than two hours after the allegation is made. If a state reporting requirement establishes a longer reporting time for certain unusual incidents other than abuse or neglect, that reporting time applies only to such incidents. In other words, all allegations and incidents of abuse or neglect, as defined in this policy, will be reported immediately, as defined in this paragraph.Review of the electronic medical record (EMR) revealed R11 was with pertinent diagnoses including but not limited to metabolic encephalopathy, depression, muscle weakness (generalized), and anxiety disorder, unspecified.Review of R11's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicates R11 is cognitively intact. Section D, Mood, revealed R11 feeling down, depressed, or hopeless 2-6 days (several days). Section E, Behavior, revealed no behaviors not exhibited during review period. Section GG, Functional Abilities and Goals, revealed R11 has impairment on one side upper extremity. She is dependent for toileting hygiene, shower/bathe self, lower body dressing, putting on/taking off footwear, chair/bed-to-chair transfer. Supervision or touching assistance when rolling left and right, and substantial/maximal assistance for sit to lying, lying to sitting on side of bed. Section H, Bowel and Bladder, revealed frequent urinary and bowel incontinence.Review of R11's care plan indicated a problem of resident at risk for falls related to deconditioning. Goals included but not limited to resident will be free from falls through review period. Interventions included but not limited to anticipate and meet resident's needs, be sure call light is in reach and encourage resident to use it when assistance is needed, and resident sent to hospital for evaluation. The care plan also indicated R11 has a behavior problem related to refusing care (showers and peri-care). The goal is that resident will have fewer episodes of behavior by next review date. Interventions include administer medications as ordered and monitor/document side effects and effectiveness, discuss resident behavior and explain/reinforce why behavior is inappropriate, and praise the resident progress/improvement in behavior.Review of the Physician's Orders for R11 included but was not limited to:DuLoxetine HCl Oral Capsule Delayed Release Sprinkle 60 MG (Duloxetine HCl), Give 1 capsule by mouth two times a day for DepressionoxyCODONE-Acetaminophen Oral Tablet 10-325 MG (Oxycodone w/ Acetaminophen) Give 1 tablet by mouth every 6 hours as needed for severe pain 5-10 on scale 0-10Review of a striked out Progress Note dated 12/16/2025 at 10:26 am revealed, During morning medication pass at approximately 0900, resident advised this writer that overnight or early this morning she fell onto the floor. Resident stated that a nurse found her on the floor and instructed her to get up. This writer observed redness to the resident's left eye and asked if she had hit her head. Resident reported that when she fell, she hit her side.table and then fell to the floor. This writer reported observations to management at approximately 0945. Resident will continue to be monitored.Strike Out Reason: Duplicate OrderStrike Out Date: 12/16/2025 18:27 (6:27 pm)[(electronically) e-SIGNED] by Licensed Practical Nurse (LPN) GGReview of a Progress Note dated 12/16/2025 at 11:00 am revealed, Writer and DON (Director of Nursing) spoke with resident and sister about incident; resident gave 3 different stories about what happened then refused all interventions. Resident refused to let nursing evaluate her and get vitals. Resident stated she was fine and it wasn't a big deal. Resident ordered staff out of her room and stated she wanted nothing but to be left alone.[e-SIGNED] by UM (Unit Manager) FFReview of a Progress Note dated 12/16/2025 at 12:03 am revealed, this writer, accompanied by the Unit Manager, visited the resident's room to discuss allegations that the night nurse spoke harshly to her following a fall. The resident reported that she fell, first hitting her overbed table and then the wall, striking her head. She initially stated that the nurse told her to get up off the floor. Upon further discussion, R11 clarified that the nurse actually told her to get up out of bed. After additional conversation, R11 returned to her original statement. R11 expressed dissatisfaction with the staff and stated that she feels she is not being properly cared for. Her sister was present during the entire conversation, and R11 consented to speak with her sister present. R11 is fully functional and capable of transferring into the community independently, home with her sister or to an assisted living setting. Her sister stated she cannot provide care for her. It was explained that R11 does not require continuous care and is able to care for herself as she is functionally able to perform all ADLs independently. Social Services was contacted to provide available resources. Because R11 reported hitting her head during the fall, she was offered transfer to the Emergency Department for evaluation. She declined, stating she had no injuries. Fall protocol was implemented, and the MD was notified.[e-SIGNED] by DONObservation and interview on 1/6/2026 at 11:38 am revealed R11 lying on bed watching television. R11 stated that she had been here about 6 months; she came for therapy. R11 stated that first name of staff, the head person, cussed her and her sister out because he wanted me to leave. The resident gave her sister's telephone number as well as consent for the surveyor to contact the sister. Interview on 1/7/2026 at 1:56 pm revealed R11 lying in bed snacking and watching television. R11 stated that the person that cussed her out was a tall, slender black guy and she stated he had a high position at the facility. R11 was able to describe where the staff member's office was located. She confirmed that the alleged perpetrator was the DON.Interview on 1/8/2026 at 9:25 am revealed R11 sitting up in bed watching television. She stated that she was a little irritated yesterday because people kept entering her room and she sort of just wanted it to be over. Interview on 1/8/2026 at 9:44 am with a family member of R11 revealed that R11 told her she had fallen the previous night and that the nurse had cursed at her.An interview on 1/8/2026 at 11:16 pm with Unit Manager (UM) FF revealed that she was notified by LPN GG that R11 reported that she had fallen and had been cursed at by the nurse on night shift. UM FF said that she went and spoke with R11, and R11 said she fell and was told to get up harshly. UM FF then notified the DON. UM FF defined verbal abuse as being spoken to harshly. She also confirmed that she reported any abuse allegations to the DON. UM FF confirmed her knowledge of having two hours to report abuse to the state. UM FF also confirmed she had in-service training on abuse when she started working at the facility.An interview on 1/8/2026 at 4:05 pm with LPN GG revealed that at shift change while making rounds, R11 told her that she had fallen off the bed and hit her head the previous night and that LPN JJ told her to get the 'curse-word' up. LPN GG stated she then reported the allegation to the UM.An interview on 1/8/2026 at 6:23 pm with DON revealed, If abuse is reported to myself, I should report to the abuse coordinator. I'm here early so a lot of time I will initiate the investigation. I submit and investigate reports of abuse to the state. When asked who was the staff member that cussed at the resident, the DON stated that he did not have a known person of interest. The DON stated that she (R11) initially told him that the staff stated, get the 'curse word' off the floor, but when the DON told her that he had to report the incident, R11 then said that the staff did not curse her and just told her to get out the bed. The DON confirmed that that the incident was not reported because the resident changed her story.An interview on 1/8/2026 at 6:23 pm with Administrator in Training (AIT)/ Abuse Coordinator revealed that after the DON talked to R11, she changed her story. The AIT stated that it was reported to him that R11 told the DON that the staff did not cuss him. AIT confirmed the allegation was not reported. The AIT also confirmed that verbal abuse was a reportable incident. The AIT confirmed that the administrator was aware of the 12/16/2025 incident on night shift and that although he was the abuse coordinator, the Administrator determined what would be reported to the state.

Based on observations, staff interviews, record review, and review of the facility policy titled, Care Plans, Comprehensive Person-Centered, the facility failed to implement the care plan for one of 38 sampled residents (R) R19. Specifically, bilateral fall mats were not used in accordance with the care plan. This deficient had the potential to increase the risk of medical complications for R19Findings include:Review of the policy titled Care Plans, Comprehensive Person-Centered revised March 2022, Policy Statement revealed: 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.Review of the electronic medical record (EMR) revealed resident R19 was admitted with pertinent diagnoses including but were not limited to metabolic encephalopathy, chronic kidney disease, stage 3a, cognitive communication deficit, and other abnormalities of gait and mobility.Review of R19's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 3, which indicates R19 has severe cognitive impairment. Section GG, Functional Status, revealed R19 was independent rolling left to right, required maximal assistance sitting to lying and lying to sitting on side of the bed. R19 is dependent for sit to stand, chair/bed to chair transfer, tub/shower transfer, toileting hygiene, and shower/bathe with one/two or more-person assistance.Review of R19's care plan indicated a problem of falls. Goals included but not limited to resident will be free of further falls and resident will resume daily activities without further accidents. Interventions included but not limited to fall mats on both sides of bed, keep resident in a high visible area when out of bed.Review of the Physician's Orders for R19 included but was not limited to:Order dated 11/25/2025 Cognitive Health OralCapsule 500 MG (milligram) (Citicoline (AlternativeMedicine)Order dated 11/24/2025 Metoprolol Tartrate OralTablet 25 MG (metoprolol Tartrate)Order dated 11/24/2025 Apixaban Oral Tablet 5 MG (apixaban) Observation and interview on 1/6/2025 at 12:00 pm revealed R19 lying in bed talking with his wife. A fall mat was on the floor on left side of the bed. No fall mat was on the floor on the right side of the bed. R19's wife states that she had concerns related to the resident's falls. Sunday he was on the floor, his head was under the bed and they sent him out. They don't check on him enough. He was usually up at the nursing station during the day. But at night, I feel they don't check on him enough.Observation on 1/7/2026 at 1:43 pm revealed resident lying in bed watching television. Bed was low. Right fall mat was not on floor. Left fall mat was up against the wall. Resident was waiting for his wife to come visit.Observation on 1/8/2026 at 9:08 am revealed resident in bed with head of bed (HOB) elevated, eating breakfast. The resident did not have a fall mat to right side of the bed. The fall mat on the left side of the bed was propped up against the wall,An interview on 1/8/2025 at 3:49 pm with Unit Manager (UM) FF revealed that during the day they kept R19 in visible areas, at the nurse's station or in activities. She confirmed that the resident did not have a mat on the right side of the bed. A mat was on the floor on the left side of the bed. She confirmed that the intervention for two fall mats was on the care plan I presented to her. She then said that that intervention was put in place when he did not have a roommate. She also stated that since the resident had a roommate, they only put a mat to the left side of the bed because that is the side R19 favored.An interview on 1/8/2025 at 4:05 pm with Licensed Practical Nurse (LPN) GG revealed that she was not familiar with the care plan. When asked how she knew the resident's plan of care, she stated she would read previous notes like admission and progress notes. She also confirmed that updates were provided during morning huddle meetings as well as midday huddle meetings during shift change.An interview on 1/8/2025 at 4:23 pm with Certified Nursing Assistant (CNA) HH revealed that when the supervisor was working, she would update staff on the residents' plan of care in huddle meetings. CNA HH stated she would also ask the nurse if there was something she needed to know in regard to providing care for a resident.An interview on 1/8/2025 at 6:23 pm with the Director of Nursing (DON) revealed CNA's have a clinical dashboard in the POC (Point of Care electronic medical record) that provides care plan details. The DON also confirmed that all licensed nurses had access to update care plan if new interventions should be put in place. He stated, we have PAR (patients at risk) every week and update care plans. Newly admitted residents had a baseline care plan that was completed by the admitting nurse. I expect staff to review the care plan and know the interventions.

Based on resident and staff interviews, record review, and review of the facility policy titled, Activities of Daily Living, the facility failed to provide assistance with activities of daily living (ADL) care for one of 38 residents (R) (R125) related to bathing. Findings include:Review of the facility policy titled Activities of Daily Living revised April 2025, revealed under Policy Statement: . Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene.Review of the electronic medical record (EMR) revealed that R125 was admitted to the facility with diagnoses including but not limited to muscle weakness, other abnormalities of gait and mobility, and irritable bowel syndrome with diarrhea.A review of the (in progress) Minimum Data Set (MDS) admission Five-Day assessment dated [DATE] documented R125 presented with a Brief Interview of Mental Status (BIMS) score of 15, indicating that the resident was cognitively intact; that the resident had impairments on both sides of the lower extremity (hip, knee, ankle, and foot); and required a wheelchair/walker for mobility.Review of a January 2026 Bathing/Shower system entry revealed N/A (not applicable) for R125 for 1/2/2026 through1/6/2026.During the screening observation and interview conducted on 1/6/2026 at 11:50 am, R125 was found to be under droplet precautions. R125 shared that since her admission, she had not had anyone available to assist her with a bath or bed bath. R125 mentioned that she requested the CNA who entered her room for bathing assistance, but the CNA informed her that she was responsible for 14 other residents and could not provide help during this shift, although she assured R125 that the next shift would assist; however, R125 noted that no name was given. R125 also mentioned that she asked the next shift's CNA for bathing assistance, but she never returned. During the interview, R125's family, who were visiting, requested a towel and washcloth from the surveyor to help provide care. R125 confirmed that she has not declined any care.An interview was conducted with the Unit Manager, Registered Nurse (RN) AA, on 1/6/2025 at 12:23 pm, who revealed that ADL care was monitored on shower sheets and in the EMR.An interview conducted on 1/6/2025 at 12:30 pm with the Director of Nursing (DON) confirmed that bathing was included in the electronic health records (EHR) and efforts were being made to transition away from paper documentation, such as shower sheets.During an interview conducted on 1/6/2025 at 3:45 pm, the DON confirmed that the designated shower days for R125 were Tuesday and Friday. Although the resident arrived on her scheduled shower day, it was indicated that CNA BB noted not applicable ( N/A.) The DON clarified that showers were not conducted upon admission; however, bed baths were offered. The DON mentioned R125 refused her shower today because her sister provided one to her and presented a shower sheet. An interview on 1/7/2025 at 4:59 pm with CNA BB revealed that if a resident did not receive a shower or bed bath, she would mark N/A in the EHR. CNA BB shared that she did not have any conversation with R125 concerning bathing, and it was not offered as an option to R125. Furthermore, CNA BB explained that it was not normal to administer showers or bed baths for new admissions, as we have been trained to adhere to the specified shower days.

Based on observations, staff interviews, record review, and a review of the facility policy titled, Oxygen Administration, the facility failed to ensure that two of 29 residents (R) (R1 and R125) were administered oxygen therapy in accordance with the physician's ordersFindings include:Review of facility policy titled Oxygen Administration revised date October 2010, revealed in section Purpose: The purpose of this procedure is to provide guidelines for safe oxygen administration. Under Preparation: 1. Verify that there is a physician's order for this procedure. Review the physician's order or facility protocol for oxygen administration. A review of the clinical record for R1 revealed he was admitted to the facility on [DATE] with diagnoses including but not limited to chronic obstructive pulmonary disease (COPD) with (acute) exacerbation, acute respiratory failure with hypoxia, paroxysmal atrial fibrillation, pneumonia, unspecified organism.The resident's most recent Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score was coded as 15, which indicated no cognitive impairment. Section J (Health Conditions): Shortness of breath or trouble breathing when lying flat. Tobacco Use. Section O (Special Treatments, Procedures, and Programs): Oxygen therapy/Continuous/Speech-Language Pathology and Audiology Services/ Respiratory Therapy.A review of the care plan initiated on 11/27/2025 revealed Focus: the resident has oxygen therapy r/t (related to) Respiratory failure, COPD with Goal: The resident will have no s/sx (signs/symptoms) of poor oxygen absorption through the review date. Intervention: Give medications as ordered by physician. Monitor/document side effects and effectiveness. OXYGEN as ordered.A review of physician's order dated 11/27/2025 for R1 revealed o2 at 2 L (liters) via nasal cannula (NC) R/T COPD, every day and night shift.An observation conducted on 1/6/2026 at 11:43 am, an observation of the resident receiving oxygen indicated a flow rate between 2.5 and 3 liters (L), being administered through the Nasal Cannula (N/C).Interview and Observation on 1/6/2026, at 12:26 pm, with Unit Manager Registered Nurse (RN) AA, who confirmed that R1's oxygen concentrator was set on 3 L. However, she indicated that the order specifies 2 L and mentioned that it was at 2 L this morning. RN AA mentioned the reason for the current setting of 3 L remained unclear. RN AA also disclosed the risk associated with R1 oxygen level settings, noting that excessive oxygen in the context of R1's chronic respiratory failure and COPD could lead to nasal dryness.Interview with the Director of Nursing (DON) on 1/6/2026 at 1:02 pm revealed that R1 displayed stubborn behaviors and could have made adjustments to the oxygen concentrator. The DON affirmed that this behavior needed to be recorded in the care plan. The DON reviewed R1's care plan, the DON acknowledged that no behaviors were documented but indicated that the updates to the care plan would be put into effect from this moment onward. Interview and observation conducted on 1/7/2026 at 4:45 pm with R1 on oxygen and confirmed that he had not made changes to the oxygen concentrator nor would he do anything like that. A review of the clinical record for R125 revealed she was admitted to the facility on [DATE] with diagnoses including but not limited topPneumonia, unspecified organism, acute respiratory failure with hypoxia, acute or chronic systolic (congestive) heart failure, paroxysmal atrial fibrillation.The resident's most recent Minimum Data Set (MDS) assessment, dated 1/6/2026, revealed a Brief Interview for Mental Status (BIMS) score was coded as 15, which indicated no cognitive impairment. A review of the Care Plan initiated on 1/5/2026 revealed Focus: R125 has altered respiratory status/difficulty breathing r/t Acute Respiratory Failure. Goal: R125 will have no complications related to SOB though the review date. Intervention: Administer medication/puffers as ordered. Monitor for effectiveness and side effects.A review of Physician Order dated 1/2/2026 Oxygen at 3 LPM (liters per minute) Via NC continuously. O2 (oxygen) Sat (saturation) to maintain sats 92% or above every day and night shift.A review of the Skilled Charting V2 dated 1/5/2026 revealed in section Respiratory 7. O2 @ 3L 8. O2 via: N/C. 11. Notable changes in respiratory function. On droplet isolation for rhinovirus.Observation on 1/6/2026 at 11:50 am of R125 receiving oxygen indicated a flow rate of 2 L, being administered through the NC.Interview and Observation was conducted on 1/6/2026 at 12:30 pm with Unit Manager Registered Nurse (RN) AA, who confirmed that R125's oxygen concentrator was set to 2 L. She indicated that her orders specify a setting of 3 L. RN AA also mentioned that the risk was low; however, the R125 was affected by a rhinovirus, similar to the flu or cold.Interview with the DON on 1/6/2026 at 1:02 pm disclosed that R125's oxygen was being phased out, which was the reason for the reduction of one liter. However, it was intended to be on the care plan, and we could develop a care plan from this point forward. The DON mentioned Respiratory Therapy should have documentation of this change.An interview conducted on 1/6/2026, at 1:13 pm with Respiratory Therapist (RT) CC, indicated that there was no documentation nor assessment identifying the liter reduction; however, we would get it in.

Based on observations, staff interviews, record review, and review of the facility's policy titled, Infection Prevention and Control Policy, the facility failed to ensure proper infection control practices were followed for two of three residents (R) (R35 and R38) observed during medication administration. Specifically, during medication observation the nurse was observed administering medications without using hand hygiene prior to or after administering medications, did not wash or sanitize her hands before or after entering an enhanced barrier precaution room and then went to another room and administered medications. These deficient practices had the potential to lead to the spread of infection and illness. Findings include:Review of facility policy titled Infection Prevention and Control Policy reviewed 2/1/2025 revealed under Policy Statement, The facility strives to prevent transmission of infections and communicable diseases, development of nosocomial infection, and effectively treat and manage nosocomial and community acquired infections. The goal of the program is to identify and reduce the risks of acquiring and transmitting infections among residents, employees, volunteers, and visitors. The program includes a system to monitor and investigate infection trends. The program is developed based on nationally recognized organizational standards and procedures. Healthcare settings component recommendations section included hand hygiene should be used after touching blood, body fluids, secretions, excretions, contaminated items; immediately after removing gloves; between patient contacts.Review of the electronic medical record (EMR) revealed R35 was admitted to the facility with pertinent diagnoses including but were not limited to contracture, right hand, human immunodeficiency virus, congenital cerebral cysts, and chronic viral hepatitis C.Review of R35's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicates R35 was cognitively intact. Section GG, Functional Abilities and Goals, revealed R35 required/was set up or clean-up assistance for activities of daily living (ADLs).Review of the Physician's Orders for R35 included but was not limited to:Order dated 1/7/2026 Gabapentin Oral Capsule 100 MG (milligram) (Gabapentin) Give 2 capsule by mouth two times a day related to CONTRACTURE, RIGHT HAND (M24.541) Order dated 12/26/2025 Intelence Oral Tablet 200 MG (Etravirine) Give 1 tablet by mouth every 12 hours for immunodeficiencyOrder dated 9/6/2025 Zoloft Oral Tablet 25 MG (Sertraline HCl) Give 50 mg by mouth in the morning for DEPRESSIONAn observation on 1/7/2026 8:48 am revealed Licensed Practical Nurse (LPN) II passing out medications to R35. She revealed an enhanced barrier sign on the door as well as personal protective equipment (PPE) hanging outside the door. LPN II did not sanitize her hands. She opened the cart, removed the medication packets and placed them on the cart. LPN II realized the resident was prescribed new medication that was not on the cart. LPN II placed medication packets back in the cart, locked the cart and went to retrieve the medication from the electronic medication machine. She did not sanitize her hands when she returned from the medication machine. She put the medicines into the medicine cup and added apple sauce to the cup. She put water into a cup. She entered R35's room and administered the medications. She exited the room without washing or sanitizing her hands and then went to the next room and began setting up her medications.Review of the electronic medical record (EMR) revealed resident R38 was admitted to the facility with pertinent diagnoses including but were not limited to unilateral primary osteoarthritis, left knee, encounter for other orthopedic aftercare, cardiomegaly, diabetes mellitus type two, and depression.Review of R38's EMR revealed a BIMS score of 15, which indicates R 38 was cognitively intact. Review of the Physician's Orders for R38 included but was not limited to:LaMICtal Oral Tablet 25 MG (milligram) (Lamotrigine)Give 1 tablet by mouth at bedtime for depressionApixaban Oral Tablet 5 MG (Apixaban) Give 1 tablet by mouth every 12 hours for AnticoagulantDepakote Oral Tablet Delayed Release 250 MG (Divalproex Sodium) Give 1 tablet by mouth three times a day for Mood DisturbanceAn observation and interview on 1/7/2026 at 9:08 am revealed LPN II administered medications to R38. LPN II did not use hand hygiene prior to setting up medications, upon room entrance or room exit. When surveyor questioned LPN II about hand hygiene, LPN II confirmed that she did not use hand hygiene when passing out the medications. When surveyor asked LPN II why hand hygiene was important, she stated that it was important to use hand hygiene to not spread infections. LPN II then removed and used a small bottle of sanitizer out of her pocket. Sanitizer stations weree located on the wall beside every two room doors. An interview on 1/8/2026 4:05 pm with LPN GG revealed she used hand hygiene before and after resident care and when she touches contaminated surface areas. LPN GG confirmed receiving infection control training upon hire. She also confirmed she actively completed training online. LPN GG stated that she would know if someone was on contact precautions because it was on the doors. She also confirmed she received updates in report.An interview on 1/8/2026 at 4:23 pm with Certified Nursing Assistant (CNA) HH confirmed hand hygiene was completed before and after providing care to residents and when entering and exiting rooms. She stated that hand hygiene was important to prevent spread of infections. CNA HH confirmed she received infection control training during orientation. She also confirmed she knew if a resident is on precautions because it will be outside the door. CNA HH stated that they receive updates from the nurses, and in huddle meetings when the supervisor was working.An interview on 1/8/2026 at 6:23 pm with the Director of Nursing (DON) revealed his expectations of his staff were to follow education in terms of hand hygiene between rooms, when passing trays, and before and after peri-care to name a few. The DON expected his staff to use appropriate PPE and follow general infection control. The DON confirmed infection control training was ongoing and handwashing in-services were usually done once a month. He stated that if they noticed clusters or trends with infections, infection control training was increased. The DON stated that precautions signs should be posted on the door and include which types of PPE the staff would need. He also stated markers were also in the EMR for nursing staff and that CNA's had a clinical dashboard in EMR.

Based on staff interviews, record review, and facility policy review, the facility failed to ensure the resident or responsible party (RP) was notified of a change in condition related to intravenous fluid and antibiotic use for one of nine sample residents (Resident (R) 4) reviewed for change in condition. This failure had the potential of R4 receiving treatments not aligned with the residents' or the responsible party's wishes for the residents' care. Findings include: Review of the facility's policy titled, Clinical Change in Condition Management, dated 2/1/2024, revealed The Interdisciplinary team strives to identify and manage all residents that are experiencing a change in condition .Clinical care management includes routine assessment, evaluation, response to changes in clinical condition and communication with residents and/or families/responsible parties .7. Verify that family/responsible party has been notified. Review of R4's undated admission Record located in the electronic medical record (EMR) under the Profile tab, indicated R4 was admitted to the facility on [DATE] with diagnoses including but not limited to acute respiratory failure with hypoxia, pneumonitis due to inhalation of food and vomit, and dementia. Review of R4's Physician Orders, dated 2/26/2025 located in the EMR under the Orders tab, revealed an order for Sodium Chloride Intravenous [IV] Solution 09% (percent), use 75 milliliters (ml) /hour intravenously every shift for volume depletion- Normal Saline IV Fluids at 75ml/hr [hour] times two liters for two administrations until finished .Levaquin (antibiotic) by mouth for pneumonia. Review of R4's Progress Notes, dated 2/8/2025, located in the EMR under Progress Notes, Licensed Practical Nurse (LPN) 2 documented Resident on IV fluids Sodium Chloride running at 75 milliliters (ml)/hour times two liters every shift for volume depletion .Also on oral antibiotic, levofloxacin for pneumonia. Further review of R4's EMR revealed no documentation of R4's RP ever being notified of R4's change in condition by the facility. During an interview on 7/1/2025 at 5:07 PM LPN1 (Unit Manager) was asked what was considered a change of condition with residents and when did you notify the family/RP. LPN1 responded Normally if there is any change in medications and/or clinical condition it is considered a change in condition and family would be notified. During an interview on 7/1/2025 at 5:19 PM, LPN2 was questioned if she recalled R4 starting his antibiotics and IV fluids. LPN2 responded that yes, she recalled the resident. LPN2 was questioned if she had notified R4's family or RP concerning R4's change in condition. LPN2 responded that if the family was in the building she would have notified them verbally, if not she would call them. LPN2 stated she couldn't recall if she had or not and did not believe she documented notifying them. During an interview on 7/2/2025 at 2:21 PM, the Director of Nursing (DON) was questioned if she was aware of LPN2 not notifying R4's family/RP, concerning him receiving IV Fluids and antibiotics. The DON responded that LPN2 had not notified the family, R4's family filed a grievance, and LPN2 and facility staff were given training in response.

Based on staff interviews and record review, the facility failed to provide an accurate Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN) as required for one of three residents (Resident (R) 8) reviewed for beneficiary notices of nine sample residents. This failure could result in the residents not being informed of the residents' responsibility related to facility costs. Findings include: Review of R8's undated admission Record located in the electronic medical record (EMR) under the Profile tab indicated the resident was admitted to the facility with diagnoses including but not limited to hypertension, dementia, and hyperlipidemia. Review of R8's unsigned Notice of Medicare Non-Coverage (NOMNC), provided by facility, revealed R8's skilled nursing and therapy services would end 6/7/2025. Review of documentation provided by the facility, representing the SNF ABN, dated 6/5/2025 and signed by the Business Office Manager (BOM) revealed the following documentation Please sign below to indicate you received and understood this notice, or nursing home representative sign acknowledging last covered day given to representative by phone. I have been notified that coverage of my services will end on the effective date indicated on this notice and that I may appeal this decision by contacting my Quality Improvement Organization (QIO) Program. SNF ABN issued to resident's responsible party (RP), on 06/5/2025, informed last covered day 6/7/2025, financial liability as of 6/8/2025. Appeal must be filed no later than noon 6/6/2025 with name of filing agency. Patient's (family name) is RP and handles all affairs at this time due to cognitive deficit issues. During an interview on 7/2/2025 at 11:07 AM, the BOM confirmed that she had no evidence that she provided the SNF ABN to R8's RP but had read it to the RP by telephone. BOM confirmed that there was no documentation of BOM providing the information, or the financial responsibility of residents for continued services. BOM confirmed R8 remained in the facility after notice was provided. During an interview on 7/2/2025 at 2:25 PM, the Director of Nursing (DON) was questioned what her expectations were related to R8's SNF ABN form. DON explained she thought there was a miscommunication related to BOM understanding of the SNF ABN form. The DON stated she expected the BOM to use the SNF ABN form.

Based on observations, resident and staff interviews, and review of relevant facility documentation, the facility failed to maintain a safe, comfortable, homelike environment in resident rooms on three of three halls. Specifically, surveyor observations included peeling paint, missing air vent covers, holes in walls, bent/broken blinds, a broken light fixture pull cord, a loose electrical wall socket, and cracked floors. The sample size was 59 residents. Findings include: 1. Initial observation of the facility on 9/15/2024 beginning at 10:45 am revealed the following concerns: room [ROOM NUMBER]: paint peeling behind the wall of bed two and in the bathroom. room [ROOM NUMBER]: a towel was wrapped around the toilet piping. room [ROOM NUMBER]: missing air vent cover in the bathroom; chipped and missing paint on the wall of the bathroom. room [ROOM NUMBER]: the toilet was leaking on to the floor and there was a puddle of clear substance on the floor behind the toilet; the sink was very slow draining. During an observation/interview with the Maintenance Director (MD) on 9/19/2024 beginning at 3:40 pm, he confirmed the following surveyor observations: room [ROOM NUMBER]-A: bathroom light did not come on when both light switches were engaged. The MD stated the light fixture likely needed a new bulb. room [ROOM NUMBER]-B: paint peeling off the wall behind bed 2 and in the bathroom. room [ROOM NUMBER]: leaking toilet around the base; slow draining sink; the MD found the pipe underneath the sink was kinked. room [ROOM NUMBER]-B: wall socket was repaired during the survey room [ROOM NUMBER]: broken piece from left bottom blade of the blinds The MD stated there was an informal decision with the corporate office and facility administration to begin facility repairs with the painting of resident rooms and bathrooms. He stated he was a one-man operation but would ask for help for more extensive repairs while he also tended to the routine maintenance duties. He stated he was not aware of the aforementioned concerns identified by the survey team. He stated he used the electronic maintenance system to perform routine duties such as checking water temperatures throughout the facility. However, he did not produce the checklist from the electronic maintenance system or a maintenance policy. He stated staff report maintenance concerns to him directly when they see him and enter concerns into a logbook kept at each nurse's station which he checks several times per day. 49138 2. An observation on 9/16/2024 at 1:18 pm revealed room [ROOM NUMBER]B to have peeling paint, holes in the wall in the bathroom, as well as a missing air vent cover. An observation on 09/16/2024 at 1:02 pm revealed room [ROOM NUMBER]B water temperature to be 125 degrees Fahrenheit (F) in the bathroom, as well as holes in the wall, missing air vent cover in the bedroom, and bent/broken blinds. An observation round on 9/19/2024 at 3:40 pm with the MD confirmed needed repairs. 50272 3. During an observation on 9/16/2024 on East Hall in room [ROOM NUMBER] B, it was observed that the string light above the bed in room [ROOM NUMBER] B was broken. To compensate for this issue, grocery bags were used to extend the string light, indicating a makeshift solution to inadequate lighting. Additionally, the bathroom floor was found to be uneven and raised, creating potential safety hazards. During an observation on 9/16/2024 on East Hall in room [ROOM NUMBER] A, it was observed that the wall socket located behind the right side of the bed was coming out of the wall, exposing the wiring and posing a significant electrical hazard. Furthermore, the lamp string light above the bed was observed to be broken. During an observation on 9/16/2024 on East Hall in room [ROOM NUMBER] B it was observed that in room [ROOM NUMBER] B, the bathroom showed notable concerns, including a missing ceiling vent covering. Additionally, a crack was observed on the floor, suggesting possible structural damage. There was also a visible gap between the floor and the baseboard. During an observation on 9/16/2024 on East Hall in room [ROOM NUMBER] it was observed the vent located on the ceiling in the shared bathroom was not properly secured to the ceiling. Furthermore, cracks were also observed on the floor near the sink.

Based on observations, resident and staff interviews, and record review, the facility failed to maintain safe water temperatures below 120 degrees Fahrenheit (F) in 17 of 22 bathrooms sampled for water temperatures on three of three halls. This failure had the potential to cause serious injury to affected residents. The facility census was 118 residents. Findings include: Initial observation of the facility on 9/16/2024 beginning at 12:15 pm revealed the water from the bathroom sinks was too hot to touch on three of three halls. Observation and interview with the Maintenance Director (MD) on 9/16/2024 beginning at 12:15 pm revealed the following: 1. room [ROOM NUMBER]=110 degrees F 2. room [ROOM NUMBER]=111 degrees F 3. room [ROOM NUMBER]=120 degrees F 4. room [ROOM NUMBER]=120 degrees F 5. room [ROOM NUMBER]=120 degrees F 6. room [ROOM NUMBER]=120 degrees F 7. room [ROOM NUMBER]=118 degrees F 8. room [ROOM NUMBER]=109 degrees F 9. room [ROOM NUMBER]=122 degrees F 10. room [ROOM NUMBER]=123 degrees F 11. room [ROOM NUMBER]=108 degrees F In an interview with R12 in room [ROOM NUMBER] on 9/16/2024 at 12:30 pm, he described the water as very hot but stated he had not suffered any burns. In an interview with R25 in room [ROOM NUMBER] on 9/16/2024 at 12:55 pm, she described the water as hot, hot but stated she had not suffered any burns. In an interview with the MD on 9/16/2024 at 1:30 pm, he stated he set the water heater at 122 degrees F. He stated the water heater was located on the 200 Hall (East) in order to provide enough hot water to the kitchen and laundry as well as the residential units. He stated that he randomly monitored the water temperatures throughout the facility at least weekly but did not keep a log for them. He stated he had not received any complaints of the water being too hot nor had he received any reports of burns to the skin. Continued observation and interview with the MD on 9/16/2024 beginning at 3:18 pm revealed the following water temperatures: 12. room [ROOM NUMBER]=107 degrees F 13. room [ROOM NUMBER]=110 degrees F 14. room [ROOM NUMBER]=115 degrees F 15. room [ROOM NUMBER]=112 degrees F 16. room [ROOM NUMBER]=113 degrees F 17. room [ROOM NUMBER]=120 degrees F 18. room [ROOM NUMBER]=116 degrees F 19. room [ROOM NUMBER]=117 degrees F 20. room [ROOM NUMBER]=121 degrees F 21. room [ROOM NUMBER]=118 degrees F 22. room [ROOM NUMBER]=118 degrees F In an interview with the MD on 9/16/2024 at 5:00 pm, he stated he had decreased the temperature of the water heater to 110 degrees F. Observation of water temperatures in the identified resident rooms measured 110 degrees F or less. He stated there was no policy related to water temperatures. Follow-up review of the water temperatures collected in the identified rooms every four hours from 5:00 pm on 9/16/2024 until 8:00 am on 9/17/2024 revealed temperatures at 110 degrees F or less. Reviews of the Grievance Log, Resident Council Minutes, and Incident Reports for the last 12 months, revealed no concerns related to the hot water.

Based on observations, resident and staff interviews, record review, and review of the facility policy titled, Resident Rights, the facility failed to maintain the dignity and privacy for one of five residents (R) (R50) with a Foley catheter. Specifically, the urinary catheter bag was left uncovered and visible while R50 was out in the hallway. Additionally, R50 was wearing a shirt on with her full name visible across her chest in thick black marker. Findings include: Review of facility's policy titled Resident Rights dated 2/1/2024 revealed under Preparation in section 1. Prior to having direct-care responsibilities for residents, staff must have appropriate in-service training on resident rights, including . b. Resident dignity and respect. Review of the electronic medical record (EMR) revealed R50 was admitted to the facility with pertinent diagnoses including but was not limited to dementia, depressive disorder, and anxiety. Review of R50's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 00, which indicates R50 was identified with severe cognitive impairment. Section GG, functional status, revealed R50 required partial/moderate assistance for activities of daily living (ADLs). Review of R50's care plan dated 4/17/2024 indicated a problem of risk for social isolation or significant changes to daily routine due to unspecified dementia, cognitive communication deficit, anxiety, major depressive disorder, and ataxia. R50 engages in both individual and group activities such as church service, bingo, coloring, and spending time with her friends and family. Goals included but not limited to express satisfaction with type of activities and level of activity involvement when asked through the review date. Interventions included but not limited to Establish and record resident's prior level of activity involvement and interests by talking with the resident, caregivers, and family on admission and as necessary. Explain to the resident the importance of social interaction, leisure activity time. Encourage the resident's participation. Invite/encourage the resident's family members to attend activities with resident in order to support participation. Review of the Physician's Orders for R50 included but was not limited to an order for a urinary catheter dated 2/2/2024. Observation and interview on 9/19/2024 9:56 am revealed R50 sitting in the hallway in a wheelchair, dressed, with shoes on, shirt with name, first and last written in large black marker across front of the shirt and slacks. R50's Foley catheter bag was hanging on the right side of the wheelchair with no dignity bag in place. R50 stated staff picked out her clothes and helped her get out of bed. R50 stated she will be moved back to her room today and that was home. Interview on 9/19/2024 at 12:00 pm with Unit Manager Licensed Practical Nurse (LPN) EE revealed staff labels clothing upon admission, and this was done inside clothing near the label. Unit Manager LPN EE added that sometimes families label items of clothing and they were told to use the same area near the label. If they saw inappropriate labeling, they notified the family that those clothes were not able to be used. Foley catheters were to be covered with a dignity bag or leg bag per policy, especially when out of room in a wheelchair. Interview with Unit Manager LPN AA on 9/19/2024 at 12:00 pm confirmed the processes for labeling clothing and the Foley catheter dignity bag were the same on the unit he managed as the unit LPN EE managed. Interview on 9/19/2024 at 2:32 pm with the Director of Nursing (DON) revealed expectations regarding labeling of clothing that the Certified Nursing Assistants (CNAs) document inventory of clothing and label them with a permanent marker in area near the label so that it is not visible and for additional clothing the same process applied. The DON added that staff who observed this would notify the CNA to ensure the change of clothing was done. The DON stated expectations for Foley catheter bags were that staff should attempt to use a leg bag which provided a higher level of dignity. If not possible, at minimum, place a privacy bag over the drainage bag.

Based on observations, record review, resident and staff interviews, and review of the facility's policy titled, Self-Administration of Medications by Patients/Residents, the facility failed to ensure one of 59 sampled residents (R) (R13) was assessed for self-administration of medication prior to leaving medications at the bedside. The deficient practice had the potential to allow unauthorized access to unsecured medications to residents and visitors at the facility. Findings include: A review of the facility's policy titled Self-Administration of Medications by Patients/Residents revised on 2/1/2024 revealed under Policy Statement: Each resident who desires to self-administer medication is permitted to do so if the healthcare center's Licensed Nurse/Registered Nurse and physician have determined that the practice would be safe for the resident and other residents of the healthcare center. Medication self-administration also applies to family members who wish to administer medication. Procedure: 1. The opportunity to self-administer medications is reviewed during the routine assessment by the healthcare center's interdisciplinary team utilizing the Electronic Health Record Observation tool, Medication Self - Administration assessment. 2. If the resident or family member desires to self-administer medications, an assessment is conducted by the head Nurse to assess the individual's cognitive, physical, and visual ability to carry out responsibility. Also, the resident or family member should in conjunction with the facility Nurse utilize the Electronic Medical Record assessment tool, Medication Self - Administration assessment to complete the administration of the medication. 3. If the Licensed Nurse determines the resident or family member to be capable of self-administration of medications, the attending physician must write an order to that effect that includes the specific medications based off the Self-Administration Medication assessment. 4. If the resident or family member demonstrates the ability to safely self-administer medications, a further assessment of the safety of bedside medication storage is conducted. 5. Bedside Storage of Medications is permitted only when it does not present a risk to confused residents who wander into the rooms of, or room with, residents who self-administer. The following conditions are met for bedside storage to occur: The manner of storage prevents access by other residents. Locking drawers or cabinets are required only if unlocked storage is ineffective. The medications provided to the resident for bedside storage are kept in the packaged as dispensed by the provider pharmacy. The Electronic Health Record Medication Administration Record form is printed off and maintained at bedside and is reviewed on each nursing shift, and the administration information is transferred to the electronic medication record. Notation of each dose self-administered is made by placing a Licensed Nurse initials in the appropriate space and noting in the nursing comments resident/patient self-administered the medications). Only one signature per shift is required by the nurse documenting the resident's report of self-administration. All nurses and aides are required to report to the Charge Nurse on duty any medications found at the bedside not authorized for bedside storage and to give unauthorized medications to the Charge Nurse for return to the family or responsible party. A review of the electronic health record (EHR) for R13 revealed diagnoses of but not limited to dysphagia following cerebral infarction, dysphagia oral phase, depression and cerebral infarction. A review of R13's quarterly Minimum Data Set (MDS) dated [DATE] revealed in section C (Cognitive Patterns) a Brief Interview for Mental Status (BIMS) score of 13, indicating cognitively intact. Further review of R13's MDS revealed section N (Medications) documented R13 is receiving antidepressants. Review of R13's care plan on 9/18/2024, revised on 4/17/2024, revealed a focus of drug regimen review will have no clinically significant medication issues identified. Furthermore R13's care plan revealed an intervention of conducting a medication reconciliation upon admission for all medications and new medications orders will be reviewed daily for any actual or potential clinically significant medication issues. During an observation on 9/16/2024 at 11:15 pm in R13's room revealed a tube of diclofenac sodium topical gel of 1 percent (%) on her bedside table. Review of R13's EHR on 9/18/2024 revealed no physician orders or assessment to be found for self-administration of medication. During an interview on 9/18/2024 at 12:40 pm with Certified Nursing Assistant (CNA) DD revealed R13 was not supposed to have medication by the bedside table. CNA DD confirmed she had seen the medication by the bedside table before. Furthermore, CNA DD revealed she had received in-service training on medications by the bedside table. During an Interview on 9/18/2024 at 12:42 pm with Licensed Nurse Practitioner (LPN) EE revealed residents were not supposed to have medications by the bedside table. LPN EE revealed it was her expectations that all CNA's must follow protocol regarding medications by the bedside table. LPN EE stated in-service training was provided for CNAs regarding medications by the bedside. LPN EE further stated a possible negative outcome was that it was not something positive for the resident and other residents might get a hold of the medication. During an interview on 9/18/2024 at 1:15 pm with the Director of Nursing (DON), it was clarified that medications should not be stored by the bedside unless a resident was assessed and deemed capable of self-administering. The DON stated in such cases, medications would typically be kept in a locked box, or nurses would bring the medications in for residents. The DON emphasized the importance of assessing residents' ability to self-administer medications. Furthermore, the DON noted potential negative outcomes if residents take medications outside the prescribed times, which could lead to side effects or adverse reactions. During an interview on 9/19/24 at 3:30 pm with the Administrator revealed his expectations were that residents were not to have any medications by their bedside table.

Based on observations, staff interviews, and review of the facility policy titled, Residents Rights Accommodation of Needs and Preference and Homelike Environment, the facility failed to accommodate the needs of one of 14 residents (R) (R112) reviewed for environmental concerns. Specifically, the facility did not ensure call light was within reach. This failure had the potential to prevent R112 from receiving care or service when needed. Findings include: Review of the facility policy titled Residents Rights Accommodation of Needs and Preference and Homelike Environment effective date 2/1/2024 states under 1. The facility will assess and interview residents for the need to make reasonable accommodations. Call light in reach for room and bathroom and the correct type for resident use to meet the resident need. Review of R112's admission Minimum Data Set (MDS) dated [DATE] revealed the resident had a Brief Interview of Mental Status (BIMS) score of five, indicating severe cognitive impairment. The resident required a manual wheelchair and two-person assistance. Observation on 9/16/2024 at 12:00 pm revealed R112 sitting in her wheelchair screaming for help while the door was closed. Upon entering R112's room, her call light device was wrapped around her bed rail, out of reach. Observation on 9/18/2024 at 3:00 pm revealed R112 sitting up in wheelchair watching her television, with her call light device out of reach. During an interview on 9/19/2024 at 2:47 pm with the Director of Nursing (DON), she stated her expectation for her staff was to ensure the residents needs and preferences and provide a homelike environment. She revealed she had given her nursing staff in-service education on resident accommodation and policy.

Based on observations, staff interviews, and review of the facility policy, Visitation, the facility failed to have a system in place which allows visitors into the facility after hours. Findings include: The policy titled, Visitation revealed in the Policy Statement: The facility permits residents to receive visitors whom he or she designates, and the resident has the right to withdraw or deny such consent at any time. Under Guideline . 3. The facility will provide immediate access for residents receiving visits from the following: a. Any representative of CMS or State representatives such as Surveyors. g. The resident's legal representative, immediate family or relatives, and any other person visiting with the resident's consent, subject to limitations outlined in this policy. Observation on 9/18/2024 at 6:00 am from the outside of the front of the facility revealed a very dark entrance. Lights were all off with the exception of security lights in the front. There was a small posting on the front door which read, call 770 422 8913 for after hours. When the number was called, three times, the phone continuously rang with no voicemail. In attempts to get into the building, surveyors walked around to the side of the building at the west hall entrance and knocked on the door, where staff let the survey team in. Interview on 9/18/2024 at 6:32 am with Licensed Practical Nurse (LPN) VV revealed the phone did not ring over here (on west wing), it must have rung on east wing. Interview on 9/18/2024 at 6:35 am with LPN EE, East Unit manager revealed the phone did not ring. Interview on 9/18/2024 at 12:10 pm with the Director of Nursing (DON), she revealed that after 8:00 pm, the front door was normally not used because it was for the visitors. Normally, everyone comes to the side door near the back. If visitors come, the number should have picked up. What happens at night is that reception turns the phone over and it should go to the nurses' station, but I would need to find out what happened. Her expectation after hours was for visitors to have the number to call. The negative effect for the phone not being picked up after hours was a visitor could be upset or a visitor could be worried if they cannot get a hold of their family members. During business hours, if someone is calling in, multiple calls (three maximum) can only go through and can only be freed up when one of the lines is answered. The DON revealed visiting hours are from 8:00 am to 8:00 pm as the standard, but if someone would like to be here after that, they are not stopped if they want to come. Interview on 9/18/2024 at 12:20 with the Administrator revealed family members and visitors were supposed to visit during visiting hours from 8:00 am to 8:00 pm. If they wanted to visit after or before visiting hours, they could call the facility and then the nature of the visit would be decided among administration. The Administrator revealed most of the family members understood the visiting hours. It was not the expectation for the phones to not transfer if they were put on transfer. He stated the expectation was for the phone to be picked up. Most families will call during business hours.

Based on record review, staff interviews, and review of the facility policy titled, Review of the Beneficiary Notice, the facility failed to provide the Notice of Medicare Non-Coverage (NOMNC) (Form CMS-10123) to two of two residents (R) (R29 and R36) who remained in the facility and were discharged from Medicare Part A services. Findings include: Review of the facility policy titled Review of the Beneficiary Notice revealed under Procedure, 3. If the resident is unable to sign, and the SNF (skilled nursing facility) is working with a legally authorized representative who is unable to be present at the facility that day, the SNF may issue the NOMNC by telephone. g. The facility must confirm the telephone contact by sending written notice to the authorized representative on the same day the call was made. 4. Copies of the completed NOMNC are: a. Given to the resident or the authorized representative who signed the NOMNC. Review of the Beneficiary Notice for R21 revealed no evidence that a NOMNC form was provided. The only notice that was provided to R29 was the Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN). The SNF ABN form revealed R29 was discharged from Medicare Part A services on 8/3/2024. Review of R29's Minimum Data Set (MDS) (End of Part A Stay) assessment dated [DATE] revealed in section A: (Identification Information) the Medicare stay documented start date of 7/19/2024 and end of Medicare stay was on 8/30/2024. Review of Beneficiary Notice for R36 revealed no evidence that a NOMNC form was provided. The only notice that was provided to R36 was the SNF ABN. The SNF ABN form revealed R36 was discharged from Medicare Part A services on 8/7/2024. Review of R36's MDS (End of PPS (Prospected Payment System) Part A Stay) assessment dated [DATE] revealed in section A: (Identification Information) the assessment was a SNF Part A PPS ( discharge assessment. The start date of the Medicare stay was 6/25/2024 and the end date of most recent Medicare stay start date was 6/25/2024 and the end date was 8/7/2024. An interview on 9/18/24 at 11:34 am with Business Office Manager (BOM) CCC revealed she was initially trained upon hire regarding ABN and NOMNC notifications. She confirmed and verified R29 and R36 were discharged from Medicare part A services with benefit days remaining, the discharge was initiated by therapy, and they both continued to live in the facility. She stated NOMNC's were for residents who were discharged from the facility and going home, and the ABN is for residents who are discharged from Medicare part A services but remaining in the facility. An interview on 9/18/2024 at 11:53 am with Physical Therapist (PT) AAA and Regional Consultant (RC) BBB for Quality risk Management (QRM) in-house rehab support, R36 was discharged from PT (physical therapy) on 7/12/2024 because he met his maximal potential for therapy. They also revealed R36 was discharged from speech therapy on 8/7/2024 and the therapist documented he achieved projected outcomes and predicted that he would be able to maintain function and he was discharged to a regular diet. R29 was discharged from OT on 8/15/2024 and the therapist documented she met maximal potential for therapy and was referred to the restorative nursing program. The stated R36 was discharged from PT on 8/30/2024 and the therapist documented she had achieved the highest practical level at discharge. An interview on 9/18/2024 at 12:14 pm with the Administrator revealed his expectation was for the staff to provide the correct notification at time of discharge from Medicare Part A. He stated the outcome of not providing correct notification could lead to the resident becoming confused, not being informed correctly, or incurring fees for their stay.

Based on observations and record review, the facility failed to accurately document the dental status in the annual Minimal Data Set (MDS) assessment for one of 59 sampled residents (R) (R72). This failure had the potential to prevent R72 from receiving necessary dental care. Findings include: Review of the clinical record for R72 revealed they were admitted to the facility with diagnoses to include but not limited to cognitive communication deficit, unspecified dementia, unspecified neurocognitive disorder with Lewy bodies, depression, and Parkinson's disease. Review of the annual MDS assessment dated [DATE], Section L (Oral and Dental Status Issues) 0200 listed options for the dental assessment to include no natural teeth or tooth fragments (edentulous), obvious or likely cavity or broken natural teeth, and none of the above were present. The assessment documented none of the above indicating no dental concerns. Observation on 9/16/2024 at 2:58 pm of R72 revealed she was missing all but one of her upper teeth. Review of the dental exam dated 7/1/2024 documented multiple missing teeth; would like upper and lower partials. Will take partials at the next dental visit. In an interview on 9/19/24 at 5:13 pm with the Chief Clinical Officer (CCO), she reviewed the most recent annual MDS assessment and confirmed R72 was incorrectly documented for oral/dental status as having none of the concerns listed. She confirmed R72 was missing most of her upper teeth. She stated she expected the MDS Coordinator to accurately assess the residents. The MDS Coordinator was not available for interview.

Based on staff interviews, record review, and review of the facility policy titled, PASRR, the facility failed to ensure that the Preadmission Screening and Resident Review (PASARR) Level II was completed for one of 59 sampled residents (R) (R92). The deficient practice had the potential for R92 to not receive specialized care to treat mental illness. Findings include: Review of the facility policy titled PASRR with an effective date of 2/1/2024, revealed that it is the policy of the facility to screen all potential admissions on an individualized basis. As a part of the preadmission process, the facility participates in the Preadmission Screening and Resident Review (PASRR) screening process (Level 1) for all new and readmissions to determine if the individual meets the criterion for mental disorder, intellectual disability or related condition. Based on the Level 1 screen, the facility will not admit an individual with a mental disorder or intellectual disability until the Level II screening process has been completed and the recommendations allow for a nursing facility admission and the facility's ability to provide the specialized services determined in the Level II screen. Review of the electronic medical record (EMR) for R92 revealed that she was admitted to the facility with diagnoses that included but were not limited to encephalopathy, depression, altered mental status, cognitive communication deficit, alcohol dependence, cannabis abuse, and post-traumatic stress disorder (PTSD). Review of the quarterly [NAME] Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14, which indicates the resident is cognitively intact. Review of the care plan for R92 revealed that she is dependent on staff for meeting emotional, intellectual, physical, and social needs related to cognitive deficits and disease process. It revealed that she experiences loneliness and/or isolation. An intervention for this situation is consult with appropriate services. Review of the progress notes from the primary physician revealed that the resident has depression and PTSD. The resident was being seen by psychiatric services for diagnosis of depression. All progress notes reviewed from psychiatric services revealed that R92 was being seen for depression and no notes indicating that the resident had a diagnosis of PTSD. An interview with the Social Services Director on 9/17/2024 at 2:54pm revealed that she does not do Level II for residents. She stated that they are completed by the hospital prior to admission. She stated that she does not have a Level II for R92. She stated that she will send in the required documents to complete the Level II.

Based on resident, resident family, and staff interviews, record review, and review of the facility policy titled, Minimum Data Set (MDS) / Care Plans, the facility failed to develop and implement a baseline care plan within 48 hours of admission for five of 59 sampled residents (R) (R49, R22, R113, R15 and R70). The deficient practice had the potential to affect the appropriate level of care and services provided for R49, R22, R113, R15 and R70. Findings include: Review of the facility policy titled Minimum Data Set (MDS) / Care Plans revised 2/1/2024 revealed in the Policy Statement: Each resident will have an individualized interdisciplinary plan of care in place. The baseline care plan will be completed within 48 hours of admission. The Interdisciplinary Team will continue to develop the care plan in conjunction with the Resident Assessment Instrument (RAI), Minimum Data Set (MDS 3.0), and Care Area Assessment (CAAS), completing and conducting Certified Compliance Professional (CCP) meeting by Day 21 post admission. The Comprehensive Care Plan will be reviewed and revised on a quarterly basis, with a significant change in condition, on re-admission from inpatient hospital stay, and as requested by the Resident/Representative. The Comprehensive Care Plan will be resident centered having the individual resident as the locus of control. The Comprehensive Care Plan will be ongoing, focusing on each individual resident as a unitary being. Residents and their representatives will play an active role in the development of goals and implementation of the residents' Comprehensive Care Plan. Under Procedure: 1. The admitting Registered Nurse will complete baseline care plan on admission within 48 hours to address the following areas: Resident/Resident Representative's initial Goals, Skin Prevention, Fall Prevention, Pain Management, Advanced Directives, Psychosocial Mood State/Adjustment to Placement/PASSR Needs as indicated, Specific Care Plan on the main reason for admission to facility. The most current MDS dated [DATE] revealed in Section C (Cognitive Patterns) a Brief Interview for Mental Status (BIMS) score of 13, indicated intact cognition. Section GG (Functional Abilities and Goals)-independent (impairment on one side/wheelchair), Section H (Bladder and Bowel)-always incontinent, Section M (Skin Conditions)-assessment/risk pressure ulcer. Review of electronic medical records (EMR) revealed R49 did not have a baseline care plan. Review of the EMR revealed R49 was admitted with diagnoses of, but not limited to urinary tract infection (UTI). Observation/ Interview on 9/16/2024 at 2:13 pm revealed R49 to be alert and oriented. R49 stated she had several UTIs and staph infections. Family stated R49 was having a difficult time healing. Family stated they cannot figure out what's causing R49 slow healing progress. R49 was currently placed at the facility short term. Interview on 9/18/2024 at 10:32 am with MDS Coordinator II revealed It was her responsibility to complete the resident's assessment upon admission, short term and long term. MDS Coordinator II inputs all information in the system. MDS Coordinator II confirmed R49 was admitted on [DATE] and she started the assessment but did not complete all care area listed on the MDS. Observation on 9/19/2024 at 11:19 am revealed R49 lying in the bed relaxing. She was observed to be alert and oriented with no concerns. Interview on 9/19/2024 at 4:22 PM with Director of Nursing (DON) revealed nurses are expected to complete baseline care plans within 48 hours upon resident admission. The most current MDS for R22 dated 8/17/2024 revealed in Section A (Identification Information) Medicaid/Medicare Certified, Section C (Cognitive Patterns) revealed a BIMS score of 9, indicating moderate cognitive impairment, Section I (Active Diagnoses) revealed atrial fibrillation and other dysrhythmias, hypertension, acid reflux, renal insufficiency, renal failure, end stage renal disease (ESRD), multi-drug resistant organism (MDRO), diabetes mellitus, UTI, hyperlipidemia, thyroid disorder, arthritis and malnutrition, Section N (Medications)-injections, insulin, antidepressant, hypnotic, anticoagulant, opioid, antibiotic and hypoglycemic, Section O (Special Treatments, Procedures, and Programs)-None. Interview on 9/17/2024 at 3:02 pm with R22 revealed R22 to be alert and oriented, she had been at the facility six weeks. R22 wants to return home as she is waiting on a discharge date . Interview on 9/18/2024 at 1:49 pm with MDS Coordinator YY revealed she reviewed R49's EMR and confirmed there was no baseline care plan. MDS Coordinator YY stated social services works with the residents and family on baseline care plans upon admission. Interview on 9/19/2024 at 4:22 PM with DON revealed nurses are expected to completed baseline care plans within 48 hours upon resident admission. 44757 2. A review of the EMR for R113 revealed there was no baseline care plan completed for the resident. A review of the EMR for R15 revealed there was no baseline care plan completed. A review of the record for R15 revealed a baseline care plan that was not completed within 48 hours. During a phone Interview with R15's family member, it was revealed that R15 had not had a care plan, and the family was not aware of her having a care plan at all. Interview on 9/17/2024 at 2:51 pm with the Registered MDS Nurse TT revealed she does not attend the care plan meetings. She revealed only the resident will attend and Social Services will usually set that up with the residents and their families. She further revealed the care plan was started on day one, developing upon admission and completed by day 14, usually done before day 14. RN TT revealed the regulations state the comprehensive assessment had to be done by day 14. Interview on 9/17/2024 at 3:00 pm with the Social Services Director did quarterly and annual care plan set up while Medical Records sets up admission care plans. Interview on 9/19/2024 at 4:22 pm with the Director of Nursing (DON) revealed nurses were expected to complete baseline care plans within 48 hours upon resident admission. 46579 3. Review of the EMR for R70 revealed that he was admitted with diagnoses that included but were not limited to acute kidney failure, mild protein calorie malnutrition, cerebrovascular disease, depression, and type 2 diabetes. Review of the 5-day admission MDS dated [DATE] revealed that he had a BIMS score of 15, indicating he is cognitively intact. Section GG, which describes functional limitations, revealed that he has impairment on both sides of his lower extremities and needs at least substantial assistance for some of his activities of daily living (ADL's) and has total dependence for toileting. Section I (Active Diagnoses) lists that he has bilateral below the knee amputations and has prosthetics on both lower extremities. Review of the care plan revealed that R70 was a high risk for falls related to gait and balance problems, bilateral below the knee amputations and incontinence. An intervention for this risk was to anticipate and meet the resident's needs, which was initiated on 9/3/2024. His admitted was 8/23/2024. Base line care plan should be completed with 72 hours of admission. Review of the admission assessment for R70 dated on 8/23/2024, revealed that the resident was a high risk for falls. The EMR also revealed that the next fall assessment was completed on 9/17/2024, after a fall. An observation of R70 on 9/16/2024 at 10:55am, revealed that he was sitting up in his wheelchair, dressed. During an interview during this time, he stated that he had fallen, because he used the call light when he had to use the restroom, and no one came to help him. He then stated that he got up and took himself to the bathroom and when he got up to pull him pants up, he had to let go of the railing and fell . An interview on 9/19/2024 at 1:24 pm with Licensed Practical Nurse (LPN) Unit Manager revealed that when an unwitnessed fall occurs, nurses are to assess the resident and make sure they were safe to move. Then they were to be transferred to the bed. Nurses were then to do a skin assessment and a pain assessment and to take a set of vital signs. They would then medicate for pain if they were complaining of pain and then notify the provider and the family. Then the nurse would then do the fall assessment in the computer, chart the pain assessment and neurological checks as directed. Then a progress note would need to be completed three days post fall. The DON was interviewed on 9/19/2024 at 2:45pm. She stated that the nurse would assess the resident and then evaluate what happened. They would need to do a root cause analyses and then come up with interventions and then put them in place. The nurse would then need to call the provider and then the family. Documentation would need to include a nurses note, an order written for interventions that would require an order, and an incident report. The fall risk assessment should be completed on admission, which is part of the admission, and residents with high risk for falls need to be care planned within 48 hours.

Based on staff interviews, record review, and review of the facility policy titled, Minimum Data Set (MDS) / Care Plans, the facility failed to develop and implement a comprehensive person-centered care plan that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs for three of 59 sampled residents (R) (R49, R111 and R92). The deficient practice had the potential to affect the care and services provided to R49, R111, and R92. Findings include: Review of the facility policy titled Minimum Data Set (MDS) / Care Plans revised 2/1/2024 revealed in the Policy Statement: Each resident will have an individualized interdisciplinary plan of care in place. The baseline care plan will be completed within 48 hours of admission. The Interdisciplinary Team will continue to develop the care plan in conjunction with the Resident Assessment Instrument (RAI), Minimum Data Set (MDS 3.0), and Care Area Assessment (CAAS), completing and conducting Certified Compliance Professional (CCP) meeting by Day 21 post admission. The Comprehensive Care Plan will be reviewed and revised on a quarterly basis, with a significant change in condition, on re-admission from inpatient hospital stay, and as requested by the Resident/Representative. The Comprehensive Care Plan will be resident centered having the individual resident as the locus of control. The Comprehensive Care Plan will be ongoing, focusing on each individual resident as a unitary being. Residents and their representatives will play an active role in the development of goals and implementation of the residents' Comprehensive Care Plan. Under Procedure: 1. The admitting Registered Nurse will complete baseline care plan on admission within 48 hours to address the following areas: Resident/Resident Representative's initial Goals, Skin Prevention, Fall Prevention, Pain Management, Advanced Directives, Psychosocial Mood State/Adjustment to Placement/PASSR Needs as indicated, Specific Care Plan on the main reason for admission to facility. 1. Review of electronic medical records (EMR) revealed R49 was admitted with diagnoses of, but not limited to urinary tract infection (UTI). Review of the most current Minimum Data Set (MDS) dated [DATE] revealed in Section C (Cognitive Patterns) a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition, Section GG (Functional Abilities and Goals)-independent (impairment on one side/wheelchair), Section H (Bladder and Bowel)-always incontinent, Section M (Skin Conditions)-assessment/risk pressure ulcer. Review of the EMR revealed R49 did not have a baseline care plan or a care area to address UTI. Observation on 9/19/2024 at 11:19 am revealed R 49 lying in the bed relaxing, she was observed to be alert and oriented with no concerns. Interview on 9/18/2024 at 10:48 am with Registered Nurse (RN) ZZ verify R49 did not have a baseline care in the EMR or a care plan to address R49's UTI Infections. RN ZZ stated it was everyone responsibility to ensure R49 was care planned for a UTI. Interview on 9/18/2024 at 1:49 pm with MDS Coordinator YY revealed she reviewed R22's EMR and confirmed there was no baseline care plan. Interview on 9/19/2024 at 4:22 PM with Director of Nursing (DON) revealed nurses are expected to completed baseline care plans within 48 hours upon resident admission. 50272 2. A review of the HER for R111 revealed diagnoses of but not limited to chest pain, unspecified and atherosclerotic heart disease of native coronary artery without angina pectoris. A review of R111's quarterly MDS dated [DATE] revealed in section C (Cognitive Patterns) a BIMS score of 15, indicating cognitively intact. Further review of R111's MDS revealed section O (Treatments) documented R111 is receiving oxygen treatment, R111 has shortness of breath with exertion and has shortness of breath or trouble breathing when lying flat. Review of the EMR of R111's physicians orders revealed an order for oxygen (O2) at 2 liters per minute via nasal cannula continuously for hypoxia. Oxygen saturation to maintain ninety percent (90%) or above every shift for shortness of breath. Review of R111's care plan revealed that there were no specific care plan interventions documented for O2 therapy. During an interview on 9/19/2024 at 9:40 am with the Director of Nursing (DON) revealed it is her expectations that all residents on O2 therapy were to be care planned and revealed nurses were expected to complete baseline care plans within 48 hours upon resident admission. During an interview on 9/19/2024 at 3:58 pm with the Administrator revealed his expectations are that all residents that are on O2 therapy are to be care planned accordingly. 46579 3. Review of the EMR for R92 revealed that she was admitted to the facility with diagnoses that included but were not limited to encephalopathy, depression, altered mental status, cognitive communication deficit, alcohol dependence, cannabis abuse and Post-Traumatic Stress Disorder (PTSD). Review of the quarterly MDS) dated [DATE] revealed a BIMS score of 14, which indicates the resident is cognitively intact. Section I (Active Diagnoses) review indicates that the resident has depression, encephalopathy, cognitive communication disorder and post-traumatic stress disorder. Review of the care plan for R92 revealed that she is dependent on staff for meeting emotional, intellectual, physical, and social needs related to cognitive deficits and disease process. It revealed that she experiences loneliness and/or isolation. An intervention for this situation is consult with appropriate services. The resident having Post Traumatic Stress Disorder as a problem and any interventions for the care of the resident and this problem is not on the care plan. Review of the progress notes from the primary physician revealed that the resident has depression and post-traumatic stress disorder. The resident was being seen by psychiatric services for diagnosis of depression. All progress notes reviewed from psychiatric services revealed that R92 was being seen for depression and no notes indicating that the resident had a diagnosis of PTSD.

Based on staff interviews, record review, and review of the facility policy titled, Minimum Data Set (MDS/Care Plans, the facility failed to include the resident (R), family, or family representative attended baseline care plan meetings and care plan meetings for one of 59 sampled residents (R) (R15). Findings include: A review of the facility policy titled Minimum Data Set (MDS)/Care Plans revealed under Policy Statement: The Interdisciplinary Team (IDT) will continue to develop the care plan in conjunction with the RAI (Resident Assessment Instrument) (MDS 3.0) and CAAS (care area assessments) completing and conducting CCP (Comprehensive Care Plan) meeting by Day 21 post admission.The Comprehensive Care Plan will be ongoing, focusing on each individual resident as a unitary being. Resident and their representatives will play an active role in the development of goals and implementation of the residents' Comprehensive Car Plan. Under procedure number 5. The resident and/or representative will be offered a Care Plan Summary during the Admission, Annual, and/or Significant Change Care Plan review meetings and upon request. 7. The IDT will review the Care Plan Summary with the resident/representative and provide any needed education/clarification. The IDT will provide the resident/representative a Current Care Plan Summary at any time as per their request. A review of the electronic medical record (EMR) for R15 revealed no baseline care plan note which documented who attended the care plan meeting. During a phone interview with R15's family member, it was revealed that R15 had not had a care plan, and the family was not aware of her having a care plan at all. Interview on 9/17/2024 at 2:51 pm with MDS Registered Nurse (RN) TT revealed that usually only the resident will attend care plan meetings and Social Services would usually set that up with the residents and their families. Interview on 9/17/2024 at 3:00 pm with the Social Services Director QQ revealed that quarterly they will get a calendar from MDS, at least by the 15th, and [Social Services] would call the families to let them know there was a letter coming for the care plan meeting and can be by phone or in person, in hopes for them to attend the care plan meetings. Social services will go and speak directly to the residents about the meeting. Upon informing the resident of the care plan meeting coming up, Social Services would ask if there was family they would like to invite. If there was a significant change or changes in the care plan, nursing would normally notify the resident. Social Services QQ further revealed there was a form used to check off who was there from different departments, and it would go in their notes, either the same day or the next day after the care plan meeting. She further revealed they try to go to every resident to let them know they have a care plan meeting ahead of time for the quarterly care plan meetings. Interview on 9/17/2024 at 3:12 pm with the Director of Medical Records (DMR) UU revealed she did rounds with the nursing units, scanned in medications to the EMR, labwork, consents, dialysis trips, new admissions, admission records, and scheduled care plans (new admission). She would share with Social Services, Business Office, Rehab, the family member or the residents themselves depending on the BIMS score, and if they were able to communicate. She scanned in anything from the Social Security office and make sure it was in the EMR. For new admissions, the admission person scanned in the admission packet and uploaded it in the system. She would call either the first contact to set up the care plan meetings and what was a good time for them to have the meeting. She revealed it was the responsibility of Social Services to upload the care plans whether it was an admission care plan or a quarterly care plan but was unable to verbalize a timeframe on when that should be put in the system. There would be documentation of who attended a care plan meeting in the care plan note, which should be under miscellaneous in the EMR system. Interview on 9/19/2024 at 4:22 pm with the Director of Nursing (DON) revealed nurses were expected to completed baseline care plans within 48 hours upon resident admission.

Based on interviews, record review, and review of facility policies, the facility failed to ensure that one of 31 sampled residents (R) (R#3) was free on a significant medication error, causing the resident to be transferred out to the emergency room and admitted to the hospital. On 1/17/2023 a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation caused or had the likelihood to cause serious injury, harm, impairment, or death to residents. The facility's Administrator and Director of Nursing were informed of the Immediate Jeopardy for F760 on 1/17/2023 at 9:32 a.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on 12/11/2022. An Acceptable IJ Removal Plan was received on 1/18/2023 related to483.45(f)(2), Free from Significant Medication Errors. Based on observations, record reviews, interviews and review of the facility's policies as outlined in the Credible Allegation of Compliance, it was validated that the corrective plans and the immediacy of the deficient practice was removed on 12/15/2022. Findings included: A review of the Medication Administration Policy dated September 2018, Medication Administration General Guidelines section 7.1 #17 indicated that during administration of medications, the medication cart is kept closed and locked when out of site of the medication nurse. No medications are kept on top of the cart. The cart must be clearly visible to the personnel administering medications when unlocked. A review of the clinical record revealed that R#3 was admitted to the facility on [DATE] with diagnosis of Arthritis, cognitive communication deficit, unsteady feet, Acute Bronchitis, Atrial Fibrillation, Anxiety Disorder, Dizziness and Giddiness, Disorientation, Morbid Obesity, Hypertension, Testicular Hypofunction, Influenza, and repeated falls. A review of the clinical record revealed that R#2 was admitted to the facility on [DATE]. A review of the Medication Administration Record (MAR) dated December 2022 revealed he was ordered Methadone 140mg (14 tabs 10 mg tabs) by mouth per day due to diagnosis of pain with a start order date of 11/25/2022 and an end date of 1/26/2023. During an interview on 1/9/2023 at 5:00 p.m. with the Director of Nursing (DON), she stated that on 12/11/2022, she received a call that R#3 was being sent out to the hospital for unresponsiveness and that the resident's family notified the facility that the resident had tested positive for Methadone. She stated that Licensed Practical Nurse (LPN) AA was interviewed and that she had explained to her that she had got the medication (Methadone 140 mg- fourteen 10 mg tablets, out for another resident (R#2, who had a physician order for 140 mg Methadone). She stated that the nurse informed her that she was called was from the medication cart to help staff with another resident. LPN AA further told the DON that she left or put the medication (Methadone 140 mg) on top of her medication cart and covered it with a drinking cup. LPN AA stated that when she returned to her cart, the medication (Methadone 140 mg) was missing. She stated that she had looked in R#2's room and did not find the medication. LPN AA stated that she pulled the Methadone again and administered the medication to R#2 and signed the other Methadone out as wasted. The DON stated that all nurses had medication administration training. During an interview on 1/10/2023 at 11:20 a.m. with the family of R#3, they stated that R#3 did not take Methadone and had never taken the medication. They stated that R#3 had never been prescribed Methadone but that when he went to the hospital, they informed them that he had tested positive for Methadone. During interview on 1/10/2023 at 5:00 p.m. with the DON, she stated that she was notified around 5:00 p.m. or 5:30 p.m. that the emergency room physician had called the facility about R#3 having a positive lab result for the drug Methadone and notified that the family member came to the facility at about the same time to find out why R#3 labs were positive for Methadone. During an interview on 1/11/2023 at 10:15 a.m. with the North and South Hall Unit Manager (UM) BB revealed that she was told that a resident was sent to the hospital for respiratory arrest. She revealed that later she was told that the hospital that R#3 had tested positive for Methadone. Unit Manager BB stated that she received a phone call from LPN AA telling her that R#3 went to hospital in respiratory distress. Unit Manager BB stated that LPN AA mentioned some Methadone was missing and that she had placed the medication on top of the medication cart with a cover and when she returned, it was missing. Unit Manager BB stated that she told LPN AA she needed to figure out where the Methadone was and report it the nurse supervisor. A review of written statement for LPN AA indicated: Towards the beginning of the shift (R#3) was administered his medication. After dealing with (R#3), this nurse was in the process of preparing (R#2) medications of fourteen tablets, 10 mg each of Methadone (140 mg). Another staff member asked for some assistance with another patient which took about 2-3 minutes total. (LPN AA) set (R#2) medication (Methadone 140 mg) on top of the cart and covered with a few drinking cups. After returning to the cart to administer (R#2's) medication, the medication (Methadone 140 mg) was unaccounted for. Around 11:15 a.m. when passing by (R#3) room, (LPN AA) heard (R#3) snoring loudly and went to check on (R#3), however (R#3) did not wake up. Made several attempts to wake (R#3) to no avail. A review of hospital notes for R#3 dated 12/11/2022 indicated chief complaint: Altered Mental Status. Presenting symptoms: disorientation and partial responsiveness. Severity: Severe. Progression: Worsening. Rapid drug screen urine for: Methadone, U- Presumptive Positive (A). Medical Decision Making: Patient obtunded on arrival. Administered Narcan and patient's mentation improved. Patient required multiple doses of Narcan for bradypnea. Initiated Narcan infusion. Rapid drug screen positive for methadone. Patient has no history of methadone use. Concerned he received another resident's medication at facility. The facility implemented the following corrective action in response the deficient practice which occurred on 12/11/2022: During an interview on 1/9/2023 at 5:00 p.m. with the DON, she revealed that LPN AA was suspended per facility policy during investigation on 12/11/2022 and was terminated on 12/13/2022 after investigation. A review of a Couching and Counseling Session form dated 12/11/2022 indicated a separation notice by phone. A review of personnel file for LPN AA indicated she was terminated on 12/13/2022. A confirmation from the Board of Nursing was provided related to the report made. A review of the form (Coaching and Counseling Session) dated 12/13/2022 noted that Stakeholder has violated Conduct and Behavior Policy. A serious med administration issue was discovered on 12/11/2022. A review of controlled medication reconciliation revealed that this was completed on 12/11/2022. A review of medical records of residents provided indicated no problems with care provided by LPN AA. A review of the Progress Notes dated 12/11/22 indicated 15 residents (R#2, R#18, R#19, R#20, R#21, R#22, R#23, R#24, R#25, R#26, R#27, R#28, R#29, R#30, and R#31) were assessed with no concerns. A review of the written statements provided by residents on 12/11/22 indicated no problems with LPN AA. On 12/11/2022 the facility obtained written statement by all staff working on day shift. Staff were educated about following medication administration processes and procedures including rights of medication pass, review of medication administration policy, lock cart, and do not store medication on top of cart. A review of in-service sign in sheets dated 12/11/2022 and 12/12/2022 revealed all licensed nursing staff received the education in-service in person or by phone. The education was verified as provided through staff interviews conducted: 1/9/23 at 10:20 a.m. - 11:32 a.m. with LPN DD, LPN EE, RN CC, and RN KK; and interview on 1/10/23 at 1:50 p.m. with LPN RR; Interview on 1/11/23 at 9:25 a.m. - 9:50 with LPN JJ, LPN UU, and LPN VV. A review of audit sheets dated 12/13/22 at 7:00 a.m. and 11:00 a.m. indicated an audit completed with no errors noted. A medication pass was conducted on 1/9/2023 with five different residents on the East and West Hall, revealed no errors noted, no medication left on top of the cart. A medication pass conducted on 1/11/2023 by surveyor with three different residents on the North and South Halls revealed no medication errors. No medications left on top of cart. A sign in sheet dated 12/14/2022 of an Ad hoc QAPI meeting was reviewed: MD, DON, Administrator, North Unit Manager, MDS, and Physical Therapist signed as being in attendance. The topic was noted as: Medication Administration, Medication Policy and Procedure, Actions taken place on 12/11/22 and prevention for further incidents. During an interview on 1/9/2023 with the DON, ADON, and Administrator revealed that an emergency QAPI was done on 12/14/2022. Interview on 1/18/2023 with the Medical Director revealed corrective Plan to prevent further medication errors was discussed with QAPI team and this plan was implemented. During an interview on 1/18/2023 with the Medical Director revealed corrective Plan to prevent further medication errors was discussed with QAPI team and this plan was implemented.

Based on observation, interview, and record review it was determined that the facility failed to provide an environment that promoted the resident's sense of psychosocial well-being and satisfaction with care received for one of 19 sampled residents (R) (R#13). R#13 received [CONDITION(S)] services three times each week, outside the facility. The transportation service failed to return the resident back to the facility after one [CONDITION(S)] session and the [CONDITION(S)] center staff were unable to reach the facility to report the resident was stranded at the [CONDITION(S)] center. [CONDITION(S)] center staff called emergency services, who in turn tried to call the facility, but the call went unanswered. When no one from the facility would answer the calls, R#13 was transported to a local hospital, where he remained until the next morning. R#13 expressed being traumatized by the incident and refused to attend the next scheduled [CONDITION(S)] session, due to fear of being abandoned again. Findings include: R#13 was admitted to the facility on [DATE]. The resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed R#13 had a Brief Interview for Mental Status (BIMS) score of 15, indicating independence in cognitive skills for daily decision making. A resident mood interview (PHQ-9) revealed the resident had a mood score of five, indicating symptoms of a mood deficit were present. R#13 was assessed as refusing Activities of Daily Living (ADL) care on one to three days during the assessment review period. R#13 received an antidepressant medication on two of the last seven days of the assessment review period. The resident was assessed to receive oxygen therapy treatment and [CONDITION(S)] services. Review of R#13's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident had a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R#13's care plan dated 3/24/22 revealed a problem category of [CONDITION(S)] due to the resident having a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The goal was for R#13 to have adequate fluid volume balance as evidenced by good skin turgor, pink and moist mucous membranes, and sufficient fluid intake. Approaches developed included: 1) Communicate with [CONDITION(S)] center regarding medication, diet, and lab results. Coordinate resident's care in collaboration with [CONDITION(S)] center. 2) Make transportation arrangements for [CONDITION(S)]. R#13 also had a care plan of risk of complications with respiratory status related to congestive heart failure (CHF), shortness of breath (SOB), and history of COVID-19. The goal was for R#13 to exhibit no symptoms of [CONDITION(S)] through the next review date. Approaches developed included: 1) Administer oxygen as ordered, observe oxygen precautions. 2) Medications/Nebs (nebulizer treatments) as ordered. Review of Progress Notes for R#13 revealed on 5/6/22 at 11:20 a.m. a Registered Dietician (RD) documented a monthly nutrition progress note for the resident. There was no further documentation on 5/6/22 in the Progress Notes. On 5/7/22 at 12:07 p.m. a Licensed Practical Nurse (LPN) documented The Resident returned from the hospital at around 10:00 a.m. He came in via ambulance on stretcher with two EMTs (Emergency Medical Technicians). No new orders. Vital signs are within his normal range. MD and family were made aware. The next documented Progress Note, made by nursing on 5/11/22 at 8:19 a.m. stated Resident refused to go for [CONDITION(S)] this morning. Doctor was notified as per doctor order a blood draw for BMP (Basic Metabolic Panel) tonight, Monitor the Resident and make sure his [sic] going for [CONDITION(S)] on Friday morning. Family was notified too. Review of a Facility Incident Report dated 5/7/22 revealed the type of incident was (the transport company) left resident (R#13) at [CONDITION(S)]. Details of the incident stated (The transport company) went to pick up resident from [CONDITION(S)]. He wasn't finished so they left and did not return. Patient was sent by [CONDITION(S)] to ER (emergency room ). The report specified the resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's physician and responsible party were notified. The incident report indicated the police was not notified and no other agencies were involved. The report specified steps taken by the facility to prevent further incidents included an investigation was initiated. Review of an investigative report dated 5/13/22 revealed the transportation company arrived at the [CONDITION(S)] center on 5/6/22 at around 7:00 p.m. to pick up R#13. The resident's [CONDITION(S)] service was not completed, and the transportation company left. R#13 completed [CONDITION(S)] service around 9:00 p.m. but the transportation company did not return to pick up the resident. The [CONDITION(S)] service sent R#13 to the ER around 10:00 p.m. to 10:30 p.m. because they couldn't reach the transport company and said they reached out to the facility. R#13 stayed at the ER until the following morning and returned to the facility. The investigation report specified The (Responsible Party) felt he was neglected because he hadn't eaten, and he is diabetic. The facility's investigation included The charge nurse at our facility stated that she called [CONDITION(S)] at around (9:00 p.m.) when he (R#13) had not returned with no answer. She also called the hospital and they said he was not there. She reached someone at [CONDITION(S)], and they said he went to the hospital with a low blood sugar. Hospital notes reflect that he was taken due to transport not arriving to pick him up. R#13 was observed on 9/15/22 at 11:35 a.m. to be seated on the side of the bed. R#13 stated he remembered very clearly the incident when he was left at the [CONDITION(S)] center without transportation back to the facility. R#13 stated at the time his chair time at the [CONDITION(S)] center started at 2:30 p.m. The [CONDITION(S)] center was running behind and he got into the chair later than scheduled. The transportation company arrived to pick R#13 up but his [CONDITION(S)] was not finished, so they left. R#13 stated he believed he got finished between 4:30 p.m. and 5:00 p.m. and there was no one there to transport him back to the facility. The [CONDITION(S)] center staff tried to call the facility but could get no answer. The [CONDITION(S)] center closed at 7:00 p.m. and staff called emergency services. R#13 stated the police and the fire department arrived at the [CONDITION(S)] center. According to the resident, the police and fire department tried to call the facility, but no one answered the phone. R#13 stated the police told him they would have to call an ambulance to transport him because he had an oxygen tank, and they could not transport him in a car because of the oxygen tank. R#13 stated the police called an ambulance and he was transported to the hospital at approximately 10:30 p.m. R#13 stated he was left on a gurney in the hallway at the hospital until 9:00 a.m. the next morning. R#13 stated he felt very anxious and thought he was having a panic attack at times during the night, but he had a cell phone and his Responsible Party (RP) kept in contact with him throughout the night. R#13 stated both he and his RP felt helpless. R#13 stated the incident had traumatized him and he was afraid to go back to [CONDITION(S)] because he was afraid, he wouldn't have a way to get back to the facility. He stated he was so afraid that he had refused to go back to [CONDITION(S)] after the incident. R#13 stated he told the facility staff he would not go back to [CONDITION(S)] until his [CONDITION(S)] chair time was changed from 2:30 p.m. back to 11:30 a.m. The change occurred and R#13 stated he now leaves for [CONDITION(S)] at 10:30 a.m. When questioned regarding if the facility staff had visited with him after the incident to allow him to talk about the incident and offer help or support, R#13 stated no one had visited. R#13 stated he didn't think the facility cared about how upset he was after the incident. An interview was conducted on 9/15/22 at 3:07 p.m. with Registered Nurse, Supervisor (RN) JJ who was working on 5/6/22 when R#13 was stranded at the [CONDITION(S)] center. RN JJ stated she realized at 6:00 p.m. that R#13 had not returned to the facility. RN JJ stated she tried to call the [CONDITION(S)] center twice, after 6:00 p.m. but got no answer. RN JJ then called the transportation service that was supposed to return R#13 to the facility, getting no answer. However, after several attempts a female answered the phone and reported she did not know what had happened regarding transportation for the resident. RN JJ stated she asked if someone could go pick the resident up and was told there were no drivers available. RN JJ stated she did not know where the resident was and had called area hospitals to find him but was told he had not been admitted . RN JJ stated R#13's RP had called, sometime around 10:00 p.m. and reported the resident was in the hospital because transportation had not picked him up. RN JJ stated she told the RP she had tried to get R#13 home, without success. RN JJ stated she had not called the Director of Nursing (DON) or Administrator to report that R#13 was missing. An interview was conducted on 9/15/22 at 1:10 p.m. with the Administrator. The Administrator stated the facility conducted an investigation regarding the 5/6/22 incident of R#13 being left at the [CONDITION(S)] center without transportation back to the facility. The facility determined no neglect had occurred. When questioned regarding R#13 reporting the incident traumatized him the Administrator stated the resident had not reported this to staff. An interview was conducted on 9/15/22 at 11:02 a.m. with the Social Services Director (SSD). The SSD stated she remembered hearing about an incident when R#13 had been left at the [CONDITION(S)] center and later transported to the hospital. The SSD stated she had not followed up with the resident after the incident to determine if he had been negatively affected. The SSD stated the nursing staff had not reported the resident was upset following the incident. An interview was conducted on 9/17/22 at 2:15 p.m. with R#13's RP. The RP stated he received a call from R#13 on 5/6/22 who reported he was stranded at the [CONDITION(S)] center. R#13 sounded very upset. R#13 reported his [CONDITION(S)] session ran late and the transportation company had left without transporting him back to the facility. The RP stated he spoke with someone from the [CONDITION(S)] center who reported they had tried to call the facility but could not get an answer. The RP was told the police and fire department were at the [CONDITION(S)] center and had also tried to call the facility but had received no answer. R#13's RP stated he tried to call the facility around eight (8) or nine (9) times, throughout the night, but no one would answer. R#13's RP stated no one from the facility called him to report the resident had not returned to the facility. The RP stated R#13 was transported to the hospital because no one from the facility would answer the phone. The RP stated R#13 called him after arriving at the hospital and reported he was on a gurney in the hallway of the hospital. R#13 reported he thought he was having a panic attack. The RP stated he kept trying to calm the resident down. R#13 reported he had not eaten and thought his sugar was low. The RP stated he spoke to a nurse at the hospital and asked them to give the resident something to eat. The RP stated he finally reached the nurse, (RN JJ) by phone on 5/7/22 at approximately 10:00 a.m. RN JJ stated they had been looking for R#13 all night and were worried he wasn't okay. The RP told RN JJ that R#13 was at the hospital because he had been abandoned at the [CONDITION(S)] center. RN JJ told the RP she had called the local hospitals but couldn't find the resident. RN JJ told the RP she had tried to call him but didn't get an answer. R#13's RP stated this was not a true statement. He had been up all night worried about R#13 and had continued to try to call the facility with no answer. R#13's RP stated he was given the Administrator's cell phone number and called him the next Monday morning (5/9/22) to discuss the situation. The Administrator reported to the RP he had received several complaints from the [CONDITION(S)] center, police, and fire department regarding the incident. The Administrator assured him the facility was putting a system in place to prevent the incident from occurring again. The RP stated however, R#13 went for [CONDITION(S)] on 5/9/22 at the incident happened a second time. The RP stated the [CONDITION(S)] center called him to report the transportation company had again failed to show up to pick up the resident. R#13's RP stated he immediately called the Administrator who stated he would take care of it. The Administrator managed to find an alternate transportation company to pick up R#13 and return him to the facility. R#13 had been stranded at the [CONDITION(S)] center for two to three hours during this incident. The next time R#13 was scheduled to go out to [CONDITION(S)], he refused to go out of fear he would not be able to get back to the facility. The resident reported to the RP he had told the facility he would not return to [CONDITION(S)] until his time in the [CONDITION(S)] chair was changed from 2:30 p.m. back to 11:30 a.m. R#13's RP stated the resident told him if he received [CONDITION(S)] service at the earlier time there would be a receptionist available at the facility to answer the phone and inform someone to help in getting him an alternate transport company. The RP stated the facility had worked with the [CONDITION(S)] center to change R#13's time in the chair to 11:30 a.m. and the resident had returned to [CONDITION(S)] services. An interview was conducted on 9/17/22 at 1:25 p.m. with the fire department dispatcher that responded when R#13 was stranded on 5/6/22 at the [CONDITION(S)] center. The dispatcher received updated reports from the fire department crew who responded to the call from the [CONDITION(S)]. The dispatcher read from the report that the [CONDITION(S)] center had called emergency services and the paramedic crew had responded. The dispatcher stated the documentation reflected that (R#13) presented with no symptoms, was on oxygen, however the oxygen tank was empty. The fire department paramedic crew provided R#13 with oxygen while waiting for transportation services to arrive; the police department had also responded, and numerous calls were made to the facility where R#13 resided but no one answered the phones; the report indicated the engine crew received and responded to the call at 8:45 p.m. and cleared the scene at 9:58 p.m.; R#13 had no complaints except he wanted to get back to the facility. The dispatcher stated the report did not specify the engine crew had tried to contact the facility, but he felt they would have tried to call since the resident was stable with no symptoms and just wanted to get back to the facility.

Based on observation, interview, and record review the facility failed to ensure services were provided in accordance with professional standards of practice one of 11 residents (R) (R#13) who received [CONDITION(S)] services related to R#13 being stranded without transportation. The facility failed to respond and assist when R#13 went out of the facility for [CONDITION(S)] treatment and had no means of transportation back to the facility. The facility's lack of response resulted in R#13 being transported to the hospital, where he remained on a gurney in a hallway, overnight. Findings include: R#13 was admitted to the facility on [DATE]. The resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of a Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed R#13 had a Brief Interview for Mental Status (BIMS) score of 15, indicating independence in cognitive skills for daily decision making. The resident was assessed to receive oxygen therapy treatment and [CONDITION(S)] services. Review of R#13's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R#13's care plan dated 3/24/22 revealed a problem category of [CONDITION(S)] due to the resident having a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The goal was for R#13 to have adequate fluid volume balance. Approaches developed included: 1) Communicate with [CONDITION(S)] center regarding medication, diet, and lab results. Coordinate resident's care in collaboration with [CONDITION(S)] center. 2) Make transportation arrangements for [CONDITION(S)]. Review of a Facility Incident Report dated 5/7/22 revealed the type of incident was the transport company left R#13 at [CONDITION(S)]. Details of the incident stated (The transport company) went to pick up resident from [CONDITION(S)]. He wasn't finished so they left and did not return. (R#13) was sent by [CONDITION(S)] to ER (emergency room ). Review of an investigative report dated 5/13/22 revealed the transportation company arrived at the [CONDITION(S)] center on 5/6/22 at around 7:00 p.m. to pick up R#13. The resident's [CONDITION(S)] treatment was not completed, and the transportation company left. R#13 completed [CONDITION(S)] service around 9:00 p.m. but the transportation company did not return to pick up the resident. The [CONDITION(S)] service sent R#13 to the ER around 10:00 p.m. to 10:30 p.m. because they couldn't reach the transport company and said they reached out to the facility. R#13 stayed at the ER until the following morning and returned to the facility. The investigation report specified The (Responsible Party) felt he was neglected because he hadn't eaten, and he is diabetic. Review of a written statement documented by the Licensed Practical Nurse (LPN) NN who was the Unit Charge Nurse where R#13 resided revealed LPN NN worked the 7:00 p.m. to 7:00 a.m. shift. LPN NN documented at the beginning of the shift she realized R#13 was not in his room. LPN NN documented being aware the resident had a scheduled [CONDITION(S)] appointment that afternoon. The LPN stated R#13 had previously told her they had changed his hours for going to [CONDITION(S)] and he did not like the new hours. LPN NN noted that at 9:00 p.m. during medication pass she realized R#13 was still not in the building or facility. At 11:00 p.m. LPN NN called the [CONDITION(S)] center but got no answer. LPN NN then called the transportation company but got no answer. LPN NN called two (2) local hospitals but was informed R#13 had not been admitted at either facility. LPN NN stated she called the on-call nurse and was told R#13 had been admitted to the hospital because his sugar level was low. The phone on East Wing rang at 7:30 a.m. and when the nurse answered the phone, she heard R#13's voice on the phone. The nurse asked the resident where he was at. The resident stated he was at the hospital. LPN NN asked R#13 how he got there, and the resident replied, the police took me to the hospital because the transportation did not come to get me. LPN NN noted she could not notify the family ahead of time because I didn't know what to tell them. R#13 was observed on 9/15/22 at 11:35 a.m. to be seated on the side of the bed. R#13 stated he remembered very clearly the incident when he was left at the [CONDITION(S)] center without transportation back to the facility. The resident stated staff at the [CONDITION(S)] center tried to call the facility to get assistance with arranging transportation, but the facility staff did not answer the phone. When the facility didn't respond to calls, the [CONDITION(S)] center staff called emergency services. R#13 stated the police and fire department responded to the [CONDITION(S)] center. According to the resident, both the police and fire department personnel tried numerous times to call the facility, but no one would answer the calls. R#13 stated the police called an ambulance service and he was transported to the hospital at approximately 10:30 p.m. He reported the ambulance service personnel told him they could not take him back to the facility because it was out of their jurisdiction. An interview was conducted on 9/15/22 at 3:07 p.m. with Registered Nurse, Supervisor (RN) JJ who was working on 5/6/22 when R#13 was stranded at the [CONDITION(S)] center. RN JJ stated she realized at 6:00 p.m. that R#13 had not returned to the facility. RN JJ stated she tried to call the [CONDITION(S)] center twice, after 6:00 p.m. but got no answer. RN JJ did not know where R#13 was and tried to call the [CONDITION(S)] center but got no answer. RN JJ denied notifying the Director of Nursing (DON) or Administrator that R#13 had not returned from the [CONDITION(S)] center. An interview was conducted on 9/17/22 at 2:15 p.m. with R#13's RP. The RP stated he received a call from R#13 on 5/6/22 who reported he was stranded at the [CONDITION(S)] center. R#13 sounded very upset. R#13 reported his [CONDITION(S)] session ran late and the transportation company had left without transporting him back to the facility. The RP stated he spoke with someone from the [CONDITION(S)] center who reported they had tried to call the facility but could not get an answer. The RP was told the police and fire department were at the [CONDITION(S)] center and had also tried to call the facility but had received no answer. R#13's RP stated he tried to call the facility around eight or nine times, throughout the night, but no one would answer. R#13's RP stated no one from the facility called him to report the resident had not returned to the facility. The RP stated R#13 went for [CONDITION(S)] on 5/9/22 and was left without transportation a second time. The RP stated the [CONDITION(S)] center called him to report the transportation company had again failed to show up to pick up the resident. R#13's RP stated he immediately called the Administrator who stated he would take care of it. The Administrator managed to find an alternate transportation company to pick up R#13 and return him to the facility. R#13 had been stranded at the [CONDITION(S)] center for two to three hours during this incident. The next time R#13 was scheduled to go out to [CONDITION(S)], he refused to go out of fear he would not be able to get back to the facility. An interview was conducted on 9/17/22 at 1:25 p.m. with the dispatcher who worked with the fire department that responded when R#13 was stranded on 5/6/22 at the [CONDITION(S)] center. They stated the police department had also responded and numerous calls were made to the facility where R#13 resided but no one answered the phones. They stated (R#13) presented with no symptoms, was on oxygen, however the oxygen tank was empty and that the fire department paramedic crew provided the resident with oxygen while waiting for transportation services to arrive. R#13 had no complaints with the exception of saying he wanted to go back to the facility.

Based on interview, record review, and policy review, the facility failed to implement a comprehensive person-centered care plan for falls for one resident (R#4). Failure to follow the care plan contributed to the resident sustaining harm. The sample size was 44 residents. Findings include: Record review of the policy and procedure titled Comprehensive Care Plans dated 9/21/16 revealed a person-centered comprehensive care plan meets the resident's medical, nursing, mental needs. The care plan will include how the facility will assist the resident to meet their needs, goals, and preferences. Review of the Fall Risk Evaluation dated 8/24/18 revealed the facility had assessed the resident as a 13 which indicated the resident was at risk for falls. Review of the Significant Change in Status Minimum Data Set (MDS) signed and dated 8/7/18 revealed the facility admitted R#4 with [DIAGNOSES REDACTED]. Continued review of the MDS revealed the resident to sometimes make self-understood and usually understands others, moderately impaired vision, short-term and long-term memory problems. The facility assessed the resident not to have displayed behaviors. Continued review of the MDS revealed R#4 required extensive assistance of two staff with bed mobility and personal hygiene, extensive assistance of one staff for dressing, toilet use, and was totally dependent on one staff for bathing. The resident was always incontinent of bowel and bladder. Review of the Care Area Assessment (CAA) Summary revealed the resident had triggered for falls. Review of R#4's care plan dated 8/7/18 revealed, Problem- resident is at risk for fall as he is dependent on staff for all are related to impaired mobility, [MEDICAL CONDITION], feeding tube and dementia. Goal- Resident will not sustain a fall or fall related injury through next review date. Approach- Staff to provide assistance to meet resident's needs for all activities of daily living. Review of the Fall-Fall with Injury-Major Investigation dated 9/24/18 at 10:50 a.m. stated, Certified Nursing Assistant OO (CNA) was giving R#4 a bed bath, turned away to the closet to retrieve clothes and towels from the chair when the CNA heard the resident scream, patient noted lying on his right side on the floor beside the resident's bed. Small amount of bright red blood noted draining from the resident's right forehead, hematoma noted. Continued review of the fall investigation revealed the resident was not able to state what had happened and continued to moan out in pain. Interview on 1/31/18 8:45 a.m. with CNA MM on the 100 Hallway revealed she was R#4's caregiver for the day. She stated she was familiar with the resident's care needs. She stated the correct way to give the resident, or any resident a bed bath would be to first gather all needed supplies then raise the bed to waist level. She stated she was aware R#4 was a fall risk and could roll out of the bed an injure himself/herself if he was not supervised during bath time. She stated she learned how to give a bed bath and prevent falls in CNA school and various in-services presented at the facility. She stated she received report from the nurses and the off going CNA on how to care for each resident during shift report and did walking rounds with the off going CNA. Interview on 1/31/18 at 2:40 p.m. with MDS Director revealed it was common sense for a staff member not to turn away from a resident while the bed is elevated. A care plan is individualized to provide specific care to each resident. He stated following the care plan is an expectation not an option.

Based on interviews, record review and policy review, the facility failed to ensure each resident received adequate supervision to prevent accidents. Harm was identified when one Resident (R), #4, sustained a [MEDICAL CONDITION] which required sutures after they fell out of the bed during a bath, unsupervised by staff. The sample size was 44 residents. Review of the policy titled, Fall Prevention dated 6/1/15 revealed it was the intent of the facility to provide residents with assistance and supervision to minimize the risk of falls and fall related injuries. Review of the Fall Risk Evaluation dated 8/24/18 revealed the facility had assessed the resident as a 13 which indicated the resident was at risk for falls. Review of the Significant Change in Status Minimum Data Set (MDS) signed and dated 8/7/18 revealed the facility admitted R#4 with [DIAGNOSES REDACTED]. Continued review of the MDS revealed the resident to sometimes make self-understood and usually understands others, moderately impaired vision, short-term and long-term memory problems. The facility assessed the resident not to have displayed behaviors. Continued review of the MDS revealed R#4 required extensive assistance of two staff with bed mobility and personal hygiene, extensive assistance of one staff for dressing, toilet use, and was totally dependent on one staff for bathing. The resident was always incontinent of bowel and bladder. Review of the Care Area Assessment (CAA) Summary revealed the resident had triggered for falls. Review of the Fall-Fall with Injury-Major Investigation dated 9/24/18 at 10:50 a.m. stated, Certified Nursing Assistant (CNA) OO was giving R#4 a bed bath, turned away to the closet to retrieve clothes and towels from the chair when the CNA heard the resident scream, patient noted lying on his right side on the floor beside the resident's bed. Small amount of bright red blood noted draining from the resident's right forehead, hematoma noted. Continued review of the fall investigation revealed the resident was not able to state what had happened and continued to moan out in pain. Review of CNA OO statement dated 9/24/18 stated, As I turned around to retrieve resident's clothes from the closet, I heard him/her scream. R#4 was lying on the floor on his/her right side. Right forehead was bleeding and a hematoma was noted. Review of the Infection Control Nurse LL statement dated and signed 9/24/18 at 11:45 a.m. revealed .Hematoma to right temporal frontal aspect of skull measuring approximately three inches across with serosanguinous drainage .Emergency Medical Services to bedside at 12:00 p.m. Review of the Emergency Department Notes signed and dated 9/24/18 at 1:08 p.m. by a Registered Nurse (RN) revealed the resident arrived from the facility after staff reported he/she was found on the floor at 11:25 a.m. Patient presented with a laceration and a hematoma to the right anterior forehead. Review of the Emergency Department Provider Notes signed and dated 9/24/18 at 2:36 p.m. by a Physician Assistant (PA) revealed R#4 required six sutures to close a three-centimeter laceration on the forehead. Review of R#4's care plan dated 8/7/18 revealed, Problem- resident is at risk for fall as he is dependent on staff for all are related to impaired mobility, [MEDICAL CONDITION], feeding tube and dementia. Goal- Resident will not sustain a fall or fall related injury through next review date. Approach- Staff to provide assistance to meet resident's needs for all activities of daily living. Telephone interview on 1/31/18 at 10:30 a.m. with CNA OO revealed she was with R#4 to provide direct care on 9/24/18. She stated she did not feel she did anything wrong when she turned her back on the resident or left the bed elevated to waist level. She stated she did not see R#4 fall out of the bed, however, when she turned around from the closet and faced the resident, the resident was on the floor. She stated she did have the bed raised to her waist, and it might have been a good idea to put the bed in the lowest position prior to turning her back on him. She stated she did not see an injury to the resident at that time. Interview on 1/30/19 at 12:40 p.m. with CNA JJ revealed anytime care was provided to a resident in the bed you should first gather all needed supplies, then raise the bed to your waist level. She stated if you had to leave the resident unattended the bed should be put back down to the lowest position. She stated you should never turn your back on a resident when providing care as the resident could fall out of the bed and sustain an injury. The CNA stated she had learned this in CNA school, and it was important to know. Interview on 1/31/18 8:45 a.m. with CNA MM revealed she was R#4's caregiver for the day. She stated she was familiar with the resident's care needs. She stated the correct way to give the resident, or any resident a bed bath would be to first gather all needed supplies then raise the bed to waist level. She stated she was aware R#4 was a fall risk and could roll out of the bed an injure himself/herself if he was not supervised during bath time. She stated she learned how to give a bed bath and prevent falls in CNA school and various in-services presented at the facility. Interview with Licensed Practical Nurse (LPN) HH on 1/30/19 at 12:35 p.m. revealed to give safe care during a bed bath you should gather all your supplies first, raise the resident's bed up to waist level, and never turn your back on the resident. She stated your eyes should remain on the resident throughout the delivered care or else the resident could roll out of the bed and sustain an injury. Interview on 1/31/19 at 8:35 a.m. with the Infection Control Nurse revealed as he was doing his infection control rounds on 9/24/18 he saw the nurses putting R#4 back into the bed from the floor. He stated the resident had a large hematoma on the forehead. He revealed in the monthly clinical meetings, the facility required the clinical staff to attend because it was an opportunity to discuss clinical expectations. He went onto state it was an expectation staff have all their supplies prior to starting a resident bath and focus only on the resident during the task. He revealed R#4's fall with contusion could have been avoided. Interview with the Unit Manager of the 200 Hallway on 1/30/19 at 11:14 a.m. in the Administrator's Office revealed during the investigation it was determined CNA OO raised R#4's bed up to give a bed bath. The CNA then turned away from the resident and did not reposition the bed to the lowest level and the resident fell out of the bed onto the floor. She stated the CNA should not have turned away from the resident. Interview with the Director of Nursing Services (DNS) on 1/31/19 at 4:00 p.m. revealed it was everyone's job and a facility goal to keep the resident's safe. She stated prior to this incident, the facility had offered education on safe care and how to prevent falls. The DNS stated the CNA should not have turned away from the resident to gather supplies. Interview with the Administrator on 1/31/19 at 3:00 p.m. revealed she expected staff to do all they can do to protect the residents. She revealed the CNA had made an error when she delivered care to R#4. She stated she was ultimately in charge of the facility and maintaining resident safety was the responsibility of the entire staff. Record review revealed the facility had provided staff education regarding activities of daily living care (ADL) as well as fall prevention monthly.