Every finding on record at Victoria Healthcare and Rehabilitation Center

Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the sanitary requirements were met in the kitchen. * The facility failed to ensure the microwave utilized to warm up the residents' food was in a sanitary condition. * The facility failed to ensure the heavy-duty blender used for puree preparation, two clear plastic pitchers and one stainless steel spatula with black handle were air dried prior to storage. * The facility failed to ensure the heavy-duty blender, kitchenware and kitchen utensils were clean and free of food particles or residue. * The facility failed to ensure the cutting board was maintained in sanitary condition and had smooth, cleanable surface. * The facility failed to ensure the storage container for dry food was completely sealed without noticeable gaps. These failures had the potential to cause cross-contamination and/or foodborne illness for the residents consuming the food prepared in the kitchen.Findings: Review of the facility's Order Listing Report dated 8/11/26, showed 70 of 71 residents consumed food prepared in the kitchen. 1. According to the USDA Food Code 2022, 4-601.11 Equipment, Food - Contact Surfaces, Nonfood Contact Surface, and Utensils, the equipment food-contact surfaces and utensils shall be clean to sight and touch, the food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations; and the nonfood- contact surface of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. According to the USDA Food Code 2017, 4-602.13, Non- Contact Surfaces, nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues. Review of the facility's P&P titled Sanitation dated 2023 showed all the equipment shall be maintained as necessary and kept in working order. All utensils, counters, shelves, and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seam, cracks, and chipped areas. Review of the facility's P&P titled Electrical Food Machines dated 2023 showed to keep and maintain all food machines in good operating, sanitary condition. This includes mixers, grinders, slicers and toasters. On 8/11/26 at 0823 hours, during the initial kitchen tour, an observation and concurrent interview was conducted with the DSS. The kitchen microwave on a countertop shelf was observed dirty with dry, crusted food residue in the microwave door and had dry food splatters inside the microwave. The DSS verified the findings and stated the microwave was used to warm up the resident's food like soup and it should have been cleaned after each use for safety and sanitation purposes. 2. According to the USDA Food Code 2022, 4-901.11, Equipment and Utensils, Air-Drying Required, that after cleaning and sanitizing, equipment, and utensils shall be air-dried or used after adequate draining before getting in contact with food. According to the USDA Food Code 2022, 4-903.11 Equipment, Utensils, Linens, and Single-Service and Single-Use Articles, cleaned equipment and utensils shall be stored in a self-draining position that allows air drying. Review of the facility's P&P titled Dishwashing dated 2023 showed the dishes are to be racked loosely without overlapping. Dishes are to be air dried in racks before stacking and storing. On 8/11/26 at 0823 hours, during the initial kitchen tour, an observation and concurrent interview was conducted with the DSS. One heavy-duty blender used for puree preparation stored on the countertop shelf was observed wet with visible water inside. In addition, there were two clear plastic pitchers were observed stored wet on the top shelf with visible water inside and one stainless steel spatula with black handle stored wet with the clean scoops. The DSS verified the findings and stated the blender, pitchers and spatula should have been air dried to prevent cross contamination. 3. According to the USDA Food Code 2022, 4-601.11 Equipment, Food - Contact Surfaces, Nonfood Contact Surface, and Utensils, the equipment food-contact surfaces and utensils shall be clean to sight and touch, the food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations; and the nonfood- contact surface of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. According to the USDA Food Code 2022, 4-602.13, Nonfood- Contact Surfaces, nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues. Review of the facility's P&P titled Dishwashing dated 2023 showed all the dishes will be properly sanitized through the dishwasher. The dishwasher will be kept clean and in good working order. Gross food particles shall be removed by careful scraping and pre-rinsing in running water. Flatware is to be pre-soaked on a solution of water and detergent per manufacturer's instructions. On 8/11/26 at 0823 hours, during the initial kitchen tour, an observation and concurrent interview was conducted with the DSS. One scoop with a yellow handle and one scoop with a green handle used for food portioning were observed dirty with dry and crusted residue. In addition, one heavy duty blender used for puree preparation stored on the countertop shelf was observed dirty with dry crusted residue inside. The DSS verified the findings and stated all the dirty kitchen utensils, kitchenware and blender should have been washed and air dried to prevent cross contamination. 4. According to the USDA Food Code 2022 Section 4-501.12, Cutting Surfaces, for surfaces such as cutting boards and blocks that become scratched and scored may be difficult to clean and sanitize. As a result, pathogenic microorganisms transmissible through food may build up or accumulate. These microorganisms may be transferred to the foods that are prepared on such surfaces. Review of the facility's P&P titled Sanitation dated 2023 showed separate chopping boards are to be used for preparing meats and vegetables. After each use, chopping boards shall be thoroughly cleaned and sanitized. On 8/11/26 at 0823 hours, during the initial kitchen tour, an observation and concurrent interview was conducted with the DSS. One yellow cutting board was observed heavily marred and had deep grooves and pits. The DSS verified the findings and stated all the cutting boards were replaced a week ago except for the yellow cutting board because the same size was not available. 5. According to the FDA Food Code 2017, Section 3-305.11 Food Storage. (A) Except as specified in (B) and (C) of this section, FOOD shall be protected from contamination by storing the FOOD: (1) In a clean, dry location; (2) Where it is not exposed to splash, dust, or other contamination; and (3) At least 15 cm (6 inches) above the floor. Review of the facility's P&P titled Ingredient Bins dated 2023 showed ingredient bins must be kept clean and covered to prevent food contamination. During the initial tour of the kitchen on 8/11/26 at 0823 hours, an observation and concurrent interview was conducted with the DSS. One clear storage plastic container labeled with Barley was not completely sealed or closed with noticeable gap. The DSS verified the findings and stated it should have been completely sealed and closed to prevent cross contamination. On 8/13/26 at 1607 hours, the Administrator and DON were informed and acknowledged the above findings.

Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to implement their antibiotic stewardship program when the facility failed to conduct an assessment for the McGeer's criteria to determine the true infection. * The facility failed to assess the McGeer's criteria for three admitted residents (Residents 4, 7, and 92) who were prescribed antibiotics in July and August 2026. This failure had the potential for inaccurately identifying true infections and potentially inhibited the residents' physicians from discontinuing the unnecessary antimicrobials.Findings: Review of the facility's P&P titled Antibiotic Stewardship revised on 1/2022 showed it is the policy of the facility to implement an Antibiotic Stewardship Program (ASP) that is incorporated in the overall infection prevention and control program which will promote appropriate use of antibiotics while optimizing the treatment of infections, at the same time reducing the possible adverse events associated with antibiotic use. This policy has the potential to limit antibiotic resistance in the post-acute care setting, while improving treatment efficacy and resident safety, and reducing treatment-related costs. The Antibiotic Stewardship refers to a set of commitments and actions designed to optimize the treatment of infections while reducing the adverse events associated with antibiotic use. This can be accomplished through improving antibiotic prescribing, administration, and management practices thus reducing inappropriate use to ensure that residents receiving the right antibiotic for the right indication, dose, and duration. The P&P further showed the facility may consider antibiotic time-out practices where an antibiotic order is stopped when a diagnostic test or symptoms of residents do not support the diagnosis of the infection. The Infection Preventionist (IP) or designee will be responsible for infection surveillance and tracking. Review of the facility's P&P titled Infection Prevention and Control Program revised 10/2022 showed the infection prevention and control program is a facility-wide effort involving all disciplines and individuals and is an integral part of the quality assurance and performance improvement program. There is an on-going monitoring for infection among residents and personnel and subsequent documentation of infections that occur. Surveillance tools are used to recognize the occurrence of infections, record their number and frequency, detect outbreaks and epidemics, monitor personnel infections, and detect unusual pathogens with infection control implications. Review of the facility's Monthly Infection Surveillance Report for July and August 2026 showed two residents were admitted from the acute care hospital in July and one resident in August with antibiotics. However, the facility failed to show documentation of the McGeer's form or an antibiotic surveillance tracking form was completed to assess for the true infection for the residents who were admitted from the acute care hospital with antibiotics. 1. Medical record review for Resident 4 was initiated on 8/13/26. Resident 4 was admitted to the facility on [DATE]. Review of Resident 4's physician's order dated 7/8/26, showed an order for daptomycin (antibiotic) IV use 400 mg daily for right hip osteomyelitis until 8/14/26. Review of Resident 4's Surveillance Data Collection Form - Skin, Soft Tissue, and Mucosal Infections dated 7/8/26, failed to show Resident 4 met the criteria for skin infection. Review of Resident 4's H&P examination dated 7/9/26, showed Resident 4 had impaired memory. 2. Medical record review for Resident 7 was initiated on 8/13/26. Resident 7 was admitted to the facility on [DATE], with diagnoses including impaired memory. Review of Resident 7's physician's order dated 7/16/26, showed an order for Azithromycin (antibiotic) 500 mg one time a day for pneumonia for three days. Review of Resident 7's Surveillance Data Collection Form - Respiratory Tract Infections (Pneumonia) dated 7/16/26, failed to show Resident 7 met the criteria for pneumonia. Review of Resident 7's H&P examination dated 717/26, showed Resident 4 had impaired memory. 3. Medical record review for Resident 92 was initiated on 8/13/26. Resident 92 was admitted to the facility on [DATE], and readmitted back to the facility on 8/6/26. Review of Resident 92's Microbiology Results dated 8/3/26, showed the urine culture of 10,000 - 20,000 CFU/ml mixed gram positive flora. Review of Resident 92's physician's order dated 8/6/26, showed an order for Amoxicillin-Pot Clavulante 875-125 mg (antibiotic) every 12 hours for UTI for five days. Review of Resident 92's Surveillance Data Collection Form - Urinary Tract Infection for Residents Without an Indwelling Catheter dated 8/6/26, failed to show Resident 92 met the criteria for UTI. Review of Resident 92's H&P examination dated 8/9/26, showed Resident 92 has the capacity to understand and make decisions. On 8/13/26 at 1350 hours, an interview and concurrent facility document review was conducted with the IP. The IP verified the above findings. The IP stated the facility uses the McGeer's criteria for surveillance to decrease the use of unnecessary antibiotic usage. The IP stated if the resident did not meet the criteria when completing the McGeer's criteria, the facility will notify the physician to decide if the antibiotic can be discontinued. When asked if surveillance is conducted for the residents admitted with an antibiotic order, the IP stated she did not and only conducted the McGeer's criteria for antibiotics ordered while at the facility. The IP acknowledged surveillance should also be conducted for the residents admitted with antibiotics. On 8/14/26 at 1330 hours, an interview was conducted with the Administrator and DON. The Administrator and DON were informed and acknowledged the above findings.

Based on interview, medical record review, and facility P&P review, the facility failed to ensure four of 11 final sampled residents (Residents 1, 9, 15, and 28) reviewed for advance directives had the right to formulate an advance directive and ensure a copy was in the medical record. * The facility failed to ensure copy of the advance directive was maintained in Resident 28's medical record. * The facility failed to ensure Residents 1, 9, and 15 were offered the opportunity to formulate an advance directive. These failures had the potential for the residents' decisions regarding their healthcare and treatment options not being honored. Findings: 1. Review of facility's P&P titled Advance Directives and Associated Documentation revised 4/2025 showed resident choices regarding advance directives will be recognized and respected. The facility must inform all adult residents of their right to accept or refuse medical or surgical treatment and, if they choose, to complete an Advance Directive. The facility is responsible for obtaining a copy of any advance directive and conservatorship or guardianship documents and placing them in the residents' health record. Further review of the P&P showed a POLST is not considered an advance directive. a. Medical record review for Resident 15 was initiated on 8/11/26. Resident 15 was admitted to the facility on [DATE]. Review of Resident 15's POLST dated 7/13/26, showed Resident 15 had capacity and had no advance directive. Review of Resident 15's H&P examination dated 7/14/26, showed Resident 15 had decision-making capacity. Review of Resident 15's MDS assessment dated [DATE], showed Resident 15 had moderate cognitive impairment. Review of Resident 15's Social Services Assessment/Evaluation dated 7/17/26, showed the resident and the resident's representative were informed in a manner easily understood, of their right to formulate advance directives. The document showed the resident and/or resident representative chose to express their wishes for advanced care planning using a POLST paradigm document. Further review of the document showed social services would provide the necessary forms, explain the process, and give the resident and their representative the Ombudsman's contact information if desired or requested. The resident and the resident representative chose to convey their wishes using the POLST at this time. However, the document did not indicate whether Resident 15 was offered the opportunity to formulate an advance directive, nor whether Resident 15 accepted or declined the formulation of an advance directive. On 8/12/26 at 0940 hours, an interview and concurrent medical record review for Resident 15 was conducted with the SSD. The SSD was unable to provide documented evidence to show whether the formulation of an advance directive was offered to Resident 15 and whether the resident accepted or refused the formulation of an advance directive. b. Medical record review for Resident 1 was initiated on 8/11/26. Resident 1 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 1's MDS assessment dated [DATE], showed Resident 1 had a BIMS of 1, meaning severe cognitive impairment. Review of Resident 1's POLST dated 6/14/26, showed Resident 1 had no advance directive. Review of Resident 1's Social Services Assessment/ Evaluation dated 6/15/26, showed Resident 1 had no advance directive and information was provided on her right to formulate an advance directive. However, the resident had severe cognitive impairment and there was no documented evidence the resident's responsible party was offered the opportunity to formulate an advance directive. Additionally, there was no documented evidence whether the responsible party accepted or refused to formulate an advance directive. Review of Resident 1's H&P examination dated 6/16/26, showed Resident 1 had no capacity to understand and make decisions and the surrogate decision maker (responsible party) was the resident's son. On 8/13/26 at 1515 hours, an interview and concurrent medical record review was conducted with the SSD. The SSD acknowledged the above findings. On 8/13/26 at 1607 hours, the Administrator and DON were informed and acknowledged the above findings. c. Review of Resident 9's medical record was initiated on 8/11/26. Resident 9 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 9's H&P examination dated 6/1/26, showed Resident 9 had the capacity to understand and make decisions. Review of Resident 9's MDS assessment dated [DATE], showed Resident 9 had a BIMS of 11, meaning moderate cognitive impairment. Review of Resident 9's Social Services Assessment/ Evaluation dated 6/18/26, showed Resident 9 had no advance directive. Further review of the document failed to show whether Resident 9 was offered the opportunity to formulate an advance directive and failed to show whether Resident 9 accepted or refused to formulate an advance directive. Review of Resident 9's POLST dated 7/7/26, showed Resident 9 had the capacity and had no advance directive. On 8/13/26 at 1512 hours, an interview and concurrent medical record review was conducted with the SSD. The SSD acknowledged the above findings. On 8/13/26 at 1607 hours, the Administrator and DON were informed and acknowledged the above findings. 2. Medical record review for Resident 28 was initiated on 8/11/26. Resident 28 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 28's Social Service assessment dated [DATE], showed Resident 28 had issued an Advanced Directive and a copy of such directives should be included in the resident's medical record. Further review of the document showed Resident 28 stated she had Advanced Healthcare Directives, and a copy had been requested but was not available at the time. Review of Resident 28's POLST dated 7/16/26, showed the Advance Directive was not available. Review of Resident 28's MDS assessment dated [DATE], showed Resident 28 had moderate cognitive impairment. Review of Resident 28's Social Service assessment dated [DATE], showed Resident 28 had issued an Advanced Directive and a copy of such directives should be included in the resident's medical record. Further review of the document showed Resident 28 stated she had Advanced Healthcare Directives, and a copy had been requested but was not available at the time. Review of Resident 28's medical record did not show a copy of the advance directive was obtained. Additionally, there was no documentation indicating whether a follow up was conducted with Resident 28 or their representative to obtain the copy for inclusion in the medical record. On 8/12/26 at 0952 hours, an interview and concurrent medical record review for Resident 28 was conducted with the SSD. The SSD verified Resident 28 claimed she had an advanced directive, and a copy was requested during admission on [DATE] and again on 7/22/26. However, the SSD was unable to locate documentation to show whether any follow up was conducted with Resident 28 or their representative to obtain the copy of the advance directive for inclusion in the resident's medical record. On 8/13/26 at 1033 hours, an interview was conducted with Resident 28. Resident 28 stated she had an advanced directive and did not remember if the facility requested her to provide a copy of it. On 8/13/26 at 1450 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings.

Based on interview, medical record review, and facility P&P review, the facility failed to ensure safe and effective transition of care for two of 18 final sampled residents (Residents 8 and 32) and one of three closed record sampled residents (Resident 94) reviewed for acute care hospitalization. * The facility failed to ensure there was documented evidence the required information (such as contact information of the practitioner responsible for the resident's care, resident's representative information, advance directive information, comprehensive care plan goals, and all other necessary information including a copy of the resident's discharge summary) was communicated to the receiving provider for Residents 8 and 94, when the residents were transferred to the acute care hospital. * The facility failed to provide the Bed Hold policy to Resident 32 when resident was transferred to the acute care hospital on 6/7/26. These failures had the potential to result in incomplete or delayed care and an increased risk of adverse outcomes during the transition to the acute care hospital.Findings: Review of the facility's P&P titled Criteria for Transfer and Discharge revised on 4/2025 showed when the facility transfers or discharges a resident, the facility shall ensure the transfer or discharge is documented in the resident's medical record and appropriate information is communicated to the receiving health care institution or provider. The P&P further showed the information provided to the receiving provider must include a minimum of the following: a. Contact information of the practitioner responsible for the care of the resident; b. Resident representative information including contact information; c. Advance Directive information; d. All special instructions or precautions for ongoing care, as appropriate, to include but is not limited to treatments and devices, transmission-based precautions, and special risks like falls, elopement, aspiration, or pressure injury; e. Comprehensive care plan goals; and f. All other necessary information, including a copy of the resident's discharge summary, and any other documentation, as applicable, to ensure a safe and effective transition of care. 1. Medical record review for Resident 8 was initiated on 8/11/26. Resident 8 was admitted to the facility on [DATE], and readmitted back to the facility on 7/10/23. Review of Resident 8's Progress Note dated 6/1/26, showed Resident 8 was transferred to the acute care hospital due to respiratory distress. Review of Resident 8's Progress Notes dated 6/2/26, showed the acute hospital physician contacted the facility to receive more information about Resident 8's demographics and the resident's condition prior to the transfer to the acute care hospital. Further review of Resident 8's medical records failed to show the facility provided information to the receiving acute care hospital as per the facility's P&P Criteria for Transfer and Discharge. 2. Closed record review for Resident 94 was initiated on 8/11/26. Resident 94 was admitted to the facility on [DATE]/26, and transferred to the acute care hospital on 5/22/26. Review of Resident 94's MDS dated [DATE], showed Resident 94's BIMS score was 1 (indicating severe cognitive impairment). Review of Resident 94's Progress Note dated 6/1/26, showed Resident 94 was transferred to the acute care hospital due to difficulty to arouse the resident. Review of Resident 94's medical records failed to show the facility provided information to the receiving acute care hospital as per the facility's P&P Criteria for Transfer and Discharge. On 8/13/26 at 1111 hours, an interview and concurrent medical record review for Residents 8 and 94 was conducted with RN 1. RN 1 verified the above findings for Resident 8 and 94. RN 1 verified there was no documented evidence Resident 8 and 94's documents were provided to the paramedics when the residents were transferred to the acute care hospital. RN 1 stated providing the paramedics and acute care hospital the copies of the residents' medical records allowed for the continuity of care and provides a reference of what happened to the residents during their stay at the facility, including the medications they are receiving. On 8/14/26 at 1330 hours, an interview was conducted with the Administrator and the DON. The Administrator and DON were informed and acknowledged the above findings. 3. Review of the facility's P&P title Admission, Transfer and discharged revised 4/2025 showed the following: - The resident, or the resident's representative shall be informed in writing of their right to exercise the bed hold provision in the event of a transfer from the facility to a general acute care hospital or at the start of a resident's therapeutic leave. Each notice shall include the duration of the State bed-hold policy (if any) and/or of the facility policy that the resident's bed will be held for the duration of seven days, during which time the resident is permitted to return and resume residence in the facility, the amount required to be paid by the resident or by the resident's payor source to hold the bed for the duration of the bed-hold period, insurance may or may not cover such costs and, accordingly, the resident may have some liability for payment of uncovered costs and the facility's policy regarding bed-hold periods permitting the resident to return. Medical record review for Resident 32 was initiated on 8/13/26. Resident 32 was admitted to the facility on [DATE], transferred to the acute care hospital on 6/7/26, and was readmitted back to the facility on 6/9/26. Review of Resident 32's Order Summary Report showed a physician's order dated 6/7/26, to transfer Resident 32 to the acute care hospital emergency department with a bed hold for seven days. Review of Resident 32's medical record failed to show documented evidence the resident and/or their responsible party were notified of the bed hold policy of seven days when the resident was transferred to the acute care hospital on 6/7/26. On 8/13/26 at 0952 hours, an interview and concurrent medical record review for Resident 32 was conducted with the MDS Nurse. The MDS Nurse verified the notification of bed hold was not communicated to Resident 32 and/or their responsible party, and verified it was not documented in Resident 32's medical record. The MDS nurse stated the facility should inform the resident about the policy of the bed hold when transfer the resident to the hospital. On 8/14/26 at 1332 hours, an interview was conducted with the DON. The DON was informed and acknowledged above findings.

Based on observation, interview, and medical record review, the facility failed to provide the treatment and care services in accordance with the professional standards of practice for one of 18 final sampled residents (Resident 63). * The facility failed to ensure a dark purplish skin discoloration on the resident's right arm with a raised surface and surrounding redness was recognized, assessed, monitored, and reported to the physician for Resident 63. This failure created the risk of delayed diagnosis and treatment of a potentially infected IV site, which could result in pain, worsening infection, or other complications for Resident 63.Findings: On 8/11/26 at 1045 hours, an observation was conducted for Resident 63. Resident 63 was observed lying in his bed. A dark purplish skin discoloration with a raised surface and surrounding redness was observed on the resident's right arm. Resident 63 stated he had received an IV medication at the hospital and believed the discoloration was related to the IV site from his hospital stay. Medical record review for Resident 63 was initiated on 8/11/26. Resident 63 was admitted to the facility on [DATE], and was readmitted on [DATE]. Review of Resident 63's MDS assessment dated [DATE], showed Resident 63 was cognitively intact Review of Resident 63's Skin Check dated 8/10/26, showed under skin issue note generalized body scattered reddish/greenish, purplish skin discoloration. Further review of the document did not show dark purplish skin discoloration with raised surface and surrounding redness was documented and if the physician was notified. Further review of Resident 63's medical record failed to show if the dark purplish skin discoloration with raised surface and surrounding redness was documented, and if the resident's physician was notified. On 8/13/26 at 1109 hours, an observation and concurrent interview and medical record review for Resident 63 was conducted with LVN 6. Resident 63 was observed lying in his bed, with a dark purplish skin discoloration with a raised surface and surrounding redness on his right arm. LVN 6 measured the area which was noted with 5 cm (length) x 4 cm (width) with surrounding redness. LVN 6 verified the observation and stated he was not previously aware of the skin issue. He stated it could represent an infected IV site and required monitoring. LVN 6 reviewed Resident 63's medical record and stated he was unable to find documented evidence the skin issue had been monitored or the physician had been made aware. LVN 6 stated he would initiate the change in condition process and notify the physician. On 8/13/26 at 1141 hours, an observation and concurrent interview for Resident 63 was conducted with CNA 2. CNA 2 verified Resident 63 had a dark purplish skin discoloration with a raised surface and surrounding redness. CNA 2 stated she had noticed the skin discoloration the previous day. When asked what action she took upon noticing the issue, CNA 2 stated she should notify the charge nurse, but acknowledged she failed to do so. On 8/14/26 at 1406 hours, an interview was conducted with the DON and Administrator. The DON stated the facility staff were aware about the above skin issue for Resident 63. The DON further stated she did not have enough staff to document and monitor bruises and minor skin issues.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to maintain IV infusion for one of one nonsampled resident (Resident 98) reviewed for IV infusion. * The facility failed to label Resident 98's IV fluid and tubing with the type of IV fluid, date, and time when it was started. This failure had the potential to compromise resident's health and safety by increasing the risk of infection, improper IV fluid management, and the inability to accurately monitor and evaluate the resident's IV therapy.Findings: Review of the facility's P&P titled Intravenous ( IV) Administration (undated) showed it was the policy of the facility IV medications shall be administered by a registered nurse. A written physician's order is required to administer medications. The order must specify, drug, dosage, frequency, route and interval. Under the sections procedure IV medications must be labeled in accordance with established procedures governing all labeling IV medications and IV solutions. Further review of the P&P showed all IV tubing is dated and timed when hung. IV tubing should be changed every 72 hours for IV fluids. Medical record review for Resident 98 was initiated on 8/11/26. Resident 98 was admitted to the facility on [DATE]. Review of Resident 98's Order Summary Report showed a physician's order dated 8/10/26, for Sodium Chloride Solution 0.9% (normal saline) to administer IV 50 ml per hour one time a day for dehydration for one day to administer total of 1 (one) liter. On 8/11/26 at 0933 hours, Resident 98 was observed sitting on a wheelchair on the right side of her bed. Resident 98 was observed receiving an IV infusion through her left wrist. The resident's IV fluid and IV tubing was not labeled with the resident's name, the type of IV fluid being given, and date/time the IV infusion was started. On 8/11/26 at 0940 hours, an observation, interview and concurrent medical record review for Resident 98 was conducted with RN 1. RN 1 confirmed the observation and stated Resident 98 was receiving 0.9% Sodium Chloride IV fluid. RN 1 acknowledged the IV fluid bag and tubing were not labeled as required. RN 1 stated the IV fluid and IV tubing for Resident 98 should have been labeled with the resident's name, the type of IV solution, and date and time the infusion was started. On 8/13/26 at 1450 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings.

Based on observation, interview, and medical record review, and facility P&P review, the facility failed to ensure one of 18 final sampled residents (Resident 2) was provided the appropriate respiratory care. * The facility failed to ensure Resident 2's oxygen was administered as ordered by the physician. This failure had the potential to affect the respiratory health and well-being of Resident 2. Findings: Review of the facility's P&P titled Resident Care - Oxygen, Use Of revised 5/2021 showed it is the policy of the facility to promote resident safety in administering oxygen. On 8/11/26 at 0908 hours, during an initial tour observation, Resident 2 was on oxygen at 4.5 LPM via nasal cannula. Medical record review for Resident 2 was initiated on 8/11/26. Resident 2 was admitted to the facility on [DATE], and readmitted back to the facility on 8/8/26. Review of Resident 2's Order Summary Report showed a physician's order dated 8/8/26, for continuous oxygen at 5 LPM via nasal cannula to maintain oxygen saturation above 90% every shift. Review of Resident 2's H&P examination dated 8/9/26, showed the resident had the capacity to understand and make decisions. On 8/11/26 at 0915 hours, an observation, interview, and concurrent medical record review for Resident 2 was conducted with LVN 1. LVN 1 verified the above findings and verified Resident 2's oxygen setting was at 4.5 LPM. LVN 1 stated Resident 2's physician's orders for oxygen was for 5 LPM and did not match what the resident was receiving. LVN 1 stated it was important to match the physician's orders to ensure the resident was provided with enough oxygen as ordered. On 8/14/26 at 1330 hours, an interview was conducted with the Administrator and DON. The Administrator and DON were informed and acknowledged the above findings.

Based on interview, medical record review, and facility P&P review, the facility failed to ensure appropriate pain management for one of 19 final sampled residents (Resident 60) and one of three closed record sampled residents (Resident 48) reviewed for pain management. * The facility failed to ensure effective pain management when Resident 48 reported the current medication was not relieving the resident's pain. In addition, the facility failed to ensure nonpharmacological pain interventions for pain was provided prior to administering pain medication for Resident 48. * The facility failed to ensure nonpharmacological pain interventions for pain was provided prior to administering the PRN pain medications for Resident 60. These failures had the potential to put Residents 48 and 60 at risk for ineffective pain management.Findings: Review of the facility's P&P titled Recognition and Management of Pain revised 7/2017 showed it is the policy of this facility to ensure that pain management is provided to the resident who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goal and preferences. The facility to assist each resident with pain management or achieve the highest practicable level of well-being and functioning by developing and implementing a plan, using nonpharmacologic and/or pharmacologic intervention to manage and/or prevent pain. The further review of the P&P showed if the pain management program is not effective, the licensed nurse will contact the resident's physician. Monitor pain status every shift using either the numerical pain rating or PAINAD scale (Pain Advanced Dementia Scoring Guide) and consult physician for additional interventions if pain is not relived by current orders. 1. a. Closed medical record review for Resident 48 was initiated on 8/12/26. Resident 48 was admitted to the facility on [DATE], and left against medical advice on 7/28/26. On 8/12/26 at 1145 hours, a telephone interview was conducted with Resident 48. Resident 48 stated he was admitted to the facility after undergoing triple bone surgery at the acute care hospital and was experiencing significant pain. Resident 48 reported the pain medication provided by the facility was ineffective. Resident 48 stated he informed multiple staff members of his pain and the ineffectiveness of the medication, but no action was taken, which led him to leave the facility. Resident 48 further stated the facility did not provide any additional interventions, including nonpharmacological interventions, for his pain. Review of Resident 48's H&P examination dated 7/27/26, showed Resident 48 had the capacity to understand and make medical decisions. The Assessment and Plan section indicated Resident 48 had sustained a right ankle fracture and had undergone open reduction and internal fixation ORIF. Further review of the P&P showed Resident 48 initially underwent a closed reduction in the emergency department and was discharged with instructions for outpatient orthopedic follow-up but later returned due to persistent severe pain. The resident subsequently underwent right ankle external fixation on 7/19/26, followed by removal of the external fixator and ORIF performed by Orthopedic Surgery. The plan included continuation of postoperative care and pain management. Review of Resident 48's Physician Order Summary dated 7/28/26, showed the following orders: - dated 7/24/26, for Oxycodone HCl 5 mg (opioid pain medication used to treat severe pain), to administer 1 tablet by mouth as needed for moderate pain, level 4–7 (on a pain scale of 0–10, with 0 indicating no pain and 10 indicating the worst possible pain); - dated 7/24/26, for Oxycodone HCl 5 mg, to administer 2 tablets by mouth as needed for severe pain, level 8–10; - dated 7/24/26, for Tylenol Extra Strength oral tablet 500 mg (acetaminophen), to administer 2 tablets by mouth every 8 hours as needed for moderate pain, level 4–7 (not to exceed 3 grams of acetaminophen from all sources in 24 hours); and - dated 7/24/26, for Tylenol oral tablet 325 mg, to administer 2 tablets by mouth every 4 hours as needed for mild pain, level 1–3 (not to exceed 3 grams of acetaminophen from all sources in 24 hours). Review of Resident 48's Progress Notes dated 7/27/26 at 2244 hours, showed the resident voiced a complaint of needing a higher dose of oxycodone PRN pain medication. The MD was notified; however, no order was received. Further review of Resident 48's medical record did not show any intervention on 7/27/26, after the resident reported needing a higher dose of pain medication and the physician was notified. On 8/13/26 at 0909 hours, an interview and concurrent medical record review for Resident 48 was conducted with LVN 4. LVN 4 stated on 7/28/26, Resident 48 complained about his pain not being managed with the current medication and needed stronger medication for pain control. LVN 4 stated he notified the MD, and the MD recommended sending the resident to the emergency department for pain management; however, the resident left against medical advice. LVN 4 stated he did not document Resident 48's report of pain or his notification to the physician in the medical record. On 8/13/2026, at 0944 hours, an interview was conducted with CNA 1. CNA 1 stated Resident 48 appeared to be in significant pain, often holding his leg and requesting pain medication. CNA 1 reported he notified the assigned nurse about the resident's pain. CNA 1 further stated Resident 48 told him the medication he was receiving was not effective, and he also communicated this information to the assigned nurse. On 8/13/26 at 1450 hours, an interview and medical record review was conducted with the DON. The DON verified Resident 48 verbalized needing a higher dose of pain medication on 7/27/26 at 2244 hours, and the physician was notified; however, no interventions were ordered. When asked what actions the facility should take when a physician did not order an intervention for pain management and the resident continues to experience pain, the DON stated the facility should transfer the resident to the emergency department for pain management. When asked DON whether this was done when Resident 48 first reported needing a higher dose of medication, the DON stated it was not done. On 8/14/26 at 1235 hours, a telephone interview was conducted with the MD. The MD confirmed the facility had notified him Resident 48 was experiencing pain and had reported his current medication was not effective. The MD stated he did not order additional pain management interventions because the resident had been admitted with a pain management regimen from the acute care hospital. The MD stated if the current regimen was ineffective, the resident could be sent to the emergency department for pain management. When asked if he could refer Resident 48 to the facility's pain specialist, the MD responded this was also an option. When asked whether the resident had been referred to the pain specialist, the MD stated he did not remember. b. Review of Resident 48's MAR for July 2026 showed the following: * For Oxycodone HCl 5 mg, 2 tablets were administered by mouth on the following dates and times:- dated 7/25/26 at 0843 hours, 1245 hours, and 1645 hours for a pain level of 8;- dated 7/26/26 at 1016 hours for a pain level of 8, and at 1806 hours for a pain level of 10;- dated 7/27/26 at 1013 hours and 1442 hours for a pain level of 8;- dated 7/28/26 at 0614 hours for a pain level of 9. * For Tylenol extra strength oral tablet 500 mg (Acetaminophen), 2 tablets were administered by mouth on the following dates and times:- dated 7/26/26 at 0628 hours for a pain level of 7;- dated 7/28/26 at 0845 hours for a pain level of 7. * For Oxycodone HCl oral tablet 5 mg, 1 tablet was administered by mouth on 7/24/26 at 2152 hours for a pain level of 7. Review of Resident 48's medical record did not show documented evidence nonpharmacological interventions were offered prior to administering the above pain medications. On 8/13/26 at 0807 hours, an interview and concurrent medical record review for Resident 48 was conducted with LVN 5. LVN 5 verified the above findings and stated the listed medications had been administered; however, she was unable to find documented evidence nonpharmacological interventions were provided prior to the administration of the pain medications. On 8/14/26 at 1406 hours, an interview was conducted with the DON and the Administrator. The DON stated Resident 48 was not referred to the pain specialist in the facility. The DON and the Administrator acknowledged the above findings. 2. Medical record review for Resident 60 was initiated on 8/11/26. Resident 60 was admitted to the facility on [DATE]. Review of Resident 60's Order Summary Report showed the following physician's orders: - dated 6/26/26, for nonpharmacological interventions for pain: 1=Repositioning, 2=Dim light and/or quite environment, 3=Relaxation, 4=Distraction, 5=Music, 6=Massage, 7=N/A (Not applicable) every shift; - dated 6/26/26, hydromorphone HCL (hydrocholoride, pain medication) 2 mg, give two tablets by mouth every four hours as needed for moderate pain (4-7); and - dated 6/26/26, hydromorphone HCL 2 mg, give three tablets by mouth every four hours as needed for severe pain (8-10). Review of Resident 60's H&P examination dated 6/28/26, showed the resident was capable and independent of decision making. Review of Resident 60's MAR for August 2026 showed Resident 60 received hydromorphone HCL 2 mg, three tablets for severe pain on the following dates and times: - dated 8/1/26 at 0618 hours; - dated 8/2/26 at 0917, 1636, and 2116 hours; - dated 8/3/26 at 0227, 0832, 1414, and 2020 hours; - dated 8/4/26 at 0647 and 1716 hours; - dated 8/5/26 at 0840 and 1650 hours; - dated 8/6/26 at 0627, 1112, and 1630 hours; - dated 8/7/26 at 0943 and 1634 hours; - dated 8/8/26 at 0919 and 1745 hours; - dated 8/9/26 at 1419 and 2310 hours; - dated 8/10/26 at 0750, 1406, and 2046 hours; and - dated 8/11/26 at 0758 and 1739 hours. Further review of Resident 60's MAR failed to show nonpharmacological interventions were offered prior to the administration of the pain medication. On 8/14/26 at 0835 hours, an interview and concurrent medical record review for Resident 60 was conducted with LVN 2. LVN 2 verified the above findings. LVN 2 stated nonpharmacological interventions should be offered prior to giving pain medication. LVN 2 stated the nonpharmacological interventions order is for every shift. LVN 2 stated if the nonpharmacological interventions were effective, then administering pain medications may not be needed to manage the resident's pain. On 8/14/26 at 1330 hours, an interview was conducted with the Administrator and the DON. The Administrator and DON were informed and acknowledged the above findings.

Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure one of 18 final sampled resident (Resident 2) investigated for dialysis was accurately monitored. * The facility failed to ensure Resident 2's Facility-Dialysis Center Communication Record was complete and accurate. This failure had the potential of not identifying negative outcomes for the dialysis resident.Findings: Review of the facility's P&P titled Dialysis (Renal), Pre and Post Care revised 3/2009 showed the facility will assess the residents in maintaining homeostasis pre- and post-renal dialysis. The P&P further showed documentation included to assess care given and condition of renal dialysis access and document all assessments in the clinical records. Medical record review for Resident 2 was initiated on 8/11/26. Resident 2 was admitted to the facility on [DATE], and readmitted back to the facility on 8/8/26. Review of Resident 2's Progress Notes dated 7/16/26, showed new oxygen order to administer continuously. Review of Resident 2's Facility-Dialysis Center Communication Record (undated) showed the following under the Facility Nurses/Post Dialysis section: - dated 7/23/26, oxygen saturation of 92%;- dated 7/25/26, oxygen saturation of 92%;- dated 7/30/26, oxygen saturation of 92%; and- dated 8/1/26, oxygen saturation of 91% at room air. Review of Resident 2's Facility-Dialysis Center Communication Record (undated) showed the following under the Dialysis Nurses section:- dated 7/26, 7/30, and 8/1/26, no documentation of oxygen levels; and- dated 8/11/26, no documentation of oxygen and pain levels. Review of Resident 2's Order Summary Report showed the following physician orders:- dated 8/8/26, for continuous oxygen at 5 LPM via nasal cannula to maintain oxygen saturation above 90% every shift;- dated 8/8/26, for dialysis every Tuesday, Thursday, and Saturdays; and- dated 8/9/26, for right upper arm AV Graft, monitor skin integrity and for signs and symptoms of increased breakdown, notify physician accordingly for changes. May apply and/or reinforce gauze with paper tape to area for signs and symptoms of bleeding ever shift. Review of Resident 2's H&P examination dated 8/9/26, showed the resident had the capacity to understand and make decisions. On 8/12/26 at 1245 hours, an interview and concurrent medical record review for Resident 2 was conducted with LVN 1. LVN 1 verified the above findings. LVN 1 stated Resident 2 was on continuous oxygen since 7/16/26, and the room air was inaccurate documentation. LVN 1 stated the dialysis nurses complete the Dialysis Nurses section; however, should not be left blank. LVN 1 further stated the Facility-Dialysis Center Communication Record forms should be completed with the resident's updated information. On 8/14/26 at 1330 hours, an interview was conducted with the Administrator and DON. The Administrator and DON were informed and acknowledged the above findings.

Based on interview, medical record review, and facility P&P review, the facility failed to ensure the necessary pharmaceutical services were provided to one of 18 final sampled residents (Resident 60). * The facility failed to ensure the administration of the controlled medication for Resident 60 was documented on the MAR. This failure had the potential for the medications to be administered in error and opportunities for drug diversion or drug misuse.Findings: Review of facility's P&P titled Controlled Medications revised 12/2019 showed when a controlled medication is administered, the licensed nurse administering the medication immediately enters all of the following information on the accountability record:- date and time of administration;- amount administered; and- signature of the nurse administering the dose, completed after the medication is actually administered. Medical record review for Resident 60 was initiated on 8/12/26. Resident 60 was admitted to the facility on [DATE]. Review of Resident 60's Order Summary Report showed a physician's order dated 6/26/26, to give Hydromorphone HCL (medication use to treat pain) 2 mg tablet, give three tablets by mouth every four hours as needed for severe pain level of 8-10 (using the 0-10 pain scale, 0 meaning no pain and 10 meaning worst pain). Review of Resident 60's H&P examination dated 6/28/26, showed Resident 60 had the capacity to understand and make decisions. Review Resident 60's Narcotic and Hypnotic record for August 2026 showed three tablets of Hydromorphone HCL 2 mg were dispensed and signed out on 8/9/26 at 0415 hours. Review of Resident 60's MAR for August 2026 failed to show documentation evidence the Hydromorphone HCL three tablets were administration on 8/9/26 at 0415 hours. On 8/12/26 at 1110 hours, an interview and concurrent medical record review for Resident 60 was conducted with LVN 1 during the medication inspection of Medication Cart A. LVN 1 verified three tablets of Hydromorphone HCL 2 mg were pulled and signed out on 8/9/26 at 0415 hours. LVN 1 verified it was not documented on Resident 60's MAR. On 8/12/26 at 1231 hours, an interview and concurrent medical record review for Resident 60 was conducted with the DON. The DON verified three tablets of Hydromorphone HCL 2 mg were pulled on 8/9/26 at 0415 hours. The DON further verified there was no documented evidence the medication was administered to the resident on Resident 60's MAR. The DON stated the process when a resident required pain medication was the licensed nurse would assess the resident, check the order, pull the medication, sign it out on the Individual Narcotic Record, administer to the resident, then document the administration on the MAR. The DON was informed and acknowledged the above findings.

Based on interview, medical record review, and facility P&P review, the facility failed to ensure the Pharmacy Consultant's recommendation from the monthly drug regimen review was followed through for one of five final sampled residents (Residents 15) reviewed for unnecessary medications. * The Pharmacy Consultant's recommendation to specify location for diclofenac gel 1% (an over-the-counter topical nonsteroidal anti-inflammatory drug (NSAID) used to relieve joint pain and stiffness) was not followed through for Resident 15. This failure posed the risk of the resident not receiving the necessary care and services or receiving unnecessary medications.Findings: Review of the facility's P&P titled Medication (Drug) Regimen Review (MRR) revised 4/2025 showed a licensed pharmacist shall review each resident's drug regimen at least monthly. The pharmacist's review must include the resident's medical chart. Identified irregularities are to be documented on a separate return report listing the resident's name, relevant drug, and the identified irregularity. The report must be sent to the attending physician, the facility's medical director, and the director of nursing services for follow-up. Further review of the P&P showed the pharmacist or facility must provide the report to the responsible physician, medical director, and director of nursing services within seven working days of the review. All communication and physician responses must be documented in the clinical record, including any new orders or changes to the medication regimen. Medical record review for Resident 15 was initiated on 8/11/26. Resident 15 was admitted to the facility on [DATE]. Review of Resident 15's Consultant Pharmacist's Medication Regimen Review date created between 8/1 and 8/2/26, showed a recommendation to specify the location and amount of grams to apply diclofenac gel 1%. There was no entry under the follow through section of the document. Review of Resident 15's Order Summary Report showed an order dated 8/9/26, for diclofenac sodium external gel 1% ( Diclofenac Sodium) to apply 2 grams to the affected area topically every eight hours as needed for pain management. Further review of the physician order did not specify the location to apply diclofenac sodium. Review of Resident 15's MAR for August 2026 showed an active order for diclofenac sodium external gel 1%, to apply 2 grams to the affected area topically every eight hours as needed for pain management. Further review of the MAR showed Resident 15 received the medication on the following dates and times:- dated 8/9/26 at 1325 and 2140 hours;- dated 8/10/26 at 1317 hours;- dated 8/11/26 at 0854 and 2145 hours; and- dated 8/12/26 at 0817 hours. On 8/13/26 at 1444 hours, an interview and concurrent medical record review for Resident 15 was conducted with the DON. The DON verified the above findings and stated she followed the pharmacy recommendation for Resident 15 and added the amount of grams of diclofenac gel 1%, to the physician's order. The DON verified she failed to follow up on the specific application location. The DON stated the pharmacy recommendation should have been followed through.

Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the menu was followed. * The facility failed to provide prune juice to Resident 12 as per her meal ticket. This failure had the potential for the resident to not receive adequate nutrition and appropriate servings to meet the resident's individual needs.Findings: Review of the facility's P&P titled Diet Orders dated 2023 showed diet orders as prescribed by the Physician will be provided by the Food and Nutrition Services Department. Nursing will send a Diet Order Communication slip to the Food and Nutrition Services Department. The FNS Director or [NAME] in charge will make or adjust the diet profile and tray card as prescribed. The diet count is also to be adjusted as needed. Any discrepancy in the diet order slip will be clarified by the FNS Director or [NAME] in charge with Nursing. Further review of the facility's P&P titled Food Preferences dated 2023 showed resident's food preferences will be adhered to within reason. Substitutes for all foods disliked will be given from the appropriate food group. Review of the facility's Order Listing Report dated 8/11/26, showed 70 of 71 residents consumed the food prepared in the kitchen. Review of the facility's menu titled Good for Your Health Menus dated 8/11/26, showed the lunch menu for 8/11/26, included curry lemon chicken, garlic rice, peas with onions, wheat roll, ice cream, milk and beverage offered with every meal. On 8/11/26 at 1215 hours, during the dining observation, Resident 12 was observed eating her lunch in the dining room. Review of Resident 12's meal ticket showed her diet order was Regular, Thin liquids and her standing orders included four fluid ounce whole milk, four fluid ounce prune juice, eight fluid ounce water and eight fluid ounce Boost Glucose Control. Resident 12 was served whole milk, Boost Glucose Control and water however, Resident 12 was not served the prune juice from the meal ticket. On 8/11/26 at 1220 hours, an observation and concurrent interview was conducted with LVN 3. LVN 3 verified Resident 12 did not receive prune juice per meal ticket. On 8/13/26 at 1607 hours, a follow-up interview was conducted with the DSS, Administrator and DON. The DSS stated the food items in the meal ticket should have been provided to the resident. The Administrator and DON were informed and acknowledged the above findings.

Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the administration of the controlled medications were accurately documented on the MAR (Medication Administration Record) for one of three sampled residents (Resident 1). * The facility failed to accurately document the hydrocodone/APAP 5-325 mg (a controlled medication) administration to Resident 1. This failure had the potential for the medications to be administered in error and opportunities for drug diversion or drug misuse.Findings: Review of the facility's P&P titled Controlled Medications revised 12/2019 showed when a controlled medication is administered to the resident the licensed nurse enters the date, time, and amount administered on the accountability record. Review of the facility's P&P titled Recognition and Management of Pain revised 7/2017 showed the medications administered to the resident will be documented on the MAR. Medical record review for Resident 1 was initiated on 9/3/25. Resident 1 was readmitted to the facility on [DATE], and discharged to the community on 8/23/25. Review of Resident 1's Order Summary Report showed a physician's order dated 8/18/25, for the following:- for hydrocodone/APAP 5-325 mg tablets, give one tablet by mouth every four hours as needed for pain level 4-7 (in a pain scale of 0-10, 0 = no pain to 10 = severe pain); and- for hydrocodone/APAP 5-325 mg tablets, give two tablets by mouth every four hours as needed for pain level 8-10, do not take more than eight tablets in 24 hours, APAP not to exceed 4,000 mg per day. a. Review of Resident 1's Tab Narcotic and Hypnotic Record for hydrocodone/APAP 5-325 mg tablets showed on 8/20/25 at 0132 hours, one tablet of hydrocodone/APAP 5-325 mg was removed from the supply. Review of Resident 1's MAR for August 2025 showed on 8/20/25 at 0132 hours, the nurse electronically signed the administration of two hydrocodone/APAP 5-325 mg tablets to Resident 1 for a pain level of 7. On 9/4/25 at 1021 hours, an interview and concurrent record review was conducted with the DON. The DON stated the nurse accidentally signed the MAR and showed two tablets were administered instead of the one tablet removed from the controlled supply. b. Review of Resident 1's Tab Narcotic and Hypnotic Record for hydrocodone/APAP 5-325 mg tablets showed on 8/22/25 at 1930 hours, one tablet of hydrocodone/APAP 5-325 mg was removed from the supply. Review of Resident 1's MAR for August 2025 failed to show documentation if the hydrocodone/APAP controlled medication removed from the supply on 8/22/25 at 1930 hours was administered to Resident 1. On 9/4/25 at 1021 hours, an interview and concurrent record review was conducted with the DON. The DON verified the one tablet of hydrocodone/APAP 5-325 mg removed from the controlled supply on 8/22/25 at 1930, was not documented in Resident 1's MAR. The DON stated the administration of the controlled medication should have been documented.

Based on observation and interview, the facility failed to ensure sanitary conditions were maintained and foods were stored in safe conditions. * There were expired food items stored inside the facility's freezer.* The stock pot was observed with black discoloration, warped and dented.* Two ceiling vents were dusty and corroded. Additionally, the meat products stored under the vents were also dusty with yellow stains/discoloration.* One cook did not wear a beard restraint.* One dietary aide placed his hands in a red bucket containing sanitizing solution and a dish rag instead of performing hand hygiene. These failures posed the risk of foodborne illness to the 68 of 68 residents who received food prepared in the facility's kitchen.Findings: 1. On 7/15/25 at 0800 hours, an initial tour of the facility's kitchen was conducted with the Dietary Supervisor. The following food items were observed inside the freezer:- one bag of bread with expiration date of 7/12/25.- one bag hamburger buns, with expiration date of 7/12/25.- one bag English muffins, with expiration date of 6/8/25. The Dietary Supervisor verified the above findings. 2. On 7/15/25 at 0800 hours, an initial tour of the facility's kitchen was conducted with the Dietary Supervisor. One stock pot measuring approximately 22 quarts was observed warped, dented on one side, and with a black substance surrounding the inner top part of the pot. The Dietary Supervisor verified the above findings. s3. On 7/15/25 at 0800 hours, an initial tour observation and concurrent interview was conducted with the Maintenance Supervisor. Two air conditioner ceiling vents located above the kitchen's ice machine and freezers were observed with dust and corrosion, and the paint surrounding the vents was peeling. Additionally, the meat products underneath the ceiling vents were observed dusty, with yellow stains and yellow discoloration. The Maintenance Supervisor verified the finding. 4. On 7/17/25 at 1130 hours, during an observation, [NAME] 1 was inside the kitchen with his moustache not covered. [NAME] 1 was not wearing a beard restraint. On 7/18/25 at 0821 hours, an observation of [NAME] 1 and concurrent interview was conducted with the Dietary Supervisor. [NAME] 1 was not wearing a beard restraint while inside the kitchen. The Dietary Supervisor verified the finding and stated [NAME] 1 should be wearing a beard restraint. 5. On 7/18/25 at 0851 hours, a dishwashing observation was conducted with Dietary Aide 2. After Dietary Aide 2 rinsed dirty dishes, he placed his hands into a red bucket with a clear solution and a dish rag in it. Dietary Aide 2 stated the bucket contained sanitizing solution and the solution was used in case of emergencies to sanitize inside the kitchen. When asked why Dietary Aid 2 placed his hands inside the solution after rinsing dirty dishes, Dietary Aide 2 stated he was sanitizing his hands. When asked if this was the process for dishwashing and hand hygiene, Dietary Aid 2 acknowledged he should have performed handwashing at the kitchen sink.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of 17 final sampled residents (Resident 1) maintained the highest practicable well-being. * Resident 1 was transferred inappropriately, via use of Resident 1's armpits and back of Resident 1's pants. * Resident 1's change of condition to her foot was not documented. These failures had the potential to cause injury and not provide appropriate care to the resident. Findings: Medical record review for Resident 1 was initiated on 7/15/25. Resident 1 was readmitted to the facility on [DATE]. a. On 7/18/25 at 1430 hours, an observation of Resident 1 and concurrent interview was conducted with CNAs 7 and 8. Resident 1 was observed sitting in her wheelchair which was positioned to the left side of her bed. CNA 8 placed her arm underneath Resident 1's left armpit. CNA 7 placed their arm underneath Resident 1's right armpit, and used their other hand to hold the back of Resident 1's pants. Both CNAs lifted and transferred Resident 1 from her wheelchair to the edge of the bed. CNA 8 stated the therapy trained the CNAs 7 and 8 to transfer Resident 1 in that way. On 7/18/25 at 1507 hours, an observation and concurrent interview was conducted with the Director of Rehab. When asked about transferring Resident 1, the Director of Rehab verbalized a gait belt was to be used for Resident 1's transfers. The Director of Rehab stated there were hooks inside the residents' rooms to place the gait belts. The Director of Rehab was informed the staff were observed transferring Resident 1 without a gait belt. Furthermore, the Director of Rehab verified there was no gait belt inside Resident 1's room. b. Review of the facility's P&P titled Change of Condition Reporting, dated 5/2019 showed a change in condition for the residents was to be documented. On 7/18/2025 at 0807 hours, an interview was conducted with LVN 5. When asked about doing a body check on Resident 1, LVN 5 stated he completed Resident 1's wound treatment after the resident's morning shower. On 7/18/25 at 1530 hours, a head to toe assessment was conducted with LVN 5 and Resident 1's responsible party. Resident 1's right foot was observed with a superficial break in skin and redness. When asked about redness and superficial break in the skin to the outer side of Resident 1's right big toe, LVN 5 stated he had not seen nor been informed about this change to Resident 1's skin. Resident 1's responsible party verified this was a change to Resident 1's foot. On 7/18/25 at 1630 hours, an interview was conducted with CNA 10. CNA 10 verified she completed Resident 1's morning shower. When asked about documenting the break in skin and wound to Resident 1's right toe, CNA 10 verified she observed the change to Resident 1's right toe but did not document it. Further review of Resident 1's medical record failed to show documented evidence of Resident 1's change in skin condition, redness and superficial break in skin to Resident 1's right toe.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure two of three final sampled resident (Residents 1 and 7) reviewed for catheter care received the appropriate care and services for an indwelling urinary catheter. * The facility failed to continuously monitor Resident 7 after the resident had a change in condition when the resident's suprapubic catheter was not draining.* The facility failed to ensure Resident 1's indwelling urinary catheter did not touch the floor.These failures had the potential for the residents to develop complications associated with the use of the indwelling urinary catheter.Findings: 1. Review of the facility's P&P titled Change of Condition Reporting dated 5/2019 showed the licensed nurse should document resident’s change of condition and response in eInteract Change of Condition UDA and in nursing progress notes, and update resident care plan, as indicated. The licensed nurse responsible for the resident will continue assessment and documentation for at least 72 hours or until the condition is stable. On 7/16/25 at 1004 hours, an observation of Resident 7 and a concurrent interview was conducted with CNA 11. Resident 7 was sitting in the wheelchair inside the room. Resident 7 was non-verbal but acknowledged when his name was called by looking at the SA. Resident 7 was observed with an indwelling urinary catheter. CNA 11 stated Resident 7 had a suprapubic urinary catheter. CNA 11 stated the urine was draining fine in the suprapubic urinary catheter. CNA 11 further stated she would report to the charge nurse if there was no urine output, if the urine looked dirty with sediments, and if there was presence of foul odor. Medical record review for Resident 7 was initiated on 7/16/25. Resident 7 was admitted to the facility on [DATE]. Review of Resident 7's MDS assessment dated [DATE], showed Resident 7 had a short- and long-term memory problem. Review of Resident 7’s eInteract Change in Condition V4.2 note dated 7/1/25 at 2024 hours, showed Resident 7’s suprapubic urinary catheter was not draining. The suprapubic urinary catheter was flushed, no resistance but the side was bulging. The physician was notified with order to send Resident 7 to the acute care hospital. Review of Resident 7’s Progress Notes dated 7/2/25 at 0022 hours, showed Resident 7 would be returning to the facility from the acute care hospital ER with a new suprapubic urinary catheter and intravenous antibiotics for UTI. Further review of Resident 7's medical record failed to show documented evidence of continued monitoring/assessment for Resident 7’s change in condition related to suprapubic urinary catheter by the licensed nurses. On 7/22/25 at 1514 hours, an interview and concurrent medical record review for Resident 7 were conducted with LVN 2. LVN 2 verified Resident 7 had a change in condition on 7/1/25, related to the resident’s suprapubic urinary catheter not draining. LVN 2 stated when the resident went to the ER and came back to the facility within 24 hours, it would be considered continuity of care. LVN 2 stated for any change in condition, the licensed nurses had to monitor the resident every shift for 72 hours. LVN 2 further stated it was important to continuously monitor the resident when there was a change in condition to make sure the resident is doing well, no signs and symptoms of complications or infection, no pain, and the vital signs are within normal range because if these symptoms were present then the nurses could report it right away to the physician and necessary treatment could be provided to the resident. LVN 2 verified Resident 7 was not continuously monitored for his change in condition. On 7/23/25 at 0805 hours, an interview was conducted with the DON. The DON stated the licensed nurses should continuously monitor the resident when there was a change in condition every shift for 72 hours and could be extended as needed. The DON stated the continued monitoring was important to determine if effective interventions were provided to the resident, if the plan of care was effective, or if they needed to update it, and for the nurses to inform the physician immediately of any complications or abnormalities related to the change in condition. The DON was informed of and acknowledged the above findings for Resident 7. 2. On 7/18/25 at 1019 hours, an observation of Resident 1 and concurrent interview was conducted with LVN 5. Resident 1's indwelling urinary drainage catheter was observed inside a privacy bag to the right side of Resident 1's bed, touching the floor. LVN 5 verified the finding and stated the indwelling urinary drainage catheter bag should not be touching the floor. Medical record review for Resident 1 was initiated on 7/15/25. Resident 1 was readmitted to the facility on [DATE]. Review of Resident 1's medical record showed Resident 1 was dependent on staff for her ADLs. Resident 1 had an indwelling urinary drainage catheter bag in place for wound management.

Based on interview, medical record review, and facility P&P review, the facility failed to provide adequate and appropriate pain management for one of 17 final sampled residents (Resident 9). * The facility failed to ensure the pain medication was administered per Resident 9's physician's order. This failure had the potential for residents not to receive the appropriate treatment for pain.Findings: Review of the facility's P&P titled Administration of Drugs revised 5/2007 showed it is the policy of this facility that medications shall be administered as prescribed by the attending physician. Medications must be administered in accordance with the written orders of the attending physician. 1. Medical record review for Resident 9 was initiated on 7/15/25. Resident 9 was admitted to the facility on [DATE]. Review of Resident 9's H&P examination dated 6/29/25, showed Resident 9 had the capacity to understand and make decisions. Review of Resident 9's Order Summary Report dated 7/17/25, showed the following physician's orders: - dated 6/26/25, to administer Tylenol (analgesic medication) 325 mg two tablets by mouth every four hours as needed for mild pain (pain scale 1-3; using the pain scale of 0 to 10 with 0 = no pain and 10 = worst pain). - dated 7/7/25, to administer hydrocodone-acetaminophen (narcotic medication) 5-325 mg one tablet by mouth every eight hours as needed for moderate pain (pain scale 4-6).- dated 7/7/25, to administer hydrocodone-acetaminophen 10-325 mg one tablet by mouth every eight hours as needed for severe pain (pain scale 8- 10). Review of Resident 9's MAR for 7/2025 showed: - on 7/9/25 at 0700 hours, Resident 9 received hydrocodone 5-325 mg medication one tablet for a pain level of eight.- on 7/9/25 at 2336 hours, Resident 9 received Tylenol 325 mg medication two tablets for a pain level of six.- on 7/10/25 at 0900 hours, Resident 9 received hydrocodone-acetaminophen 5-325 mg medication one tablet for a pain level of eight.- on 7/11/25 at 0111 hours, Resident 9 received hydrocodone-acetaminophen 5-325 mg medication one tablet for a pain level of eight. - on 7/13/25 at 0038 hours, Resident 9 received hydrocodone 5-325 mg medication one tablet for a pain level of eight.- on 7/13/25 at 2348 hours, Resident 9 received hydrocodone-5-325 mg medication one tablet for a pain level of eight. On 7/22/25 at 0745 hours, an interview and concurrent medical record review for Resident 9 was conducted with LVN 4. LVN 4 verified the above findings. LVN 4 verified Resident 9 did not receive the right medication for the pain and the MD order was not followed. On 7/22/25 at 1538 hours, an interview and concurrent medical record review for Resident 9 was conducted with the DON. The DON verified the above findings and stated the pain medication would be effective if it was given accurately.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary dialysis care to one of three final sampled residents (Resident 93) reviewed for dialysis care. The facility failed to ensure Resident 93's dialysis access site was accurately assessed. Resident 93 had a vascular dialysis access on the right upper chest, however, the resident was assessed for shunt, and bruit and thrill post-dialysis. In addition, Resident 93's care plan to address the dialysis included monitoring for the fistula. These failures had the potential for Resident 93 not being provided with appropriate dialysis care, and the possibility of medical complications related to dialysis care. Findings: Medical record review for Resident 93 was initiated on 7/15/25. Resident 93 was admitted to the facility on [DATE]. Review of Resident 93's Order Summary Report showed the following physician's orders:dated 7/9/25, for dialysis on Tuesday, Thursday, and Saturday;dated 7/9/25, to observe and maintain no pressure on the shunt or dialysis catheter on the right upper chest every shift; anddated 7/9/25, for post-dialysis, to check shunt for bleeding. Remove pressure dressing after three hours. Review of Resident 93's LN - Initial admission Record dated 7/9/25, under the Dialysis section, showed Resident 93 received hemodialysis, and had a vascular catheter on the right upper chest. The record also showed thrill and bruit are not applicable. Review of Resident 93's plan of care showed a care plan problem initiated on 7/9/25, to address Resident 93's dialysis related to renal failure, and right upper chest dialysis catheter site. The interventions included the following:- To monitor dialysis access site on the right upper chest for signs and symptoms of infection, swelling, and bleeding;- To observe and maintain no pressure on shunt or dialysis catheter on the right upper chest;- To check and change dressing daily at access site, and document;- To check arteriovenous fistula every day for bruit and thrill;- Do not draw blood or take the blood pressure in arm with graft;- To check the shunt post-dialysis for bleeding. Remove pressure dressing after three hours. Review of Resident 93's Facility - Dialysis Center Communication Record dated 7/10/25, under Facility Nurses/ Post Dialysis section showed bruit and thrill are present. Review of Resident 93's Facility - Dialysis Center Communication Record dated 7/12/25, under Facility Nurses/ Post Dialysis section, showed bruit and thrill are present. On 7/18/25 at 0815 hours, an observation and concurrent interview was conducted with Resident 93. When asked about the dialysis access site, Resident 93 stated she only had one dialysis access site on the right upper chest. On 7/18/25 at 1342 hours, an interview and concurrent medical record review was conducted with RN 1. RN 1 stated Resident 93's dialysis access site was a vascular catheter on her right upper chest. RN 1 verified the physician's orders included to check the shunt post-dialysis. RN 1 stated the resident's medical records were reviewed during the stand-up meeting. RN 1 also verified Resident 93's dialysis communication record showed documentation for the presence of bruit and thrill. RN 1 stated there should be no bruit and thrill present because the resident had a vascular catheter, not a shunt or fistula. RN 1 further verified the Resident 93's plan of care to address dialysis included interventions not applicable to the resident such as changing the dressing at access site, not drawing blood or taking the blood pressure on the arm with graft, checking the fistula daily, checking shunt post-dialysis. On 7/18/25 at 1455 hours, an interview and concurrent medical record review was conducted with the MDS Coordinator. The MDS Coordinator stated the MDS staff initiated the care plan, then the licensed nurses could update the care plan too. The MDS Coordinator stated the licensed nurses get the residents' information from the admission records, medication lists, and diagnoses then formulate the care plan. The MDS Coordinator verified Resident 93's plan of care to address the dialysis included interventions not applicable to Resident 93. The MDS Coordinator stated the resident's care plan to address dialysis was initiated by the MDS Assistant, and did not know why the MDS Assistant included the interventions not applicable to Resident 93. On 7/22/25 at 1554 hours, an interview and concurrent medical record review was conducted with the DON. The DON verified the above findings. The DON stated Resident 93 had a vascular access dialysis site so there should be no bruit and thrill. The DON stated the MDS staff initiated the care plan for all the residents, and the MDS nurse might have clicked the inapplicable interventions from the care plan library in the electronic health record.

Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to provide the necessary pharmaceutical services as per the facility P&P for one nonsampled resident (Resident 30).* The facility failed to ensure the administration of the controlled medication for Resident 30 was documented on the MAR. This failure had the potential for the medications to be administered in error and opportunities for drug diversion or drug misuse.Findings: Review of the facility's P&P titled Pharmacy Services Controlled Medication revised 12/2019 showed when a controlled medication is administered, the licensed nurse administering the medication immediately enters all of the following information on the accountability record: Date and time of administration, amount administered, signature of the nurse administered the dose, completed after the medication is actually administered. Review of facility's P&P titled Medication Administration revised 5/2007 showed all the current drug and dosage schedules must be recorded on the resident's electronic medication administration record (eMAR). Medical record review for Resident 30 was initiated on 7/16/25. Resident 30 was admitted to the facility on [DATE]. Review of Resident 30's H&P examination dated 3/31/25, showed Resident 30 had the capacity to understand and make decisions. Review of Resident 30's Order Summary Report dated 7/16/25, showed a physician's order dated 4/6/25, to give hydrocodone-acetaminophen (controlled pain medication) 5-325 mg one tablet by mouth every eight hours as needed for moderate pain (pain level of 4-7) and two tablets for severe pain (pain level of 8-10, , using the 0-10 pain scale; zero meaning no pain and 10 meaning worst pain). Review of Resident 30's Narcotic and Hypnotic Record showed one tablet of hydrocodone-acetaminophen 5-325 mg was dispensed and signed out on 7/6/25 at 2028 hours. Review of Resident 30's July 2025 MAR failed to show the documentation one tablet of hydrocodone-acetaminophen 5-325 mg was administered on 7/6/25 at 2028 hours. On 7/16/25 at 1100 hours, an interview and concurrent medical record review for Resident 30 was conducted with the DON. The DON verified the above findings.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary pharmacy services to ensure proper storage and labeling of medications. * The facility failed to ensure the medical label on the on the bubble pack of losartan (antihypertensive medication) was correct. * The facility failed to ensure LVN 1 did not leave medications unattended at bedside during medication administration observation. * The facility failed to ensure LVN 1 did not leave the medication cart (Medication Cart A) unlocked and unattended. These failures had potential to result in unsafe medication administration, cross-contamination of the medications and post the risk for non-licensed staff to have access to the medicationsFindings: 1. Review of the facility's P&P titled Medication Ordering and Receiving from Pharmacy revised 1/2018 showed each prescription medication label includes.specific directions for use. Improperly or inaccurate labeled medications are rejected and returned to the dispensing pharmacy. Review of the facility's P&P titled Medication Storage in the Facility revised 1/2018 showed only licensed nurses, pharmacy personnel, and those lawfully authorized to administer medications such as medication aides permitted to access medications. Medication rooms, carts, and medication supplies are locked when not attended by persons with authorized access. On 7/17/25 at 0903 hours, a medication administration for Resident 77 was conducted with LVN 1. The following was observed: a. The label on the bubble pack of losartan for Resident 77 showed to hold the losartan medication when SBP was more than 130 mmHg. Medical record review for Resident 77 was initiated on 7/15/25. Resident 77 was admitted to the facility on [DATE]. Review of Resident 77's Order Summary Report showed a physician's order dated 7/4/25, to administer losartan 50 mg one tablet by mouth two times a day. To hold if SBP is less than 130 mmHg, and to notify the physician if held more than 72 hours. On 7/17/25 at 0933 hours, an interview was conducted with LVN 1. LVN 1 verified the label on the bubble back for losartan medication did not match the physician's order. LVN 1 also verified there was no change of direction sticker on the bubble pack. b. LVN 1 was observed preparing medications for Resident 77 and placed all the prepared medications on a small tray. Medication Cart A was parked by LVN 1 by the resident's doorway. LVN 77 was observed entering Resident 77's room, Resident 77 was observed lying in bed, and a Resident 77's family member was seated near the bed, with the curtains drawn. LVN 1 was observed placing the tray with the medications at bedside, then LVN 1 was observed using the alcohol-based hand rub by the door and was also observed talking to a staff. The medications were left at the bedside unattended and unsupervised. Then LVN 1 went back and placed a straw on the resident's cup, and LVN 1 went to the sink to wash her hands. The medications were left at bedside unattended and unsupervised. Then LVN 1 was observed going back to the medication cart to get a spoon. The medications were left at the bedside unattended and unsupervised. Then LVN 1 administered the oral medications to Resident 77. LVN 1 was observed going back to the medication cart to get tissue papers. The nasal spray medication was left at bedside unattended and unsupervised. On 7/17/25 at 1109 hours, an interview was conducted with LVN 1. LVN 1 verified she left the medications at the bedside, while Resident 77 was lying in bed and Resident 77's family member was seated near the bedside, with the curtains drawn. LVN 1 stated she forgot to get the straw, spoon, and tissue paper so she had to go back to the medication cart. 2. On 7/17/25 at 1106 hours, an observation and interview was conducted with LVN 1. Medication Cart A was observed parked in front of the nurses' station, facing the hallway. LVN 1 was observed going inside the nurses' station, and left Medication Cart A unlocked and unattended while a CNA was observed passing by. LVN 1 verified the above findings. LVN 1 stated she forgot to lock the medication cart. On 7/22/25 at 1608 hours, an interview was conducted with the DON. The DON stated the losartan medication was initially ordered to hold if the SBP was more than 130 mmHg, but the physician's order was changed to hold if the SBP was less than 130 mmHg. The DON stated the nurses should have placed a change of direction sticker. The DON stated the medications and medication cart should not be left unattended.

Based on interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to ensure one of two sampled residents (Resident 1) was free from accident hazards. * Resident 1 had a fall while being transferred on 9/14/20. The facility failed to investigate the fall and there were no interventions put in place to prevent Resident 1 from further falls. The PT evaluated Resident 1 on 9/16/20, and recommended two-person assistance for transfers. This recommendation was not communicated to the nursing staff and was not implemented. This failure resulted in Resident 1 sustaining another fall during transfer on 12/5/20, with a fracture to the right leg, which required a transfer to an acute care hospital for surgical intervention. Findings: Review of the facility's initial report received from the DON dated 12/6/20, showed Resident 1 had an assisted fall on 12/5/20 at 0920 hours, and sustained a distal femoral fracture to the right lower extremity (a [MEDICAL CONDITION] thigh bone above the knee). Review of the facility's P&P titled Fall Management System revised 2/2015 showed the fall incidents will be investigated to determine probable cause factors and the investigation will be reviewed by the interdisciplinary team. The summary of the investigation and recommendations will be documented in the resident's clinical record. Medical record review for Resident 1 was initiated on 12/11/20. Resident 1 was admitted to the facility on [DATE]. Review of Resident 1's MDS dated [DATE], showed Resident 1 had no cognitive impairment. Review of the Progress Notes showed the nursing entry dated 9/14/20, showing Resident 1 was being transferred by the CNA from the toilet to her wheelchair and .her legs gave way. The documentation showed the CNA held Resident 1 to prevent her from falling, and called for assistance. Another CNA came to assist with the transfer. Resident 1 was noted with a skin tear to the left lower leg. Review of the medical record failed to show documentation Resident 1's fall on 9/14/20, was investigated and reviewed by the interdisciplinary team. Review of the Rehabilitation Services Screening Tool dated 9/16/20, showed Resident 1 was seen by the PT due to a fall on 9/14/20, when transferring from the bedside commode by a CNA. The documentation showed Resident 1 was a high risk for falls with weight bearing activities. All transfers and gait training were to be performed with two CNAs or RNAs. Review of Resident 1's PT Discharge Summary dated 10/7/20, under Discharge Recommendations, showed Resident 1 required maximum assistance with two persons and a two-wheeled walker during transfers. The discharge plan showed the care planning conference was held with the interdisciplinary team to review Resident 1's functional skills and discharge plans. Review of Resident 1's plan of care showed a care plan problem addressing Resident 1's risk for complications related to ADL care and self-care performance deficit was developed on 10/6/19. The interventions included one to two staff participation with transfers. The care plan was not revised to reflect the recommendation by the PT on 9/16/20, for Resident 1 to be assisted by two CNAs or RNAs for transfers. The care plan also did not include the recommendations made by PT on the Discharge Summary dated 10/7/20, for Resident 1 to be provided with maximum assistance of two persons for ambulation using a two-wheeled walker. Cross reference to F657. Review of Resident 1's Documentation Survey Report (CNA's ADL flowsheet) from October to December 2020 showed inconsistencies of the number of persons required to assist Resident 1 during transfers. For example, for the month of October 2020, the documentation showed Resident 1 was provided with one-person physical assistance for transfers on the 0700 to 1500 hours shift from 10/1 to 10/16/20. However, on 10/17, 10/21, and 10/24/20, Resident 1 was provided with two-persons' physical assistance for transfers. Review of the Progress Notes showed an entry from RN 1 dated 12/5/20, showing the physician was notified Resident 1 had an assisted fall when she was being transferred by CNA 3 from the bed to shower chair due to her knees .gave up. The documentation showed Resident 1's right knee was in a slightly inward position, with limited range of motion. The physician ordered a STAT (immediately) X-ray of the right knee. Review of Resident 1's right knee x-ray report dated 12/5/20, showed suspected nondisplaced supracondylar distal femoral fracture ([MEDICAL CONDITION] bone at the knee). Review of Resident 1's Discharge Summary from the acute care hospital dated 12/8/20, showed Resident 1 was admitted to the acute care hospital on [DATE], for a closed fracture (when the bone broke but there was no open wound in the skin) of the distal end of the fibula (lower leg bone). The documentation showed Resident 1 presented to the emergency department with the right knee pain level of 10 (on a pain scale of 0 to 10 with 0 = no pain to 10 = severe pain). Resident 1 had an open reduction internal fixation of the right distal femur (surgery to stabilize and heal the right thigh bone) on 12/7/20. On 12/10/20 at 1100 hours, an interview was conducted with CNA 1. CNA 1 stated she was familiar with Resident 1's care and Resident 1 was able to stand and transfer with one-person assistance prior to the fall incident on 12/5/20. When asked if CNA 1 witnessed Resident 1 fell during a transfer from bed to shower chair on 12/5/20, CNA 1 stated no. CNA 1 stated she went into Resident 1's room after the fall incident and saw Resident 1 sitting on the floor with her legs stretched out. CNA 1 stated RN 1 came into Resident 1's room and assessed Resident 1. CNA 1 stated she assisted CNA 3 to transfer Resident 1 from the floor to the shower chair after the assessment. On 12/10/20 at 1400 hours, an interview was conducted with CNA 2. CNA 2 stated she was familiar with Resident 1. CNA 2 stated she did not know the details of the fall incident but stated Resident 1 required one-person assistance for transfers prior to the fall incident. On 12/10/20 at 1430 hours, an interview was conducted with Resident 1. When asked what took place on the morning of 12/5/20, Resident 1 stated she was transferring from one chair to another with CNA 3 and her leg gave way which caused her to fall on her right side. Resident 1 stated CNA 3 tried to help her but could not. Resident 1 stated an x-ray of her right leg was done on 12/5/20, and she was transferred to the acute care hospital where she had surgery on her right leg. On 12/10/20 at 1505 hours, 1/8/2021 at 1512 hours, and 1/11/2021 at 0915 hours, an interview and concurrent medical record review was conducted with PT 1. PT 1 stated the last time she worked with Resident 1 was on 10/7/20. PT 1 verified the PT Discharge Summary dated 10/7/20, showed Resident 1 required two-person assist with a two-wheeled walker for all transfers. When asked if she communicated Resident 1's need for two-person assistance to the direct care staff, PT 1 stated no. PT 1 stated she usually communicated the resident's needs to the DSD or the charge nurse, but was unable to provide documentation to show Resident 1's needs were communicated on or after 10/7/20. PT 1 stated she completed the Rehabilitation Services Screening Tool on 9/16/20, after Resident 1 had a fall incident on 9/14/20. PT 1 stated she recommended all transfers for Resident 1 were to be performed with two CNAs/RNAs. PT 1 was unable to provide documentation to show she communicated or provided training to direct care staff after the screening tool was completed. On 12/10/20 at 1530 hours, 12/23/20 at 1509 hours, and 1/19/21 at 1016 hours, an interview and concurrent medical record review was conducted with the DON. The DON stated Resident 1 required one-person assistance during transfers prior to the fall incident on 12/5/20. When asked if the IDT meeting was conducted for Resident 1 after the documented fall episode on 9/14/20, the DON stated no. The DON stated they did not consider the incident as a fall since the CNA prevented Resident 1 from falling when Resident 1's legs gave way during a transfer. The DON stated the incident was not investigated. When asked if a care planning conference for Resident 1 was conducted with the interdisciplinary team after Resident 1 was discharged from PT services on 10/7/20, the DON stated no. The DON verified the above findings. On 12/18/20 at 1550 hours, an interview was conducted with CNA 3. CNA 3 stated she was familiar with Resident 1's care and Resident 1 required one-person assistance for transfers prior to the fall incident on 12/5/20. CNA 3 stated she assisted Resident 1 transfer from a wheelchair to a shower chair on the morning of 12/5/20. CNA 3 stated she positioned Resident 1's wheelchair and the shower chair next to each other and assisted Resident 1 from the wheelchair to a standing position. CNA 3 stated she let go of Resident 1 once Resident 1 was in a standing position and was balanced. CNA 3 stated Resident 1 attempted to transfer to the shower chair on her own from a standing position but fell . CNA 3 stated Resident 1 fell and caught herself on her bed and CNA 3 assisted her to the floor. CNA 3 stated she paged for assistance and RN 1 and CNA 1 came into Resident 1's room. CNA 3 stated RN 1 assessed Resident 1. CNA 3 stated CNA 1 assisted in transferring Resident 1 from the floor to the shower chair. CNA 3 stated Resident 1 did not complain of pain after the fall. On 12/18/20 at 1630 hours, an interview was conducted with RN 1. RN 1 stated Resident 1 required one-person assistance for transfers prior to the fall incident on 12/5/20. RN 1 stated Resident 1 fell in her room on 12/5/20, while being assisted by CNA 3 to transfer from the wheelchair to the shower chair. RN 1 stated she did not witness the fall. RN 1 stated she observed Resident 1 on the floor after the fall and completed the physical assessment. RN 1 stated Resident 1's right knee was bent inward, appeared slightly larger than the left knee, but the skin was intact with no discoloration. RN 1 stated Resident 1 complained of a little pain but was able to move her right foot and toes. RN 1 stated three staff members assisted Resident 1 from the floor to the shower chair after the assessment. RN 1 stated she contacted Resident 1's physician immediately thereafter. On 1/8/2021 at 1330 hours, an interview and concurrent medical record review was conducted with the Director of Rehabilitation. The Director of Rehabilitation stated Resident 1 required two-person assistance with more than 75 percent effort with a two-wheeled walker for all transfers. The Director of Rehabilitation stated the PT was responsible for informing and training the direct care staff as needed. When asked if Resident 1's needs and functional skills were discussed with the interdisciplinary team in October 2020, the Director of Rehabilitation stated he did not recall and was unable to provide documentation to show Resident 1's needs were communicated to the direct care staff.