Every finding on record at Weston County Health Services

Based on medical record review, resident representative and staff interview, facility incident report review, plan of correction review, and policy and procedure review, the facility failed to protect the resident's right to be free from sexual abuse by a resident for 1 of 4 sample residents (#3) reviewed for abuse. This failure resulted in actual harm to resident #3. The findings were:1. Review of the quarterly MDS assessment dated [DATE] showed resident #3 had severely impaired cognitive function and diagnoses which included cerebral palsy, anxiety disorder, anoxic brain damage, and unspecified disorder of adult personality and behavior. Further review showed the resident was non-verbal, non-ambulatory, impaired in both lower extremities, and wheelchair bound. In addition, the resident was dependent upon staff for all mobility, eating and hygiene activities, and required substantial to maximal assistance with upper and lower body dressing. Review of the quarterly MDS assessment dated [DATE] showed resident #4 had a BIMS score of 14 out of 15 and had diagnoses which included anemia, hypertension, and diabetes mellitus. Further review showed resident #4 ambulated with a walker and was independent with mobility. The following concerns were identified: a. Review of the facility incident report dated 7/1/26 and timed 12:48 PM showed CNA #1 observed resident #4 with his/her hand inside the shirt of resident #3 while in the solarium common area television room. Resident #4 then immediately removed his/her hand from the inside of resident #3's shirt and left the solarium room.b. Interview with CNA #1 on 8/13/26 at 2:51 PM confirmed she had witnessed resident #4 with his/her hand down the shirt of resident #3. The CNA stated .[his/her] left hand was down the front of [resident #3's] shirt and appeared to be touching his/her [skin] . She revealed resident #4 had removed his/her hand from resident #3's shirt and had left the solarium room following the observation. She revealed As soon as I got [resident #3] back to [his/her] room following the incident, the resident started flaying both arms around and leaning [his/her] head forward, which is what [s/he] does when anxious.c. Interview with resident #3's family representative on 8/13/26 at 1:34 PM revealed .Resident #4 shouldn't have touched resident #3 and resident #3 would have been fearful of resident #4. d. Review of the document titled Plan of Correction dated 7/7/26 showed .Systemic changes implemented.The care plans for both residents were reviewed and updated if required to reflect the identified risks, interventions, and monitoring needs.e. Interview with the nursing home administrator on 8/13/26 at 3:57 PM revealed she was aware of the incident and she stated the facility had developed a plan of correction which included a behavioral contract with resident #4. She revealed the plan included supervision by staff when resident #4 was in common areas and hourly checks. She revealed resident #3 was relocated to the secure unit of the facility. f. Review of the care plan last revised 7/29/26 for resident #4 showed no identified risks, interventions, or monitoring had been documented.2. Interview with the nursing home administrator on 8/13/26 at 4:10 PM confirmed the care plan for resident #4 had not been updated according to the facilities plan of correction.3. Review of the document titled Abuse/Neglect Policy last revised 12/19 showed .It is the policy of [NAME] County Manor that each resident will be free from abuse.

This requirement was not met as evidenced by:Based on observation, resident trust account review, Amazon order review, medical record review and staff and resident representative interview, the facility failed to protect residents from misappropriation of resident property for 1 of 3 sampled residents (#2) reviewed for misappropriation of property. The findings were: 1. Review of the 1/14/25 quarterly MDS assessment showed resident #2 had a BIMS score of 3 out of 15, which indicated severe cognitive impairment, and diagnoses which included dementia, non-traumatic brain dysfunction, and meniere's disease. Further review showed the facility managed the resident's funds through a trust account. Attempts to interview the resident were unsuccessful due to cognitive debilities. The following concerns were identified:a. Review of the document titled Business Order Information provided by the NHA on 3/30/26 at 4:30 PM showed an Amazon order was placed for resident #2 on 2/10/25 which included 3 Meta [NAME] virtual reality headsets in the amount of $399.99 per unit.b. Review of the document titled [NAME] County Health Services Trust Transaction History provided by the patient services coordinator on 3/31/26 at 11:12 AM showed a debit from the residents' trust account dated 2/10/25 in the amount of $1,878.78 for Amazon purchases.c. Observation on 3/30/26 at 1:45 PM showed 3 Meta [NAME] virtual reality headsets in their original boxes (one opened) in the activities storage room located near the main dining room.d. Interview with the activities director on 3/30/26 at 1:46 PM revealed she did not know who the devices belonged to and they had been stored in the closet since February of 2025. She further revealed the devices required an internet source and she didn't know how to use them.e. Interview with the resident's responsible party on 3/31/26 at 10:15 AM revealed s/he knew nothing about the Meta [NAME] purchase. In addition, s/he did not believe the resident would have been capable of operating the virtual reality devices.f. Interview with the NHA on 3/31/26 at 10:30 AM revealed the resident was obligated to spend down his/her trust account as Medicaid requirement and 3 Meta [NAME] virtual reality headsets were ordered for the resident and possibly some friends to utilize.

Based on medical record review, facility incident review, resident and staff interview, and policy and procedure review, the facility failed to protect the resident's right to be free from physical abuse by a resident for 1 of 6 sample residents (#50) reviewed for abuse. This failure resulted in actual physical harm to resident #50. The findings were:1. Review of the quarterly MDS assessment dated [DATE] showed resident #50 had a BIMS score of 5 out of 15, which indicated severe cognitive impairment, and diagnoses which included non-traumatic brain dysfunction, non-Alzheimer's dementia, and asthma. Further review showed the resident required substantial/maximal assistance from staff to move from sitting to lying, lying to sitting, sitting to standing, and chair/bed-to-chair transfer. The following concerns were identified:a. Interview with resident #50 on 12/9/25 at 9:52 AM revealed another resident had gotten upset with him/her and grabbed resident #50 around his/her neck and twisted.b. Review of a facility incident report dated 10/26/25 and timed 11:15 AM showed a staff member was walking by resident #50's room and observed resident #16 on resident #50's side of the room. The staff member reported resident #16 appeared to be hitting resident #50's head while resident #50 was seated in his/her wheelchair. The incident report showed after the residents were separated, resident #50 had redness noted in a few areas of his/her head. Further review showed resident #50 complained of intermittent headache since the incident occurred.c. Review of a Change of Condition progress note for resident #50 dated 10/26/25 and timed 11:20 AM showed .Physical Aggression Received This nurse was called to [resident #50]'s room following NSA [name]'s arrival to the room after hearing yelling. When this nurse arrived, [resident #50] was found seated in [his/her] wheelchair and appeared startled after being the recipient of physical aggression from [his/her] roommate. [Resident #50] was assessed for injury with mild redness noted to the back of [his/her] head, no redness to the shoulders which were the affected areas per witness report . [S/He] and [his/her] roommate have bickered in the past. [Resident #50] had been away from the room for a couple of days, just returned home yesterday afternoon . What nurse thinks is going on with resident is: to have been the recipient of physical aggression. When asked what happened, why did [s/he] get hit by [his/her] roommate, [resident #50] stated I don't know, [S/he]'s got a temper on [him/her]. It's just one of those things. [Resident #50] reported feeling unsafe at the facility with the aggressor as [his/her] roommate. [S/He] reported feeling safe at the facility so long as the aggressor was not [his/her] roommate .d. Review of a progress note for resident #50 dated 10/26/25 and timed 11:36 AM showed .Called and spoke with [resident representative] to notify her of [resident #50]'s physical aggression received from [his/her] roommate. Notified [representative] that the roommate was relocated from their shared room to another residence. She verbalized Poor [resident #50], that poor [guy/gal] just can't catch a break. Notified [representative] [resident #50] is now on regular full VS and neurological observations as [s/he] was hit in the head by [his/her] roommate and she appreciated the update and verbalized understanding to the plan of care. She looks forward to an update as appropriate .e. Review of a Late Entry progress note for resident #50 dated 10/28/25 and timed 2:30 PM showed .This writer was approached by CNA who stated the following, 'I was just talking with [resident #50] who told me [s/he] saw [resident #16] walk down the hall and [s/he] has to see [him/her] in the lunchroom and [s/he] felt a bit uncomfortable. I told [him/her] I was very sorry that happened to [him/her] and I reassured [him/her] [s/he] was safe and that I would tell the proper person to come and talk with [him/her].' This writer thanked CNA for the information and assured her that we will follow up on this information. This writer also overheard [resident #50]'s new roommate telling [resident #50] that [s/he] needed less oxygen, that [s/he] needed to ask for more medicine if [s/he] had a headache, that [s/he] was a lawyer and [s/he] knew all about 'these situations'. This writer and administrator will speak with [resident #50]'s roommate regarding these comments. This writer and administrator went to [resident #50]'s room to speak with [him/her] and [s/he] appeared in good spirits. [Resident #50] was asked if [s/he] felt safe here in the facility and in [his/her] room with [his/her] new roommate and [s/he] stated 'yes.' [Resident #50] did state 'I got hit in the head by that [guy/gal] and [s/he] is out of here now.' [Resident #50] did not express any further comments about the incident that occurred this past Sunday. [S/He] did state 'I was just in the hospital and I'm feeling a bit better now.' This writer and administrator will follow up with social services to come and talk with [resident #50] and Geri psych NP will be contacted to get [him/her] on the schedule to be seen this week. This writer and administrator assured [resident #50] that [s/he] is safe and that we are always here monitoring everybody. [Resident #50] thanked this writer and administrator for stopping in.f. Review of a Change of Condition progress note for resident #16 dated 10/26/25 at 11:20 AM showed .Physical Aggression Initiated This nurse was called to [resident #16]'s room following NSA [name]'s arrival to the room after hearing yelling. When this nurse arrived, [resident #16] was found seated in [his/her] recliner and appeared visibly angered yelling [S/He] wouldn't shut up. Bilateral hands were closed in fists and the right knuckles were notably red. [S/He] had reportedly been hitting [his/her] roommate in [his/her] head and shoulders with closed fist per witness report. Appeared to have started on: 10/26/2025 [resident #16]'s Mirtazapine was recently restarted. [S/He] and [his/her] roommate have bickered in the past. [His/Her] roommate had been away from the room for a couple of days, just returned home yesterday afternoon . [Resident #16] appeared visibly angered . What nurse thinks is going on with resident is: to have been angered by [his/her] roommate and initiated physical aggression. When asked if [s/he] felt safe at the facility, [resident #16] verbalized I can take care of myself, I can handle myself. [S/He] denied feeling unsafe at the facility. When notified that [s/he] would be vacating [his/her] residence, [s/he] stated Why do I have to move? [S/He] started it. This nurse notified [resident #16] that [s/he] was physically aggressive towards [his/her] roommate and would be vacating his residence . 2. Interview with NSA #1 on 12/11/25 at 12:25 PM revealed on the day of the incident, she was in room [ROOM NUMBER] and heard yelling. The NSA went down the hall and saw resident #16 hitting resident #50. She revealed resident #50 was in his/her wheelchair in front of his/her recliner and resident #16 was yelling. She revealed resident #50 was not saying anything. She revealed she called out for some help, and a CNA, then a nurse came and they took over care. She revealed resident #50 did not say if s/he was hurting and the NSA did not see any injuries. Further interview revealed she was unsure what started the altercation. 3. Interview with LPN #2 on 12/11/25 at 12:52 PM revealed she was called down to the residents' room because she was told resident #16 had been hitting resident #50. She revealed resident #50 had some red marks noted and resident #16 had some redness to his/her knuckles. She revealed the residents had bickered with each other in the past; however, she was not sure what was said that provoked the physical altercation. She revealed resident #50 was aware it happened and did indicate s/he had pain. The LPN revealed resident #50 said s/he should have a headache due to all the redness and s/he did not feel comfortable in resident #16's presence. Further interview revealed resident #16 was moved to a different room. 4. Review of the facility policy titled Abuse/Neglect Policy last revised 12/2019 showed .Additionally, residents will be protected from abuse, neglect, and harm while they are residing at the facility .

Based on observation, staff interview, temperature log review, policy and procedure review, and 2022 Food Code review, the facility failed to ensure a professional standards for food service safety were followed in 1 of 1 kitchen. The census was 53. The findings were: Regarding dish machine temperature logs: 1. Observation on 12/8/25 at 3:22 PM showed the facility used a [NAME] high temperature sanitizing dishwashing machine. The temperature of the wash and rinse cycles, were to be recorded at breakfast, lunch and dinner. The highest daily temperature was to be recorded one time per day. Review of the [NAME] dishwashing machine manufacturer's instructions showed the minimum temperature of the wash cycle was 150 degrees Fahrenheit [F], and the minimum final rinse temperature was 180 degrees F. The following concerns were identified: a. Review of the October 2025 dish machine log sheet showed the required breakfast, lunch, and dinner temperatures, and daily temperature test was not documented on the form 51 out of 124 opportunities. Review of the November 2025 dish machine log sheet showed the required breakfast, lunch, and dinner temperatures, and daily temperature test was not documented on the form 77 out of 120 opportunities.b. The breakfast, lunch, dinner, and daily high temperature were missing on 10/23, 11/3, 11/14, 11/25, 11/26, 11/28, 11/29, and 11/30.c. The breakfast and daily high temperature were missing on 10/12, 10/19, 10/20, 11/5, 11/9, 11/17, 11/18, and 11/27.d. The breakfast, lunch and daily high temperature were missing on 10/27, 10/28, 10/31, and 11/24.e. The lunch, dinner and daily high temperature were missing on 10/14, 10/16, 10/21, 10/26, 11/2, 11/6, 11/8, 11/10, 11/11, 11/12, and 11/13.f. The dinner and daily high temperature were missing on 10/7, 10/11, 10/15, 10/22, 10/23, 10/24, 10/25, and 10/26.g. The dinner temperature was missing on 10/6.h. The lunch and daily high temperature were missing on 10/29, 10/30, 11/22 and 11/23.i. The lunch and dinner temperature were missing on 11/1, 11/15, 11/16, and 11/20.j. The lunch temperature was missing on 11/19, and 11/21.k. The daily high temperature was missing on 10/8 and 11/7. 2. Interview with the dietary manager on 12/8/25 at 3:25 PM confirmed the temperature logs were incomplete. 3. Review of the facility policy titled Daily Temperature Recording last revised 1/2020 showed .The AM cook will be responsible for monitoring and recording the temperatures of the freezer, and both walk-in refrigerator [sic] on the posted daily temperature record. 2. Obvious problems with temperatures in these areas will be reported to the supervisor immediately. 3. The temperatures of the above units will be monitored by staff on both shifts during the course of their work. 4. The dish machine wash and rinse temperatures will be monitored by dietary staff during each shift of dishwashing and recorded. 5. The Aide or [NAME] catching dishes will be responsible for recording the dish machine wash and rinse temperatures three times daily on the attached daily temperature record which is posted in the main kitchen. 4. Review of the 2022 FDA Food Code showed (A) The temperature of the wash solution in spray type warewashers that use hot water to SANITIZE may not be less than: (1) For a stationary rack, single temperature machine, 74 [degrees] C (165 [degrees] F); (2) For a stationary rack, dual temperature machine, 66 [degrees] C (150 [degrees] F); (3) For a single tank, conveyor, dual temperature machine, 71 [degrees] C (160 [degrees] F); or (4) For a multitank, conveyor, multitemperature machine, 66 [degrees] C (150 [degrees] F). Regarding the Freezer, walk-in #1 and #2, reach in: 1. Review of the October and November 2025 daily temperature logs for the freezer, walk-in #1, walk in-in #2, and reach in showed the temperature was to be documented on both the morning and afternoon shifts. The expected temperature was 0 degrees Fahrenheit for the freezer, and 41 degrees Fahrenheit for refrigerators. The following concerns were identified: a. The walk-in freezer morning shift temperatures were missing on 10/20, 10/29, 10/31.b. The walk-in freezer, walk-in #1 and #2 refrigerators, and reach-in cooler afternoon shift temperatures were missing on 10/16, 10/17, 10/18, 10/19, 10/23, 10/24, 10/25, 10/26, 10/27, 10/28, 10/29, 10/31, 11/4, 11/5, 11/6, 11/7, 11/8, 11/9, 11/10, 11/11, 11/12, 11/13, 11/15, 11/16, 11/18, 11/19, 11/20, 11/21, 11/25, 11/26, 11/28, 11/29, and 11/30.c. The walk-in freezer, walk-in #1 and #2 refrigerators, and reach-in cooler morning and afternoon shift temperatures were missing on 10/29, 11/1, 11/2, 11/3, 11/14, 11/17, 11/22, 11/23, 11/24, and 11/27. 2. Interview with the dietary manager on 12/8/25 at 3:25 PM confirmed the temperature logs were incomplete. 3. Review of the facility policy titled Daily Temperature Recording last revised 1/2020 showed .The AM cook will be responsible for monitoring and recording the temperatures of the freezer, and both walk-in refrigerator [sic] on the posted daily temperature record. 2. Obvious problems with temperatures in these areas will be reported to the supervisor immediately. 3. The temperatures of the above units will be monitored by staff on both shifts during the course of their work. 4. The dish machine wash and rinse temperatures will be monitored by dietary staff during each shift of dishwashing and recorded. 5. The Aide or [NAME] catching dishes will be responsible for recording the dish machine wash and rinse temperatures three times daily on the attached daily temperature record which is posted in the main kitchen. Regarding food temperatures: 1. Review of the October and November 2025 Food temperature logs showed the temperature was to be logged at breakfast, lunch, and dinner. The following concerns were identified:a. No lunch temperatures were recorded on 10/23.b. No dinner temperatures were recorded on 10/12, 10/16, 10/18, 10/22, 10/26, 10/27, 10/28, 10/30, 11/1, 11/6, 11/10, and 11/21.c. No lunch and dinner temperatures were recorded on 10/15, 10/21, 11/2, 11/3, 11/5, 11/8, 11/9, 11/11, 11/12, 11/13, 11/14, 11/15, 11/16, 11/18, 11/19, 11/21, 11/25, 11/28, 11/29, and 11/30.d. No temperatures for breakfast, lunch, or dinner were recorded 11/17, 11/22, 11/23, 11/24, and 11/27. 2. Interview with the dietary manager on 12/8/25 at 3:25 PM confirmed the temperature logs were incomplete. 3. Review of the facility policy titled Recording Food Temps last revised 7/2025 showed The temperatures of time-temperature controlled foods will be monitored each meal by dietary staff in a sanitary manner. Procedures. 1. The AM, noon and PM cooks will, check hot foot temperatures before placing hot foods into the portable steam table. All hot foods must be maintained in the steam table at least 140 degrees F. A temperature of 160 degrees prior to placing foods into the steam table is desirable.6. The cook for each meal is responsible for checking and maintaining proper temperatures during meal service. Temperatures should be checked with a thermometer at least two times during at breakfast and once at lunch and dinner. 4. Review of the 2022 FDA Food Code showed . Records must be maintained to verify that the critical limits required for food safety are being met. Records provide a check for both the operator and the regulator in determining that monitoring and corrective actions have taken place . Regarding beard restraint: 1. Observation on 12/10/25 starting at 10:05 AM showed the dietary aide #1 washed dishes, prepared gravy, and served lunch from the tray line to residents. Further observation showed he had visible facial hair and did not wear a beard restraint. 2. Interview with the dietary manager on 12/10/25 at 12:30 PM revealed she was unaware the dietary staff with beards should wear a beard restraint. 3. Review of the facility policy titled Traffic Control last revised 8/2025 showed .signs are posted on the door to the kitchen regarding the requirement of hair nets upon entrance. 4. Review of the 2022 FDA Food Code showed .2-402 Hair Restraints 2-402.11 Effectiveness. (A) Except as provided in (B) of this section, FOOD EMPLOYEES shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed FOOD; clean EQUIPMENT, UTENSILS, and LINENS; and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES. (B) This section does not apply to FOOD EMPLOYEES such as counter staff who only serve BEVERAGES and wrapped or PACKAGED FOODS, hostesses, and wait staff if they present a minimal RISK of contaminating exposed FOOD; clean EQUIPMENT, UTENSILS, and LINENS; and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES.

Based on resident, resident representative, and staff interview, grievance log review, call light log review, and policy and procedure review, the facility failed to ensure sufficient nursing staff was provided to ensure the highest practicable physical, mental and psychological well-being of 3 of 4 units (Four Corners, [NAME] Creek, Unit 6) reviewed for staffing. The findings were: 1. Review of the quarterly MDS assessment dated [DATE] showed resident #36 had a BIMS score of 15 out of 15, which indicated the resident was cognitively intact, and had diagnoses which included left foot drop, lumbago with sciatica, major depressive disorder, and pneumonia. Further review showed the resident was dependent for toilet transfers. The following concerns were identified: a. Interview with the resident on 12/9/25 at 8:27 AM revealed s/he had to wait a long time for the call light to be answered, and meal times were a longer wait time. b. Interview with the resident's representative on 12/9/25 at 11:31 AM revealed the resident would use his/her call light, staff would come in and turn it off and move the rolling table, and the resident was then unable to reach the call light or phone. They reported the resident has been left sitting in feces in his/her recliner due to the extended wait times. Further interview revealed the resident's roommate would often push his/her call light in order to get assistance for the resident because s/he could not reach the call light. c. Observation on 12/10/25 at 4:17 PM showed the resident was sitting in his/her recliner and crying, and reported the bedside table was not placed close enough in front of him/her to reach the call light and phone. d. Review of the facility grievance log showed a grievance was filed on 12/6/25 by the resident's family which stated the resident was found by a family member with his/her bedside table, call light and cell phone out of reach. Further, the resident's call light had been turned off by a CNA who had left to find help to assist him/her, and the CNA did not return to assist the resident while the family member was still in the room. 2. Interview with 7 residents during resident council on 12/9/25 at 10:04 AM revealed the residents were told the average response time for call lights was 7 minutes; however, they reported the call lights are turned off by staff, residents were told the staff will be right back, and they never see them again. 3. Interview with resident #17 on 12/9/25 at 10:15 AM revealed s/he waited 73 minutes for a call light to be answered. 4. Interview with staffing coordinator on 12/11/25 at 10:52 AM revealed there are usually 6 CNAs when the facility was fully staffed, unless staff called off, which happened frequently. 5. Interview with CNA #2 on 12/11/25 at 11:06 AM revealed the facility did not have enough staff to provide cares for residents at all times. Further interview revealed there were times when there was only 1 staff in the locked unit and 2 for the rest of the building. This resulted in residents who were soaked in the morning. She reported there have been times when 1 CNA has been responsible for 27 residents at night. 6. Interview with CNA #1 on 12/11/25 at 11:06 AM revealed there were times when there were only 2 CNAs at night, and the day staff stayed late to help residents so they could go to bed when they wanted, and not have to stay up until midnight because there was not enough staff to help. Further interview revealed she had seen call lights that had been on for over an hour. 7. Review of the call light log for resident #36 showed the call light wait times on 11/16/25 of 49 minutes at 8:37 AM, 11/18/25 of 69 minutes at 6:49 AM, 11/23/25 of 84 minutes at 8:21 PM, and 11/23/25 of 84 minutes at 9:46 PM. 8. Review of the call light log for resident #17 showed call light wait times on 11/23/25 of 35 minutes at 9:13 PM, 12/6/25 of 34 minutes at 8:23 PM, and 12/6/25 of 34 minutes at 8:58 PM. 9. Interview with the DON on 12/11/25 at 1:45 PM revealed she did not have an expected time frame for CNAs to answer call lights. She reported if non-clinical staff answered the light, they would leave it on for clinical staff. Further interview confirmed she has been drilling staff on call lights, and she currently had a contest for staff regarding call light times. Her expectation for staff during the day was to have 2 CNAs on each hall to partner and help each other out, and if staff called out, she would try to replace them and assist the direct care staff. She reported she did not have a facility policy on answering call lights.

Based on observation, staff interview, medical record review, and policy and procedure review, the facility failed to ensure infection prevention practices were implemented for 1 of 2 sample residents (#27) reviewed for urinary catheters. The findings were: 1. Review of the quarterly MDS assessment dated [DATE] showed resident #27 had a BIMS score of 13 out of 15, which indicated the resident was cognitively intact, and had diagnoses which included, renal insufficiency, neurogenic bladder, congestive heart failure and history of a stroke. The following concerns were identified.a. Observation on 12/10/25 at 8:57 AM showed resident #27 was in bed and his/her urinary catheter bag was on the floor and uncovered.b. Interview with the DON on 12/10/25 at 4:41 PM revealed that catheter bags were expected to be in covered bags, below the level of the resident's bladder, and shouldn't have been on the floor. c. Interview with CNA #1 on 12/11/25 at 10:56 AM revealed that catheter bag should have been in covers and not touching the floor. d. Interview with Infection Preventionist on 12/11/25 at 10:18 AM confirmed catheter bags should never touch the floor and should have been stored in bag covers to protect privacy and avoid contamination. Further interview revealed clinical staff were trained upon hire regarding infection prevention policies in relation to catheter bag placement. e. Review of facility policy titled Care of Urinary Catheters last revised 7/2025 showed .Keep the collection bag off the floor .

Based on medical record review and staff interview, the facility failed to ensure a transfer notice and bed-hold notice was provided in writing for 2 of 2 sample residents (#9, #50) reviewed for hospitalizations. The findings were:1. Review of a progress note dated 10/23/25 and timed 2:50 AM showed resident #50 was was sent to emergency room for evaluation and treatment related to low oxygenation, and lung sounds which included expiratory wheezes and rales or crackles. The following concerns were identified:a. Review of a Resident Bed Hold Notice dated 10/23 showed the resident's representative was contacted related to transfer and the bed-hold; however, there was no evidence the notifications were provided and received in writing. 2. Review of a Change of Condition progress note dated 10/19/25 and timed 2:08 AM showed resident #9 was transferred to the hospital after the resident was found on the floor with large black colored emesis. The following concerns were identified: a. Review of a bed Hold Policy form dated 10/29/25 showed the resident's agent was notified by the nurse of the resident's transfer and a different 'responsible party was notified of the bed hold policy; however, there was no evidence the notifications were provided and received in writing. 3. Interview with the DON and social services director on 12/11/25 at 8:49 AM confirmed the facility did not have evidence the residents or resident representatives were notified of transfer or discharge or bed-hold policy in writing. They revealed the notices were mailed; however, they did not have any way to confirm it was received.

Based on medical record review and staff interview, the facility failed to offer and/or provide pneumococcal vaccination for 1 of 5 sample residents (#1) reviewed for immunization status. The findings were: 1. Review of the immunization record for resident #1 showed the resident received the pneumococcal PPSV 23 vaccine on 1/1/94 and the pneumococcal PCV 13 vaccine on 9/25/17. Review of the CDC pneumococcal vaccine recommendations showed the resident was recommended to receive the pneumococcal PCV20 or PCV21 5 years after s/he received the PCV 13 vaccine. The following concerns were identified: a. Review of the resident's medical record showed an annual pneumococcal vaccination was offered and declined in 2024; however, there was no evidence the resident was offered annually after the declination. 2. Interview with the MDS coordinator on 2/11/25 at 10:41 AM revealed she did not think the resident had been offered the pneumococcal vaccine since s/he declined in 2024.

Based on medical record review and staff interview, the facility failed to ensure adequate monitoring of psychotropic medications for 2 of 5 sample residents (#1, #7) reviewed for unnecessary medications. The findings were:1. Review of the quarterly MDS assessment dated [DATE] showed resident #1 had a BIMS score of 15 out of 15, which indicated the resident was cognitively intact, and had diagnoses which included anxiety disorder, depression, and post-traumatic stress disorder. Further review showed the resident had no behaviors exhibited and received antianxiety and antidepressant medications. Review of the physician orders showed the resident received buspirone (antianxiety) 10 milligrams [mg] by mouth two times daily, which was ordered on 3/31/25, and sertraline (antidepressant) 100 mg by mouth at bedtime, which was ordered on 3/21/25. The following concerns were identified:a. Review of the physician orders showed Observe for Behavior: Anxiety *Document if resident is having behavior and Observe for Behavior: s/s [signs and symptoms] depression *Document if resident is having behavior . Review of the medical record showed no evidence the facility had identified resident specific or medication specific target symptoms of anxiety or depression.b. Review of the order history for the sertraline showed the original order was for 25 mg by mouth at bedtime, which was ordered on 8/1/24. The sertraline was increased to 50 mg at bedtime on 10/23/24, 75 mg at bedtime on 1/24/25, and 100 mg at bedtime on 3/21/25. Review of Behavior Monitoring for January 2025 and March 2025 showed no evidence of s/s depression noted.c. Review of a psychiatry note dated 1/23/25 showed the resident reported struggling with grief and mood instability, significant emotional distress, and a hard time keeping it together following the death of a family member. 2. Review of the admission MDS assessment dated [DATE] showed resident #7 had a BIMS score of 13 out 15, which indicated the resident was cognitively intact, and diagnoses which included anxiety disorder. Further review showed the resident had no behaviors exhibited and received antianxiety and antidepressant medications. Review of the physician orders showed the resident received fluoxetine (antidepressant) 20 mg by mouth daily, which was ordered on 11/11/25. The following concerns were identified: a. Review of the physician orders showed Observe for Behavior: Anxiety *Document if resident is having behavior . Review of the medical record showed no evidence the facility had identified resident specific or medication specific target symptoms of anxiety. 3. Interview with the DON and RN care coordinator on 12/11/25 at 1:29 PM confirmed the facility had not identified resident specific or medication specific target symptoms. The revealed resident #1 was able to verbalize feelings and resident #7 was new to the facility and must have been missed.

Based on observation, staff interview, and medical record review, the facility failed to ensure call lights were placed within residents' reach to accommodate resident needs for 1 of 19 sample residents (#45) reviewed. 1. Review of the quarterly MDS assessment dated [DATE] showed resident #45 had a BIMS score of 8 out of 15, which indicated the resident was moderately impaired and had diagnoses which included, chronic pain syndrome, urinary and bowel incontinence, hemiplegia, and was dependent upon staff for functional abilities, including mobility. Review of the care plan, last revised 10/20/25, showed the resident had a morse fall score of 55, which indicated a high fall risk and required his/her call light within reach. The following concerns were identified:a. Observation on 12/9/25 at 8:22 AM showed CNA #1 and CNA #2 provided cares for the resident. The resident's breakfast tray was given to him/her and s/he was asked to call when finished with his/her breakfast. The resident's call light was observed on the floor, beside the bed, at that time. b. Observation on 12/9/25 at 8:43 AM showed CNA #1 returned to the resident's room, then left, and the call light remained on the floor.c. Observation on 12/9/25 at 9:20 AM showed LPN #1 entered the resident's room and handed the resident his/her call light. Interview with LPN #1 at that time revealed the resident's call light was on the floor when she entered the room and she placed it within the resident's reach. d. Interview on 12/11/25 at 11:50 AM with CNA #1 revealed the resident's call light should have been operable and left within resident reach. e. Interview with the DON on 12/11/25 at 11:34 AM confirmed staff were expected to provide residents with their call light and ensure it was within reach.

Based on observation, staff interview, record review, and policy and procedure review, the facility failed to ensure thorough wound assessments were completed for 1 of 4 sample residents (#8) reviewed for wound care. The findings were: 1. Review of the significant change MDS assessment dated [DATE] showed resident #8 admitted to the facility on [DATE] and had a BIMS score of 99, which indicated the resident had severe cognitive deficits. The resident had diagnoses which included non-traumatic brain dysfunction, non-Alzheimer's dementia, and anxiety disorder. Further review showed the resident was at risk for developing pressure ulcers/injuries, and had 2 unstageable pressure injuries presenting as deep tissue injuries. The following concerns were identified:a. Review of the Situation, Background, Assessment, Recommendation (SBAR) form dated 11/2/25 and timed 5:35 PM showed the resident had 2 new blisters on both heels. The wound assessment showed .Right heel is 4.5 cm by 2.5 cm. Left heel is 6 cm by 5 cm. Both are draining. Mepilex applied to both and boots to both feet at all times. b. Review of the Head to Toe Skin Checks dated 11/2/25 and timed 9:08 showed Callouses to left foot remain. New blisters to bilateral heels are unchanged.c. Review of the Braden Scale for Pressure Sore Risk dated 11/3/25 showed the resident had a score of 13 out of 23, which indicated s/he was at moderate risk for pressure sores. d. Review of a progress note dated 11/3/25 and timed 11:32 showed the risk management team met to review the incident, heel protector boots were initiated, and the wound nurse was contacted to evaluate the resident. e. Review of Wound - Weekly Observation Tool dated 11/6/25 and timed 2:17 PM showed wound #1 on the left heel was a deep tissue injury, and was measured as length 7.5 cm, width 7.5 cm. The description of the peri-wound tissue was pink, intact and the wound edges and shape were described as irregular. f. Review of Wound - Weekly Observation Tool dated 11/6/25 and timed 2:17 PM showed wound #2 was a deep tissue injury, and was measured as length 3.5 cm, width 2.5 cm and depth 0 cm. The description of the peri-wound tissue was pink, intact and the wound edges and shape were irregular. g. Review of Head to Toe Skin Checks dated 11/9/25 and timed 8:45 PM showed .existing bruising, pressure areas to B/L heels with treatment plan in place, callous to bottom of L foot with treatment plan in place. There was no evidence the wound size, progress, or treatment effectiveness was assessed.h. Review of Head to Toe Skin Checks dated 11/16/25 and timed 11:15 PM showed .pressure areas to B/L heels with treatments in place and callous to bottom of L foot with treatment as ordered. There was no evidence the wound size, progress, or treatment effectiveness was assessed.i. Review of Head to Toe Skin Checks dated 11/23/25 and timed 8:41 PM showed .calluses [sic] to bottom of L foot.blisters to B/L heels. There was no evidence the wound size, progress, or treatment effectiveness was assessed. j. Review of Head to Toe Skin Checks dated 11/30/25 and timed 8:30 PM showed .calluses [sic] to bottom of L foot new dressing.blisters to B/L heels new dressings. There was no evidence the wound size, progress, or treatment effectiveness was assessed.k. Review of progress note dated 11/14/25 and times 9:22 PM showed Left heel began bleeding some after resident got [him/herself] into a sitting position on [his/her] bed and rubbed [his/her] foot along the edge of the bedframe. Cleansed and covered with dressing. There was no evidence the wound size, progress, or treatment effectiveness was assessed. 2. Observation on 12/10/25 at 12:45 PM showed LPN #3 measured and placed a bandage on the resident's left heel, and measured the right lateral heel. Interview with LPN #3 at that time revealed a scab fell off the resident's right heel, and she felt the wound would heal up quickly. 4. Interview on 12/10/25 at 12:50 PM with RN #1 revealed the certified wound care nurse assessed the wound within the first week so she could stage it and complete a wound evaluation form. Following the first assessment, the wound care nurse had not completed any further assessment, and the floor nurses changed the dressings and visually assessed the wounds. 5. Interview on 12/11/25 at 1:13 PM with the DON revealed wound care progress was documented by nursing staff who completed weekly skin assessments, and the effectiveness of the wound care was evaluated by the nurse observation. Further interview confirmed measurements were not documented in the weekly skin assessments. 6. Review of the facility policy titled Identification, Treatment and Prevention of Pressure Ulcers last updated 10/2023 showed .1. Document healing in chart and/or weekly skin review book . and IV. Staging and measuring wounds A. Use [NAME] form for wound assessment and follow-up and stage as directed weekly and prn. B. Measure wound top to bottom and side to side .

Based on medical record review and staff interview, the facility failed to ensure preadmission screening was performed and was accurate for 2 of 3 sample residents (#1, #39) with qualifying diagnoses. The findings were: 1. Review of the quarterly MDS assessment dated [DATE] showed resident #1 had diagnoses which included anxiety disorder, depression, and post-traumatic stress disorder. The following concerns were identified:a. Review of a PASRR Level I completed on 10/10/23 showed no primary psychiatric diagnosis listed and the decision indicated a PASRR level II was not indicated due to no evidence of mental illness or intellectual disability. b. Interview with the social services director on 12/11/25 at 8:27 AM revealed a new mental health diagnosis or significant behavior would trigger a need for a new PASRR. She revealed the diagnosis of post-traumatic stress disorder would trigger a PASRR level II and it should have been completed when the resident returned to the facility. 2. Review of a psychiatric note dated 3/28/25 showed resident #39 received a new diagnosis of post-traumatic stress disorder. The following concerns were identified:a. Review of the medical record showed no evidence a PASSR level I was completed after the resident received the post-traumatic stress disorder diagnosis. b. Interview with the social services director on 12/11/25 at 10:15 AM revealed she was not aware the resident had a diagnosis of post-traumatic stress disorder. She confirmed a new PASRR level I and possibly level II should have been completed.

Based on staff interview and review of the Payroll Based Journal (PBJ), the facility failed to ensure the mandatory submission of staffing was submitted to CMS for 1 of 4 quarters reviewed (10/1/23 through 12/31/23). The census was 38. The findings were: 1. Interview with the DON on 7/10/24 at 4:32 PM revealed the staffing was not submitted for the 10/1/23 through 12/31/24 quarter. She stated the data did not get submitted in time so it was missed. 2. Review of the PBJ for 10/1/23 through 12/31/23 showed the facility failed to submit data for the quarter.

Based on observation, QAPI minutes review, job posting review, and staff interview, the facility failed to ensure the QAPI committee included a qualified administrator who attended meetings. The census was 38. The findings were: 1. Observation on 7/10/24 at 9:45 AM of the current open positions showed the nursing home administrator position was included. Further, observations throughout the survey showed no administrator was in the facility. 2. Review of the 5/9/24 and 6/13/24 QA committee attendance sign in sheet showed the administrator was not present. 3. Interview with the CEO on 7/8/24 at 1:20 PM revealed the administrator was put on leave. Further, she stated the facility did not have a delegated administrator, and it was a problem and it was something the facility was working on. 4. Interview with the DON on 7/10/24 at 10:09 AM revealed the administrator had been on leave for the last 3 months. Further interview with the DON on 7/11/24 at 11:29 AM revealed the facility met monthly for QAPI, with all attendees, for facility improvement and to increase communication. 5. Interview with the administrator on leave on 7/10/24 at 3:12 PM revealed the former CEO put her on leave on 4/23/24 and she was told not to enter the building. She stated it was impossible to do the overall management for the facility since she was unable to enter the building or be in contact with staff.

Based on observation, QAPI minutes review, and staff interview, the facility failed to ensure a qualified administrator was able to manage the facility and report to the governing body. The census was 38. The findings were: 1. Observation on 7/10/24 at 9:45 AM of the current open positions showed the nursing home administrator position was included. Further, observations throughout the survey showed no administrator was in the facility. 2. Review of the 5/9/24 and 6/13/24 QAPI committee attendance sign in sheet showed the administrator was not present. 3. Interview with the CEO on 7/8/24 at 1:20 PM revealed the administrator was put on leave. Further, she stated the facility did not have a delegated administrator, and it was a problem and it was something the facility was working on. 4. Interview with the DON on 7/10/24 at 10:09 AM revealed the administrator had been on leave for the last 3 months. 5. Interview with the administrator on leave on 7/10/24 at 3:12 PM revealed the former CEO put her on leave on 4/23/24 and she was told not to enter the building. She stated it was impossible to do the overall management for the facility since she was unable to enter the building or be in contact with staff.

Based on observation, staff interview, and policy review the facility failed to ensure clean dressing changes were kept clean for 1 of 1 wound care observation (resident #8). The findings were: 1. Observation on 7/9/24 at 10:12 AM of resident #8 wound care with LPN #1 and LPN #2 showed they performed hand hygiene, and donned gloves and gowns. LPN #2 then closed the curtains, turned on the lights, pulled the supplies out of the storage bag, and opened the dressing packages, and dated the dressing. She then moved the extra gloves twice. The nurses turned the resident to his/her side. LPN #2 removed the old dressing, and cleaned the wound. She then doffed her gloves and donned the gloves she had moved earlier, without performing hand hygiene. 2. Interview with the LPN #2 on 7/9/24 at 10:28 AM revealed the procedure performed was her normal routine when doing a dressing change. She stated she should have used hand sanitizer between dirty and clean. 3. Interview with DON on 7/9/24 at 2:22 PM revealed it is the facility's expectation for staff to do hand hygiene, put on gloves, and complete hand hygiene when they remove their gloves. 4. Review of policy Hand Hygiene revised 1/2024 showed .1. Indications for hand washing and hand antisepsis.I. Decontaminate hands after removing gloves . 6. Other aspects of hand hygiene . D . Gloves do not replace hand hygiene, decontaminate hands after removal of gloves. E. Change gloves during patient care if moving from a contaminated-body site to a clean-body site.

Based on observation and staff interview the facility failed to to ensure the activities program was directed by a qualified professional. The census was 39. The findings were: 1. Random observations from 4/10/23 to 4/13/23 in the solarium and activities room showed residents participating in various activities. 2. Interview on 4/10/23 at 3:39 PM with the activities director revealed she had not completed the special training needed to coordinate the program. 3. Interview on 4/12/23 at 10:16 AM with the human resources director confirmed the activities director had not completed the training required to coordinate the activities program.

Based on staff interview, review of staff schedules, and review of the Staffing Data Submission Payroll Based Journal (PBJ) report, the facility failed to ensure an RN worked at least 8 consecutive hours within each 24 hour period, 7 days a week. The census was 39. The findings were: 1. Review of the PBJ report showed no RN coverage for 8 consecutive hours in a 24 hour period for the following 12 days: 5/14/22 and 5/15/22, 6/5/22, 6/11/22 and 6/16/22, 8/6/22 and 8/7/22, 10/1/22 and 10/2/22, 11/13/22, 12/10/22 and 12/11/22. Further review of the facility staff schedules showed no RN coverage for the following 8 days: 10/30/22, 11/11/22, 11/27/22, 1/8/23, 2/4/23, 2/5/23, 2/17/23 and 2/18/23. 2. Interview with the DON on 4/13/23 at 2:34 PM revealed s/he could not recall the facility having a day without an RN present in the building; however, due to a new scheduling program she was unable to provide evidence RN staffing requirements were met.

Based on review of the facility investigation report, staff and resident representative interview, review of policy and procedure, review of facility training documentation, and State Survey Agency incident report review, the facility failed to protect the residents right to be free from physical abuse by staff for 1 of 1 sample residents (#23) reviewed for abuse allegations. The findings were: 1. Review of the 2/7/23 quarterly MDS assessment showed resident #23 had a staff assessment which determined the resident was severely cognitively impaired. The resident exhibited physical behavioral symptoms directed toward others; behavioral symptoms not directed toward others; and rejection of care 4 to 6 days of the 7-day look-back period. In addition, the resident exhibited verbal behavioral symptoms directed toward others 1 to 3 days of the look-back period. Review of State Survey Agency incident reports showed an allegation of abuse was reported by the facility on 4/3/23 at 9:33 AM. The following concerns were identified: a. Interview with EVS #1 on 4/12/23 at 9:25 AM revealed she was mopping the dining room floor at the end of the noon meal when she witnessed an incident between NSA #1 and the resident. EVS #1 stated NSA #1 was attempting to remove a soiled clothing protector from the resident; however, the resident was resisting and saying no, no, no. NSA #1 continued to attempt to remove the clothing protector and the resident reached over and grabbed NSA #1's arm. NSA #1 reacted by yelling at the resident You won't treat me like that and slapping the resident's face. EVS #1 stated she was only 10 to 15 feet away and could hear the slap. Afterward, the resident had a stunned expression on his/her face. b. Interview with NSA #2 on 4/12/23 at 4:41 PM revealed she was seated at the computer desk at the back of the dining room at the time of the incident. NSA #2 stated she heard a commotion between NSA #1 and the resident about a clothing protector and witnessed the resident grab NSA #1's arm; however, she did not see or hear a slap. Review of an interview by the facility with NSA #2 dated 4/3/23 and timed 11:45 AM showed [NSA #2] freely gave information that she is very hard of hearing in her left ear which was the ear that was turned towards the event taking place and she was a good 30 feet or more from the occurrence . c. Interview with NSA #1 on 4/12/23 at 8:50 AM revealed she was going to take the resident out of the dining room after the noon meal and attempted to remove her soiled clothing protector. NSA #1 stated the resident resisted the removal of the clothing protector and the NSA tried to trade a clean clothing protector for the soiled one; however, the resident did not want it. NSA #1 stated the resident grabbed her hard leaving a bruise and spit on her. NSA #1 stated she remembered she raised her hand; however, honestly, do not remember making any contact with the resident. NSA #1 stated when the resident was resisting or rejecting care the approach was supposed to be leave the resident alone and that is what I probably should have done. d. Interview with the resident's representative on 4/11/23 at 9:23 AM revealed he was aware of an investigation being conducted related to an incident where an aide allegedly slapped the resident. He thought it might have been a defensive move since the resident did strike out at people and perhaps the aide was not properly trained. The resident's representative stated if the resident was being resistant it was best to leave him/her alone for a few minutes and s/he would forget all about it and be fine. e. Review of a statement provided to the facility from MA #1 dated 4/3/23 and timed 10:30 AM showed she had wheeled the resident out of the dining room after the incident and the resident was pleasant and did not have any marks on his/her face. 2. Interview with the DON on 4/13/23 at 10:58 AM revealed the facility had erred on the side of the resident and had terminated NSA #1's employment. In addition, the facility had an in-service in January 2023 which included abuse and reporting. After the incident occurred the DON went to each staff member and verbally instructed them on abuse and reporting and provided them a copy of the abuse policy. However; review of the Abuse, Prevention of abuse and Abuse reporting policy education form showed only 23 employees had been educated from 4/4/23 to 4/13/23. Review of the personnel roster showed the facility had 128 employees and 6 volunteers. 3. Review of the Abuse/Neglect Policy, last reviewed 9/2022, showed It is the policy of [NAME] County Manor that each resident will be free from Abuse. Abuse can include verbal, mental, sexual, or physical abuse, corporal punishment or involuntary seclusion .Additionally, residents will be protected from abuse, neglect, and harm while they are residing at the facility. No abuse or harm of any type will be tolerated, and residents and staff will be monitored for protection. The facility will strive to educate staff and other applicable individuals in techniques to protect all parties.

Based on review of facility policies, the review of State Survey Agency incident report logs, and staff interview, the facility failed to develop and/or implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with Section 1150B of the Act for 1 of 1 allegations of abuse reviewed. The findings were: 1. Review of the facility's policy Abuse/Neglect Policy, last reviewed 9/2022 showed .a. Employees must always report any abuse or suspicion of abuse immediately to the Administrator or designee .Each covered individual shall report to the State Agency and one or more law enforcement entities for the political subdivision in which the facility is located, any reasonable suspicion of a crime against any individual who is a resident of or is receiving care from, the facility, and each covered individual shall report immediately, but not more than 2 hours after forming the suspicion . Review of the State Survey Agency incident report logs showed an allegation of abuse was reported by the facility on 4/3/23 at 9:33 AM. The following concerns were identified: a. Interview with EVS #1 on 4/12/23 at 9:25 AM revealed she had witnessed an incident between resident #23 and NSA #1 which she thought was abusive on 4/2/23 at approximately 1:15 PM in the facility's dining room. EVS #1 stated she did not immediately report the incident; however, she contacted MA #1 later in the afternoon. b. Interview with MA #1 on 4/13/23 at 1:21 PM revealed she had spoken to EVS #1 after 6 PM on 4/2/23 and then spoke with the former DON at approximately 6:50 PM to report the incident. 2. Interview with the DON on 4/13/23 at 10:58 AM confirmed the allegation of abuse occurred on 4/2/23 at approximately 1:30 PM and was witnessed by EVS #1 who did not immediately report the incident because she was afraid of retaliation. The DON stated the incident was first communicated to MA #1 who then informed the former DON. The DON stated the former DON trained her on the use of the State Survey Agency incident reporting database on 4/3/23 and this was when the allegation of abuse was reported. In addition, the DON stated the police were not notified.

Based on staff interview, medical record review, and policy and procedure review, the facility failed to promptly assess 1 of 6 sample residents (#51) who had a change of condition. This failure resulted in a delay in treatment and actual harm to the resident. In addition, the facility failed to perform neurological assessment for 1 of 6 sample residents (#16) with falls. The findings were: 1. Review of a Health Status Note dated 11/19/16 and timed 4:16 PM showed resident #51 was scheduled to go out with his/her family; however, the trip was canceled because the resident stated s/he did not .feel well enough to go . Further review of the medical record failed to show any evidence a nursing assessment was completed when the resident complained of feeling unwell. 2. Review of a Change of Condition late entry note dated 11/20/16 and timed 8 AM showed resident #51 was unresponsive when the nurse attempted to wake him/her up for breakfast. The resident was noted to have had complaints of an upset stomach the previous day. Further, the note indicated the change .Appeared to have started on: 11/19/16 . and the resident was transferred to the hospital on [DATE]. 3. Review of the ER Note dictated on 11/21/16 at 1:13 AM showed resident #51 was admitted on [DATE] and the family member stated the resident did not feel well yesterday and canceled a family outing that had been planned and reports that (s/he) was complaining of nausea and may have had some vomiting also . The note indicated the resident had not been seen since 7:30 PM on 11/19/16, 12 1/2 hours prior to being found unresponsive. During the physical examination the resident's blood glucose was determined to be less than 20 and 2 amps (ampoules) of D 50 ([MEDICATION NAME] 50%) was given. The resident's blood sugars improved; however, the resident remained unresponsive. Further, the physician was notified by the laboratory that the resident's lactic acid was elevated and the physician determined the resident was in septic shock, administered [MEDICATION NAME] (an antibiotic) 1 gram IV (intravenous), and transported the resident by air to a higher level of care. The [DIAGNOSES REDACTED]. 4. Interview with the DON on 2/9/17 at 10:10 AM confirmed a nursing assessment was not completed when the resident complained of feeling unwell on 11/19/16, and further revealed the resident was not placed on change of condition monitoring but should have been. 5. Review of the policy titled Change in a Resident's Condition or Status last revised 04/2014 showed .1. The Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician or On-Call Physician when there has been: .d. a significant change in the resident's physical/emotional/mental condition; .2. A significant change of condition is a decline or improvement in the resident's status that: .d. Ultimately is based on the judgement of the clinical staff and the guidelines outlined in the Resident Assessment Instrument and 42 CFR 483.20 (b)(ii) . 6. Review of the 1/25/17 annual MDS assessment showed resident #16 had [DIAGNOSES REDACTED]. The resident had a BIMS score of 13 (cognitively intact) and required the extensive assistance of 1 person for bed mobility and transfers. The following concerns were identified: a. Review of an Incident Note dated 11/14/16 and timed 2:55 PM showed the resident was found on the floor next to his/her bed. The resident denied hitting his/her head and stated, I didn't fall. The note further indicated the resident had activated the call light but was unable to remember why and .does become confused and delusional at times . b. Review of the progress notes between 11/14/16 and 11/17/16 showed no evidence of follow-up documentation or neurological assessments. c. Review of a Change of Condition note dated 1/3/17 and 2:30 PM showed the resident slid off his/her bed to get closer to the wheelchair. There was no documentation to show if the event was witnessed or unwitnessed. d. Review of the progress notes between 1/3/17 and 1/6/17 showed no evidence neurological assessments were performed. e. Interview with the DON on 2/9/17 at 10:10 AM revealed neurological assessments were not completed for either of the falls because there was no evidence of a head injury; however, she confirmed that without a neurological assessment, the facility could not be sure there was not a head injury. 7. Review of the policy titled Performing Neurological Assessments last revised on 11/2013 showed .Accurate neurological assessments will be performed immediately on any resident with a suspected head injury (including after falls), after physician orders, and/or as deemed necessary by the nurse on duty .