Every finding on record at Valley Center

Based on observation and staff interview, the facility failed to store and dispose of garbage and refuse properly. One (1) of the three (3) dumpsters located outside of the facility had one sliding door that was open. During two different observations of the kitchen during the survey process, the lid for the trash can located in the dining room was not on, and was sitting on the floor. This was a random opportunity for discovery that has the potential to affect every resident at the facility. Facility census: 122.Findings include: a) Healthcare Services Group policy #30 titled Dispose of Garbage and Refuse states: All garbage and refuse will be collected and disposed of in a safe and efficient manner.The Dining Services Director coordinates with the Director of Maintenance to ensure that the area surrounding the exterior dumpster area is maintained in a manner free of rubbish or other debris.Appropriate lids are provided for all containers.b) 04/01/2026 at 12:19 PM This surveyor noticed that one of the garbage dumpsters located outside of the dining room had one of the doors opened without any employee around. The Director of Nursing verified these findings at 12:23 PM and said I will have someone go outside, and close the door. I notified the Healthcare Services Group (HCSG) District Manager (DM) at 12:25 PM, she verified this finding, and the door to the dumpster was closed at 12:26 PM. c) 04/02/2026 at 10:25 AM This surveyor went to the kitchen to ask for the diet guides for today, and found one (1) trash can with the lid sitting on the floor. The HCSG DM came to see what I needed, and she immediately put the trash can lid on, and I let her know that both of the trash cans outside of the dish room are soiled and need to be cleaned. She said I will take care of this. I asked her if she has a cleaning schedule posted, and she stated 'not at this time, it is being revamped.

Based on observation and staff interview, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food safety. Additionally, the facility failed to follow the proper sanitation practices for the kitchen and the food preparation equipment. The facility also failed to ensure that all employees that enter the kitchen have their hair properly restrained. This practice had the potential to affect more than a limited number of residents. Facility census: 122. Findings include: a) Healthcare Services Group (HCSG) policy #28 titled Environment states: All food preparation areas, food service areas, and dining areas will be maintained in a clean and sanitary condition. The Dining Services Director will ensure that the kitchen is maintained in a clean and sanitary manner, including floors, walls, ceilings, lighting, and ventilation. All food contact surfaces will be cleaned and sanitized after each use. The Dining Services Director will ensure that a routine cleaning schedule is in place for all cooking equipment, food storage areas, and surfaces. b) HCSG policy #27 titled Equipment states: All foodservice equipment will be clean, sanitary, and in proper working order. All equipment will be routinely cleaned and maintained in accordance with manufacturer's directions and training materials. All staff will be properly trained in the cleaning and maintenance of all equipment. All food contact equipment will be cleaned and sanitized after each use. All non-food contact equipment will be clean and free of debris. c) Initial walkthrough of the kitchen on 03/31/2026 at 9:06 AM. The Healthcare Services Group (HCSG) District Manager (DM) accompanied this surveyor during, and acknowledged the following findings to be accurate. The facility did not follow the FDA Food Code or their own policies for the following: The can opener was soiled and needed to be cleaned The toaster's crumb tray needed to be cleaned The exhaust hood needed to be cleaned The stove top had food debris and grease build-up The top of the juice machine has dust build-up and needed to be cleaned The ice scoop holder's cover was broken off and needs to be replaced The ice scoop holder was soiled and needed to be cleaned There was black build-up on the dish room wall The walk-in refrigerator temperature was not recorded on 03/30/2026 for the evening shift The south pantry ice scoop holder was soiled The refrigerator in the south pantry needed to be wiped out with sanitizer on the inside The TCU pantry refrigerator needed to be wiped clean with sanitizer on the inside The microwave in the north pantry was soiled and needed to be cleaned The ice scoop holder in the north pantry was soiled and needed to be cleaned d) Dining Observation for lunch on 03/31/2026 at 12:25 PM The North hall beverage cart had multiple tumblers that were wet nesting. Nurse Aide (employee #49) took those off of the cart. The cart was also visibly soiled with food particles and debris. The Office Manager sent the cart back to dietary to be cleaned and asked for it to be sent back, so they could serve the residents beverages for lunch. The office manager and Nurse Aide #49 both agreed that the cart was soiled and the tumblers were wet. 12:28 PM The TCU hall beverage cart had tumblers that were wet nesting. Administrator #150 acknowledged that was an issue and sent those back to the kitchen. 12:30 PM The South hall beverage cart was visibly soiled with food particles and debris. Nurse Aide (employee #61) verified this. 04/01/2026 at 9:35 AM e) HCSG policy #18 titled Food Storage: Dry Goods states: All dry goods will be appropriately stored in accordance with the FDA Food Code. Storage areas will be neat, arranged for easy identification, and date marked as appropriate. HCSG policy #24 titled Staff Attire States: All staff members will have their hair off the shoulders, confined in a hair net or cap, and facial hair properly restrained. f) Follow up visit to the kitchen. A black substance on the dish room wall Two (2) opened loaves of bread not dated One (1) package of hamburger buns not dated Two (2) cleaning clothes not in a bucket with sanitizer The stove top has built up food particles and debris Two unidentified activity employees came into the kitchen without a hairnet on g) 04/02/2026 at 10:25 AM This surveyor went to the kitchen to ask for the diet guides for today, and found one (1) trash can with the lid sitting on the floor. The HCSG DM came to see what I needed, and she immediately put the trash can lid on, and I let her know that both of the trash cans outside of the dish room are soiled and need to be cleaned. She said I will take care of this. I asked her if she has a cleaning schedule posted, and she stated 'not at this time, it is being revamped. h) 04/02/2026 at 12:23 PM During dining observation this surveyor noticed that a popcorn maker located in the south dining room was soiled and not covered. I asked Nurse Aide (employee #7) if the popcorn maker should be cleaned and covered? She stated I know they are hard to clean and it should be covered. i) 04/02/2026 at 12:33 PM During dining observation, the dietary department sent three (3) resident meal trays down the hallway on a soiled black cart. I asked Nurse Aide (employee #88) to verify that the cart was sent out soiled, she stated the cart is soiled and was sent that way. At 12:35 PM the DON approached and verified that the resident meal trays should not have been sent out on a soiled cart and stated that I will clean it now. I also told the DON about the popcorn maker located in the south dining room, and he asked the Environmental Services (EVS) Account Manager (AM) to please take care of it. e) North Pantry/Nourishment Room storage: On 04/07/26 at 4:59 PM, while checking the night snack inventory, in the North Pantry Nourishment room, it was observed a plastic container of fruit was on the top shelf of the refrigerator with the lid partially open, exposing the fruit to air. Staff Interviews: On 04/07/26 at 3:30PM During an Interview with employee #11, she acknowledged the bowl of fruit with the opened lid and reclosed the lid. On 040/7/26 at 4:15PM Interview with the DON he acknowledged the fruit belonged to a resident and had been removed from the refrigerator and was replaced for the resident.

Based on observation and staff interview, the facility failed to maintain an infection control program to prevent communicable diseases during clean linen transport, during catheter care for Resident #29, North and South shower rooms, soiled linen throughout the facility, Resident #9, #42, and #46's wheelchairs as well as the facility wheelchairs and Geri-chairs throughout the facility, and an unclean and unsanitary room for Resident #7. These were random opportunities for discovery. Resident Identifiers: #29, #9, #42, #46, #39, #25 and #7. Facility Census: 122. a) Resident #7 On 03/31/2026 at approximately 2:57 PM, observation of Resident #7's room revealed two full urinals placed on the floor at the bedside. Additionally, a brown-like substance was observed on the floor in multiple locations, including near the bedside commode. The bedside commode was noted to be soiled with a similar brown-like substance, indicating a lack of proper cleaning and sanitation. These findings were observed and confirmed at the time of observation with Nurse #16. b) Resident #9 During an interview with Resident #9 in room [ROOM NUMBER], on 03/31/26 at 10:45 AM, it was observed that both arms were ripped and split down the sides in the plastic cover exposing the inner padding on her wheelchair. c) Resident #42 During entrance interviews and observations on 03/31/26 at approximately 11:45AM, It was observed in room [ROOM NUMBER] that Resident #42's wheelchair had cracks in the back rest with exposed padding. Resident #42 stated the wheelchair was the one the facility gave her to use. h) Resident #46 During an interview with Resident #46 on 03/31/26 at 12:10 PM in room [ROOM NUMBER], a small hole in the middle of the seat on the edge of her wheelchair with exposed padding was observed. Observations on 03/31/26 at 10:00 AM found multiple wheelchairs and Geri-chairs in the halls with holes, tears, and exposed padding: -Geri-chair located outside room [ROOM NUMBER] was observed with a 1/2-inch-long tear towards the back of the right-side arm plastic covering exposing the inner padding. -Geri-chair located in the exit hallway to the courtyard was observed with holes and tears in the top edges of the back rest and the corner edge of the right arm pad had holes in the plastic cover with exposed inner padding. -Observation of a wheelchair in the hall outside Room# 301 found the seat was ripped with exposed padding -Observation of a wheelchair located next to the door leading to the North courtyard, was observed with a 1-inch-long tear in the left seat corner edge exposing the inner padding. In a facility walk through and interview with the director of nursing on 03/31/26 at 10:00 AM, he acknowledged the wheelchairs and Geri-chairs in the facility hallways with rips, and tears exposing the inner padding and stated he would start a list for the Infection Preventionist. During a facility walk through with the Administrator on 04/07/26 at 9:40 AM, She acknowledged the wheelchairs observed in room [ROOM NUMBER]. #301, and #306 with holes and tears exposing the inner padding and would add them to the list for the infection preventionist. Findings Include: On 03/31/26 at 10:45 AM, an observation of the Manager-In-Training (MIT) #144 pushing an uncovered clean linen cart was made. MIT #144 was interviewed at this time. MIT #144 stated, Oh, I didn't know. On 03/31/26 at approximately 12:45 PM, the Director of Nursing (DON) and the Administrator were notified. The Administrator confirmed the clean linen should be covered during transport. On 03/31/26 at approximately 2:15 PM, the facility policy entitled, Linen Handling was reviewed. Under number 3, the policy states, Clean linen shall be delivered to patient care units on covered linen carts with covers down. i) Resident #29 On 04/07/2026 at 10:43 AM, catheter care was observed for Resident #29 which was being completed by Nurse Aide (NA) #57. After catheter care was completed, NA #57 did not remove the soiled gloves or complete hand hygiene. NA #57 pulled up Resident #29's brief and shorts, straightened his shirt, assisted the resident to a seated position on the edge of the bed, assisted with putting the resident's shoes on, transferred the resident to the wheelchair and moved the wheelchair by the handles with the soiled gloves. On 04/07/26 at 10:59 AM, the South Unit Manager was notified and confirmed the soiled gloves and hand hygiene should have been completed prior to assisting the resident after the catheter care was completed. On 04/07/26 at 11:05 AM, the Administrator and the Director of Nursing (DON) were notified and confirmed the soiled gloves and hand hygiene should have been completed after the catheter care was performed. The Administrator stated, we will get her in here and provide education immediately. On 04/07/26 at 11:25 AM, the facility procedure entitled, Catheter: Indwelling urinary-Care of was reviewed. Number 18 and 19 of the procedure states, Remove gloves and any other PPE (personal protective equipment) worn .perform hand hygiene. On 03/31/26 at approximately 10:06 AM, an observation of the North shower room was made. The observation found an open conditioner and body wash bottle lying on the shower room floor open with the contents spilling out on a wet, unclean floor as well as multiple personal items and a soiled washcloth laying on a shower bed. On 03/31/26 at approximately 10:18 PM, the Administrator and Director of Nursing (DON) were invited into the North shower room. Both the Administrator and the DON confirmed the shower room and the shower bed were unclean. The Administrator stated, We will get it cleaned up. On 03/31/26 10:21 PM, an observation of the South shower room was made. The observation found multiple areas of a dried brown substance, two (2) band aids and one (1) bloody bandage as well as a broken top of a shampoo bottle in the floor of the shower. Three (3) soiled wash- cloths were observed on a shelf located in the shower area. On 03/31/26 at 10:25 PM, the DON was invited into the south shower room. The DON stated, let me get this cleaned up. On 03/31/26 at 10:30 PM, an observation revealed a soiled gown on a wheelchair and a soiled blue lift pad on a Geri chair located outside the South unit shower room. On 10/31/26 at 10:32 PM, the DON was notified and removed the soiled items from the wheelchair and the Geri chair. The DON stated, I'll take them to the soiled utility room.

Based on observation, record review and staff interview, the facility failed to ensure a dignified experience with toileting for Resident #3, catheter care for Resident #29 and dining for Resident #17. This was true for three (3) of 39 residents reviewed during the survey process. Resident Identifiers: #3, #29, and #17. Facility Census: 122.Findings Include: a) Resident #3 An initial interview was held with Resident #3 on 03/31/2026 at 11:14 AM. Resident #3 stated, They won't take me to the bathroom .they said if I fall, I'll sue them .if someone will help me I can use the wheelchair and the bars in the bathroom .they tell me to use the brief or bed pan .I cannot have a bowel movement in a brief. One or two of the girls will take me, the rest will not. On 04/02/2026 at 1:30 PM, a lift transfer evaluation dated 01/27/26 indicated the resident was dependent for transfers using the mechanical lift with two (2) staff members. This was the last documented lift transfer evaluation until 04/02/26. The care plan under the focus area of dependent for ADL (activities of daily living) care, a review found two (2) interventions regarding toileting. The first intervention states, (Name of Resident) is dependent on staff for toileting, lower body dressing and transfers; and, mechanical lift for transfer x2 dependent. (Typed as written.) However, a review from 03/03/26 through 04/02/26 under the tasks tab for toileting found the resident was assisted to the toilet via wheelchair on 10 occasions with staff assistance x 1 (one) and the mechanical lift was not used. After Surveyor intervention, the Director of Nursing (DON) did a lift transfer assessment on 04/02/26 at 1:34 PM. Upon completion of the assessment, the resident was changed from a mechanical lift for transfers to a gait belt. The DON stated, She is a dialysis patient, maybe therapy felt she was too inconsistent to make her a gait belt. An additional interview was held with the resident on 04/02/26 at 1:40 PM. The interview was asking the resident to explain how the staff transferred her when not using the mechanical lift. The resident stated, they put the wheelchair beside the bed, they assist me to stand, then I stand and pivot and get in the wheelchair. Then they take me to the bathroom, and I use the bars to stand. The staff member pulls my pants down and helps me to sit down. Once I am finished, I stand back up using the bars, then the staff cleans me, pull my pants up and I get back in the wheelchair. I was able to do this when I was still in the hospital. Some of the people tell me I cannot get up to go to the bathroom, they say if I fall, I can sue them. I don't know why they haven't let me use the bathroom .I have been using the bathroom for many years .I can fall out of bed or wherever, I could sue them if I fall. I'm not someone who sues people. I just want to use the bathroom .I am unable to have a bowel movement in the brief or when I use the bedpan .my stomach really hurts when I need to go and I can't go to the bathroom. The man (DON) was just here and said I really did good when I showed him, I was able to do it (transfer with the gait belt). On 04/02/26 at 1:50 PM, the DON stated, I've updated the care plan, and put in a request for physical therapy to address toileting tasks and request to use the commode. On 04/02/26 at approximately 2:20 PM, an interview was held with the Administrator. The Administrator confirmed the issue with the transfer status for Resident #3. The Administrator stated, I understand this is an issue .we are doing a facility-wide audit for transfers. An interview was held with the Director of Rehabilitation Services (DORS) on 04/02/26 at approximately 3:00 PM. The DORS stated, we communicated with the floor in February 2026 to change the resident to a gait belt. b) Resident #29 On 04/07/2026 at 10:43 AM, catheter care was observed for Resident #29 which was being completed by Nurse Aide (NA) #57. NA #57 did not pull the privacy curtain before the care was provided. The resident's bed is closest to the bedroom door. On 04/07/26 at 10:59 AM, the South Unit Manager was notified and confirmed the privacy curtain should have been closed. On 04/07/26 at 11:05 AM, the Administrator and the Director of Nursing (DON) were notified and confirmed the privacy curtain should have been closed prior to the catheter care. The Administrator stated, We will get her in here and provide education immediately. On 04/07/26 at 11:25 AM, the facility procedure entitled, Catheter: Indwelling urinary-Care of was reviewed. Number 4 of the procedure states, Explain procedure and provide privacy. c) Resident #17 A policy titled Resident Rights Under Federal Law, states the purpose of the policy is to treat each resident with respect and dignity, and care for each resident in a manner and in an environment that promotes maintenance or enhancement of their self-esteem and self-worth. Resident #17 was served his lunch tray on 04/02/26 at 12:47 PM in his room. The nurse aide was observed by State Surveyor setting the tray on the end of the bed next to the bedside commode and leaving the resident's room. Upon entering the room, the State Surveyor observed the bedside commode had the lid open and had bloody stool in the bucket. An interview with Administrator at 12:55 PM confirmed the bedside commode should have been emptied before lunch or the lid closed while Resident #17 was eating to promote the resident's dignity.

Based on record review and staff interviews, the facility failed to ensure Resident #81, Resident #49, and Resident #51's medical power of attorney (MPOA) were contacted in a timely manner when these residents experienced a change in their condition. This was true for three (3) of three (3) residents sampled for notification of changes during the Long-Term Care Survey Process. Census: 122 Resident identifier: #81, #49, #51c) Resident #51 On 04/02/26 at 9:00 AM, an investigation into a complaint was completed. The record review for Resident #51 found a change of condition dated 03/24/26. The resident did not have medical decision-making capacity. However, upon further review the resident was notified, but the Health Care Surrogate (HCS) was not. The resident was noted with worsening lower back pain. On 04/02/26 at 9:05 AM, the Administrator was notified that the HCS was not notified of the change in condition. The Administrator confirmed the HCS should have been notified. Findings include: A policy titled Change in Condition: Notification of, states a Center must immediately inform the patient, consult with the patient's physician, and notify, consistent with their authority, the patient's representative, where there is an accident involving the patient which results in injury and has the potential for requiring physician intervention; and a significant change in the patient's physical, mental, or psychosocial status (that is, a deterioration in health, mental or psychosocial status in either life-threatening conditions or clinical complications. A) Resident #81 Resident #81 has a Change in Condition form regarding a fall dated 03/23/26 that shows the facility attempted to contact Resident #81's Medical Power of Attorney (MPOA) without success. Resident #81 has a MPOA and an alternate MPOA listed on his profile to contact in case of an emergency. An interview with Director of Nursing (DON) at 4:50PM on 04/07/26 confirmed the facility did not attempt to contact the alternate MPOA/emergency contact regarding the resident's fall on 03/23/26. B1) 11/27/25 In a note dated 11/27/25 at 3:49PM, a change in condition was reported with behavioral symptoms. The same note reads, nurse obtains urine specimen via straight cath resident tolerates well. The Power of Attorney (POA) was notified per the documentation on the change of condition form at 4:00PM. Resident #49's son stated in an interview on 03/31/26 at 9:20AM that he had been at the facility the morning of 11/27/25 and no one said anything about this procedure. He stated he did not become aware of this until it had already been completed. An interview with Director of Nursing at 4:37PM on 04/01/26 confirmed that Resident #49's POA was notified of procedure after it had been done according to documentation. B2) 12/18/26 Resident #49 had a fall on 12/18/25 with an incident report dated 12/18/25 at 9:15PM. According to the Change in Condition form, the physician was notified at 10:03PM, but the resident's Power of Attorney (POA) was notified on 12/19/25 at 9:44AM. An interview with Director of Nursing (DON) at 4:37PM on 04/01/26 confirmed Resident #49's POA was not notified in a timely manner according to documentation.

Based on observation and staff interview, the facility failed to provide a safe, clean, comfortable, and homelike environment for 17 of 71 resident rooms observed during the long-term care survey process. Rooms 119, 120, 121, 124, 125, 126, 201, 204, 205, 206, 207, 209, 210, 212, 213, and 305. Facility Census: 122.Findings include: Genesis Policy titled OPS200 Safe and Homelike Environment states: The resident has the right to a safe, clean, comfortable, and homelike environment that de-emphasizes the institutional character of the setting. 03/31/2026 at 10:30 AM a) room [ROOM NUMBER] - (Resident #74) has wall damaged near the bathroom sink. b) room [ROOM NUMBER] - (Resident #60) has three areas on the wall and the ceiling that are were damaged. c) room [ROOM NUMBER] - (Resident #72) the wallpaper near the tv has a large piece ripped off. There was one area on the bathroom ceiling and one on the bathroom wall that needed to be painted. The windowsill was dusty and the top of the wardrobe was dusty. d) room [ROOM NUMBER] - (Resident #16) has a large area of wall damage across from the bathroom that needs to be painted. 04/06/2026 at 2:30 PM On 04/06/26 at 2:30 PM Administrator #148 accompanied this surveyor to the rooms listed above and acknowledged the damage and stated I will have maintenance paint those areas today. I will have housekeeping clean room [ROOM NUMBER] today. She gave this surveyor a list of facility repairs needed, that were identified in August 2025. She also stated the facility is waiting on a quote from a company named Groundworks to complete some of the repairs. e) room [ROOM NUMBER] Resident #135 and #46 shared a bathroom The following was observed in this shared bathroom: -unfinished drywall patches above the sink around the wall -unfinished drywall patches around the wall to the right of the toilet, -loose and missing areas of caulking around the sink/wall -plastic sink pipe covering came off and laying under the sink. -Peeling paint above the sink on the right wall During an interview with Registered Nurse #46 on 03/31/26 at 3:30 PM, she acknowledged the plastic pipes, unfinished drywall patches, loose caulking and peeling paint around the sink and stated, I don't know much about that, but I'll report it to get maintenance down here for repairs. During an interview with the DON 03/31/26 4:00 pm he stated he was made aware of the issues in room [ROOM NUMBER]. In a facility walk through on 04/08/26 at 9:15 AM with the Administrator the Administrator acknowledged the dry wall, sink caulking, and pipe wasn't completely repaired yet, stated she would make sure the repairs were reported to the maintenance department immediately. On 03/31/26, a tour of the Transitional Care Unit (TCU) was completed with the Director of Nursing (DON) from 10:41 AM through 11:20 AM. All bathrooms appeared dirty, dingy and dark. All observations of the rooms on the TCU are as follows: f) room [ROOM NUMBER]: sink was leaking on the floor of the bathroom as well as through the wall to the corridor, baseboards in the bathroom were pulling away from the walls, unfinished sheet rock, a black substance at the base of the toilet and two (2) lights were burnt out g) room [ROOM NUMBER]: unfinished sheet rock and a strong urine smell in the bathroom and a black substance at the base of the toilet h) room [ROOM NUMBER]: unfinished sheet rock and a strong urine smell in the bathroom, a black substance at the base of the toilet, commode running constantly i) room [ROOM NUMBER]: unfinished sheet rock as well as an area needing patched in the bathroom, a black substance at the base of the toilet j) room [ROOM NUMBER]: unfinished sheet rock in the bathroom and a black substance at the base of the toilet k) room [ROOM NUMBER]: unfinished sheet rock in the bathroom and a black substance at the base of the toilet l) room [ROOM NUMBER]: unfinished sheet rock as well as an area needing patched in the bathroom, strong urine smell, a black substance at the base of the toilet m) room [ROOM NUMBER]: unfinished sheet rock in the bathroom, toilet paper holder missing and five (5) lights bulbs burnt out n) room [ROOM NUMBER]: unfinished sheet rock in the bathroom and a black substance at the base of the commode o) room [ROOM NUMBER]: unfinished sheet rock in the bathroom, tiles loose and falling from shower wall, sink needs replaced and a black substance at the base of the toilet p) room [ROOM NUMBER]: ceiling needs repaired, unfinished sheet rock in the bathroom, sink needs replaced and a black substance at the base of the toilet On 03/31/26 at 11:30 AM, the Administrator was notified of the issues found. The DON confirmed being present during the tour of the TCU and that the findings were correct. The Administrator stated, I will do an audit . On 03/31/26 at approximately 1:45 PM, the Administrator stated, I have completed my audit .we will get started on these issues immediately.

Based on observation, record review, resident interview and staff interview, the facility failed to develop and/or implement the care plan for Resident #3 and #29's transfer status, #7's fall precautions, #31's fractures, #96 and #87's shower preference and #46's gradual dose reduction (GDR) of psychotropic drugs. This was true for seven (7) of 39 residents reviewed during the survey process. Resident Identifiers: #3, #29, #7, #31, #96, #87, and #46. Facility Census: 122. Findings included a) Resident #87 Clinical documentation reviewed on 04/02/2026 at 11:38 AM revealed the resident's care plan specified showers on Tuesdays and Fridays to support the resident's hygiene needs and preferences. However, review of the resident's activities of daily living (ADL) documentation indicated this established care plan was not consistently followed. Instead, the resident routinely received bed baths in place of scheduled showers. Record review documented the resident received bed baths on the following dates: 03/10, 03/11, 03/12, 03/14, 03/15, 03/16, 03/17, 03/18, 03/19, 03/20, 03/21, 03/22, 03/23, 03/24, 03/25, 03/27, 03/28, 03/29, 03/30, 03/31, and 04/01/2026. In contrast, showers were documented only on 03/13, 03/26, 04/02, and 04/03/2026, demonstrating a pattern of deviation from the established care plan schedule. This pattern indicates the resident's individualized care plan for hygiene was not consistently implemented as written. The repeated substitution of bed baths in place of showers reflects a lack of adherence to resident-specific care directives and may impact resident preference, dignity, and overall quality of care. This concern was confirmed with the Director of Nursing (DON) on 04/02/2026 at approximately 12:00 PM, who acknowledged the discrepancy between the care plan and documented care provided. Failure to consistently follow the established care plan has the potential to result in unmet resident preferences and diminished quality of individualized care. b) Resident #46 A record review, completed on 04/06/2026 at 10:00 AM, revealed: -A physician order, dated 03/19/2026, for Olanzapine Oral Tablet Disintegrating 5 MG. Give 1 tablet by mouth at bedtime for antipsychotic. -In a Monthly Medication Regimen Review, completed on 03/20/2026 at 2:32 PM, the consulting pharmacist recommended a Gradual Dose Reduction of Resident #46's Olanzapine. A Gradual Dose Reduction (GDR) refers to the stepwise tapering of a medication dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the dose or medication can be discontinued. -On 03/20/2026, the attending physician agreed to and signed off on the GDR. The new order should have read, Olanzapine 2.5 MG. Give 1 tablet by mouth at bedtime. -Review of the March 2026 Medication Administration Record (MAR) revealed the physician order had never been updated. Resident #46 continued to receive the Olanzapine at the original dose of 5 MG (once per day) on the following dates and times: 03/20/2026 at 7:51 PM 03/21/2026 at 10:41 PM 03/22/2026 at 9:37 PM 03/23/2026 at 10:17 PM 03/24/2026 at 10:03 PM 03/25/2026 at 10:37 PM 03/26/2026 at 8:55 PM 03/27/2026 at 10:08 PM 03/28/2026 at 10:11 PM 03/29/2026 at 9:12 PM 03/30/2026 at 9:01 PM 03/31/2026 at 8:58 PM 04/01/2026 at 9:13 PM 04/02/2026 at 11:22 PM Resident #46 continued to receive the higher dose of Olanzapine from 03/20/26 – 04/02/2026, for a total of 14 days. Upon request, the Director of Nursing (DON) produced a copy of the care plan for Resident #46. The care plan focus stated: Resident is at risk for complications related to the use of antipsychotic drugs. The care plan goal stated: Resident will have the smallest most effective dose without side effects throughout the next review period. The care plan interventions stated: Gradual dose reduction as ordered. During an interview on 04/06/2026 at 12:16 PM, the (DON) was asked why the gradual dose reduction was not completed. The DON stated, I think it got overlooked, that's all I got for you. The Administrator was interviewed on 04/06/2026 at 3:37 PM. The Administrator acknowledged that the attending physician had signed off on a GDR for Resident #46. It was also acknowledged that Resident #46 had received an excessive dose of his/her antipsychotic medication for 14 days. When asked why the GDR was not done, the Administrator stated, I don't know, I feel it just wasn't done. c) Resident #3 An initial interview was held with Resident #3 on 03/31/2026 at 11:14 AM. Resident #3 stated, They won't take me to the bathroom .they said if I fall I'll sue them .if someone will help me I can use the wheelchair and the bars in the bathroom .they tell me to use the brief or bed pan .I cannot have a bowel movement in a brief. One or two of the girls will take me, the rest will not. On 04/02/2026 at 1:30 PM, a lift transfer evaluation dated 01/27/26 indicated the resident was dependent for transfers using the mechanical lift with two (2) staff members. This was the last documented lift transfer evaluation until 04/02/26. The care plan under the focus area of dependent for ADL (activities of daily living) care, a review found two (2) interventions regarding toileting. The first intervention states, (Name of Resident) is dependent on staff for toileting, lower body dressing and transfers; and, mechanical lift for transfer x2 dependent. (Typed as written.) However, a review from 03/03/26 through 04/02/26 under the tasks tab for toileting found the resident was assisted to the toilet via wheelchair on 10 occasions with staff assistance x 1 (one) and the mechanical lift was not used. After Surveyor intervention, the Director of Nursing (DON) did a lift transfer assessment on 04/02/26 at 1:34 PM. Upon completion of the assessment, the resident was changed from a mechanical lift for transfers to a gait belt. The DON stated, she is a dialysis patient, may be therapy felt she was too inconsistent to make her a gait belt. An additional interview was held with the resident on 04/02/26 at 1:40 PM. The interview was asking the resident to explain how the staff transferred her when not using the mechanical lift. The resident stated, they put the wheelchair beside the bed, they assist me to stand, then I stand and pivot and get in the wheelchair. Then they take me to the bathroom and I use the bars to stand. The staff member pulls my pants down and helps me to sit down. Once I am finished, I stand back up using the bars, then the staff cleans me, pull my pants up and I get back in the wheelchair. I was able to do this when I was still in the hospital. Some of the people tell me I cannot get up to go to the bathroom, they say if I fall I can sue them. I don't know why they haven't let me use the bathroom .I have been using the bathroom for many years .I can fall out of bed or where ever, I could sue them if I fall. I'm not someone who sues people. I just want to use the bathroom .I am unable to have a bowel movement in the brief or when I use the bedpan .my stomach really hurts when I need to go and I can't go to the bathroom. The man (DON) was just here and said I really did good when I showed him I was able to do it (transfer with the gait belt). On 04/02/26 at 1:50 PM, the DON stated, I've updated the care plan, and put in a request for physical therapy to address toileting tasks and request to use the commode. On 04/02/26 at approximately 2:20 PM, an interview was held with the Administrator. The Administrator confirmed the issue with the transfer status for Resident #3. The Administrator stated, I understand this is an issue .we are doing a facility-wide audit for transfers. An interview was held with the Director of Rehabilitation Services (DORS) on 04/02/26 at approximately 3:00 PM. The DORS stated, we communicated with the floor in February, 2026 to change the resident to a gait belt. d) Resident #29 On 04/07/2026 at 10:43 AM, catheter care was observed for Resident #29 which was being completed by Nurse Aide (NA) #57. Upon completion of the catheter care, the NA asked the resident did he want to get up in his wheelchair. The resident stated, yes. After assisting the resident to the side of the bed in a seated position, NA #57 put the resident's shoes on him. The NA assisted the resident to a standing position by holding under the resident's arm and pivoted the resident in front of the wheelchair and plopped the resident down in the wheelchair. On 04/07/26 at 10:59 AM, the South Unit Manager was notified and was asked How should the transfer be completed? The South Manager confirmed the resident was a gait belt transfer. NA #57 was interviewed at this time as well. NA #57 stated, I'm sorry I was nervous .I should have used the gait belt. On 04/07/26 at 11:05 AM, the Administrator and the Director of Nursing (DON) were notified and confirmed the gait belt should have been used with Resident #29. The Administrator stated, We will get her in here and provide education immediately. e) Resident #7 During a tour of the facility on 04/07/26 at approximately 10:45AM, State Surveyor noticed that a fall mat was placed at the right side of Resident #7's bed, but that the bed was not in the lowest position. Resident #7 is care planned for a fall mat to the right side of the bed and bed in low position as resident is at risk for falls related to impaired mobility. An interview with Director of Nursing (DON) at 11:00AM on 04/07/26 confirmed resident's bed is not in the lowest position and therefore the care plan was not being implemented. g) Resident #31 A review of Resident #31's care plan revealed there is no indication of resident's fractures mentioned in relation to her comprehensive care. An interview with Director of Nursing at approximately 4:00PM on 04/06/26 confirmed the care plan did not include mention of Resident #31's fractures. h) Resident #96 A review of Resident #96's care plan reveals he prefers to take a shower. The bathing task documentation shows that Resident #96 was not offered a shower from 03/24/26 to 03/31/26. An interview with Administrator at 9:48AM on 04/02/26 confirms Resident #96 did not receive a shower from 03/24/26 to 03/31/26 with no refusals and that his care plan states he prefers showers.

Based on record review, and staff interview the facility failed to ensure resident received the care and services to help them maintain and or attain their highest practicable physical, mental and psychosocial well being. For Resident #14 there was a delay in starting an ordered antibiotic. The facility did not notify the physician when the residents blood sugar was over 400 for Resident #12. For Resident #48 the facility failed to provide prompt wound evaluation and treatment. Finally for Resident #87 the facility failed to ensure basic hygiene tasks were performed to keep the resident from scratching his own skin. This was true for four (4) of 39 sampled residents. Resident Identifiers: #14, #12, #48, and #87. Facility Census: 122. b) Resident #12 On 03/06/2026 at 12:00 PM, a blood glucose fingerstick reading of 413 mg/dL was obtained. This value exceeds the facility's defined critical threshold for hyperglycemia. Review of the clinical record revealed no documented evidence that the physician was notified of this critical result. Facility protocol for blood glucose monitoring and physician notification was reviewed and confirmed that the physician is to be notified for blood glucose readings less than 70 mg/dL or greater than 400 mg/dL. No documentation was identified to indicate physician notification, new orders, or clinical interventions in response to the elevated blood glucose level. During an interview on 03/06/2026 at 2:40 PM, the nurse practitioner (NP) confirmed that the physician should have been notified of the blood glucose reading of 413 mg/dL and acknowledged that failure to do so is not consistent with facility protocol. c) Resident #48 On 03/31/2026 at approximately 10:30 PM, observation revealed Resident #48 lying in bed with multiple open, circular areas noted on the right outer thigh. The areas exhibited redness surrounding the wound edges, and active bleeding was observed. During the observation, the resident verbalized pain, stating, I can't do this again tonight. At that time, Licensed Practical Nurse (LPN) #13 asked the resident if he would like a bandage applied, to which the resident responded, Yes. LPN #13 was observed obtaining supplies from the treatment cart and applying a bandage to the affected areas. A review of the clinical record revealed no documented evidence of assessment, treatment, or wound care provided on 03/31/2026 at approximately 10:30 PM. Further review of the medical record revealed no documentation of wound care, assessment, or treatment from 03/31/2026 through 04/07/2026. On 04/07/2026 at 11:49 AM, the Director of Nursing (DON) confirmed that the resident's wounds had not been treated since 03/31/2026. d) Resident #87 On 03/31/2026 at 9:29 AM, observation revealed the resident had long, untrimmed fingernails and visible scratches present behind the right ear. The affected area appeared reddened with superficial skin breakdown. An interview conducted with the resident's wife at that time indicated awareness of the condition, and she stated that the resident's fingernails were trimmed following the observation. On 04/02/2026 at 9:05 AM, follow-up observation by the surveyor, in the presence of the Director of Nursing (DON), revealed that scratches remained present behind the resident's right ear, indicating lack of resolution. There was no observable evidence at that time that the area had been fully treated or had healed. A review of the clinical record revealed no documented evidence of a wound assessment, treatment, or monitoring of the scratched area following the initial observation on 03/31/2026. During interview on 04/02/2026, the DON acknowledged the presence of the scratches and stated that the nurse practitioner (NP) would be notified, a wound assessment would be completed, and nursing assistants would be interviewed to determine contributing factors. The DON further indicated that the incident would be reported as neglect. Findings Include: a) Resident #14 A review of Resident #14's medical record found a Urinalysis Culture and Sensitivity which was resulted on 12/24/25 at 10:02 am. A further review of the electronic medical record found a note entered by the Nurse Practitioner on 12/24/25 at 11:42 am which read as follows, .Long-term care resident of the center being seen today to follow-up on final urine culture results. She did have complaints recently of some dysuria, which she does report continues. A urine specimen was obtained via straight cath, with initial UA results appearing negative. However, final culture results are back today, positive for greater than 100,000 colonies of E. coli. She has no complaints other than dysuria today Assessment & Plan:E. coli UTI: I have ordered Bactrim DS 1 orally every 12 hours for 5 days. Her eGFR was 42 on 11/12/25.A review of the medication administration record found the order for Bactrim DS 1 orally every 12 hours was not entered into the medical record until 12/26/25. A review of the medication administration record (MAR) for the month of 12/2025 found the first dose of bactrim was not administered until 12/26/25 at 9:00 PM. An interview with the Director of Nursing (DON) on 04/07/26 at 1:18 PM, confirmed there was a delay in starting the antibiotic ordered by the Nurse Practitioner. He was unable to provide an explanation as to why the medication was not started or 12/24/25. He confirmed the pharmacy did make a delivery to the facility on [DATE] and 12/25/25. An interview with the DON he confirmed that there was a delay from 12/24/26 to 12/26/26 and the medication should have been started before that.

Based on observation and staff interviews, the facility failed to ensure the resident environment remains as free of accident hazards as is possible This was true for The Transitional Care Unit dining and 6 out of 12 sampled residents. Resident identifiers: #135, #136, #7, #17, #3, and #29. Facility Census:122 a) Resident #77 On 03/31/2026 at 3:50 PM, observation of the resident's room revealed a container of bleach cleaning wipes (Micro-Kill), identified as a white bottle with a blue lid, left unattended at the resident's bedside. The container was observed to be within reach and accessible to the resident, indicating it was not stored in a secure or supervised location. The presence of a chemical cleaning agent at the bedside created the potential for accidental exposure, ingestion, or misuse, which could result in harm to the resident. This observation is inconsistent with standard safety practices requiring hazardous materials to be properly labeled, stored, and secured to prevent resident access. At approximately 4:06 PM on 03/31/2026, an interview was conducted with the Director of Nursing (DON), who confirmed that the cleaning wipes were not appropriately secured at the time of observation. The DON acknowledged that cleaning agents should not be left unattended in resident care areas and should be stored in designated, secured locations when not in use. There was no evidence to indicate that measures were in place at the time of observation to prevent resident access to the cleaning product. The unsecured item was removed from the resident's bedside following surveyor identification of the concern. Proper storage and handling of hazardous chemicals is necessary to maintain a safe and sanitary environment and to protect residents from avoidable risks of injury or exposure. b) Resident #135: During an entrance interview with Resident # 135 on 03/31/26 at 10:45 AM, it was observed in her bathroom above the sink that the drywall was loose with chunks and pieces falling from the wall into the sink. On 03/31/26 at 10:48 AM, In an interview with RN #46, she acknowledged the dry wall chunks that fell from the wall and in the sink were an accident hazard. She stated she would get maintenance down there right away for repairs. On 04/08/26 at approximately 9:30AM, a recheck of Resident #135's room with the Administrator, it was observed the drywall patch and chunks of drywall spillage was not yet repaired. She acknowledged the disrepair and stated she would make sure the maintenance department would attend to it immediately. c) Resident #136: On 03/31/2026 2:38 PM, during the entrance interview with Resident #136, a medicine cup was observed on her bedside table with a white creamy substance in it. Upon asking the resident what was in the cup she stated it was Bio-Freeze medicine left there for her to rub on her feet because they hurt. On 03/31/26 at 2:40PM During an interview with Registered Nurse # 46, she stated even though the resident was alert and oriented, she was not care planned to give herself medications and that it shouldn't have been left there. She removed it from her bedside and disposed of it On 03/31/2026 at 2:46 PM, the DON acknowledged he had been made aware of the Bio-freeze left at a resident's bedside, and reported, staff education on medications at bedside started on that date. On 03/31/26, during an tour of the TCU dining room at 10:30PM, It was observed that sheet rock chunks approximately 1/2 inch in size and saw dust piles with small wood splinters in the lower kitchen cabinets. This was true for all shelves in the bottom cabinets to the right and left of the sink and also in the island cabinets across from the sink. These cabinets were of easy access by all residents who enter that unit dining room. During an interview with the night shift supervisor on 03/31/26 at 10:43PM, she acknowledged the sheet rock chunks and wood splinters/saw dust in the bottom cabinets and stated the debris was left over from the recent remodel and that she did not know the cabinets were left like that. d) Resident #3 An initial interview was held with Resident #3 on 03/31/2026 at 11:14 AM. Resident #3 stated, They won't take me to the bathroom .they said if I fall I'll sue them .if someone will help me I can use the wheelchair and the bars in the bathroom .they tell me to use the brief or bed pan .I cannot have a bowel movement in a brief. One or two of the girls will take me, the rest will not. On 04/02/2026 at 1:30 PM, a lift transfer evaluation dated 01/27/26 indicated the resident was dependent for transfers using the mechanical lift with two (2) staff members. This was the last documented lift transfer evaluation until 04/02/26. The care plan under the focus area of dependent for ADL (activities of daily living) care, a review found two (2) interventions regarding toileting. The first intervention states, (Name of Resident) is dependent on staff for toileting, lower body dressing and transfers; and, mechanical lift for transfer x2 dependent. (Typed as written.) However, a review from 03/03/26 through 04/02/26 under the tasks tab for toileting found the resident was assisted to the toilet via wheelchair on 10 occasions with staff assistance x 1 (one) and the mechanical lift was not used. After Surveyor intervention, the Director of Nursing (DON) did a lift transfer assessment on 04/02/26 at 1:34 PM. Upon completion of the assessment, the resident was changed from a mechanical lift for transfers to a gait belt. The DON stated, she is a dialysis patient, may be therapy felt she was too inconsistent to make her a gait belt. An additional interview was held with the resident on 04/02/26 at 1:40 PM. The interview was asking the resident to explain how the staff transferred her when not using the mechanical lift. The resident stated, they put the wheelchair beside the bed, they assist me to stand, then I stand and pivot and get in the wheelchair. Then they take me to the bathroom, and I use the bars to stand. The staff member pulls my pants down and helps me to sit down. Once I am finished, I stand back up using the bars, then the staff cleans me, pull my pants up and I get back in the wheelchair. I was able to do this when I was still in the hospital. Some of the people tell me I cannot get up to go to the bathroom, they say if I fall, I can sue them. I don't know why they haven't let me use the bathroom .I have been using the bathroom for many years .I can fall out of bed or wherever, I could sue them if I fall. I'm not someone who sues people. I just want to use the bathroom .I am unable to have a bowel movement in the brief or when I use the bedpan .my stomach really hurts when I need to go and I can't go to the bathroom. The man (DON) was just here and said I really did good when I showed him, I was able to do it (transfer with the gait belt). On 04/02/26 at 1:50 PM, the DON stated, I've updated the care plan, and put in a request for physical therapy to address toileting tasks and request to use the commode. On 04/02/26 at approximately 2:20 PM, an interview was held with the Administrator. The Administrator confirmed the issue with the transfer status for Resident #3. The Administrator stated, I understand this is an issue .we are doing a facility-wide audit for transfers. An interview was held with the Director of Rehabilitation Services (DORS) on 04/02/26 at approximately 3:00 PM. The DORS stated, we communicated with the floor in February, 2026 to change the resident to a gait belt. e) Resident #29 On 04/07/2026 at 10:43 AM, catheter care was observed for Resident #29 which was being completed by Nurse Aide (NA) #57. Upon completion of the catheter care, the NA asked the resident did he want to get up in his wheelchair. The resident stated, yes. After assisting the resident to the side of the bed in a seated position, NA #57 put the resident's shoes on him. The NA assisted the resident to a standing position by holding under the resident's arm and pivoted the resident in front of the wheelchair and plopped the resident down in the wheelchair. On 04/07/26 at 10:59 AM, the South Unit Manager was notified and was asked how the transfer should be completed? The South Manager confirmed the resident was a gait belt transfer. NA #57 was interviewed at this time as well. NA #57 stated, I'm sorry I was nervous .I should have used the gait belt. On 04/07/26 at 11:05 AM, the Administrator and the Director of Nursing (DON) were notified and confirmed the gait belt should have been used with Resident #29. The Administrator stated, We will get her here and provide education immediately. f) Resident #7 During a tour of the facility on 04/07/26 at approximately 10:45AM, State Surveyor noticed that a fall mat was placed at the right side of Resident #7's bed, but that the bed was not in the lowest position. Resident #7 is care planned for a fall mat to the right side of the bed and bed in low position as resident is at risk for falls related to impaired mobility. An interview with Director of Nursing (DON) at 11:00AM on 04/07/26 confirmed resident's bed is not in the lowest position. g) Resident #17 A lift assessment dated [DATE] indicated Resident #17 should use a total lift full body sling for transfers. A change in condition communication form dated 09/25/25 that the facility used to communicate a fall, reads: Resident noted on floor in room on knees near bed. Unassisted attempt to transfer from [Bedside commode] BSC to bed. In an interview with Director of Nursing (DON) at 10:30AM on 04/06/26, he stated a resident should not have a BSC in the room if they are using a total lift for transfers.

Based on food tray temperatures, resident interviews and staff interviews, the facility failed to serve food that was attractive, palatable and at a safe and appetizing temperature to prevent foodborne illness. The facility failed to ensure hot foods were served hot. This failed practice was true for three (3) of three (3) meal trays tested throughout the survey process. Residents identified: #99 and #60. Facility census: 122.

Based on record view and staff interview, the facility failed to ensure informed consent was obtained for psychotropic medications. This was found true for two (2) of five (5) residents reviewed. Resident #12 and Resident #46. Facility census: 122. a) Resident #12 A record review for Resident #12 revealed a physician order for Buspirone HCl 5 mg (milligram), to be administered as one (1) tablet by mouth. Further review of the clinical record revealed no documented evidence of informed consent for the use of Buspirone. Documentation indicated the medication was initiated on 03/01/26; however, there was no evidence that informed consent had been obtained prior to initiation of the medication. This finding was confirmed with the Director of Nursing (DON) on 04/01/26 at approximately 3:45 PM. Findings included: b) Resident #46 A record review for Resident #46 on 04/06/26 found the following physician order: Olanzapine oral tablet disintegrating 5 MG (Olanzapine) Give one (1) tablet by mouth at bedtime for antipsychotic. On 04/06/26 at 11:11 AM the surveyor asked the Director of Nursing (DON) for consent form. The one that was provided was dated 09/18/2025, for the anti-depressant drug named Lexapro. The DON stated this is the only one we have for her.

Number of residents sampled: Number of residents cited: Based on record review and staff interview, the facility failed to ensure each resident's drug regimen was free from unnecessary drugs. This was true for one (1) of five (5) residents reviewed under the Unnecessary Medications Pathway throughout the Long-Term Care Survey Process. Resident identifier: #46. Facility Census: 122 Findings included: a) Resident #46 A record review, completed on 04/06/2026 at 10:00 AM, revealed:-The following physician order, dated 03/19/2026: Olanzapine Oral Tablet Disintegrating 5 MG Give 1 tablet by mouth at bedtime for antipsychotic.-On 03/20/2026 at 2:32 PM, the consulting pharmacist recommended a Gradual Dose Reduction of Resident #46 (Olanzapine). A Gradual Dose Reduction (GDR) refers to the stepwise tapering of a medication dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the dose or medication can be discontinued.-On 03/20/2026, the attending physician agreed to and signed off on the GDR. The new order should have read, Olanzapine 2.5 MG Give 1 tablet by mouth at bedtime.-Review of the March 2026 Medication Administration Record (MAR) revealed the physician order had never been updated.-Resident #46 continued to receive the (Olanzapine) at the original dose of 5 MG (once per day) on the following dates and times: 03/20/2026 at 7:51 PM. 03/21/2026 at 10:41 PM. 03/22/2026 at 9:37 PM. 03/23/2026 at 10:17 PM. 03/24/2026 at 10:03 PM. 03/25/2026 at 10:37 PM. 03/26/2026 at 8:55 PM. 03/27/2026 at 10:08 PM. 03/28/2026 at 10:11 PM. 03/29/2026 at 9:12 PM. 03/30/2026 at 9:01 PM. 03/31/2026 at 8:58 PM. 04/01/2026 at 9:13 PM. 04/02/2026 at 11:22 PM. During an interview on 04/06/2026 at 12:16 PM, I asked the Director of Nursing (DON) why this dose reduction was not completed? He stated I think it got overlooked, that's all I got for you. The Administrator was interviewed on 04/06/2026 at 3:37 PM. The Administrator acknowledged the attending physician for Resident #46 had signed off on a GDR and the resident had received an excessive dose of his/her antipsychotic medication for fourteen days. 04/06/2026 12:16 PM Resident #46 was re-admitted to the facility on [DATE]. The Registered Pharmacist completed a medication regimen review on 03/20/2026. The pharmacist recommendation stated: Routine Antipsychotic use must be evaluated by Doctor of Medicine (MD) on admission for potential Gradual Dose Reduction (GDR) or Discontinue (DC). Please consider reduction if appropriate. The facility's Physician agreed to this pharmacy recommendation and signed off on it on 03/20/2026. Per the pharmacy recommendation, and with the facility physician agreeing to it, the dose reduction for the antipsychotic Olanzapine should have changed the order from Olanzapine 5 MG, give one (1) tablet by mouth (PO) at bedtime to Olanzapine 2.5 MG, give one (1) tablet by mouth (PO) at bedtime. This never occurred, and Resident #46 continued on the original order for Olanzapine 5 MG. This surveyor asked the Director of Nursing (DON) why this reduction was not made? He stated I think it got overlooked, that's all I got for you. 04/06/2026 3:37 PM This surveyor asked Administrator #148 why this reduction was not made? She stated I don't know, I feel it just wasn't done. 04/06/2026 4:15 PM Administrator #148 gave me a copy of Resident #46 Medication Administration Record (MAR) for the Months of March 2026 and April 2026. Resident #46 continued to receive the higher dose of Olanzapine for fourteen days, March 20 - April 02 2026. Resident #46 was sent to the emergency room (ER) on 04/03/2026. She is still out of the facility (OOF) at this time. [NAME], [NAME] (46) [NAME], [NAME] - RESIDENT NOTE 04/02/2026 11:26 AM

Based on record review, staff interview and resident interview, the facility failed to develop a baseline care plan for a resident ordered oxygen therapy by the physician. This failed practice had the potential to affect a limited number of residents. Resident Identifier: #29. Facility Census: 125.Findings included: a) Resident #29 On 06/03/26, Resident #29's medical record was reviewed for oxygen therapy. Oxygen therapy orders were reviewed by the state surveyor. The resident's orders stated, Incentive Spirometer - encourage patient to use as often as tolerate, every day shift Pre tx: Evaluate heart rate, respiratory rate, Pulse Oximetry and Lung sounds in supplementary documentation. and Oxygen at 2 L/min Nasal Cannula, every shift for Shortness of Breath. The resident's baseline care plan was reviewed for oxygen therapy. No focus, goals or interventions were listed on the baseline care plan for oxygen therapy. The care plan was reviewed and confirmed with Corporate Registered Nurse #19 and the Director of nursing (DON). The federal regulatory guidelines for a baseline care plan were reviewed with Corporate Registered Nurse #19 and the DON.

Based on record review, staff interview and observation, the facility failed to ensure call lights were within reach for dependent residents. This failed practice had the potential to affect a limited number of residents. Resident Identifiers: #19 and #47. Facility Census: 125.Findings included: a) Resident #19 On 06/03/26 at 12:25 PM, Resident #19's call light was not in reach. The call light was on the opposite side of the bed across from the resident who was sitting in her wheelchair. The Administrator confirmed the call light was not in reach and moved it within the resident's reach. The call light had been placed out of reach across the bed on the resident's paralyzed side. b) Resident #47 On 06/03/26 at 6:30 PM, Resident #47's call light was observed on the floor. At 6:35 PM, Activities Director #166 confirmed the call light was on the floor and picked it up, placing it within reach of the resident. The facility's policy and procedure for Call Lights stated, 4. Staff will ensure the call light is within reach of the patient and secured as needed.

Based on record review and interview, the facility failed to honor Resident #49's bathing choices from 03/23/26 to 03/31/26. This was true of one (1) of five (5) residents sampled for choices during the Long-Term Care Survey Process. Census: 122 Resident identifier: #49Findings include: a) Resident #49 Resident #49's care plan from 02/03/26 stated the resident prefered to take a shower.The bathing task for the month of March shows Resident #49 had a shower twice per week by Nurse Aide (CNA) #15 from 03/01/26 through 03/22/26. After that date, Resident #49 only had bed baths. Further, the bathing tasks showed there were no refusals of showers during that time frame. In an interview with Resident #49 and her son on 03/31/26 at 10:02 AM, she stated she only gets showers when NA #15 is working. She further stated she had not been asked if she wanted a shower since 03/22/26. An interview with Director of Nursing (DON) confirmed that according to documentation, Resident #49 has not been offered a shower since 03/22/26.

Based on record review and staff interviews, the facility failed to ensure the Minimum Data Set (MDS) accurately reflected the residents' current condition. This was true for two (2) of 39 residents sampled for accuracy of assessments during the Long-Term Care Survey Process. Census: 122 Resident identifier: #31, #57Findings included: A) Resident #31 A1) Section GGThe significant change Minimum Data Ser (MDS) dated [DATE] section GG, shows resident is ambulating 10 feet with supervision. A physical therapy Discharge summary dated [DATE] reveals Resident #31 was able to stand without moving in the parallel bars, but unable to take steps at that time.In an interview with Physical Therapist Assistant (PTA) #122 on 04/06/26 at 3:04PM, he stated Resident #31 has not been able to walk since the fractures occurred. A2) Section IThe same MDS, section I, does not have other fractures box checked indicating that Resident #31 does not have any fractures at the time of the MDS.Resident #31's diagnosis list includes fourth (4th) and fifth (5th) metatarsal fractures. An interview with Director of Nursing at approximately 4:00PM on 04/06/26 confirmed the MDS was inaccurate and did not include fractures in her diagnoses. B) Resident #57The Minimum Data Set (MDS) dated [DATE] has Resident #57 listed as being able to walk ten feet with supervision.The last physical therapy discharge date d 01/05/26 lists Resident #57 as not applicable in the walk ten feet section. In an interview with Physical Therapist Assistant (PTA) #122 at 2:44PM on 04/07/26, PTA #122 stated Resident #57 has not walked in the three (3) years he has worked in this facility. An interview with Administrator #148 at 2:50PM confirmed resident's MDS is inaccurate.

Based on resident interview, staff intervew and record review, the facility failed to revise a care plan to indicate Resident #24's preference for night time care. This was true for one (1) of 39 residents reviewed during the survey process. Resident Identifier: #24. Facility Census: 122. Findings Include: a) Resident #24 On 04/06/2026 at 2:00 PM, a record review was completed for Resident #24. Also, a review of a facility-reported incident (FRI) dated 12/08/25 was reviewed. The allegation of neglect was noted in the FRI for Resident #24 regarding incontinence care at night time. The resident was interviewed on 04/06/26 at approximately 3:00 PM regarding the allegation of neglect. The resident stated, you know how it is .I don't remember that but I'm sure if I said it .it must have happened. An interview was held with the Social Services Director (SSD) on 04/06/26 at 3:00 PM. The SSD was asked, did you find any evidence the allegation of neglect was verified? The SSD stated, let me look over it. On 04/06/26 at 3:30 PM, an interview was held with the Administrator. The Administrator stated, the resident does want to woken up between the hours of 10PM-6AM .Resident will use call light to ask for care. At this time, a revision of the care plan was provided indicating the resident did not want to be awakened between the hours of 10:00 PM through 6:00 AM. An additional interview was held with Resident #24 on 04/06/26 at 3:50 PM. Resident #24 stated, if I need help I let them know .I usually sleep through the night .I wear my CPAP (continuous positive airway pressure) and I usually sleep well. The resident was unable to clarify if this intervention added to the care plan was indeed his preference.

Based on observation, staff interview, and family interview, the facility failed to ensure necessary activities of daily living (ADL) care, including personal hygiene and grooming, for two (2) of eight (8) of sampled residents. This was found true for Resident #87 and Resident #96. Facility census 122.a) Resident #87 On 03/31/2026 at approximately 2:24 PM, an interview was conducted with the resident's wife, who reported observing the resident with a dirty face, neck, and hands, as well as soiled bedding. She further stated that the resident's fingernails were long and untrimmed and reported observing scratches behind the resident's right ear, which she attributed to the resident scratching. The resident's wife indicated she personally trimmed the resident's fingernails, cleaned his face and neck, and requested staff assistance to change the resident's shirt and bedding. The reported observations indicate the resident was not maintained in a clean and well-groomed condition, and grooming needs, including nail care, were not adequately addressed by facility staff. The presence of long fingernails and resulting scratches raised concerns regarding the facility's provision of routine hygiene and prevention of avoidable injury. On 04/02/2026 at approximately 9:05 AM, observation of the resident was conducted with the Director of Nursing (DON), which confirmed the presence of scratches behind the resident's right ear. During interview, the DON acknowledged the findings and indicated that the Nurse Practitioner (NP) would be notified, a wound assessment would be completed, and staff interviews would be conducted to further investigate the concern. The DON further stated that the incident would be reported as neglect. Failure to ensure the resident was maintained in a clean, well-groomed condition and to prevent avoidable injury has the potential to negatively impact the resident's health, dignity, and overall well-being. b) Resident #96 In an interview with Resident # 96 on 03/31/26 at 11:33AM, he stated he had not had a shower in five (5) or six (6) days. Resident #96 had a care plan that reads, Provide resident/patient with extensive assist x 1 for bathing. According to bathing task documentation, Resident #96 had one (1) bed bath between 03/25/26 and 03/31/26 with no refusals documented during that time frame. Resident #96 was on the shower schedule for every Tuesday and Friday. An interview with Administrator at 9:48 AM on 04/02/26 confirmed Resident #96 did not receive a shower from 03/24/26 to 03/31/26 with no refusals and that his care plan states he preferred showers.

Based on observation and staff interview, the facility failed to ensure access to fluids at bedside for one (1) resident, placing the resident at risk for inadequate hydration. This was found at a random opportunity for discovery. This was found true for one (1) resident. Resident identifier: #77. Facility census: 122. a) Resident #77On 03/31/2026 at 3:07 PM, observation of the resident's room revealed no water present at the bedside. At approximately 3:15 PM, the observation was reviewed with LPN #16, who confirmed that no water was present at the bedside at the time of observation. There was no evidence to indicate that fluids had been recently offered or were readily accessible to the resident.Water was subsequently provided to the resident following surveyor intervention.

Based on record review and staff interview the facility failed to coordinate with the appropriate State-designated authority, to ensure that individuals with a mental disorder, intellectual disability or a related condition received care and services in the most integrated setting appropriate to their needs when completing/revising a Pre-admission Screening and Resident Review (PASARR). This was true for 1 of 30 residents sampled. Resident Identifier: #66. Facility census: 122. Findings Included:a) Resident #66On 04/01/26 at 11:00 AM record review found Resident #66 had the following medical diagnosis:Psychoactive Substance AbuseReview of the PASARR dated 04/01/26 found that this diagnosis was not identified on the PASARR.The above information was confirmed with The Social Worker on 04/02/26 at 10:00AM, who agreed that the additional medical diagnosis should have been on the PASARR.

Based on observation, resident interview, staff interview and record review, the facility neglected to provide appropriate wound care and monitoring per the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The failure to provide the necessary wound care services to Resident #3 resulted in a negative physical outcome leaving the Resident with feelings of despair. This failed practice was true for one (1) of three (3) residents reviewed for abuse. Resident identifier: #3. Facility census:127. Findings included: a) Resident #3 During an interview on 02/28/22 at 2:35 PM, Resident #3 was asked what happened to her left leg (anterior thigh area). The Resident stated this past weekend the skin graft on the left thigh had been draining. In addition, the Resident stated they [facility staff] are not supposed to put anything on the left leg to cover the wound. The Resident stated that a nurse named [first and last name of LPN # 143] worked night shift and told a Nurse Aide (NA) go get a pillowcase, since they can't cover it and put a pillowcase on the leg to keep the drainage off the sheets. They covered my leg with a pillow case. When they took the pillowcase off, it ripped off the scabs where it was stuck. The blood just poured. Now it looks like this. Resident stated, I just want to break down and cry. I give up. The Resident's voice was trembling while explaining the events that took place resulting in the condition of the left anterior thigh wound. Review of the Minimum Data set with an assessment reference date (ARD) of 02/18/22 coded the resident's brief Interview for mental status (BIMS) score as 15. A score of 15 indicates the resident is cognitively intact. On 2/28/22, at 2:27 PM, observation of the wound on the left anterior thigh revealed two (2) oblong shaped open areas approximately 3 cm in diameter in the lower half of the skin graft wound site. The two (2) open areas were bright pink in color with blackened skin edges rolled up away from center of the open area. The open areas had a moderate amount of serosanguineous drainage. (serosanguineous drainage is a thin, watery fluid that is pink in color due to the presence of a small amount of red blood cells). During an interview on 02/28/22 at 2:49 PM, NA #62 stated, We [NA #62 and NA #30] took the pillowcase off the leg when we changed the Resident. The scabs came with it where it had bleed through. It was like ripping off a band aid. NA #62 stated he told the nurse about it but can't remember who the nurse was, but he did report it. On 02/28/22 at 5:01 PM, NA #30 was asked to verify if the Resident had a pillowcase that was placed on the wound on the left anterior thigh overnight. NA #30 stated, Yea, on Saturday morning when we changed her, NA #62 took the pillowcase off the left leg, and it pulled the scabs off with it and started to bleed. During an interview on 03/01/22 at 1:50 PM NA #7 stated, Sunday [2/27/22] when me and NA #30 changed [Resident #3's first name], she had a little white patch of some sort covering the bottom half of the wound on her left upper leg [left anterior thigh wound] and was half off/half on. I left the patch on there, not my job to take it off. Review of Patient #3's medical record showed an order to cleanse left anterior thigh with saline, pat dry daily and LOTA (leave open to air). Start date: 11/11/21. At 2:00 PM on 03/01/22 at 2:00 PM, Registered Nurse (RN) #80 verified the order for the wound to be left open to air. The RN stated the wound on the left anterior thigh should not have any type of covering on it. The RN stated the wound originates from a former skin graft donor site they had been treating for quiet some time. On 03/01/22 at 2:40 PM, in the presence of the Licensed Social Worker (LSW) #107, Resident #3 was asked to verify the incident that happened over the weekend with her skin graft wound site on left anterior leg. The Resident stated, Friday night, [LPN #143's first and last name] told the NA to put the pillowcase over the leg because it was bleeding all over the place. Then the next morning (on 02/26/22) [NA #62's first name] took it off, and then it gushed the blood because he ripped scabs off when he pulled it off. The Resident was asked who would have put a type of cover, in the form of bandage or patch on the wound Saturday night that NA #30 would have been referring to? The Resident stated, [RN #5's first name] put a [MEDICATION(S)] (alginate dressing that locks fluid away as a gel) on there Saturday night to keep it from bleeding, it came off on its own. The Resident tearfully exclaimed, Why does this keep happened to me? Progress Note dated 12/20/21 at 7:31 PM, written by Nurse Practitioner (NP) #182 stated the resident did previously have an open area to this site that recently resolved. The wound nurse reports that the patient has significant [CONDITION(S)] with several open areas that are draining heavily. Progress Note from the on-call provider dated 02/26/22 at 1:30 AM stated a primary chief complaint of purulent (white, yellow, or brown fluid and might be slightly thick in texture indicating infection) drainage. The note stated the Resident had a chronic wound on left thigh, originally a skin graft which has been intermittently infected. It has started draining again, purulent material, moderate drainage no with no fever, chills, nausea, vomiting. Physical exam findings were provided by nurse (LPN#5) for the telephone encounter. The diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Treatment ordered was [MEDICATION(S)] 800-160 mg, give 1 tablet by mouth two times a day for 10 days. Review of the Resident's medial record showed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Resident's Mediation Administration Record (MAR) indicated the 10:00 PM dose of [MEDICATION(S)] antibiotic on 2/26/22 was not administered. Progress Note dated 03/01/22 at 3:31 PM, showed a wound assessment and indicated a stable abscess that was in-house acquired. Location: Left Thigh (Medial) was assessed today. Prognosis: Slow to Heal: wound healing is slow or stalled but stable, little/no deterioration. The practitioner has been notified. This was the first wound assessment that had been completed since 12/24/21. On 03/02/22 at 1:31 PM, Corporate RN #138 stated that no skin and wound evaluation assessments were completed for month of January or February 2022. Corporate RN #138 stated, The Nurse Practitioner is here seeing Residents today, I will provide you with any order changes the Nurse Practitioner documents the visit. Record review for Resident #3 indicated the Resident follows with the wound center for pressure ulcers to her buttocks; however, the wound center was NOT providing wound care for the left anterior thigh skin graft wound site. Progress Note dated 03/02/22 at 2:49 PM, written by Nurse Practitioner (NP) #182 stated the Resident has a history of a left thigh skin graft with poor wound healing. Nursing reported purulent drainage on 02/26/22 to the on-call provider and she was ordered [MEDICATION(S)]. Continue [MEDICATION(S)] as ordered and cleanse wound with wound cleaner and pay dry, dressing changes with Thera honey sheets and ABD pad every 3 days as needed. Review of Resident #3's Treatment Administration Record (TAR) showed the resident did not receive wound care treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] --01/01/22 --01/02/22 --01/03/22 --01/10/22 --01/13/22 --01/14/22 --01/15/22 --01/16/22 --01/17/22 --01/28/22 --01/30/22 --02/13/22 --02/21/22 --02/26/22 Review of Residents diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the facility's investigation of neglect, resulting from the surveyors discovery and notification of facility staff, found the following investigation: Witness Interview Record dated 03/02/22 contained a statement from LPN #143 taken by the Administrator and RN #104. The record stated, (typed as written), There wasn't an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . I took wet dressing off. I cleaned area to protect wound. I used clean pillowcase to tent area to keep it clean and clear while she looked up dressing. A signed written statement dated 03/02/22 from Nurse Aide (NA) #30 stated, When we lifted blanket, we saw pillowcase stuck to her leg. [First name of NA #62] removed it. It was very hard to get. He removed it himself. Contingent Staff Performance/Conduct Investigation Form dated 03/02/22 completed by the Administrator, stated LPN [last name of LPN #143] instructed NA to apply pillowcase to tent graph site, which stuck to site having to be removed. She did not follow order to be open to air. LPN instructed NA to perform non approved/ordered treatment outside her scope of practice. The facility neglected to provide appropriate wound care and monitoring per the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The failure to provide the necessary wound care services to Resident #3 resulted in a negative physical outcome leaving the Resident with feelings of despair.

Based on record review, staff interview, resident interview and observation, the facility failed to ensure the resident environment over which it had control was as free from accident hazards as possible. Resident #60, a resident who independently smokes, was noted to keep his cigarettes and lighter in his room with him when he is not smoking. Resident #60 indicated he kept his smoking materials including his lighter in his [NAME]et pocket. The facility's policy verified all smoking materials would be locked up at the nurses desk or in the residents room. The facility's policy prohibited lighters being kept anywhere other than locked up at the nurses station. The facility identified the following residents as being confused, wandering, and rummaging residents: Resident #56, #39,#69, #92, #25, #86, #29, #79, #272, #9, #120, #78, #13, #81, #117, #23, #31, #89, #46, #118, and #116. The facility's failure to implement their smoking policy and their non-compliance to ensure the resident environment was free from accident hazards placed these 21 residents in a situation where serious injury and/or death was likely. The facility was notified of the Immediate Jeopardy (IJ) situation at 2:00 p.m. on 11/19/19. They provided a Plan of Correction (P[NAME]) at 4:28 p.m. on 11/19/19 and the P[NAME] was accepted by the state agency at 4:35 p.m. on 11/19/19. The IJ was abated at 8:50 a.m. on 11/20/19. The facility abatement plan of correction included the following. 1. Director of Nursing (DON) removed smoking supplies, including lighters, from Resident #60 possession @ 1245pm on 11/19/19. DON re-educated Resident #60 regarding the smoking policy and procedure to include all smoking materials including lighters are to be secured at 12:45 PM on 11/19/19 and resident #60 voiced understanding. Residents # 56, 39, 69, 92, 25, 29, 79, 272, 9, 120, 78,13,81, 117, 23, 31, 89, 46, 116, and 118 rooms were searched on 11/19/19 by 2:46 pm with no additional findings on the residents or in his/her resident room. 2. All residents of the facility have the potential to be affected. The DON/designee conducted rounds of all resident rooms by 2:46 pm to ensure smoking materials including lighters are secured on 11/19/19 with any corrective action immediately upon discovery. No residents have experienced any negative outcome. 3. The DON/designee will re-educate all staff including agency staff starting 11/19/19 at 3:00 PM regarding the resident environment remains free of accident hazards as is possible to include the center smoking policy to ensure that resident smoking materials including lighters are secured at all times, with a posttest to validate understanding. Staff and agency staff not available during this timeframe will be provided reeducation including posttest by the DON/designee upon day of return to work before providing care. New staff and agency staff during orientation will be provided education including posttest by the DON/designee. 4. DON/designee will monitor starting on 11/19/19 to ensure Resident smoking materials including lighters are maintained in a cabinet at nursing station across all shifts for 2 weeks, including weekends and holidays, then 3 times a week for 2 weeks then randomly thereafter to ensure that smoking materials including lighters are secured and residents who smoke follow the smoking policy. 5. Results of monitors will be reported by the DON/designee monthly at the Quality Improvement Committee (QIC) for any additional follow up and/or inservicing until the issues are resolved and randomly thereafter as determined by the QIC committee. Upon abatement of the immediate jeopardy at 8:50 a.m. on 11/20/19. The scope and severity of the deficient practice is reduced to an E. Resident identifiers: #60, #56, #39,#69, #92, #25, #86, #29, #79, #272, #9, #120, #78, #13, #81, #117, #23, #31, #89, #46, #118, and #116. Facility census: 127. Findings included: a) Resident #60 A review of Resident #60 smoking assessments dated 03/23/19, 06/24/19 and 09/24/19 verified Resident #60 was capable of smoking independently and did not need staff or family supervision while smoking. An interview with Resident #60 on 11/19/19 at 11:53 a.m. confirmed he keeps his smoking supplies in his [NAME]et pocket at all times. He was sitting in the dining room and did not have his [NAME]et with him. He stated it was in his room and his cigarettes and lighter were in the pocket of his [NAME]et. When asked how he ensures other residents don't get his smoking supplies he stated, Ain't nobody got no business in my [NAME]et. An interview with Registered Nurse (RN) #78 and RN #259 at 11:55 a.m. on 11/19/19 confirmed Resident #60 did not have any smoking supplies at the Nurses Station. They both confirmed they worked yesterday and today and Resident #60 had not asked them for smoking supplies either day. RN #259 went and spoke to the resident in the dining and asked him where his smoking supplies were and Resident #60 informed her they were in his [NAME]et in his room and he was going to smoke after he at his lunch. Both RN #259 and RN #78 confirmed Resident #60 smoked, all the time, but sometimes he does not have supplies at the desk. An interview with the Director of Nursing (DON) at 12:00 p.m. on 11/19/19 found she would not be surprised if Resident #60 kept his smoking supplies in his room because he is very non-compliant about things. She stated, I would hope he would follow the rules and give them back. She indicated after lunch she would go talk to him and get them from him. Review of the facility's smoking policy found (typed as written): --Smoking supplies (including, but not limited to, tobacco, matches, lighters, lighter fluid, etc.) will be labeled with the patient's name, room number, and bed number, maintained by the staff, and stored in a suitable cabinet kept at the nurses station. --If the patient is cognitively and physically able to secure all smoking materials, the Center may allow him/her to maintain his/her own tobacco or electronic cigarette products in a locked compartment. --Patient's will not be allowed to maintain their lighter, lighter fluid, or matches. A review of Resident #60's care plan found the following focus statement: --Patient may smoke independently per smoking assessment. This focus statement was created on 03/25/19 by the DON. The goal associated with this practice statement read as follows: --Patient will smoke safely x 90 days. This goal was initiated on 03/25/19 and a target date of 12/31/19. The interventions and goals associated with this care plan Included: --Educate patient/health care decision maker on the facility's smoking policy --Inform and remind patient of location of smoking areas and times --Reassess patients ability to smoke independently with any change in condition --Ensure that there is no oxygen use in smoking area(s). --Ensure that appropriate cigarette disposal receptacles are available in smoking areas --Monitor patients compliance to smoking policy --Maintain patients smoking materials at nurses' station All interventions were added to the care plan on 03/25/19 by the DON. Observations with the DON of Resident #60, at 12:32 p.m. on 11/19/19, found the resident left the dining room and went to his room put on his [NAME]et and exited the building to the north court yard and took his cigarettes out his pocket along with his lighter and began to smoke. When Resident #60 exited the dining room, the DON told him that he would have to give her his cigarettes and lighter when he was done and the resident agreed. The DON agreed the facility was not implementing their smoking policy or Resident #60's care plan. The following residents were identified by the facility as being confused, wandering, and rummaging residents: Resident #56, #39,#69, #92, #25, #86, #29, #79, #272, #9, #120, #78, #13, #81, #117, #23, #31, #89, #46, #118, and #116. Of the 21 residents identified as confused, wandering, rummaging residents 2 were on the 200 hall with Resident #60. There were 9 on the 100 hall which connects to the 200 hall just adjacent to Resident #60's room. The facility's failure to implement their smoking policy and their non-compliance to ensure the resident environment was free from accident hazards placed these 21 residents in a situation where serious injury and/or death was likely as a result [MEDICAL CONDITION] fire-related injuries.

Based on staff interview and facility policy review, the facility failed to ensure an effective quality assurance (QA) program was implemented after determining Licensed Practical Nursing (LPN) staff were performing Intravenous (IV) therapy without having IV training and verification which resulted in an Immediate Jeopardy. On 11/08/18 at 4:27 PM, the Administrator and the Director of Nursing (DON) were notified verbally that Immediate Jeopardy existed and began on 10/26/18, when Resident #58 was readmitted with a peripheral inserted central catheter (PICC). According to an audit provided by the Administrator and the DON on 11/09/18 at 8:30 AM, LPN #3, #27, #133, #156 and #177 performed IV therapy for Resident #58 and #76 without having an IV certification. This information was not addressed in QAPI (Quality Assurance and Performance Improvement). committee. Immediate Jeopardy was abated on 11/08/18 at 6:47 PM when the facility completed a full audit of all residents who had IV access that would require IV therapy. The facility revised the staffing schedule to ensure an RN or an IV certified LPN would be performing IV therapy for the four residents with IV access and any newly admitted residents with IV access. Although the Immediate Jeopardy was removed, the facility remained out of compliance at severity level two (no actual harm, with potential for more than minimal harm that is not immediate jeopardy until systemic issues related to IV training and verification of LPNs. See F883 (Facility Assessment), F726 (Staff Competency) and F684 (Quality of Care) for additional information. The facility census was 128. Findings include: An interview was conducted on 11/08/18 at 11:20 AM, the staff development Registered Nurse (RN) #15 who was responsible for staff development. She stated she completed an audit on 10/03/18 regarding which LPN staff had IV training and verification. She stated she identified a number of LPN staff who were not IV trained and notified the Director of Nursing (DON) and the Administrator of the results of her audit. An interview was conducted on 11/08/18 at 12:30 PM with the Administrator and the DON. The Administrator and the DON stated they were notified of RN #15's audit regarding LPN IV training and verification. They stated they were not aware any LPNs were performing IV therapy without being IV certified. The Administrator stated the audit information had not been discussed in QA. An interview with the Regional Medical Director for the facility on 11/09/18 at 10:35 AM was conducted. She stated she does attend QA (Quality Assurance) meetings regularly. She stated she was not aware LPNs were performing IV therapy without training and verification of such. She stated this had not been discussed in QA. She stated her expectation was for nurses to be trained on the care they were providing. Although the facility identified the need for LPN IV training and competency for a number of LPN staff, the facility failed to follow through with an improvement plan to ensure LPNs were performing IV therapy with properly training. See F684, F838 and F726 for failure to ensure residents received appropriate IV therapy by a qualified staff member.

Based on observations, clinical record review, staff and resident interviews, and facility policy review, the facility failed to ensure two (Resident #58 and #76) of four sampled residents were provided appropriate care and services related to standards of practice and competency for Intravenous (IV) therapy resulting in an Immediate Jeopardy. On 11/08/18 at 4:27 PM, the Administrator and the Director of Nursing (DON) were notified verbally that Immediate Jeopardy existed and began on 10/26/18, when Resident #58 was readmitted with a peripheral inserted central catheter (PICC). Resident #58 and #76 was ordered to have IV therapy. An audit provided by the Administrator and the Director of Nursing (DON) on 11/09/18 at 8:30 AM revealed LPN #3, #27, #133, #156 and #177 performed IV therapy for Resident #58 and #76 without having IV training and verification of such. Immediate Jeopardy was abated on 11/08/18 at 6:47 PM, The facility completed a full audit of all residents who had IV access that would require IV therapy. The facility revised the staffing schedule to ensure a Registered Nurse (RN) or an IV trained and verified LPN would be performing IV therapy for the four residents with IV access and any newly admitted residents with IV access. Although the Immediate Jeopardy was removed, the facility remained out of compliance at severity level two (no actual harm, with potential for more than minimal harm that is not immediate jeopardy) until LPNs are trained and competent with IV therapy. See F726 (Staff Competency) for additional information. Findings included: 1. A comprehensive chart review for Resident #58 was conducted on 11/06/18 at 11:07 AM and noted the following information. The Admission Record identified Resident #58 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Per review of the hospital records, Resident #58 was admitted to the hospital on [DATE] after a CT (computerized tomography) scan identified the resident had [MEDICAL CONDITION]. Resident #58 was diagnosed with [REDACTED]. Resident #58's re-admission Physician order [REDACTED]. The document stated under the section Other Orders, a peripherally inserted central catheter (PICC) with two lumens (a lumen is tube for obtaining blood or giving IV medications through) was in place. A PICC line is a thin, soft, long catheter (tube) that is inserted into a vein in the upper arm, leg or neck. The tip of the catheter is positioned in a large vein that carries blood into the heart. The PICC line is used for long-term intravenous (IV) antibiotics, nutrition or medications, and for blood draws, which is considered IV therapy. An initial Nursing assessment dated [DATE] noted Resident #58 had a PICC line upon admission back to the facility. A care plan was initiated on 10/27/18 and documented the PICC line was inserted due to a pending [MEDICAL CONDITION] start date. There was no information on the care plan that directed the clinical staff to change the transparent dressing or to change the needleless connection device after blood was taken from these devises. A comprehensive Minimum Data (MDS) assessment dated [DATE], was reviewed. Section C for Cognition revealed a Brief Interview for Mental Status (BIMS) test scored Resident #58 as 15 out of 15 which indicated the resident was fully cognitively intact. An interview was conducted with Resident #58 on 11/05/18 at 3:07 PM. During this interview the resident showed her PICC site on her right arm. The resident said that she needs her blood drawn from the needleless connection device since she has tiny veins. During this interview, her transparent dressing site was observed and there was a hand-written area dated 10/22/18. Continued review of the chart on 11/06/18 at 11:07 AM, revealed a document entitled Central Line Catheters for the month of (MONTH) (YEAR) and (MONTH) (YEAR) had an area identified as Change Needleless Connection Device. For the month of (MONTH) (YEAR), the transparent dressing was scheduled to be changed on 10/27/18. This area was not signed off as completed. There was a section on this form that directed staff to sign off if needleless connection devices were changed after a blood draw. The laboratory results were reviewed and noted the Resident #58 had blood draws on 10/29/18. There was no documented evidence on the central line catheter form that the needleless connection devices were changed after this blood draw. For the month of (MONTH) (YEAR), the central line form identified Resident #58 had her transparent dressing changed on 11/05/18, ten days after admission. The resident also had a blood draw on this same date. There was no documented evidence on the central line form that indicated the needleless connection devices were changed after the blood draw. On 11/06/18 at 1:24 PM, in an interview with LPN #156 on the unit, she revealed she did not have a great deal of experience with PICC lines but had performed IV therapy. She stated infection control was critical with the PICC line device. She stated the time frame for changing the dressing of a PICC line was three days and the orders were pre-printed on the PICC line form. The DON confirmed LPN #156 signed the PICC line flush order for Resident #58 as completed on 10/27/18. The audit completed by the Administrator and the DON could not verify IV training for LPN #156. Another interview was conducted with Resident #58 on 11/06/18 at 2:15 PM. She verified that she had blood drawn from her PICC line since her readmission to the facility. She said that she was unsure if the clinical staff changed the tips of the PICC lumen after each blood draw or not. An interview was conducted with Registered Nurse (RN) #173 on 11/06/18 at 3:34 PM. RN #173 verified the PICC line connections devices had not been changed when the dressing was changed on 11/05/18. She stated the needleless connection devices were to be changed after each blood draw. On 11/07/18 at 10:27 AM, the DON was interviewed. She stated she was not aware that LPN's were performing IV therapy without training and verification. The DON and the Administrator were interviewed on 11/07/18 at 11:10 AM. The DON confirmed there was no evidence to show the needleless connection devices were changed after the blood draws. On 11/08/18 at 9:46 AM, a telephone interview was conducted with LPN #3 related to Resident #58 PICC line orders. LPN #3 stated, she was the nurse who signed off on the central line and said she was trained in IV and PICC therapy. She stated she could only flush the PICC line. LPN #3's initials were verified by the DON as documented performing IV therapy for Resident #58. The audit completed by the Administrator and the DON confirmed LPN #3 was not verified as trained in IV therapy. During interview with the DON on 11/08/18 at 11:30 AM, she confirmed the dressing had not been changed since the resident was re-admitted to the facility on [DATE]. According to the Central Line Catheter flowsheet, the dressing and connection devices were scheduled to be changed on 10/27/18 on the 7A - 7P shift. The box to document completion was blank. On 11/08/18 at 11:37 AM, an interview was conducted with RN #15. RN #15 confirmed LPN #3 was the nurse who flushed the PICC line in (MONTH) and (MONTH) (YEAR). She stated she was not aware of LPN #3 performing IV therapy without training. 2. A focused chart review for Resident #76 was conducted on 11/08/18 at 12:30 PM. The following information was reviewed related to Resident #76's IV port (a round disc placed under the skin with an internal catheter for intravenous access): The Admission Record identified Resident #76 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the care plan for Resident #76 initiated on 05/12/16, revealed an Infusaport (an IV port placed in the upper chest for intravenous access). The goal stated, the resident would have no complications related to IV therapy. The interventions stated, flush the port per facility policy and RN to access and flush port every month as ordered. Review of the form titled, Central Venous Access Device ([MEDICAL CONDITION]) - Physician/Licensed Independent Practitioner (LIP) Order Sheet dated 10/01/18 was completed. The order stated, RN to access 28th of month Flush with 10ml (milliliters) of NS (normal saline) then de-access (sic) (de-access) (to remove the needle and catheter used to flush, give medications or obtain blood through). Review of Resident #76's Central Line Catheter Protocol orders for the month of (MONTH) (YEAR) were completed. Resident #76 was prescribed tigecycline (antibiotic) 100mg (milligrams) IV for one dose then, 50 mg IV every 12 hours for five days for a urinary tract infection. Also, RN: access 1P (infusaport) 28th each month, Flush 10ml with NS (normal saline) and deaccess (sic) (de-access). The Infusion Medication and Central Line Catheters flowsheets for the month of (MONTH) (YEAR) was reviewed. The medication and the IV flush order for (MONTH) (YEAR) was documented as completed twice a day for five days and signed by the nurse administering. LPN's #3, #27, #133, #156 and #177 were documented as flushing and/or administering the IV antibiotic medication. In an interview with the DON on 11/08/18 at 2:34 PM, she confirmed two of the LPN signatures identified on the Infusion Medication and Central Line Catheter flowsheets were not trained in IV therapy. On 11/08/18 at 2:48 PM, LPN #27 was interviewed by phone. She stated she had not completed an IV course. She stated she accessed Resident #76's IV port by hanging the IV medication and hooking the medication solution bag to the tubes in the port. She stated after the antibiotic medication was completed, she flushed the IV port tube. The facility's policy titled, IV Nursing Qualifications and Education dated revised 03/15/16 was reviewed. The policy stated, .The (company name) licensed nursing staff may perform infusion therapy activities based on the state regulations and must successfully complete a (company name) infusion therapy education program, a current pharmacy vendor provided program, or the Test - Out.licensed staff must demonstrate skills competency prior to administering and managing infusion therapy.licensed staff nurses must complete the IV Skills Self - Assessment to evaluate experience.competency .will be maintained in the employee's personnel file. The undated Competency Testing Module was reviewed. The note for newly hired nurses' states information related to IV therapy under the LPN scope of practice versus the RN scope of practice. The form stated, State requirements must be followed when more restrictive. Under the title, Tier 1, the LPN cannot perform during orientation until completion of Management of Infusion Therapy Course and associated competencies. The facility policy entitled, Central Vascular Access Device ([MEDICAL CONDITION]) Dressing Change dated as revised on 05/01/16. The policy stated, .Licensed nurses according to state law and facility policy. The nurse is responsible and accountable for obtaining and maintaining competence with infusion therapy within his or her scope of practice. Competency validation documented in accordance with organizational policy.the dressing was to be changed, .24 hours post insertion or upon admission and at least weekly. The facility policies entitled Central Vascular Access Device ([MEDICAL CONDITION]) Needleless Connector Change dated as revised 05/01/16. The policy stated, .Needleless connectors are changed .Upon admission at least every 7 days .After blood is drawn through the needleless connector .Any time the integrity of the needleless connector is in question .

Based on record review, staff interview, review of the State Board of Examiners for Licensed Practical Nurses, and review of the facility policy, the facility failed to ensure Licensed Practical Nurses (LPN) who performed the skill set of Intravenous (IV) therapy were competent and trained to perform IV therapy within their scope of practice and state regulations. The facility was unable to provide verification of competency and IV training for five (#3, #27, #133, #156 and #177) of 13 LPNs who were performing IV therapy. This practice resulted in Immediate Jeopardy. On 11/08/18 at 4:27 PM, the Administrator and the Director of Nursing (DON) were notified verbally that Immediate Jeopardy existed and began on 10/26/18, when Resident #58 was readmitted with a peripheral inserted central catheter (PICC). According to nurse standards of practice and state regulations, only Registered Nurses and trained LPNs with verification were to perform IV therapy. According to an audit provided by the Administrator and the DON on 11/09/18 at 8:30 AM, LPN #3, #27, #133, #156 and #177 performed IV therapy without having IV training and verification as required by the facility. Immediate Jeopardy was abated on 11/08/18 at 6:47 PM, The facility by completing a full audit of all residents who had IV access that would require IV therapy. The facility revised the staffing schedule to ensure an RN or an IV certified LPN would be performing IV therapy for the four residents with IV access and any newly admitted residents with IV access. Although the Immediate Jeopardy was removed, the facility remained out of compliance at severity level two (no actual harm, with potential for more than minimal harm that is not immediate jeopardy) until LPNs were trained and competent with IV therapy including PICCs (peripheral inserted central catheters which is a thin, soft, long catheter (tube) that is inserted into a vein in the upper arm, leg or neck and positioned in a large vein that carries blood into the heart). See F883 (Facility Assessment), F867 (QAPI) and F684 (Quality of Care) for additional information. Findings included: Review of the State Board of Examiners for Licensed Practical Nurses on 11/06/18 at 3:56 PM, revealed the following: .Licensed Practical Nurses perform duties and procedures for which training has been provided during the 12-month training program. The administration of IV fluids is not a part of the standard curriculum for accredited schools of practical nursing in the state.Each LPN would have to have extra training after graduating and taking state boards. In an interview with staff development Registered Nurse (RN) #15, on 11/06/18 at 4:03 PM, it was revealed she was unaware of the scope of practice related to IV training and verification for LPNs. Interview with RN #15 on 11/08/18 at 10:12 AM, revealed she did not have copies of all of the LPN's IV training and verifications. She stated she should have requested and kept copies when the staff members were hired. An interview was conducted on 11/08/18 at 11:20 AM with RN #15. She stated an audit of LPN staff with IV training and verification was completed on 10/03/18. She stated a portion of the LPN staff were not IV trained. She did not provide the number of LPNs not trained in IV therapy. She notified the DON and the Administrator of the audit result. She stated she would not know which LPN was working out of their scope of practice because she did not have a copy of each LPN's IV to verify training. In an interview with RN #15 on 11/08/18 at 4:40 PM, she revealed she provided orientation for newly hired LPNs. She stated she has the new employees come in for two days of orientation and competency training on medication administration and IV care and competency. She stated, even if an LPN has verification of IV training, the LPN would still need to attend the pharmacy IV course per facility policy. She stated LPNs who were not IV trained should know better than to do something outside their scope of practice. She stated none of the newly hired nurses during orientation IV competency had ever told her they could not touch IVs due to not being trained. On 11/08/18 at 5:41 PM, RN #15 provided the Nursing Qualifications and Education policy regarding IV nursing and the revision was dated 03/15/16. The document was titled, Competency Testing Module. The policy revealed the following: . (the company) licensed nursing staff may perform infusion (IV) therapy activities based on state regulations and must successfully complete a (company) infusion (IV) therapy education program, a current pharmacy vendor provided program or the Test - Out.Newly hired nurses may complete the IV Skills Self-Assessment to evaluate experience.Verification of the nurses' completion of an infusion (IV) education program, ongoing training and skills competency, and attendance at in-services will be maintained in the employee's personnel file. A review of the new orientation Competency Testing module packet for nurses was completed on 11/08/18 at 5:41 PM. The following information was noted: .In order to assure that Nursing is able to deliver quality care in a safe manner. It is necessary to perform competency testing on license nurses. Part of the competency testing listed in the packet was Infusion Therapy Skills. The packet information stated, in order for a license practical nurse (LPN) to perform infusion therapy they must be in compliance with state regulations and must be followed. On 11/08/18 at 6:44 PM, the Administrator stated she had not been aware there were LPNs [MEDICATION NAME] outside of their scope of practice.

Based on interview and review of the Facility Assessment Tool, the facility failed to ensure Licensed Practical Nurses (LPNs) were competent performing Intravenous (IV) therapy for the resident population. This affected five (#3, #27, #133, #156 and #177) of 13 LPNs performing IV therapy without IV training and verification of such. On 11/08/18 at 4:27 PM, the Administrator and the Director of Nursing (DON) were notified verbally that Immediate Jeopardy existed and began on 10/26/18, when Resident #58 was readmitted with a peripheral inserted central catheter (PICC). Resident #58 and #76 was ordered to have IV therapy. According to an audit provided by the Administrator and the DON on 11/09/18 at 8:30 AM, LPN #3, #27, #133, #156 and #177 performed IV therapy for Resident #58 and #76 without having IV training and demonstrating competency. Immediate Jeopardy was abated on 11/08/18 at 6:47 PM, The facility completed a full audit of all residents who had IV access that would require IV therapy. The facility revised the staffing schedule to ensure an RN or an IV certified LPN would be performing IV therapy for the four residents with IV access and any newly admitted residents with IV access. Although the Immediate Jeopardy was removed, the facility remained out of compliance at severity level two (no actual harm, with potential for more than minimal harm that is not immediate jeopardy) until LPNs were trained and competent in IV therapy. See F726 (Staff Competency), F867 (QAPI) and F684 (Quality of Care) for additional information. The facility census was 128. Findings included: The Facility Assessment Tool dated 11/27/17 was reviewed on 11/08/18 at 8:30 AM. The facility assessment identified in Section, Acuity, that the facility offered IV medications to two residents at the time the assessment was completed. In the Section, Resident support/care needs, the facility documented IV (peripheral or central lines) therapy would be a service the facility provided. In the Section Staff training/education and competencies, the facility identified IV therapy as one of the educations and training competencies reviewed and provided throughout the year as needed related to resident acuity. In the Section, Working with medical practitioners, the company was to ensure licensed credentialed care providers were to adhere to standards of practice and if gaps in this system would be addressed as they arose. In Section Staff type, LPN's were identified as providing direct care for residents related to the facility acuity assessment. An interview was conducted on 11/08/18 at 11:20 AM with Registered Nurse (RN) #15 who was responsible for staff development. She stated she completed an audit on 10/03/18 regarding which LPN staff had IV certification. She stated she identified a number of LPN staff who were not IV trained to perform IV therapy. She notified the Director of Nursing (DON) and the Administrator of the result of her audit. She stated the facility did not have a system to monitor IV training of the LPN's. An interview was conducted on 11/08/18 at 12:30 PM with the Administrator and the DON. The Administrator and the DON stated they were notified of RN #15's audit regarding LPN IV certification. However, they were not aware any LPNs were performing IV therapy without verification of IV training. The Administrator stated she had not revised the facility assessment to reflect the need for standards of care and competencies for LPNs who were non-IV trained. She stated the facility does review annually the Facility Assessment Tool; however, had not been updating it as needed. She stated she was responsible for the facility assessment and coordinating the information incorporated in the facility assessment. On 11/09/18 at 10:05 AM, an interview with RN #15 Staff Development was completed. She stated, Human Resources (HR) notifies her that a new LPN has been hired. She stated the facility used an Excel spreadsheet for IV competencies. She stated whoever checks the nurse for IV competency would complete the Excel spreadsheet. She stated she could not determine by the Excel spreadsheet which LPN had training or not. RN #15 stated, in order to be completely checked off for IV competency, the LPN would have to complete the pharmacy IV course. She could not provide a response for how the facility was ensuring LPNs who were not IV trained were not performing therapy related to PICC (peripheral inserted central catheter) lines and IV ports. A PICC line is a thin, soft, long catheter (tube) that is inserted into a vein in the upper arm, leg or neck. The tip of the catheter is positioned in a large vein that carries blood into the heart. The PICC line is used for long-term intravenous (IV) antibiotics, nutrition or medications, and for blood draws, which is considered IV therapy. On 11/09/18 at 10:54 AM, an interview with RN #15 Staff Development was completed. RN #15 stated she does not have an LPN do anything hands on with a resident in regard to IV competency. She stated the training is all done in a classroom. She stated the LPN was told not do anything with IVs; a port or a PICC line until they have been IV trained through the pharmacy.

Based on record review, resident interview, and staff interview, the facility failed to ensure Resident #3's ability to ambulate did not decline unless unavoidable. This was true for one (1) of six (6) sampled residents. Resident #3's physical therapy was discontinued on 01/25/16 at which time he was able to ambulate 55 feet with minimal assistance using a wheeled walker with contact guard and verbal cues. His prognosis at the time of discharge from physical therapy was, Good to maintain min (minimal) a (assist) overall with RNP (Restorative Nursing Program) and nursing transfers. The physical therapist recommended a Restorative Nursing Program for gait training/ambulation. This restorative nursing program was never implemented and Resident #3 was not assisted with ambulation by nursing after his discharge from physical therapy on 01/25/16. On 03/16/16 physical therapy completed another evaluation and Resident #3 was placed back onto therapy's caseload. The residents' baseline ability to ambulate with a wheeled walker on 03/16/16 was 10 feet with maximal assistance. This demonstrated a significant decline in the distance he was able to ambulate and his assistance needed when ambulating compared to his abilities at discharge from physical therapy on 01/25/16. The facility's failure to provide the recommended RNP to Resident #3 upon his discharge from physical therapy on 01/25/16 likely contributed to Resident #3's decline in his abilities to ambulate therefore constituting actual harm to Resident #3. Resident Identifier: #3. Facility Census: 121. Finding include: a) Resident #3 Review of Resident #3's medical record at 12:46 p.m. on 04/12/16, found an admission date of [DATE]. Further review of the medical record found he received physical therapy during the following time frames: 09/21/15 through 10/19/15, 01/11/16 through 01/25/16, and 03/16/16 through 03/25/16. Review of the physical therapy initial evaluation dated 01/11/16 completed by the Director of Rehabilitation Physical Therapist (PT) # 150 found, Resident #3 placed onto Physical Therapy's case load on 01/11/16 with a long term goal of being able to safely ambulate on all surfaces 20 feet using a wheeled walker and contact guard with verbal cues to achieve reduction in risk of falls and/or functional decline. Review of the physical therapy discharge summary completed by PT #150 on 01/29/16 found upon discharge from physical therapy on 01/25/16, Resident #3 was able to ambulate 55 feet with minimal assistance. In the comments section PT #150 noted, again min (minimal) a (assistance) consistently but improved from overall mod (moderate) a (assistance) and buckling during gt (gait) gt (gait) pattern has improved. The discharge recommendations of PT #150 was for Resident #3 to have a RNP for gait training/ambulation and minimal assistance transfers with nursing. The discharge [DIAGNOSES REDACTED]. Further review of the medical record found no indication the RNP recommended by PT #150 for Resident #3 was ever implemented. Review of the restorative nursing records found no records for this time frame. Review of the Activities of Daily Living (ADL) flow sheets found Resident #3 had no occurrences of ambulation in his room or in the corridor until April 2016. Review of the Physical Therapy Initial Evaluation completed by PT #150 on 03/16/16 (electronically signed for completion on 03/20/16) found the following under the section titled, Problem List/Impairments typed as written: Pt (Patient) at this time does show a decline in overall gt (gait) with RW (rolling walker) and max ( maximal) a (assistance) levels with significant knee instability and increase risk for falls. pt is min (minimal) a (assistance) overall with transfer from bed to chair and to bed but unsafe and buckling of B (Bilateral) knees in stance also showing increase risk for falls. weakness noted In BLE (bilateral lower extremities) with RNP completed. Under the section titled, Skilled Justification, PT #150 noted (typed as written): pt (patient) at this time requires POC (Plan of Care) x (times) 1 wk (week) to regain strength and min (minimal) a (assistance) overall with with gt (gait/ambulation) and RNP to maintain function and activity within facility at max (maximum) potential. pt (patient) request due to his noted decline and request to walk daily. PT #150 noted a decline in the residents gait/ambulation with a rolling walker. She also noted the RNP was completed however there is no indication in the record that Resident #3 ever received a RNP after his most recent discharge from Physical Therapy on 01/25/16. Due to Resident #3's noted declines he was again placed on the Physical Therapy case load and the following long term goals were developed, Patient will safely ambulated on all surfaces 50 feet using a Wheeled Walker with minimal assistance with verbal cues to achieve a reduction in risk of falls and/or functional decline. And, Complete as RNP for gt (gait training) as well as there (therapeutic) ex (exercises) for 3-5 times per week for 6 weeks to maintain min (minimal) a (assistance) activity for gt (gait/ambulation) within facility per pts (patients) request. PT #150 noted Resident #3's baseline on 03/16/16 in regards to ambulation was 10 feet with maximal assistance. This was a significant decline from his noted status by PT #150 on 01/25/16 of 55 feet with minimal assistance. An interview with PT #150 at 3:53 p.m. on 04/12/16, confirmed Resident #3's RNP was not implemented upon his discharge from physical therapy on 01/25/16. She indicated she should have completed a Restorative/Rehabilitation Nursing Program Plan and then met with the Restorative Nurse and educated Restorative on the plan. She indicated this was never done therefore nursing was not aware Resident #3 needed to be placed on a restorative ambulation plan. PT #150 was then asked what type of RNP did Resident #3 require in January 2016 she stated the plan should have been implemented for ambulation with a rolling walker to maintain and/or improve his ambulation abilities at the time of his discharge from Physical Therapy on 01/25/16. PT #150 was then asked why Resident #3 required physical therapy again beginning on 03/16/16, she indicated that it was due to a decline in his ability to ambulate and that he and his family indicated he would like to have assistance with walking each day to build up his strength. PT #150 was then asked if Resident #3 has since regained and maintained his abilities to ambulate since his Physical therapy and the subsequent RNP began in March 2016 she stated that he has. An interview with Resident #3 at 8:30 a.m. on 04/14/16 confirmed that he was now getting to walk almost every day with nursing. He stated he can tell his legs are getting a lot stronger and that he has made big improvements since March 2016. He indicated that he wishes they would have been helping him to walk sooner than this. During an interview with the Director of Nursing (DON) at 10:06 a.m. on 04/13/16, she asserted Resident #3 could not have had a decline in ambulation since prior to his most recent discharge from therapy on 03/23/16 he had never walked with nursing. Her statement is true, nursing had not assisted Resident #3 with walking until 03/29/16 which is the date his current RNP began. This however; was not because Resident #3 was unable to walk, but was a result of the facility's failure to implement the RNP for ambulation recommended by PT #150 upon his discharge from physical therapy on 01/25/16. At that time he had the ability to walk at least 55 feet with minimal assistance as noted in the Physical Therapy Discharge Summary. If the facility would have implemented the RNP then Resident #3 would have began walking with nursing prior to 03/29/16 and could have possibly avoided the decline in his ambulation ability between 01/25/16 and 03/16/16.

Based on record review and staff interview, the facility failed to ensure each resident received care and services to assist them in attaining and/or maintaining their highest practicable level of well-being, affecting two (2) of thirty-two (32) Stage II sample residents and resulting in actual harm to one (1) of these residents (#61). Resident #61, who was readmitted to the facility on [DATE], was receiving multiple antihypertensive (blood-pressure reducing) medications for hypertension (high blood pressure), for which staff was to assess her blood pressure prior to administration and hold these medications if her systolic blood pressure (SBP) was greater than 110 mmHg. On 12/17/10, 12/18/10, 12/19/10, 12/20/10, and on the morning of 12/21/10, Resident #61 received scheduled doses of antihypertensives without evidence that staff had assessed her SBP prior to each dose. At 10:00 a.m. on 12/21/10, Resident #61 was transferred to the hospital for low blood pressure. Resident #48's personal preferences for advance directives, as expressed on the resident's Physician order [REDACTED]. The resident's monthly recapitulation of physician's orders [REDACTED]. not honoring the resident's advance directives for end-of-life care. Resident identifiers: #61 and #48. Facility census: 124. Findings include: a) Resident #61 Medical record review revealed this [AGE] year old female's active [DIAGNOSES REDACTED]. The resident was receiving [MEDICAL TREATMENT] outside the facility on Monday, Wednesday, and Friday. Further review revealed the resident's initial admission to the facility was on 11/23/10. She had several admissions and discharges to the facility before her discharge to home on 02/09/11. The resident was re-admitted to the facility on [DATE]. Review of the December 2010 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]'s systolic blood pressure before administration as follows: - [MEDICATION NAME] 2 mg by mouth three (3) times a day (TID) at 8:00 a.m., 2:00 p.m., and 10:00 p.m. - [MEDICATION NAME] 50 mg by mouth TID at 8:00 a.m., 2:00 p.m., and 10:00 p.m. Hold if SBP is less than 110. - [MEDICATION NAME] 5 mg by mouth two (2) times at day (BID) at 9:00 a.m. and 9:00 p.m. Hold if SBP is less than 110. - [MEDICATION NAME] 0.2 mg by mouth TID at 6:00 a.m., 2:00 p.m., and 10:00 p.m. Hold if SBP is less than 110. According to the physician's orders [REDACTED]. This would require nursing staff to obtain the resident's SBP daily at the following times: 6:00 a.m., 8:00 a.m., 9:00 a.m., 2:00 p.m., and 10:00 p.m., to assure the SBP was not less than 110 mmHg before administering the medications prescribed to treat the resident's hypertension. On 12/17/10, the resident was readmitted to the facility at 8:28 p.m. The facility obtained the resident's blood pressure at 8:28 p.m., according to documentation on the weights and vitals summary. Review of the MAR indicated [REDACTED] On 12/18/10, the facility obtained the resident's blood pressure at 9:37 a.m., according to documentation in the facility's weights and vitals summary. According to documentation on the MAR, nursing staff administered [MEDICATION NAME] 50 mg at 8:00 a.m., 2:00 p.m., and 10:00 p.m.; [MEDICATION NAME] 25 mg at 8:00 a.m., 2:00 p.m., and 10:00 p.m.; [MEDICATION NAME] 0.2 mg at 6:00 a.m., 2:00 p.m., and 10:00 p.m.; and [MEDICATION NAME] 5 mg at 9:00 a.m.. On 12/19/10, the resident's blood pressure was obtained at 7:41 p.m., according to the documentation in the facility's weights and vitals summary. Documentation on the MAR indicated [REDACTED] On 12/20/10, the resident's blood pressure was obtained at 4:53 p.m. and 7:12 p.m., according to the documentation on the facility's weights and vitals summary; however, nursing notes written on 12/20/10 stated the resident was out of the facility at [MEDICAL TREATMENT] and did not return to the facility until 6:00 p.m. on 12/20/10. Review of the MAR indicated [REDACTED] On 12/21/10, a nursing note documented the resident's blood pressure was 87/37 when obtained at 10:00 a.m. The resident was sent to the hospital. Further review of the medical record revealed a transfer form to the hospital which documented the reason for the transfer as: "BP (blood pressure) 88/37 (symbol for arrow) 80/40 P (pulse) 67." The 12/21/10, a nursing note also documented, "... AM (morning) meds. (medications) not given d/t (due to) low BP..." Review of the MAR indicated [REDACTED]. There was no evidence the resident's SBP pressure was verified before administering the 6:00 a.m. dose of [MEDICATION NAME]. In an interview with the facility's acting director of nursing on the afternoon of 04/26/11, she verified the resident's blood pressures would be documented in the nursing notes or on the weights and vital summary. She was unable to produce documentation to verify the resident's SBP was consistently obtained as ordered by the physician before administering the above antihypertensive medications at the documented dates and times. She was unable to explain how the resident's blood pressure was obtained at 4:53 p.m. on 12/20/10 when the resident was not at the facility. Multiple antihypertensive medications were administered daily from 12/17/10 through 12/21/10, at numerous times throughout the day, without first verifying the resident's SBP was not less than 110 mmHg, as directed by the resident's physician. The resident was transferred to the hospital for low blood pressure on 12/21/10. -- b) Resident #48 Review of Resident #48's monthly recapitulation of physician's orders [REDACTED]. Review of the resident's POST form, dated 11/19/10, found in Section B the resident had chosen limited additional interventions. Review of Section E of the POST form also found the basis for this order was the resident's personal preferences, which had been discussed with the health care surrogate (HCS). In an interview on 04/28/11 at 9:30 a.m., the registered nurse (RN) unit manager (Employee #52) disclosed the resident's HCS had rejected an offer of hospice services, because he did not want comfort measures only. Employee #52 also confirmed, during this interview, that the monthly recap orders did not agree with the information found on the resident's POST form respect to advance directives. .

Based on medical record review and staff interview, the facility failed to ensure a resident did not develop pressure ulcers unless the resident's clinical condition demonstrated they were unavoidable. On 01/06/11, a nurse assessed Resident #92 (who had no history of a pressure ulcer to her coccyx since at least 10/01/09) as having an area on her coccyx measuring 5.25 cm x 2 cm x 0 cm and identified as "incontinence-associated [MEDICAL CONDITION]" or "IAD". According to a skin integrity report with entries made weekly from 01/09/11 until 03/20/11, the alteration in skin integrity on the resident's coccyx / buttocks continued to be identified as IAD. On 03/23/11, the area was then identified as a Stage 3 pressure ulcer measuring 8.0 cm x 7.5 cm x 0.3 cm with granulation, slough, and [MEDICATION NAME] tissue present. No interventions had been implemented to prevent worsening of the area of altered skin integrity, other than the application of INZO ("invisible zinc oxide") cream, until after it was identified as a Stage 3 pressure sore. This resulted in actual harm to one (1) of thirty-two (32) Stage II sample residents. Resident identifier: #92. Facility census: 124. Findings include: a) Resident #92 1. Review of Resident #92's most recent comprehensive assessment, an annual minimum data set version 3.0 (MDS 3.0) with an assessment reference date (ARD) of 03/08/11, revealed this [AGE] year old female was admitted to the facility on [DATE]. In Section G, the assessor noted Resident #92 was totally dependent on staff for all activities of daily living including bed mobility, transferring, and toilet use, with impairments on both sides with functional limitations in range of motion in her upper and lower extremities. In Section I, the assessor noted her active diagnoses, including [MEDICAL CONDITION], dementia other than Alzheimer's, [MEDICAL CONDITIONS], cancer, wound infection (other than foot), and cardiac [MEDICAL CONDITION]. In Section M, the assessor indicated Resident #92 was at risk for developing pressure ulcers (based on the use of a formal assessment instrument / tool and clinical assessment), she did not currently have any unhealed pressure ulcers, and no pressure ulcers were present on the prior MDS. Also in Section M, the assessor noted that none of the following conditions was present: infection of the foot, [MEDICAL CONDITION](s), other open [MEDICAL CONDITION] on the foot, open lesion(s) other than ulcers, rashes, cuts, surgical wound(s), and burn(s). According to documentation in Section M1200 (skin and ulcer treatments), Resident #92 was receiving a pressure reducing device for her chair and bed, a turning / repositioning program, the application of non-surgical dressings other than to feet, and the application of ointments / medications other than to feet. -- 3. Review of Resident #92's previous assessment, an abbreviated quarterly MDS 3.0 with an ARD of 12/12/10, revealed the following information in Section M: She was at risk for developing a pressure ulcer (based the presence of a Stage 1 or greater ulcer, scar over bony prominence or a non-removable dressing / device, the use of a formal assessment instrument / tool, and clinical assessment), and she currently had an unhealed pressure ulcer at Stage 3 measuring 0.6 cm x 0.5 cm x 0.1 cm for which she was receiving a pressure reducing device for her chair and bed, ulcer care, and the application of ointments / medications other than to feet. -- 4. On 04/27/11 at 12:30 p.m., an interview with a registered nurse (RN - Employee #84) revealed Resident #92 had a pressure ulcer that was acquired in-house. -- 5. Review of Resident #92's skin integrity report, with an "initial date" of 01/06/11 that resident was noted to have [MEDICAL CONDITION] to her buttocks / coccyx area. No further description of the area's characteristics was provided for this date, such as a description of the area's appearance or any measurements of the area's dimensions. An entry on this skin integrity report, dated 01/09/11, indicated no pressure ulcer was present, the skin's appearance was described as "I" ("intact/pink"), the area measured as 5.25 cm x 2 cm with no depth, and no update was made to the resident's care plan. The next entry on the skin integrity report, dated 01/16/11, indicated no pressure ulcer was present, the appearance of the area of [MEDICAL CONDITION] was coded "I", "scattered" written in lieu of any measurements of the area's dimensions, with no change in the area and no update made to the resident's care plan. Entries dated 01/23/11 and 01/30/10 related similar details. The next entry on the skin integrity report, dated 02/07/11, indicated no pressure ulcer was present, the appearance of the area was coded "I/peeling" with "scattered" in lieu of any measurements of the area's dimensions. The block for indicating whether any updates were made to the resident's care plan was left blank. The next entry dated 02/14/11 was the same. (Note the assessor was using the terms "I" (for "intact/pink") and "peeling" simultaneously to describe the area's appearance.) An entry dated 02/21/11 indicated no pressure ulcer was present, the appearance of the area was coded as "I/flaking" with "scattered" written in lieu of any measurements of the area's dimensions. There was no change in the area, and the block for indicating whether any updates were made to the resident's care plan was left blank. The next entry on the skin integrity report, dated 02/28/11, indicated no pressure ulcer was present, the appearance of the area was coded as "I/peeling" with "scattered" in lieu of any measurements of the area's dimensions. The block for indicating whether any updates were made to the resident's care plan was left blank. The next entry on the skin integrity report, dated 03/06/11, indicated no pressure ulcer was present, the appearance of the area was coded as "I/peeling", with "scattered" written in lieu of any measurements of the area's dimensions, no change in the area, and no update made to the resident's care plan. The next entry on the skin integrity report, dated 03/14/11, indicated no pressure ulcer was present, the appearance of the area was coded as "I/peeling" with "scattered" in lieu of any measurements of the area's dimensions. The block for indicating whether any updates were made to the resident's care plan was left blank. The next entry on the skin integrity report, dated 03/20/11, indicated no pressure ulcer was present, the appearance of the area was coded as "SB" ("blister/serous"), the area now measured 8 cm x 5 cm x 0.2 cm with "SS" ("serosanguineous") drainage present. The assessor coded the wound edges as "R" ("rolled"), and no changes were made to the resident's care plan. The next entry on this form was a handwritten note stating, "See new sheet 3/23/11. " Documentation on the new skin integrity sheet identified the initial status of the area on the resident's coccyx / buttocks noted the presence of an IHA (in-house acquired) Stage 3 pressure ulcer identified on 03/23/11. The appearance of the area was coded as "G / S10% / E" ("granulation" / "slough 10%" / "[MEDICATION NAME]"), the area now measured 8.0 cm x 7.5 cm x 0.3 cm with "min SS" ("minimal serosanguineous") drainage and healthy edges present, and no changes were made to the resident's care plan. -- 6. Review of the resident's past MDS assessment revealed Resident #92 was admitted to the facility on [DATE] with no pressure ulcers present on admission. Review of her minimum data set version 2.0 (MDS 2.0) assessments from her annual comprehensive assessment with an assessment reference date (ARD) of 10/01/09 through an abbreviated quarterly assessment with an ARD of 07/13/10 revealed she had no pressure ulcers during any of the assessment reference periods, to include no pressure ulcers present when she returned to the facility from hospital stays on 04/15/10 and 05/26/10. On her abbreviated quarterly MDS 2.0 with an ARD of 09/22/10, the assessor noted the presence of two (2) pressure ulcers - one (1) Stage 2 and one (1) Stage 3, which were acquired in-house. One (1) of these pressure ulcers was healed prior to the MDS of 12/12/10, and the other was healed prior to the MDS 3.0 of 03/08/11, although the MDS 3.0 of 03/08/11 did not acknowledge the presence of a pressure ulcer having been encoded on the preceding MDS. According to her MDS assessments from 10/01/09 through the present, her mobility was impaired, she was incontinent of bowel and bladder, and she was totally dependent on staff for ADL performance. These risk factors for pressure sore development were not new for this resident. -- 7. Review of Resident #92's care plan found the following problem statement, which was created on 10/22/08 and revised on 03/23/11 (quoted as typed): "Resident is at risk for skin breakdown due to decreased mobility and incontinence related to a history of advanced dementia and OA ([MEDICAL CONDITION]) and OP ([MEDICAL CONDITION]). <P> Eval: Continue with focus, goal and interventions. Stage II noted to right heel and stage III noted to left heel per skin intergrity report on 9/21/10. "12/15/10 Eval: Continue with focus, goal and interventions. Stage II noted to left heel per wound report. "1/20/11 Stage III to left heel resolved. (Resident #92) has IAD (incontinence-associated [MEDICAL CONDITION]) notes to buttocks, noted to be improving. 2-10-11- IAD on buttocks. "3/19/11: (Resident #92) continues to have IAD to buttocks. She remains at severe risk for further breakdown related to poor p.o. (oral) intake, hx (history) of pressure ulcers, incontinence, general debility. "3/23/11: IAD on coccyx / buttocks now noted to be St III (Stage 3 pressure ulcer). Remains at severe risk for furhetr breakdown d/t (due to) hx PUs (pressure ulcers), incontinence, and limited mobility." The goal associated with this problem statement was: "(Resident #92) will not show signs of skin breakdown through next review." The interventions established to achieve this goal were (quoted as typed): "Provide prompt peri-care after each episode of incontinence. Apply INZO cream to affected areas with each cleansing. Monitor skin for signs / symptoms of skin breakdown i.e. redness, cracking, blistering, decrease sensation, and skin that does not blanche easily. Provide supplements as ordered. Evaluate for any localized skin problems, i.e. dryness, redness, pustules, inflammation with AM (morning) care. Observe skin condition with ADL care daily and report. LALM (low air loss mattress) with side bolsters." All of the above interventions had creation dates of 10/22/08, with the exception of the LALM, which was added on 03/23/11 - after the Stage 3 pressure ulcer was identified. No new interventions were implemented to address pressure ulcer prevention once the IAD was identified on the resident's buttocks / coccyx until after the area developed into a Stage 3 pressure ulcer. - 8. Review of Resident #92's physician's orders [REDACTED]. On 02/21/11, the physician discontinued the skin paste and ordered INZO cream to the buttocks every shift for excoriation. On 03/23/11, the physician discontinued the INZO cream to the buttocks, ordered the LALM, and ordered the following wound treatment (quoted as written): "Cleanse coccyx / Buttocks /c (with) wound cleanser. Pat dry. Apply Sureprep around wound. Apply Hydrogel gauze to wound & cover /c dry dressing. Change daily & PRN (as needed)." On 04/22/11, the physician ordered (quoted as written), "To be up in geri-chair with two pillows vertical behind her back to float her spine. And one pillow under her calves to float her heels." Review of the resident's nursing progress notes revealed no additional interventions regarding the prevention of the pressure ulcer to the resident's coccyx. Review of the resident's therapy progress notes revealed no interventions to address the prevention of pressure ulcer development on the resident's coccyx / buttocks were initiated until 03/24/11, after the Stage 3 pressure ulcer was identified. -- 9. On 04/28/11 at 10:20 a.m., an interview with a corporate nurse consultant (Employee #54) revealed all interventions, to address pressure ulcer prevention and/or treatment, should have been listed on the care plan or in the progress notes. On 04/28/11 at 10:30 a.m., an interview with the RN (Employee #84) revealed there were no other interventions in place, other than application of the INZO cream to the coccyx. An interview with the therapy program manager (Employee #6) confirmed that therapy interventions to address the treatment of [REDACTED]. .

Based on record review and staff interview, the facility failed to provide adequate monitoring for two (2) of thirty-two (32) Stage II sample residents whose medication regimens included duplicate therapy and/or medication contraindicated for use with the elderly, resulting in actual harm to one (1) of these residents (#61). Resident #61, who was readmitted to the facility on [DATE], was receiving multiple antihypertensive (blood-pressure reducing) medications for hypertension (high blood pressure), for which staff was to assess her blood pressure prior to administration and hold these medications if her systolic blood pressure (SBP) was greater than 110 mmHg. On 12/17/10, 12/18/10, 12/19/10, 12/20/10, and on the morning of 12/21/10, Resident #61 received scheduled doses of antihypertensives without evidence that staff had assessed her SBP prior to each dose. At 10:00 a.m. on 12/21/10, Resident #61 was transferred to the hospital for low blood pressure. Resident #94, a [AGE] year old female resident, was receiving [MEDICATION NAME] three (3) times a day for neck pain, and the use of [MEDICATION NAME] (a drug not recommended for long term use in the elderly due to the potential harmful side effects) was not being monitored as required for Resident #94. Resident identifiers: #61 and 94. Facility census: 124. Findings include: a) Resident #61 Medical record review revealed this [AGE] year old female's active [DIAGNOSES REDACTED]. The resident was receiving [MEDICAL TREATMENT] outside the facility on Monday, Wednesday, and Friday. Further review revealed the resident's initial admission to the facility was on 11/23/10. She had several admissions and discharges to the facility before her discharge to home on 02/09/11. The resident was re-admitted to the facility on [DATE]. Review of the December 2010 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]'s systolic blood pressure before administration as follows: - [MEDICATION NAME] 2 mg by mouth three (3) times a day (TID) at 8:00 a.m., 2:00 p.m., and 10:00 p.m. - [MEDICATION NAME] 50 mg by mouth TID at 8:00 a.m., 2:00 p.m., and 10:00 p.m. Hold if SBP is less than 110. - [MEDICATION NAME] 5 mg by mouth two (2) times at day (BID) at 9:00 a.m. and 9:00 p.m. Hold if SBP is less than 110. - [MEDICATION NAME] 0.2 mg by mouth TID at 6:00 a.m., 2:00 p.m., and 10:00 p.m. Hold if SBP is less than 110. According to the physician's orders [REDACTED]. This would require nursing staff to obtain the resident's SBP daily at the following times: 6:00 a.m., 8:00 a.m., 9:00 a.m., 2:00 p.m., and 10:00 p.m., to assure the SBP was not less than 110 mmHg before administering the medications prescribed to treat the resident's hypertension. On 12/17/10, the resident was readmitted to the facility at 8:28 p.m. The facility obtained the resident's blood pressure at 8:28 p.m., according to documentation on the weights and vitals summary. Review of the MAR indicated [REDACTED] On 12/18/10, the facility obtained the resident's blood pressure at 9:37 a.m., according to documentation in the facility's weights and vitals summary. According to documentation on the MAR, nursing staff administered [MEDICATION NAME] 50 mg at 8:00 a.m., 2:00 p.m., and 10:00 p.m.; [MEDICATION NAME] 25 mg at 8:00 a.m., 2:00 p.m., and 10:00 p.m.; [MEDICATION NAME] 0.2 mg at 6:00 a.m., 2:00 p.m., and 10:00 p.m.; and [MEDICATION NAME] 5 mg at 9:00 a.m.. On 12/19/10, the resident's blood pressure was obtained at 7:41 p.m., according to the documentation in the facility's weights and vitals summary. Documentation on the MAR indicated [REDACTED] On 12/20/10, the resident's blood pressure was obtained at 4:53 p.m. and 7:12 p.m., according to the documentation on the facility's weights and vitals summary; however, nursing notes written on 12/20/10 stated the resident was out of the facility at [MEDICAL TREATMENT] and did not return to the facility until 6:00 p.m. on 12/20/10. Review of the MAR indicated [REDACTED] On 12/21/10, a nursing note documented the resident's blood pressure was 87/37 when obtained at 10:00 a.m. The resident was sent to the hospital. Further review of the medical record revealed a transfer form to the hospital which documented the reason for the transfer as: "BP (blood pressure) 88/37 (symbol for arrow) 80/40 P (pulse) 67." The 12/21/10, a nursing note also documented, "... AM (morning) meds. (medications) not given d/t (due to) low BP..." Review of the MAR indicated [REDACTED]. There was no evidence the resident's SBP pressure was verified before administering the 6:00 a.m. dose of [MEDICATION NAME]. In an interview with the facility's acting director of nursing on the afternoon of 04/26/11, she verified the resident's blood pressures would be documented in the nursing notes or on the weights and vital summary. She was unable to produce documentation to verify the resident's SBP was consistently obtained as ordered by the physician before administering the above antihypertensive medications at the documented dates and times. She was unable to explain how the resident's blood pressure was obtained at 4:53 p.m. on 12/20/10 when the resident was not at the facility. Multiple antihypertensive medications were administered daily from 12/17/10 through 12/21/10, at numerous times throughout the day, without first verifying the resident's SBP was not less than 110 mmHg, as directed by the resident's physician. The resident was transferred to the hospital for low blood pressure on 12/21/10. -- b) Resident # 94 Medical record review revealed Resident #94, a [AGE] year old female, was receiving [MEDICATION NAME] 10 mg every eight (8) hours, which was ordered on [DATE] for a complaint of neck pain. Review of the resident's list of active [DIAGNOSES REDACTED]. Review of OBRA's "Unnecessary Drugs in the Elderly" found [MEDICATION NAME] is a muscle relaxant that is poorly tolerated in the elderly due to it strong [MEDICATION NAME] side effects of sedation, weakness, dry mouth, blurred vision, [MEDICAL CONDITION], constipation, confusion, [MEDICAL CONDITION], and hallucinations. Also discovered during this review was that the use of this drug should be used only for a short duration of not greater than seven (7) days. Review of physician progress notes [REDACTED]. Review of the resident's comprehensive care plan, provided by the interim director of nursing (DON - Employee #109) on 04/27/11, found no problem statement addressing the resident's neck pain and the use of [MEDICATION NAME], with monitoring for side effects and the use of non-pharmacological interventions, had been developed. Further interview with the DON confirmed this was the only care plan available. The use of [MEDICATION NAME] (a drug not recommended for long term use in the elderly due to the potential harmful side effects) was not being monitored as required for Resident #94. .

Based on medical record review, review of hospital records, and staff interview, the facility failed to provide care and services for one (1) of ten (10) sampled residents to prevent an avoidable decline in the condition of a left foot abrasion. On 03/15/11, documentation in Resident #84's medical record described the presence of an "intact" abrasion across the top of the resident's left foot. On 03/16/11, a TED (compression) hose was applied to his foot to reduce [MEDICAL CONDITION]. A clarification order, also dated 03/16/11, directed nursing staff to: "Check skin integrity below TED hose Q (every) shift." On 03/27/11, facility documentation noted the wound had decreased in length, increased in width, and was described as being "intact" with a "scab" present. On 03/30/11, Resident #84 was sent to the hospital at the request of his family for evaluation of the wound. Hospital records revealed this resident had a Stage III pressure sore with damage down to the fascia and required antibiotic therapy for [MEDICAL CONDITION] (infection into the tissues). Medical record review disclosed skin assessments (which were to be done on every shift after the application of the compression hose) were not completed in accordance with a physician's orders [REDACTED]. Facility census: 124. Findings include: a) Resident #84 1. Medical record review, on 04/13/11, revealed this [AGE] year old male resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. This resident was alert and answered simple questions appropriately but had some cognitive and perceptual deficits. His physician determined he lacked the capacity to understand and make informed medical decisions for himself, and his medical power of attorney (MPOA) was serving as his surrogate decision-maker. According to the resident's current comprehensive care plan, which was provided by the facility's staff development nurse (Employee #5) on 04/14/11, this resident was non-ambulatory and dependent upon staff for all activities of daily living (ADLs). -- 2. Review, on 04/12/11, of facility incident / accident reports for the month of March 2011 found an incident report was initiated for Resident #84 on 03/15/11 at 3:00 p.m., for "unwitnessed" abrasions on the tops of both feet. The description of the incident stated (quoted as written), "Abrasions noted to top of Right & Left feet. Previously noted to right foot on 3/3/11. Noted to left foot on 3/13/11." The abrasion on the right foot measured 5 cm x 0.4 cm (with no depth), and the abrasion on the top of the left foot measured 9 cm x 0.5 cm (also with no depth). First aid was to include: "RN assessment - cleanse abrasions, pat dry, apply SurePrep." Review of the facility's investigation into this incident (completed on 03/18/11) found under the heading "Possible Causes for Incident": "Abrasions to bilateral top of feet may have been caused by socks or resident's position. Resident very restless @ (at) times." -- 3. Review of nursing notes, dated 03/13/11 (prior to completion of the incident report) documented (quoted as typed): "(Resident #84) has a new onset / change in skin integrity as evidenced by abrasion. Location: top of left foot. ... New orders obtained. Cleanse site with w/c, pat dry, apply non sting sureprep to site Qshift and leave open to air." A nursing note, dated 03/15/11 at 12:28 p.m., stated: "Lotion applied to bilateral feet per this nurse at this time. Feet dry. Left foot swollen. MPOA aware. Will address with MD." A nursing note, dated 03/15/11 at 15:33 (3:33 p.m.), stated (quoted as typed): "... New orders noted for ted hose, wound nurse consult D/T (due to) previously noted areas on top of feet, and A & D ointment to bilateral feet. MPOA aware of new orders." A nursing note, dated 03/16/11 at 17:24 (5:24 p.m.), stated (quoted as typed): "Order clarification for ted hose to be worn to left leg at all times. Check skin integrity Q shift below ted hose. ..." -- 4. Review of his physician's orders [REDACTED]. Wound care nurse eval." A notation on the order stated (quoted as written), "done 3/15/11 3:45 p.m." Another order was written later on 03/15/11 for: "(1) A&D ointment to bilateral feet Q (every) shift D/T (due to) dry skin. (2) No sting sureprep to to (sic) top of left foot Q day D/T abrasion." Further review found the following clarification order dated 03/16/11: "TED hose to left leg at all times. Check skin integrity below TED hose Q shift." On 03/30/11, an order was received to: "Place TED hose on hold until abrasion to top of left foot is resolved." Also on 03/30/11, an order was received to: "Send resident to (local hospital) ER (emergency room ) for evaluation abrasion & swelling to left foot." -- 5. An assessment recorded by nursing staff at the ER at 19:56 (7:56 p.m.) on 03/30/11 stated (quoted as typed): "... Skin not intact. Pressure sore with damage down to fascia (Stage III) noted. Located on left ankle. Present on arrival (area on lateral ankle and at flexion point of joint). ..." (Note: The definition of a Stage III pressure sore is: "Full thickness skin loss involving damage to, or necrosis of, subcutaneous tissue that may extend down to, but not through, underlying fascia. The ulcer presents clinically as a deep crater with or without undermining of adjacent tissue.") Further review of the hospital records disclosed Resident #84 was treated in the ER with intravenous (IV) antibiotics ([MEDICATION NAME] and [MEDICATION NAME]), and he was discharged back to the facility with an order for [REDACTED]. According to the nursing notes, Resident #84 returned to the facility at 3:30 a.m. on 03/31/11. The physician's assistant saw Resident #84 on the afternoon of 03/31/11 and gave the following orders at 3:45 p.m.: "1) D/C (discontinue) order for Sureprep to top of Lt (left) foot. 2) Cleanse top of Lt foot /c (with) wound cleanser, Pat dry. Apply [MEDICATION NAME] gel & cover /c dry dressing. Change daily & PRN. 3) Consult wound clinic. 4) Keflex 500 mg po (by mouth) qid (four (4) times a day) x 10 days for [MEDICAL CONDITION]." -- 6. On 04/13/11, the facility's nurse practice educator (NPE), a registered nurse (RN - Employee #5) was asked for evidence of the weekly skin assessments and the skin integrity assessments (ordered on [DATE]) to be done on every shift following the application of the TED hose to Resident #84. Employee # 5 stated these assessments would have been recorded in the nursing notes on every shift. -- 7. Review of nursing notes from 03/16/11 (when the TED hose to the left foot was ordered) to 03/30/11 (when application of the TED hose was put "on hold") found no evidence of skin assessments of the left foot having been completed on every shift as ordered. - A nursing note, dated 03/17/11 at 9:27 a.m., stated: "Previously noted abrasions to top of right foot and top of left foot continue. Skin continues to be very dry to bilateral feet. A & D ointment continues D/T dry skin. Applied per this nurse." - A nursing note, dated 03/20/11 at 15:08 (3:08 p.m.), stated: "... TED hose to left leg in place. ..." There was no indication the skin integrity had been checked. - A nursing note, dated 03/22/11 at 00:38 (12:38 a.m.), stated: "... TED hose to LLE (left lower extremity) in place ..." There was no indication the skin integrity had been checked. - A nursing note, dated 03/22/11 at 12:16 p.m., stated: "... TED hose in place to LLE. ..." There was no indication the skin integrity had been checked. No further nursing notes were made regarding the TED hose until 03/27/11 at 18:49 (6:49 p.m.), when the nurse recorded (quoted as typed): "... Resident medicated x 3 this shift, resident crying out in pain this evening during dinner crying out and stating to please put him in bed, could not tolerate the pain. Some pain relief noted after assisting resident back to bed. Resident continues with 25mcg [MEDICATION NAME] and [MEDICATION NAME] 10 Q4 prn (every 4 hours as needed) for pain. Ted hose removed from left leg and kept off due to abrasion to ankle with indentation from ted hose. ..." - A nursing note, dated 03/29/11 at 13:48 (1:48 p.m.), stated: "... MD PA (physician's assistant) in to see resident. ..." -- 8. Review of a progress note related to physician service visit on 03/29/11 found the following under the heading "Chief complaint / History of present illness": "... (L) ankle still has ulcer." Under the heading "Assessment / Plan" was written: "... (5) Abrasion / ulceration ..." No description of this ulceration was recorded. A previous entry related to a physician service visit on 03/23/11 made no mention of the presence of this wound. An entry related to a physician service visit on 03/15/11 stated: "... mild abrasion improving ..." -- 9. Further review of nursing notes revealed a late entry by the wound nurse (Employee #72), entered at 15:30 (3:30 p.m.) on 03/29/11, stating: "Went to room to evaluate abrasion to top of L (left) foot. Abrasion measurements obtained and noted to be increased. Scab intact. ..." - A nursing note, on 03/30/11 at 17:20 (5:20 p.m.), revealed the resident's sister / MPOA had become concerned about the condition of the resident's left foot and stated she would like the resident to be sent to the hospital ER (emergency room ) to be evaluated by a "real doctor" for the abrasion and swelling of the left foot. - A nursing note, dated 03/30/11 at 18:50 (6:50 p.m.), stated the resident was transported to the hospital ER. (The resident returned to the facility at 3:30 a.m. the next morning.) -- 10. Review of the resident's Skin Integrity Report, completed by the wound nurse weekly, revealed the wound nurse began weekly observations and measurements of the abrasion to the top of Resident #84's left foot on 03/15/11. - When it was discovered on 03/15/11, documentation on the Skin Integrity Report described the abrasion as 9 cm in length and 0.5 cm in width with no depth, and the surrounding tissue and wound edges were described as healthy. - On 03/21/11, documentation on the Skin Integrity Report indicated the skin was intact, length was 9 cm, width was 0.5 cm, the surrounding tissue was healthy, and no drainage was present. - On 03/27/11, documentation on the Skin Integrity Report indicated the skin was intact with a scab. The length was 5 cm, the width was 1.3 cm, the surrounding tissue was red, and the wound edges were healthy. - On 03/29/11, documentation on the Skin Integrity Report indicated the skin was intact with a scab, the length was 2.1 cm and width was 5.1 cm. The surrounding tissues and wound edges were described as healthy with no drainage present. -- 11. According to the weekly Skin Integrity Report, between 03/21/11 and 03/27/11, the wound on top of the resident's left foot decreased in length (from 5 cm to 2.1 cm), increased in width (from 1.3 cm to 5.0 cm), and declined from being intact to being intact with a scab present. There were no nursing notes, physician progress notes [REDACTED]. A progress note recording physician service visit on 03/29/11 noted "(L) ankle still has ulcer" and "abrasion / ulceration", although the terms "ulcer" and "ulceration" were not used by nursing staff in the facility when describing this wound - which was referred to only as an "abrasion" that was intact. An assessment of the resident's foot, completed by nursing staff in the hospital'sER on [DATE], described the skin on the resident's left foot as "not intact" and as being a Stage III pressure sore involving the fascia. This failure to monitor the skin integrity of the resident's left foot after applying the TED hose, which already had an abrasion across the top, resulted in delayed identification and treatment of [REDACTED].

Based on incident report review, medical record review, staff interview, and family interview, the facility failed to ensure one (1) of nine (9) sampled residents received prompt medical attention following a fall from bed. The facility failed to contemporaneously collect and record physical assessment data following a fall (to identify possible injuries), failed to immediately notify the resident's family and physician of the fall, failed to communicate the fall to oncoming shifts so that staff would know to monitor the resident for possible sequelae of the fall, and failed to assess / monitor the resident after the fall to identify the need for, and obtain, medical intervention until after a family member intervened. On 10/16/10 at approximately 9:00 p.m., Resident #100 was said to have "slithered" out of her bed and onto the floor unassisted. The licensed practical nurse (LPN) who observed the incident (Employee #128) did not complete an incident report or document anything about the event in the resident's medical record at the time of the occurrence. She generated a "late entry" nursing note and an incident report (both dated 10/16/10), stating Resident #100 had no apparent injury related to the fall and no complaints of pain. When interviewed, Employee #128 admitted to not having completed a thorough assessment after the fall occurred on 10/16/10, and she admitted to not having documented anything about this fall (on either an incident report or in the nursing notes) until after the family's visit, which occurred on the evening of 10/17/10. No contemporaneous entries were made in the resident's nursing notes about Resident #100 having an injury until 6:20 p.m. on 10/17/10, when the nurse on duty at that time (Employee #34) recorded that the resident's son found a bruise on the resident's right shoulder that was dark purple in color; when interviewed, Employee #34 reported she had not been aware of the fall on 10/16/10 at the bruising was discovered by the family. This bruise, which extended from her neck, across her shoulder, and down her right arm, was readily visible to the family (as the resident was wearing a hospital gown), and it was turning black in color when found by the family on 10/17/10. The facility had no knowledge of this bruise until the family brought it to their attention. Only after the son intervened, did the facility contact the physician, and Resident #100 was later diagnosed with [REDACTED]. Although it could not be ascertained whether the fracture was sustained during the fall on 10/16/10, during the transfer back to bed after the fall on 10/16/10, or during a fall that occurred at an earlier date, the facility failed to identify the presence of the injury and obtain medical intervention until after the resident's family intervened. Resident identifier: #100. Facility census: 115. Findings include: a) Resident #100 1. Review of facility records, conducted on 11/16/10 at approximately 11:00 a.m., revealed an incident report dated 10/16/10 for an event said to have occurred at 9:00 p.m. on 10/16/10 involving Resident #100. The report stated, "As I was starting up the hallway to do my med pass, Heard (sic) resident in Rm (#) yelling out. When (sic) entered the room and walked to her side (sic). She already started out of bed on her arms before I get (sic) to her; the bottom half slithered out. Asked resident if she could get up and she attempted but went down on her right side. Low bed and mats (sic)." This report, which was signed as having been prepared by Employee #128 on 10/16/10, contained no assessment information in the section titled "Initial Assessment", which prompted the assessor to record information such as vital signs and an examination for any changes in the resident's range of motion. -- 2. Review of the resident's electronic medical record revealed the following consecutive entries in the nursing progress notes: - An entry dated 10/15/10 at 19:03 (7:03 p.m.) written by Employee #43, a registered nurse (RN) - "Skin assessment performed per orders. New skin tear on rt (right) knee where pt (patient) scraped off a scab. ... Pt has dry,cracked (sic) skin around her mouth which had bled a few times today ... Pt has small healing bruise on rt upper back. ... Lt (left) heel wound continues to improve." - An entry dated 10/16/10 at 21:00 (9:00 p.m.) identified as being a "late entry", written by Employee #128, an LPN - "As I was starting up the hallway to do my med pass. (sic) Write heard resident yelling out. When (sic) entered the room and walked to her side. (sic) She already started out of the bed on her arms before I could get to her; the bottom half (sic) slithered out and unto (sic) the mat. Asked resident if she could get up (sic) and she attempted but went down onto her right side. I then went out and got CNA's (certified nursing assistants) to help assist her back into bed. When I had given the resident her meds (sic) which I had already had in the room with me at the time. (sic) I assessed resident and did not see any injuries at this time. Resident did not complain of any pain nor (sic) distress noted." - An entry dated 10/17/10 at 18:20 (6:20 p.m.) written by Employee #34, an LPN - "At 5pm (sic) son reported to this nurse that he found a bruise on residents (sic) shoulder. This nurse noted bruise to right shoulder dark purple in color. Tylenol administered as ordered prior to family arriving. Family requested to speak with administrator and called his cell phone. Paged Dr. (name) and obtained stat order for xray (sic) to right shoulder. Called quality (sic) Mobile with new order. Administrator and DON (director of nursing) came in and talked with the family. Family then requested that resident be sent to ER for xray (sic). B/P 123/69 Temp 98.6 R18 P87 o2 sats 95%. Called (ambulance company name) but had (sic) no ambulance available. Called 911 for transport to ER. Resident left facility at 6:20 pm." - An entry dated 10/17/10 at 23:46 (11:46 p.m.) written by Employee #27, an LPN - "resident (sic) returned to facility at this time, via ambulance stretcher alone ... received report from d/c (discharging) nurse at (name of hospital), she stated she (the resident) has a FX (fracture) to her right clavicle ..." There were no entries between the note identified as a "late entry" dated 10/16/10 at 9:00 p.m. and the note dated 10/17/10 at 6:20 p.m.; there was no evidence the licensed nursing staff of this facility contemporaneously collected and recorded any physical assessment data for this resident after she fell on [DATE] and leading up to the time the resident's family found the dark purple bruise on the resident's right shoulder. -- 3. A review of the nursing notes after the resident's return to the facility on [DATE] revealed an entry dated 10/18/10 at 08:47 (8:47 a.m.), written by Employee #34, stating, "Late entry for 10/17/2010. During med pass at 10am (sic) this nurse ask (sic) resident if she was having any pain. Resident denied pain. Resp (respirations) even and unlabored. No signs of pain or discomfort noted. Resident was lying on back and was awake. At 12p (sic) administered prescribed dose of Tylenol (sic) and ask (sic) resident again if she had any pain and she denied pain. Administrated schelduled (sic) medication at 2:30pm (sic) and resident was resting quietly in bed and showed no signs of pain or discomfort. At 4p (sic) checked residents (sic) blood sugar and she was turned on her side and she asked for a drink of water. No signs of pain or discomfort noted and no facial grimace noted. Ask (sic) resident how if (sic) she was feeling ok and she stated she was 'fine'." All of this information was entered into the record on the morning after the resident returned from the hospital, after having been diagnosed with [REDACTED]. -- 4. review of the resident's medical record revealed [REDACTED]. According to her most recent comprehensive assessment (for a significant change in status) with an assessment reference date (ARD) of 08/16/10, Resident #100 was described as being alert and disoriented with short and long-term memory problems and moderately impaired cognitive skills for daily decision-making. She was also described as requiring limited assistance with bed mobility and transfers. According to her most recent full assessment (a Medicare re-admission / return assessment) with an ARD of 09/26/10, her cognitive status remained unchanged, she was now totally dependent on staff for all activities of daily living (including bed mobility and transfers), and a test for standing balance could not be attempted at that time. Review of the resident's care plan revealed a problem statement related to the resident's risk for complications associated with diabetes. The first intervention listed to address this problem was: "Assess skin integrity daily with care and report abnormalities." Review of the resident's activities of daily living (ADL) flowsheet for October 2010 revealed the nursing assistants documented having provided assistance to Resident #100 with ADLs as follows: 10/16/10 on evening shift - total dependence for transferring by two (2) nursing assistants; total dependence with bathing (partial bed bath); extensive physical assistance with dressing by two (2) nursing assistants; and total dependence for personal hygiene by one (1) nursing assistant. 10/16/10 on night shift - extensive physical assistance for transferring by two (2) nursing assistants; extensive physical assistance for bathing by two (2) nursing assistants (sponge / bed bath); and total dependence with dressing by one (1) nursing assistant. No information was available about any ADL assistance that had been provided on the day shift of 10/17/10 (the places to record this were left blank), and no information was available any ADL assistance provided on the evening shift, because staff recorded "OOF" (out of facility) for the entire shift, even though the resident was not transferred to the hospital until 6:20 p.m. on 10/17/10. (See also citation at F514.) The performance of transferring, dressing , bathing, and/or personal hygiene on these shifts for this dependent resident would have provided opportunities for staff to have observed bruising as it developed on the resident's right neck, shoulder and upper arm, especially while she was wearing a hospital gown (as had been observed by the family on the evening of 10/17/10). -- 5. Review of an "unusual occurrence", self-reported by the administrator to the State survey and certification agency on 10/18/10, revealed the following: "On 10/17/10 MPOA of (Resident #100) had a concern about the bruise on her left shoulder and questioned if it was fractured. The administrator was notified by the MPOA that he needed to see it. (Note: The reference to the left shoulder appears to be a mistake as the nursing note for 10/17/10 reflected the son found a bruise on the resident's right shoulder.) "The Resident (sic) is DNR (do not resuscitate), limited treatment, Hospice. Has a history of multiple falls related to behavior issues (sic). According to physician determination of capacity, the resident lacks capacity to make her own healthcare decisions due to Dementia, Stage 7. "On 10/16/10 at approximately 9:00pm (sic) the resident was observed to have been 'slithering out and onto the mat. Asked resident if she could get up and as she attempted went down onto her right side. Resident was assessed and the nurse did not see any injuries at this time. Resident did not complain of any pain nor distress noted. (No quotation mark was present to indicate where the quoted material ended.) "During med pass at 10am (sic) on 10/17/10, the nurse asked resident if she was having any pain. Resident denied pain. Respirations were even and unlabored. No signs of pain or discomfort noted. Resident was lying on back and was awake. At 12p (sic) administered prescribed does of Tylenol and ask resident again if she had any pain and she denied pain. Administered scheduled medication at 2:30 pm and resident was resting quietly in bed and showed no signs of pain or discomfort. At 4p (sic) checked residents (sic) blood sugar and she was turned on her side and she asked for a drink of water. No signs of pain or discomfort noted and no facial grimace noted. Asked resident if she was feeling ok and she stated she was 'fine.' "On 10/17/10 at approximately 5:30pm (sic) the family visited and voiced concerns and wanted her to be sent to the Hospital (sic) for an evaluation. The Clavicle (sic) was fractured. The resident was returned to the facility with continued meds. Resident is being observed and monitored." -- 6. A telephone interview with the administrator, on 12/08/10 at approximately 9:30 a.m., revealed Resident #100 received hospice services. She had a physician's orders [REDACTED]." According to the administrator, Hospice Care had ordered this, because the family felt the multiple falls the resident was having may have been related to her having untreated pain. The administrator also said he had observed the resident, after the family contacted him on the evening of 10/17/10, and did not find her to be in any pain. -- 7. During a telephone interview on 12/08/10 at approximately 12:15 p.m., the resident's family member stated they came to the facility to visit on 10/17/10. At that time, they had not visited in approximately two (2) days. They discovered Resident #100 had a large bruise on the back of her neck which extended down her right arm. This bruise was readily visible to the family (as the resident was wearing a hospital gown) and was described as turning black in color. The family brought this to the attention of the administrator and nursing staff, who denied seeing it prior to the family bringing it to their attention. (See also citation at F157.) -- 8. The facility was re-entered on 12/09/10, in order for the surveyor to collect additional information regarding the resident's fall and subsequent identification and treatment of [REDACTED].#100 had the following documented events in the days prior to 10/16/10: - 10/01/10 at 6:45 p.m. - "Resident was in shower room with CNA when CNA attempted to stand resident to dry her off. When CNA was drying resident, resident decided to sit on floor. Resident was lowered to floor by CNA." - 10/10/10 at 3:00 p.m. - "Resident sitting in WC (wheelchair); went to stand up to go to room. She went down to the floor." - 10/11/10 at 10:30 a.m. - "Resident sitting in w/c (wheelchair) in hallway by nurses (sic) station - noted to roll out of w/c to floor." - 10/11/10 at 11:15 a.m. - "Resident noted to be scratching at right forearm then scab noted in hand - bleeding noted from right forearm." - 10/11/10 at 3:00 p.m. - "Resident found curled up on safety mat next to bed. Stated 'I'm hiding they are going to kill me.' When asked if she fell or climbed she stated she climbed to hide from people trying to kill her. " - 10/12/10 at 8:45 a.m. - "Pt (patient) was sitting in wheelchair in dining room requesting to 'go to Bed'. Pt was informed it would be a few minutes. Then pt leaned forward and fell on to floor." - 10/13/10 at 5:15 p.m. - "Resident was sitting at nurses (sic) station in w/c when resident put herself in the floor. When asked why she stated she was hiding cause (sic) they were gonna kill her." The director of nursing (DON) reported, at about 11:45 a.m. on 12/09/10, that most of the time Resident #100 did not have any injuries from these incidents but that bruising would appear later. -- 9. Employee #128, when interviewed on 12/09/10 at approximately 12:30 p.m., reported she had worked as Resident #100's nurse on the night of 10/16/10. She said she had responded to the resident's hollering out and, when she entered the room, the resident was coming out of the bed arms first; before she could intervene, the resident had "slithered" the bottom half of her body onto the mat. Following this, she went to get assistance from two (2) nurse aides (Employees #29 and #129). Employee #128 reported she believed the three (3) of them used a sheet to transfer the resident back into her bed; however, she was not positive that this was how the transfer back to the bed occurred. Employee #128 stated she did not consider this event a "fall" and, as a result, she did not complete an incident / accident report at the time of the occurrence. She commented that she later was disciplined for not doing so. Employee #128 admitted that she had not documented anything about Resident #100's fall that occurred on the evening of 10/16/10 until the family became upset. (The family was noted by Employee #34 to have discovered the bruise during a visit that began around 5:00 p.m. on 10/17/10.) (NOTE: According to Appendix PP of the State Operations Manual promulgated by the Centers for Medicare & Medicaid Services, "'Fall' refers to unintentionally coming to rest on the ground, floor, or other lower level but not as a result of an overwhelming external force (e.g., resident pushes another resident). An episode where a resident lost his/her balance and would have fallen, if not for staff intervention, is considered a fall. A fall without injury is still a fall. Unless there is evidence suggesting otherwise, when a resident is found on the floor, a fall is considered to have occurred.") Employee #128 commented that she guessed she just forgot to fill out the top initial assessment portion on the report. This section was left blank. She said she asked the resident if she was hurt, and the resident said she was not. She also said she asked the resident if she was in pain, and the resident denied that as well. Employee #128 said she had a concern that the resident may have injured her hip. This concern was due to the fact that she had asked the resident if she could get up after the fall and the resident tried but landed on her right side. The LPN said she assessed the resident's right hip by applying pressure to the area to see if the resident expressed experiencing pain; the resident did not. She denied physically assessing any other part of the resident's right side, and she did not perform any range of motion exercise to any areas on the resident's right side to check for injuries. Employee #128 said she was aware the resident had a bruise to her right shoulder from a previous fall. -- 10. Employee #129 was interviewed by telephone at approximately 1:00 p.m. on 12/09/10; he no longer worked at the facility. He confirmed that he assisted the LPN with getting the resident back to bed on 10/16/10; he said he thought they picked the resident up under her arms to get her back into bed. He reported having no other knowledge of anything pertaining to the fall. -- 11. Employee #34 was interviewed by telephone on the early afternoon on 12/09/10. She acknowledged she was the LPN assigned to work with Resident #100 on 10/17/10, and that she was at the facility when the resident's family arrived and questioned the bruise on the resident's shoulder. She reported she did not know how the bruise got there, but she told the family she thought the resident had fallen on 10/15/10. She stated she told the family they would probably get faster results from having a mobile imaging company perform the x-ray on the resident's shoulder but the family insisted on having the resident sent out to a local emergency room . She related that Employee #128 did not tell her anything about the resident falling on 10/16/10 when she reported to work at 7:00 a.m. on 10/17/10. Employee #34 said Resident #100 acted very pleasant on during the day on 10/17/10. She reported she always asks the residents if they are in pain and said Resident #100 denied being in pain. -- 12. The DON and administrator acknowledged that Employee #128 failed to thoroughly assess Resident #100 following the fall on 10/16/10. However, the DON and administrator reported their beliefs that the facility had provided quality care to the resident and that staff had mainly failed to document their assessments and findings .