Every finding on record at Wrights Healthcare and Rehabilitation Center

Based on observation, interview and record review the facility failed to check the temperature of food items and use proper hand hygiene during meal preparation and meal-plating service.Finding Included: During an observation on 1/19/26 at 10:26 a.m., Staff B, [NAME] was preparing raw meat wearing blue gloves, he grabbed a black notebook, opened it, placed the notebook back on the rack and continued preparing the raw meat. During an observation on 1/19/26 at 10:36 a.m., A three compartment sink with soiled dishes in all three compartments was next to a tan rack with a silver pan, a sliver metal lid and multiple other clean dishes were observed on the clean side of the dish area. During an observation on 1/20/26 at 12:05 p.m. Staff B was wearing a black hooded shirt that had two strings hanging down to his mid chest area. The strings were touching the resident's food as Staff B was putting the food trays together. Staff E, Cook, microwaved a soup and did not take the temperature prior to putting it on a resident's tray. During an observation on 1/21/26 at 10:13 a.m. no temperature logs were observed on one freezer or the two refrigerators in the kitchen. Inside of a refrigerator there was a block of cheese in plastic wrap undated. During an observation on 1/21/26 at 11:57 a.m., Staff B, [NAME] was observed with blue gloves, exited the kitchen area, rolled in a silver food tray cart, and began plating food. During an observation on 1/21/26 at 12:10 p.m., Staff B, [NAME] placed a purple bowl with a clear lid with black wording Soup, onto a resident food tray. During an observation on 1/21/26 at 12:15 p.m., Staff B, [NAME] placed a purple bowl with a clear lid with black writing mixed vegetables, from the microwave on the side of the grill. The bowl sat on the side of the grill until 12:46 p.m. and was placed onto a resident lunch tray. Two staff members entered the kitchen and did not wash their hands or don hair nets. During an observation on 1/21/26 at 12:28 p.m. Staff F, Certified Nursing Assistant (CNA), was observed putting her right finger in her mouth, removing her finger and then grabbing a food tray and went into a resident's room without using any hand hygiene. During an interview on 1/20/26 at 11:30 a.m. Staff C, Dietary Manager, stated the three-compartment sink is used to scrub pots. The dirty dishes go into the first part of the sink and we scrub them. We will use the second sink to rinse and then the dishes go through the dish machine. There is rack that goes in between the sink and the clean dishes to keep the clean dishes from becoming contaminated with the dirty dishes. During an interview on 1/22/26 at 11:15 a.m. with Staff B he said, We don't temp soups. Staff B stated that soups should have the temperature taken but it doesn't happen all the time unless it's boiling then he would check the temperature before it sent out. Staff B said if he goes from a food item to a non-food item, he needs to change his gloves but said he forgot to change his gloves when he grabbed a binder in the kitchen while prepping raw chicken on 1/20/26. Staff B said when they unglove, they should be washing their hands and sanitizing them before putting gloves back on. During an interview on 1/22/26 at 12:31 p.m. with Staff F, CNA, she stated they put on hand sanitizer before they grab a tray and then help the resident get settled prior to grabbing the next tray and they would sanitize again before getting that next tray. During an interview on 1/22/26 at 11:31a.m., the Assistant Director of Nursing, (ADON), and Infection Preventionist (IP), stated we do monthly hand hygiene education with all staff. Kitchen staff should be using gloves, changing gloves in-between tasks and wearing hair nets while in the kitchen. When Staff B, Cook, grabbed the binder and left the kitchen I would have expected him to remove his gloves, and replace them before continuing to prepare food. Hair nets should be worn when you enter the kitchen. I would not think hoodie is a replacement for a hairnet. If staff have long hair, it should be tied back. The hoodie should not be worn to prevent the tie strings from getting into the food. Dirty dishes should not be near clean dishes because there is the possibly of those clean dishes getting dirty again. During an interview on 1/22/26 at 12:09 p.m., the Nursing Home Administrator (NHA) and Director of Nursing (DON) stated we would expect food temperatures to be completed for each food item being served. All staff are expected to use hand hygiene and to wear hair nets while in the kitchen. During an interview on 1/21/26 at 4:25 p.m. with the Certified Dietary Manager (CDM) she stated the expectation is you should wash your hands and then put on fresh gloves. The CDM stated she has been gone for a while and hasn't completed a hand hygiene in-service yet since coming back this week. She stated any food that is made should have the temperature checked like every other item for safety. Soups should have the temperature completed and the staff should not be eyeballing how hot soup is or what temperature a food item is. She stated since soups are not being served right away, they should be tested for the correct temperature before being served We know we have work to do in the kitchen. We will get it cleaned up. During an interview on 01/22/26 at 10:02 a.m. with Director of Nursing (DON) said she expects her staff to use proper hand sanitizer before and after passing meal trays. A review of the facility's policy titled, Food Preparation and Handling dated 01/13/2011, revealed the following, All food items served to residents and clients are prepared in a central kitchen following a six-week cycle menu plan. Food items will be prepared using methods designed to preserve maximum nutritional value, enhance flavor and be free of harmful bacteria. In the general guidelines it states: All food items, while being prepared, are protected against contamination from insects, rodents, unclean utensils or work surfaces, unnecessary handling, coughing, sneezing, and any other source of contamination. Foods will be prepared and served with clean tongs, scoops, forks, spoons, spatulas, knives, plastic gloves or other suitable implements to minimize handling and avoid contact of food are all points during preparation and service. A review of the facility's policy titled, Maintaining a Sanitary Try Line dated 12/15/2025, revealed the following policy: This facility prioritizes tray assembly to ensure foods are handled safely and held at proper temperatures in order to prevent the spread of bacteria that may cause food borne illness. Listed in the compliance guidelines it states the following: During tray assembly, staff shall wash hands before and after wearing or changing gloves. Change gloves after sneezing, coughing or touching face, hands, or hair with gloved hand. Wear hair restraints, bonnets, caps, nets, to cover hair when preparing or handling food. Prior to service take food temperatures and periodically throughout the meal service to ensure proper hot (at or above one hundred thirty-five degrees) or cold holding temperatures (at or below forty-one degrees) are maintained. A review of the facility's policy titled, Pot and Pan Washing, Rinsing, Sanitizing in a two-compartment sink, along with proper way to Air Dry. stated at the end of the document: Reminder the 2nd sink is not to be used to place dirty pots and pans.

Based on observations, record reviews and interviews the facility failed to develop and implement a comprehensive, person-centered care plans for two residents (#5 and #39) out of two reviewed.Findings Included:Review Resident #5's admission record showed admission to the facility on [DATE] with diagnoses to include parkinsonism-11/4/25, opioid dependence-11/24/25, anxiety-11//24/25, post-traumatic stress disorder (PTSD)-11/24/25, psychosis-11/24/25 and major depressive disorder-11/24/25.Resident #5's care plan did not address PTSD diagnosis, triggers and interventions to decrease expressions or indications of distress.Review of Resident #5's order summary report, dated 1/22/26 revealed orders including the following medications: Clonazepam 0.5mg daily for anxiety, Sertraline 150 mg for depression and Wellbutrin XL 150 mg for major depressive disorder.Review Resident #5's psychiatry and psychology note dated 1/8/25 revealed PTSD (Post Traumatic Stress Disorder): The history suggests that this patient has suffered from significant trauma resulting in nightmares, flashbacks, and hypervigilance in the past. The symptoms have caused significant distress and functional impairment to the patient. The symptoms have lasted for more than one month and have occurred without any substance use or organic brain pathology Review Resident #5's psychiatry and psychology note dated 1/15/25 revealed . We are tailoring the following non-pharmacological treatments for current psychiatric diagnoses according to the patient's functional and cognitive status .minimizing triggers and exacerbating factors .Review of Resident #5's psychology progress note dated 12/18/25 revealed .Therapeutic efforts also included aiding the patient in identifying the precipitants of unproductive feelings and behaviors . This resident's emotional symptoms are sufficient to alter baseline functioning and therefore, treatment is medically necessary.Review of Resident #5's Minimum Data Set (MDS), dated [DATE] Section C, Cognitive Patterns reveals Brief Interview for Mental Status (BIMS) 10, indicating moderate cognitive impairment. Section I, Active Diagnoses PTSD is selected.During an interview on 1/22/26 at 12:43 p.m., the MDS nurse said Resident #5 denied having PTSD, and she does not know where the diagnosis came from.During an interview on 1/22/26 at 12:43 p.m., the Social Services Director (SSD) said it is her role to initiate PTSD care plan and did not think a PTSD care plan was required for Resident #5. Review of Resident #39's admission record showed admission to the facility on 1/20/17 and readmission on [DATE] with diagnoses including the following: syncope and collapse, orthostatic hypotension, cerebral infarct, cerebral ischemia, abnormalities of gait and mobility, need for assistance with personal care, and type 2 Diabetes Mellitus.Review of an incident note for Resident #39 dated 12/25/25 revealed the resident fell and sustained injuries including a laceration on his left forehead just above the eyebrow with appox of 1.0 in and a skin tear on right elbow. During an observation and interview with Resident #39 on 1/20/26 at 12:02 p.m. there is swelling, bruising and a wound above the left eyebrow with a small amount of clear drainage and on the right lateral elbow a skin tear approximately 1 inch x 1 inch, with a small amount of bleeding. Both wounds are uncovered.On 1/21/25 at 8:50 a.m. during medications administration observation with Staff A, Licensed Practical Nurse (LPN) Resident #39 wounds to the forehead and right elbow were uncovered. Before leaving Resident #39's room the Director of Nursing (DON) entered and said she will return to place dressings on Resident #39's wounds.Review of Resident #39's orders on 1/20/26 did not reveal wound care orders for the wounds on the left forehead and right elbow. Review of Resident #39's care plans on 1/20/26 did not reveal interventions for the wounds on the left forehead and right elbow.During medication administration on 1/21/26 at approximately 9:10 AM Staff A, LPN said Resident 39's nurse said the wounds were not covered because he always take it [dressing] off.During an interview on 1/21/26 the DON said she was not aware Resident #39's wounds were uncovered because they were healed.Review of facility policy titled, Comprehensive Care Plan, implemented 9/2022 revealed the following:Policy:It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and ALL services that are identified in the resident's comprehensive assessment and meet professional standards of quality.Person-centered care means to focus on the resident as the locus of control and support the resident in making their own choices and having control over their daily lives.Professional standards of quality means that care and all services are provided according to accepted standards of clinical practice. Standards may apply to care provided by a particular clinical discipline or in a specific clinical situation or setting. Policy Explanation and Compliance Guidelines:1. The care planning process will include an assessment of the resident's strengths and needs and will incorporate the resident's personal and cultural preferences in developing goals of care. All services provided or arranged by the facility, as outlined by the comprehensive care plan, must meet professional standards of quality, and incorporate culturally competent and trauma-informed care as indicated.2. The comprehensive care plan will be developed within 7 days after the completion of the comprehensive MDS assessment. All Care Assessment Areas (CAAs) triggered by the MDS will be considered in developing the plan of care. Other factors identified by the interdisciplinary team, or in accordance with the resident's preferences, will also be addressed in the plan of care. The facility's rationale for deciding whether to proceed with care planning will be evidenced in the clinical record.3. The comprehensive care plan will describe, at a minimum, the following:a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.b. Any services that would otherwise be furnished, but are not provided due to the resident's exercise of his or her right to refuse treatment.

Based on interview, and record review, the facility failed to ensure an accurate PASRR screening was completed for four residents (#4, 5, 34, and 40) of five residents reviewed for PASRR. 1. Review of the admission record showed Resident #40 was admitted to the facility on [DATE] with diagnoses that include bipolar disorder, and dementia. Review of Resident #40's level I Preadmission Screening and Resident Review (PASRR) dated 12/2/25 revealed a level II PASRR evaluation not required was marked. During an interview on 1/30/25 at 10:50 a.m. with the Director of Nursing (DON), and the Minimum Data Set (MDS) nurse the MDS nurse said she does not consider bipolar disorder to be a serious mental illness. She said based on her understanding options in PASRR Level I Section B – Intellectual Disability (ID) or suspected ID must be selected to trigger a Level II referral. In further reviewing Resident #40's PASRR Level 1 the MDS nurse said that on the PASRR Section II question six which the answer is selected as no, the question asks if the individual has a secondary diagnosis of dementia . the MDS nurse replied, That probably should be a yes. 2. Review of Resident #4's showed admission to the facility on 9/25/25 with diagnoses to include parkinsonism, neurocognitive disorder with lewy bodies, generalized anxiety disorder, depression, psychosis, major depressive disorder, and obsessive-compulsive disorder. Review of Resident #4's Level I PASRR, dated 10/1/25 revealed the qualifying diagnoses were not checked. The review showed the Level I PASRR was incomplete, and a level II was not submitted for consideration following qualifying diagnoses. During an interview on 1/30/25 at 10:42 a.m. with the Director of Nursing (DON), and the Minimum Data Set(MDS) nurse. The MDS nurse said she does not consider Resident #4's diagnoses to be serious mental illnesses. The MDS nurse stated she does not believe Resident #4 meets the criteria to submit to a PASRR level II. 3. Review of Resident #34's showed admission to the facility on 3/12/25 and readmission on [DATE] with diagnoses to include parkinsonism-10/27/25, major depressive disorder-1/2/26, insomnia-12/18/25 and bipolar disorder-10/5/25. Review of Resident #34's Level I PASARR, dated 10/2/25 revealed the qualifying diagnoses were not checked. The review showed the Level I PASARR was incomplete, and a level II was not submitted for consideration following qualifying diagnoses. 4. Review of Resident #5's admission record showed admission to the facility on [DATE] with diagnoses to include parkinsonism-11/4/25, opioid dependence-11/24/25, anxiety-11//24/25, post-traumatic stress disorder (PTSD)-11/24/25, psychosis-11/24/25 and major depressive disorder-11/24/25. Review of Resident #5's Level I PASRR dated 11/28/25 revealed qualifying diagnoses for substance abuse was not checked and PTSD was not listed. The review showed the Level I PASRR was incomplete, and a level II was not submitted for consideration following qualifying diagnoses. During an interview on 1/30/25 at 10:42 a.m. with the Director of Nursing (DON), and the Minimum Data Set(MDS) nurse. The MDS nurse said she does not consider bipolar disorder to be a serious mental illness. Resident #5 does not meet the criteria to submit to a PASRR level II. In reference to Resident #34's PASRR Level I the MDS nurse said based on her understanding options in PASRR Level I Section B – Intellectual Disability (ID) or suspected ID must be selected to trigger a Level II referral. Review of facility's policy, titled Resident Assessment-Coordination with PASARR program, revised 1/2025 revealed the following: Policy: This facility coordinates assessments with the preadmission screening and resident review (PASRR) Program under Medicaid to ensure that individuals with a mental disorder, intellectual disability, or a related condition receives care and services in the most integrated setting appropriate to their needs. Policy Explanation and Compliance Guidelines: - All applicants to this facility will be screened for serious mental disorders or intellectual disabilities and related conditions in accordance with the State's Medicaid rules for screening. - PASRR Level I — initial pre-screening that is completed prior to admission -Negative Level I Screen — permits admission to proceed and ends the PASRR process unless a possible serious mental disorder or intellectual disability arises later. -Positive Level I Screen — necessitates a PASRR Level Il evaluation prior to admission. - PASRR Level Il — a comprehensive evaluation by the appropriate state-designated authority (cannot be completed by the facility) that determines whether the individual has MD, ID, or related condition, determines the appropriate setting for the individual, and recommends any specialized services and/or rehabilitative services the individual needs. -The facility will only admit individuals with a mental disorder or intellectual disability who the State mental health intellectual disability authority has determined as appropriate for admission. -A record of the pre-screening shall be maintained in the resident's medical record . -The Social Services Director or designee shall be responsible for keeping track of each resident's PASRR screening status, and referring to the appropriate authority. -Recommendations, such as any specialized services, from a PASRR level Il determination and/or PASRR evaluation report will be incorporated into the resident's assessment, care planning, and transitions of care. -Any level Il resident who experiences a significant change in status will be referred promptly to the state mental health or intellectual disability authority for additional resident review. -A resident who demonstrates increased behavioral, psychiatric, or mood-related symptoms. -A resident with behavioral, psychiatric, or mood-related symptoms that have not responded to ongoing treatment. - A resident who experiences an improved medical condition — such that the residents' plan of care or placement recommendations may require modifications. -A resident whose significant change is physical, but has behavioral, psychiatric, or mood related symptoms, or cognitive abilities, that may influence adjustment to an altered pattern of daily living. -A resident whose condition or treatment is or will be significantly different than described in the resident's most recent PASRR Level Il evaluation and determination. - Any resident who exhibits a newly evident or possible serious mental disorder, intellectual disability, or a related condition will be referred promptly to the state mental health or intellectual disability authority for a level Il resident review. Examples include: -A resident who exhibits behavioral, psychiatric, or mood related symptoms suggesting the presence of a mental disorder (where dementia is not the primary diagnosis). -A resident whose intellectual disability or related condition was not previously identified and evaluated through PASRR. -A resident transferred, admitted , or readmitted to the facility following an inpatient psychiatric stay or equally intensive treatment.

Based on observations, interviews, and record review, the facility failed to protect the residents' right to be free from abuse by an agency staff member, for one resident (#1) out of 3 residents sampled for abuse. On 11/04/2024 a physical altercation was witnessed to occur between Staff A, Agency Certified Nursing Assistant and Resident #1. Resident #1 suffered injuries to include: purple discoloration of the left eye on the eye lid and under the eyebrow, purplish discoloration along his left jaw line, and a swollen right forearm with redness near his elbow extending down to his mid forearm. Resident #1 was transferred to a higher level of care for evaluation and treatment as a result of the altercation. Findings included: Review of Resident #1's Admission Record revealed he was admitted to the facility on [DATE]. His diagnoses included dementia without behavioral disturbances, glaucoma, Type 2 Diabetes Mellitus without complications, personal history of transient ischemic attack, cerebral infarction without residual deficits, hypertension, hyperlipidemia, retention of urine, anemia, benign prostatic hyperplasia without lower urinary tract symptoms, and cerebral vascular disease. Review of Resident #1's Admission Minimum Data Set (MDS), dated [DATE], Section C, Cognitive Patterns, revealed a Brief Interview for Mental Status (BIMS) score of 3 out of 15, indicating severe cognitive impairment. Review of Resident #1's Determination of Incapacity form, dated 8/30/24, revealed he was deemed incapacitated as of 8/30/24. An observation was made on 11/12/24 at 9:45 AM of Resident #1. He was observed to be lying in bed on his right side with his eyes closed. His left forearm was observed to be larger than his right forearm with redness near his elbow extending down to his mid forearm. He was observed to have a bandage on his left wrist and a discolored area to his left and right hand. There was no bruising observed on the left side of the residents face. The right side of his face was not visible. An observation was conducted on 11/4/24 at 12:00 PM of Resident #1. He was observed to be in his wheelchair in the dining room being assisted by staff eating his ice cream. There was no facial bruising observed. His left forearm arm was observed to be larger than his right with a red area from his mid forearm to his elbow. Review of Resident #1's late entry incident note, dated 11/4/24 at 7:10 AM, revealed: Staffing coordinator [sic] responded to a female voice yelling from behind the closed door of resident' room. Upon entering room to investigate she observed assigned agency CNA [Certified Nursing Assistant] involved in a physical and verbal altercation with the resident. Resident was naked and lying on his back in his bed. The staffing coordinator [sic] directed the agency CNA to exit the room/facility and summoned the nurse to evaluate resident. Another CNA assisted staffing coordinator [sic] in applying brief and covering resident for comfort pending [sic] action by abuse prevention coordinator. Review of Resident #1's late entry incident note, dated 11/4/24 at 8:00 AM, written by the Director of Nursing (DON), revealed: This writer rec'd [received] call from staffing coordinator [sic] at approximately 7:10 a [AM] reporting that she had witnessed a physical altercation between the resident and the CNA assigned to him. She had already directed the CNA to exit the facility and the nurse on duty had completed an initial evaluation of the resident. Upon arriving at the facility, this writer approached resident at his bedside where he was observed lying on his right side in reverse direction (head towards footboard) in his bed resting quietly. This writer immediately noted purplish-red discoloration of resident's left eye orbit/lid extending corner to corner and around the outside, as well as purplish-red discoloration along his lower left jawline. Resident initially attempted to push this writer away, but calmed with soothing verbal reassurance and touch. This writer lifted the sheet that was covering him and noted that resident's left forearm was swollen, red and warm to touch. Resident would not allow the writer to assess further. No additional acute injuries were apparent. Resident known to have multiple other areas of bruising, skin tears and abrasions of various sizes and healing stages to bilateral upper and lower extremities, as well as left forehead/upper eyebrow prior to this incident. This writer notified the APRN [Advanced Practical Registered Nurse] of the event and requested a bedside visit ASAP [as soon as possible]. Additional notifications and reports were made to the resident's daughter, law enforcement, and regulatory agencies as required. Review of Resident #1's late entry Transfer to Hospital Summary, dated 11/4/24 at 10:12 AM, revealed: At the direction of [Sheriff's Office] resident transferred to [emergency room ] via [Emergency Medical Services (EMS)] for further evaluation and treatment r/t [related to] incident that occurred earlier this morning. Resident was assisted from bed to stretcher w/o [without] incident by EMS and facility staff. Resident somnolent but responsive at the time of transfer. VSS [vital signs stable]. [Family]aware of transfer. Review of Resident #1's Admission Note, dated 11/4/24 at 7:51 AM, revealed: Resident readmitted with a red area to left arm and ecchymosis noted to left eye and left [NAME] [sic] Discoloration noted to upper and lower extremities Sitting [sic] up in bed at present eating dinner NO [sic] s/s [signs/symptoms] of respiratory distress Call [sic] bell in reach. Review of Resident #1's Incident note, dated 11/6/24 at 11:10 PM, revealed: Resident continues to be monitored following incident on 11/4. Resident out of bed in main common area. Today seating was changed to gerichair per therapy to improve comfort and reduce restless behaviors when out of bed with good results. Resident rested quietly for most of the day. Monitoring of injuries ongoing. Left eyelid and inner canthum remain dark purple in color - fading bruising of outer canthum and left lower jaw line. Swelling and redness of left forearm improved, but elbow remains swollen andtender [sic] to touch. Resident also has multiple areas of bruising, skin tears and abrasions of multiple sizes at various stages of healing r/t other events (e.g. falls), including nearly resolved area of discoloration above left eyebrow. Seen today by medical director during rounds. Resident exhibiting no obvious adverse response to 11/4 incident. Will continue to monitor. Review of Resident #1's Hospital Transfer Form, dated 11/4/2024 at 9:38 AM, revealed: Other Reason for Transfer: pain and swelling left arm, pain and bruising jaw. .Skin/Wound Care .2. Other wounds or bruises present (describe): Left eye bruised Left jaw bruised Review of Resident #1's Trauma/Stressful Event Screening Tool, dated 11/8/24 at 4:59 PM, revealed: Indicate which individual participated in the interview 1. Other (explain below) 1a. Explain other Staff-Director of Nursing 2. Instructions: Say to the resident: Sometimes things happen to people that are unusual or especially frightening, horrible or traumatic. For example: a serious accident or fire, physical or sexual assault or abuse, an earthquake or flood, a war, seeing someone killed or seriously injured or having lost a love through homicide, suicide or an unusual accident or event? 2a. Have you ever experienced this kind of event? Yes 2aa. Information on the traumatic event as per residents choice to share details (explain below). Resident experienced physical and verbal abuse by a caregiver on 11/4/24. As of 11/8/24 - resident demonstrates baseline behaviors with no obvious indicators of residual psychological distress related to the incident. Resident has severe cognitive deficits secondary to dementia diagnosis and may have no recall/memory of event. Ongoing monitoring. 2b. Ask the Resident or Representative: In your life, have you ever had any experience that was so frightening, horrible or upsetting that I the past month you/they have experienced: NONE of the above experienced, no further intervention required. Review of Resident #1's care plan with a creation date of 9/19/24 revealed; [Resident #1] has cognitive deficits R/T a diagnosis of dementia. On 11/8/24 the care plan was updated to include He is at increased risk for adverse interactions due to dementia-related behaviors that include resistance to care, verbal outbursts and physical defensiveness. The goal revealed [Resident #1] will be safe, free of distress and will maintain current cognitive function for as long as possible through next review date. The interventions revealed Administer medications as ordered. Monitor resident response in regard to need, effectiveness and side effects. Attempt to identify specific stressors and educate staff to what they are so they can be minimized if possible. Ensure safety then leave and reapproach when demonstrating care resistance. Explain all care prior to starting and talk to resident throughout care. Identify things resident[sic] enjoy (e.g. music, preferred TV show, etc.) that can be played during care. If able, plan care during time of day/shift when resident is more approachable and allow rest periods if necessary to complete task. If resistive, seek out caregivers that resident is familiar with and trusts to assist with care. Reorient resident as needed and provide TLC [tender loving care] and reassurance. Speak clearly and slowly in a calm voice using short, simple sentences. An interview was conducted on 11/12/24 at 12:05 PM with the Staffing Coordinator. She said at 6:40 AM she was looking for a broom. Resident #1' s room and her office share a wall. She walked out of her office to get a broom from the housekeeper and as she was walking back she heard a female voice, screaming, yelling, and cursing coming from Resident #1's room so she entered his room, his bed was near the window and the dividing curtain was not drawn so she saw Resident #1 on his back completely nude, his head was at the foot of the bed and his feet were at the head of the bed with his legs bent and together. Staff A, Agency, CNA, was between the window and his bed standing towards the middle of the bed where his knees were bent. Staff A, Agency, CNA's back was to the window and when the Staffing Coordinator opened the door her and Staff A, Agency, CNA made eye contact. The Staffing Coordinator said to Staff A, Agency, CNA What the [expletive] are you doing, get out of here! as the Staffing Coordinator was saying that, Staff A, Agency, CNA looked at Resident #1 and said, You're piece of [expletive] and she was shoving his legs and arms pushing him away from her and when she would push his legs and his arm on his left side he would recoil back because he does not move that way. The Staffing Coordinator repeated herself and said Get out of here! As Staff A, Agency, CNA was walking out of the residents room she threw a pile of sheets, Resident #1's clothing for the day, and a folded up unused brief at his face. The Staffing Coordinator called out for help and Staff B, Agency, CNA came in as Staff A, Agency, CNA was exiting. Resident #1 was swinging his fists at that time and He was scared and reactive, I talked softly to him, got a sheet on him, and pillow under his head. Then the Staffing Coordinator said she called out for Staff C, LPN Supervisor and he came in and then the Staffing Coordinator exited the room. She saw Staff A, Agency, CNA was gathering her belongings in the small dinning room and the Staffing Coordinator followed behind her until she was out of the building. The Staffing Coordinator said there were no other altercations with Staff A, Agency, CNA with staff or other residents as she was exiting the facility, There was not even a word spoken from her. She exited the facility and the doors were locked. The Staffing Coordinator said she went back to Resident #1's room, Staff C, LPN Supervisor was assessing Resident #1 and The Staffing Coordinator called the Director of Nursing (DON) and put her on speaker phone so the Staffing Coordinator and Staff C, LPN Supervisor could tell her what they saw. Staff C, LPN Supervisor told the Staffing Coordinator 20 minutes prior to the incident he did not notice any facial bruising or swelling to the residents' left forearm. The Staffing Coordinator said she saw Resident #1 had bruising on his left eye and under his left jaw. On his left hand, the first knuckle was red from where he swung at Staff A, Agency, CNA and she hit his hand away. His left forearm was red, hot, and swollen from about his mid forearm up to his bicep area. When the staff member pushed him the second time, the Staffing Coordinator said she noticed Resident #1 had a bandage on his left bicep, from a previous skin tear, had attached to Staff A, Agency, CNA's glove and completely removed it off his skin. The Staffing Coordinator said Resident #1 was very scared. She sat with him until he calmed down and he said to her Let's just all be nice to each other, and he ended up going back to sleep with no further incident. By then the DON came in and she started her assessment and he was still a little skittish with her but then calmed down and she was able to finish her assessment. The Staffing Coordinator said Resident #1 enjoyed music and was a very sweet man. She said she did not provide him with personal care but from what she knew he was not resistive to personal care or had any behaviors. The Staffing Coordinator said Staff A, Agency, CNA had abuse and neglect training with an 88% passing rate through her agency in July of 2024. She said Staff A, Agency CNA used to work at the facility through a different agency company and the only concern was she was not reliable, she had a lot of call outs. The Staffing Coordinator said Staff A, Agency, CNA had worked with Resident #1 a total of five times including the day of the event. A phone interview was conducted on 11/4/24 at 1:16 PM with Staff C, LPN Supervisor. He said, on 11/4/24, he was giving report to the oncoming nurse. The staff coordinator went into Resident #1's room because she heard something and that's when he heard the Staffing Coordinator tell Staff A, Agency, CNA she had to leave. Then he saw Staff A, Agency, CNA exit the room and Staff B, Agency, CNA went in the room with the Staffing Coordinator to finish providing care. Staff C, LPN Supervisor said when Staff A, Agency, CNA exited the room she told him Resident #1 was resisting care and she was leaving and probably won't be able to come back. Staff C, LPN, Supervisor said Oh okay what happened? but she just left. Then the Staffing Coordinator called him into the room to assess Resident #1 and he said, Why what's wrong and [Staffing Coordinator] said to me something happened in here with [Resident #1]. Staff C, LPN, Supervisor said he assessed Resident #1, and saw his left arm was swollen and red. Staff C, LPN Supervisor, said Resident #1 doesn't really feel pain but he was acting like it was hurting him. Then when the resident looked at him, he saw Resident #1 had a blue area under his eye and above his eye and he said What happened in here because he did not have that when I was in his room less than an hour before that. He said he told the DON what he saw and gave a statement. Staff C, LPN Supervisor said his interactions with Resident #1 were minimal because he did not get any medications on the night shift, but he would get restless at night and Staff C, LPN Supervisor would talk with him and get him in his chair But he was a very pleasant person. I did not know him to be resistive to care. A family phone interview was conducted on 11/12/24 at 1:56 PM. She said she was told One of the other nurses or someone from agency slapped [Resident #1]. She said the police and the Nursing Home Administrator had told her that his arm was really swollen, and they were going to order a mobile X-ray but it was going to take too long so they recommended to have him sent out to the hospital. The family member said they called the deputy a couple days after the event and the deputy said Staff A, Agency, CNA was cooperative with the investigation and is denying she hurt him and saying the person who reported her does not like her. The family member said But I can't see someone making up a story like that. The family member said they saw his left arm was red and swollen but the hospital told them they took X-ray's, and it wasn't broken or fractured. The hospital also said he had a bruise under his jaw. I just don't see how someone could do that to [Resident #1]. He's cooperative and such a nice person I don't know how someone could do that. An interview was conducted on 11/12/24 at 2:04 PM with the DON. She said she received a phone call at home about 10 minutes after 7:00 AM on 11/4/24. The Staffing Coordinator called and said she had witnessed Staff A, Agency, CNA slapping at Resident #1. Staff C, LPN Supervisor was at the bedside so she asked about Resident #1's condition and the DON had asked the Staffing Coordinator where Staff A, Agency, CNA was and she said the CNA had left the building and Staff C, LPN Supervisor was in the middle of evaluating Resident #1 and the DON said she got dressed and came to the facility. Then she got to the facility and immediately went into Resident #1's room and did an assessment and found purple discoloration of the left eye on the eye lid and under his eyebrow. There was also purplish discoloration along his left jaw line. She said Resident #1 was covered with the sheet at the time so she removed the sheet, and she noticed his left arm was red and swollen but he would not let her assess it any further. At first when she assessed Resident #1, he was comfortable, in bed, and quiet. It wasn't until she went to assess his arm he tried to push her away with his other arm and started to move about in the bed but, she reassured him by kneeling down next to him and rested her hand on his head and let him know it was okay they were going to take care of him and he calmed right down, nodded his head, and closed his eyes, and went back to sleep. The DON said that was when she started making the notifications to the authorities, Resident #1's family, and Resident #1's ARNP and asked her to do an urgent onsite visit. Law Enforcement came out and they took over and they said it was their protocol for the resident be taken to the hospital. So, EMS came and the ARNP showed up, but she was not able to see the resident before he left. Resident #1 was evaluated in the emergency room and they did numerous X-ray's and cat scans and they didn't find any acute fractures and he returned to the facility. He returned to the facility and his injuries and behaviors were monitored. The DON said she did training with the staff related to abuse neglect and exploitation. Dementia training was done in January for all staff which included managing difficult behaviors. 100% of staff have completed the abuse and neglect training which included a post test. She said she was not sure how many of the staff have received dementia training because they had newly hired staff but she plans to do the training with all her staff. The DON said Resident #1 can be very, very sweet but when it comes to personal bedside care, he can be resistive and push you away, Kind of like what he did when I went to assess his arm. But if he does not want to be bothered, he'll push you away. The DON said they had not had any previous concerns with Staff A, Agency, CNA. The DON said after their 5-day investigation they determined Staff A, Agency, CNA's actions did meet the definition of abuse and due to Resident #1's injuries the facility believe abuse did occur. A phone interview was conducted on 11/12/24 at 4:44 PM with Resident #1's APRN she said on the day of the event (11/4/24) the resident went out to the hospital to be assessed. The APRN said she came to the facility and the sheriff's office had been notified and they said it was their protocol to have the resident evaluated in the emergency room . In the emergency room they took X-ray's and there were no fractures present. She said she was able to see the resident yesterday (11/11/24) and upon her exam the resident's left arm was red and swollen and there was some old bruising around the eye. She said Resident #1 was at his normal baseline, tired after lunch and pleasantly confused. She said she has heard from the staff Resident #1 can have some periods of combativeness with care, but he has not been combative or resistive to care during her exams. Review of Staff A, Agency, CNA's Agency credentialing documentation revealed FL. Alzheimer 's Disease & Dementia Awareness was missing. An interview was conducted on 11/12/24 at 4:34 PM. With the Staffing Coordinator, she said the facility has a binder of all of the facility's policies and procedures and when the Agency staff accept the position on the agency portal they acknowledge they know where the binder is but they are not required to review the binder of policy's prior to starting their shift, it is just used as a reference. If we were to go over all the contents in the book, that would be an hour that they would not be caring for the residents. I cannot force them to read the book. Review of the facility's Abuse, Neglect, and Exploitation Policy with a revision date of June 20, 2024, revealed Purpose: Wrights Healthcare and Rehabilitation Center has developed operational polices and procedures for screening and training employees, protection of residents and for the prevention, identification, investigation, and reporting of abuse, neglect, mistreatment, and misappropriation of property; to include the use of physical and/or chemical restraints. The Administrator, Director of Nursing and Risk Manger in the facility are responsible for ensuring the implementation and ongoing monitoring of these requirements. Definitions: Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting harm, physical pain, mental anguish. .physical abuse includes, hitting, slapping, pinching, pulling, and kicking. It also includes controlling behavior through corporal punishment. .The facility's abuse prevention officer is the Director of Nursing or designee. The Risk Manger is the Assistant Director of Nursing or Designee. Residents of this facility shall be protected from occurrences of abuse, neglect, exploitation, misappropriation of property, mistreatment of neglect. Staff and other relevant parties as determined by management shall be trained at least annually on abuse, neglect and exploitation, procedures for reporting incidents of this nature, dementia management, and abuse prevention. .II Training: Train employees through orientation and on-going sessions on issues related to abuse prohibition practices such as: 1) Appropriate interventions to deal with aggressive and/or catastrophic reactions of residents. .5) In addition to the freedom from abuse, neglect, and exploitation, requirements in 483.12, facilities must also provide training to their staff that at a minimum educates all staff on: 483.95(c) Activities that constitute abuse, neglect, exploitation, and misappropriation of resident property as set forth at 483.12. 483.95(c) Procedures for reporting incidents of abuse, neglect, exploitation, or the misappropriation of resident property. 483.95(c) Dementia management and resident abuse prevention

Based on observations, interview, and record review, the facility failed to store and prepare food in accordance with professional standards for food service safety related to labeling and dating foods, discarding expired foods, and using appropriate hand hygiene. Findings included: On [DATE] at 9:58 a.m., an initial tour of the kitchen was conducted with the Certified Dietary Manager (CDM). The following concerns were observed: the wall in the kitchen was ripped and missing tiles; a box of bruised, cut, and sprouted potatoes; two opened bags of blueberries, one opened bag of strawberries, one opened bag of pineapple chunks, one opened bag of cauliflower florets, one opened bag of broccoli, and one opened bag of egg patties was observed in the reach in freezer undated; an opened bag of hotdog buns and one opened container of garlic parmesan wing sauce was observed in the dry storage room undated; one opened 16 oz bottle of water was observed in the dry storage room; two bottles of heavy-duty degreaser and two containers of sanitizers were observed sitting on the top of boxes of water with water damage in the outside storage area outside of the walk in freezer; an opened bag of unknown food was observed in the walk-in freezer without a label and date; spillage, 16 oz white Styrofoam cup with an unknown frozen substance, small frozen substance in a fast-food cup was observed in the freezer of the homestyle refrigerator without a label and date; and one unknown container of food, an opened stick of butter, a small container of corn and spaghetti, and food in a fast-food wrapper was observed in the bottom of the homestyle refrigerator without a label and date (photographic evidence obtained). The CDM confirmed that this refrigerator was for residents only. On [DATE] at 11:40 a.m., Staff H, Dietary Aide, took the temperature of the foods for lunch. She took the temperature of a milk and walked towards the trash can, removed the lid from the trash can, discarded the milk, and proceeded to finish taking the temperatures. She was wearing gloves, did not perform hand hygiene, or change gloves after touching the lid of the trash can. On [DATE] at 11:55 a.m., the CDM reported all foods should be labeled and dated. He stated he had explained hand washing to staff this morning. The CDM stated the water damage on the boxes of water was probably from a roof leak. The policy and procedure provided by the facility Maintenance Log with an effective date of [DATE] revealed the following: Policy Statement Our facility shall strive to ensure that the facility systems and building will be in good repair and free of potential hazards. The one-on-one in-service record provided by the facility Labeling and Dating Foods undated revealed the following: Why Label? Foods are labeled for food safety. Information on the label tells staff when food is approaching dates from when it would be removed from service. Labels include the name of the item, date it was prepared or opened and a date the time should be used by. General Labeling Items are labeled when opened with opening date. Use By Details All foods placed in the refrigerator are to be labeled with name of item, date item is placed and date it is to be used. The in-service manual provided by the facility Hand Washing and Glove Usage dated 2019 revealed the following: Learning Objectives 1. The Employee will be aware of requirements for frequency of hand washing. 2. The Employee will be able to identify situations in which hands require washing. Hands should be washed when contaminated and after handling soiled dishes and trash. Always change gloves if the gloves get ripped, torn, or contaminated. Contamination can occur after touching a nonfood item such as the door or trash can. Hands should be washed when contaminated and after handling soiled dishes or trash.

Based on observation, record review, and interview, the facility failed to confirm the accuracy of a Pre-Admission Screening and Resident Review and failed to correct the document for two (Residents #6, and #12) of twenty-eight sampled residents. Findings Included: 1. A review of Resident #6's Admission Record revealed the resident was admitted on [DATE] with unspecified severity unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety and unspecified single episode major depressive disorder. The Preadmission Screening and Resident Review (PASRR), dated 8/3/23, for Resident #6 did not include any Mental Illness diagnoses. Section IV of the screening revealed that the resident did not have a diagnosis or suspicion of Serious Mental Illness or Intellectual Disability and a Level II PASRR evaluation was not required. A review of Resident #6's active Order Summary Report identified the resident received the antipsychotic medication of Aripiprazole daily for mood disorder with psychosis, Memantine twice daily for dementia, the antidepressant Trazodone for unspecified single episode of Major Depressive Disorder, and Venlafaxine (antidepressant) daily for depression. An interview was conducted on 9/20/23 at 2:22 p.m. with the Director of Nursing (DON). The DON reported that the residents' PASRR's are done in the hospital and when the resident was admitted , she scans through the PASRR to ensure if Level II had been done if indicated. The DON reviewed Resident #6's Admission Record and PASRR and identified that the PASRR was incorrect. The Director stated she would have to look into having someone redo them, either a Registered Nurse or physician. 2. A review of Resident #12's Admission Record revealed the resident was admitted on [DATE] and 6/10/21. The Admission record included the principal diagnosis of unspecified severity unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, and secondary diagnoses of chronic Post-Traumatic Stress Disorder (PTSD), and unspecified recurrent major depressive disorder. The mental illness diagnoses, including dementia had an onset date of 2/25/21. A review of Resident #12's Preadmission Screening and Resident Review (PASRR), dated 12/20/20, did not identify the resident had any mental illness or suspected mental illness. The services section of the screening did list dementia as additional information. A further review of the PASRR revealed that it did not identify the residents dementia diagnosis as primary. The screening revealed No diagnosis or suspicion of Serious Mental Illness of Intellectual Disability indicated. Level II PASRR evaluation not required. During an interview on 9/20/23 at 2:27 p.m., the Director of Nursing reviewed Resident #12's PASRR and Admission Record then confirmed the primary diagnosis of the resident was dementia and that the PASRR should identify PTSD and the dementia diagnosis. 43453 48441

Based on interview and record review, the facility did not ensure grievances were addressed in a timely manner for resident council members with the potential to affect a census of 50 residents. Findings included: A review of an undated document titled, Nursing Home Resident's Rights, showed each resident shall have the right to present grievances and recommend changes in policies and services free from restraint, interference, coercion, discrimination, or reprisal. A review of the facility's grievance logs dated May 2023 to September 2023 showed the facility did not have any grievances recorded. The review showed no documentation related to any concerns/complaints the residents may have had. A review of Resident council meeting minutes revealed on-going grievances reported as follows: On 08/31/23 at 2:00 p.m., a resident council meeting was held attended by 7 residents. The residents reported concerns with, increased bugs sightings. Call lights responses still longer than they would appreciate. Nurses and CNAs (certified Nursing assistants) on personal phone calls and using earbuds while giving medications/care. Concerns with the upcoming football season and how it will affect call light response times during game times. The review did not show any recorded resolutions. On 07/26/23 at 2:00 p.m., a resident council meeting was held attended by 9 residents. The residents reported concerns about, earphones/phone use within rooms or at the end of hall. Shift change is very loud and disruptive. Residents are upset that CNA's are made aware of trays they do not like or want. CNAs are reportedly not coming back with alternative. Lack of name tags and/or not introducing themselves or explaining the purpose of visit. Residents reported cockroaches and cockroach eggs in clothes/ closet. The review did not show any recorded resolutions. On 06/29/23 at 2:00 p.m., a resident council meeting was held. The residents reported they had the same concerns with call lights, staff being loud in hallways, use of personal cell phones in care areas, and medications not given when asked. The review did not show any recorded resolutions. A review of council meetings held on 5/24/23, 4/26/23, and 3/21/23 revealed the same on-going concerns without documented evidence of facility ensuring or attempting to provide a resolution. On 09/19/23 at 11:00 a.m., this surveyor conducted a resident council meeting attended by 12 residents. The residents confirmed they had been reporting concerns or complaints to the Activities Director. The residents stated they did not always receive a response. The residents stated they tell staff when they had a problem and did not necessarily fill out a grievance form. They said, We just tell them if there is a problem. They work on resolving it. The residents reported sometimes some staff were very rude and they waited a long time to receive care. The Group voiced concerns related to staff use of personal cell phones during care, Food concerns, meal tickets were ignored, medications were not administered in a timely manner, and activities were baby-like. These residents stated they had reported their grievances to nursing staff, social services, and the Nursing Home Administrator (NHA). The group confirmed the activities director would document their issues in the council meeting minutes. On 09/19/23 at 12:32 p.m. an interview was conducted with the Activities Director. She stated she would consider a grievance to be anything that could not be resolved in the moment. She confirmed residents voiced grievances in resident council meetings sometimes they go to her with concerns such as missing clothing issues, food not palatable, residents not happy with nursing staff, meds not passed on time, staff being on the phone, and inappropriate loud conversations during shift changes. She stated she did not fill out a grievance form. She said, I defer to the appropriate department. I address the issue verbally. All managers get a copy of resident council minutes. She stated she expected the appropriate departments to provide the residents with feedback. She stated if the issue was not resolved, it was revisited and reported to the NHA. She stated the residents concerns were generally discussed in team meetings and education went out to staff. She confirmed she had not filled out individual grievances for residents who voiced concerns. On 09/19/23 at 1:09 p.m., an interview was conducted with the NHA, DON (Director of Nursing) and the Activities coordinator. The NHA stated a grievance was a concern that could not be rectified on the spot, or anything that required a follow-up action. The DON stated they were notified of resident's concerns through their procedure box. She stated the box had forms and anyone could ask for a form if they felt their issue was not resolved. She stated staff and residents could fill out the form. The NHA stated they did not have any grievances listed on the logs because he thought they had resolved all the issues. He stated he was not aware of any outstanding concerns. The DON stated she would normally review issues from resident council and send a form to the departments. The DON said, I know it is not documented, but we speak to the residents all the time. She stated she recently received a concern that a staff had an issue with a resident. She said, I addressed the dynamics of the staffing, same day. I addressed the issue pertaining to that resident. I did not fill out a grievance form. I know the staff behaviors are on-going. I see how there should be a grievance filed for that resident. The NHA confirmed he was aware of grievances related to staff and residents verbal interactions. He said, I know we address issues all the time but, if it is not documented it did not happen. We can do better at logging the issues and providing follow -up. Review of a facility policy titled, Resident Rights-Grievances, dated 06/07/22, showed it is the policy of the facility to allow the resident and or legal representative to voice a grievance in such a manner to acknowledge and respect resident rights. (1.) The resident has the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal. Such grievances include those with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and of other residents and other concerns regarding their LTC (long term care) facility stay. (2.) The resident has the right to, and the facility will make prompt efforts, to resolve grievances the residents may have in accordance with this paragraph.

Based on observation, interview, and record review, the facility did not ensure one (Resident #14) of twenty-eight sampled residents received on-going nursing assessments following a change in condition during 2 of 3 days of survey. Findings included: Review of an undated facility policy titled, Resident Right-Notification of Change, showed it is the policy of the facility to inform the resident and or their legal representative of changes in the resident's condition or plan of care in such a manner to acknowledge and respect resident rights. A need to alter treatment significantly means a need to stop a form of treatment . or commence a new form of treatment to deal with a problem. On 09/18/23 at 12:30 p.m., Resident #14 was observed sleeping in her bed all morning. The resident did not eat lunch. The resident did not respond to the interview. A review of an admission record for Resident #14 showed she was admitted to the facility on [DATE] with a primary diagnosis of unspecified dementia. On 09/18/23 at 12:34 p.m., an interview was conducted with Staff L, Certified Nursing Assistant (CNA). She stated Resident #14 did not look well. She said, it looks like she is not feeling well. Staff L stated she would notify the nurse. On 09/19/23 9:22 a.m. an interview was conducted with Staff M, Licensed Practical Nurse (LPN). She stated the resident was sick. She said, the resident has had a lingering cough for quite some time. She stated the resident had been tested for Covid twice and the results came back negative. Staff M stated the resident had a negative chest x-ray on 09/17/23, but her condition had not improved. Staff M stated she normally worked in this hall, and she thought the ARNP (Advanced Registered Nurse Practitioner) had seen the resident the day before. Staff M reviewed the resident's record with the surveyor and confirmed there had been no current notes or nursing progress notes indicating the resident's condition. A review of Resident #14's EMR (electronic Medical Record) revealed the resident did not have any notes from 08/22/23 to 09/19/23. A review of physician orders for Resident #14 revealed no new orders. A review of Evaluations conducted on Resident #14 showed no health assessments/ evaluations documented. On 09/19/23 at 2:40 p.m., an interview was conducted with Staff L, CNA. She stated Resident #1 was about the same. Staff L said, there has been no change. She is not eating. Staff L confirmed Resident #14 had not been feeling well for some time and that she was not herself. Staff L stated the nurses knew and she did not need to notify anyone. On 09/19/23 at 2:45 p.m., an interview was conducted with Staff K, LPN. She stated Resident #14 was still not feeling well. She stated the resident had had some lingering cough and sore throat. Staff K stated she had texted the doctor. She said, I don't know the last time she was seen. I'm waiting for notification that the doctor has received the message. Staff K confirmed resident #14 had not been feeling well for at least a couple weeks. Staff K stated there should have been nursing notes showing the resident's progress. A review of Resident #14's weight and vitals summary log dated 09/01/23 to 09/19/23 showed the resident's temperature was checked on 09/3/23 and 09/19/23. The reading on 09/19/23 showed 97.2, with a notation low of 97.8 exceeded The resident's blood pressure was obtain one time during this period on 09/19/23, with a reading of 102/69. The record revealed no further evaluation and monitoring. On 09/19/23 at 02:48 p.m., an interview was conducted with Staff N, CNA. She stated the resident had not been feeling well for at least 2 days. She stated the resident ate a little that morning but had not eaten lunch. Staff N stated she worked with this resident almost daily. She stated if a resident was unwell, they notify the nurse or the DON. On 09/19/23 at 02:50 p.m., an interview was conducted with the Director of Nursing (DON). The DON stated if a resident was not feeling well, she would expect nursing staff to complete a 24-hour report. She stated a CNA can initiate a Stop and Watch program when they note a change in condition (CIC) such as a resident not eating or if they had increased pain. She stated nursing staff including CNA's can initiate an alert. The DON stated she had not received a 24-hour report or any alerts on Resident #14. She stated the resident had a chronic cough and swallowing problems, but she was not aware she had not been eating or that her condition had changed. The DON said, I'd expect a nurse to put in a note regarding the resident's health care status and note if there was a CIC. The DON stated vitals should be taken regularly to monitor the resident's progress. 09/19/23 at 3:42 p.m., a follow -up was conducted with the DON. She stated she assessed the resident herself and put in a note. The DON read the progress note revealing the resident was, tired, weak, confused, and drowsy. Resident care of intermittent sore throat with dry cough . lung sounds clear but diminished on auscultation . Follow-up call placed today as resident's symptoms persist and intake is decreased. The DON stated she would expect staff to notify the physician and family if a resident was not feeling well. She stated she would expect the resident to be closely monitored. She said, This would include vitals, frequent checks and pushing fluids. Review of an undated facility policy titled, Notification of Change in Condition, showed the purpose of the policy is to ensure the facility promptly informs the resident, consults the resident's physician, and notify, consistent with his or her authority, the resident's representative when there's a change in the resident's condition requiring notification. Under procedure, the facility will inform the resident, consult with the resident's physician and/ or notify the resident's family member or legal representative when there's a change requiring such notification. This process is reinforced as part of the facility QAPI (quality assurance and performance improvement) program through communication systems and processes such as walking rounds, shift hurdles, Stop and Watch and use of predictive data. Situations requiring notification include: 1 (b.) potential to require physician intervention. (2.) A significant change in resident's physical mental or psychosocial status that is a deterioration in health mental all psychosocial status.

Based on observation, record review, and interview, the facility failed to revise the care plan with appropriate interventions following a fall on 04/20/23 for one resident (Resident #37) out of the sampled twenty-eight residents. The resident had a second fall on 04/23/23 in the same location and around the same time. Resident #37 was discharged to the hospital on 04/28/23 and was found to have a fractured cervical spine (C1). Findings included: On 09/18/23 at 11:43 a.m., Resident #37 was observed sitting in the main dining room in a wheelchair and wearing a neck brace. On 09/19/23 at 10:27 a.m., Resident #37 was observed sitting in the dining room in a wheelchair and wearing a neck brace. The Admission Record showed Resident #37 was admitted to the facility on [DATE] with diagnoses to include progressive supranuclear ophthalmoplegia, unspecified displaced fracture of first cervical vertebra, subsequent encounter for fracture with routine healing, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, major depressive disorder, and history of falling. Section C (Cognitive Patterns) of the Minimum Data Set (MDS) dated [DATE] showed Resident #37 had a Brief Interview for Mental Status (BIMS) score of 09 out of 15 which indicated moderately impaired cognition. Section G (Functional Status) showed Resident #37 required extensive assistance with two plus persons physical assist for bed mobility and transfers. He needed extensive assistance with one-person physical assist for walk in the room, walk in the corridor, locomotion on and off the unit, dressing, toilet use, and personal hygiene. Resident #37 needed limited assistance with one person physical assist with eating. Section J Health Conditions showed Resident #37 has had a fall with a major and minor injury. A review of the progress notes showed the following: 04/20/23 (no time) - Staff heard a thud in the large dining room and saw Resident #37 on the floor on his knees with his head on the floor. The resident leaned forward and fell out of the wheelchair. He was assessed and found to have a complaint of pain to the head, a hematoma to the forehead, and a skin tear to the dorsal right hand between the first finger and thumb. 04/20/23 at 14:04 (2:04 p.m.) - The Advanced Registered Nurse Practitioner (ARNP) was notified of the fall with no new orders. The family was contacted. 04/20/23 at 22:37 (10:37 p.m.) - Resident #37 was doing well post fall from this afternoon. He had a bump on the right side of his forehead and an ice pack has been placed on and off as he will allow. His vital signs improved throughout the evening and were all within normal limits at 2200. He tore the first bandage off the right hand but was replaced with an allevyn. He denied any pain or discomfort other than the soreness of the bump on his head. Post fall monitoring continued for 72 hours total and is on the 24-hour report sheet. 04/23/23 (illegible time) - Resident #37 experienced a ground level unwitnessed fall. He was found on the floor of the main dining room next to a wheelchair on the left side. The resident was assessed, and a laceration was noted on the right side of the forehead accompanied by swelling. Resident #37 complained of pain to the head/headache with no other injuries or complaint of pain or discomfort. His vitals were within normal limits. He was returned to wheelchair, placed in an environment for additional monitoring, and administered as needed (PRN) pain medication. Resident #37 was able to answer yes or no questions and agree with statements when interviewed for root cause. He agreed that he was trying to put his shoe back on. He was alert and oriented to baseline. Neuro checks were initiated. An attempt to contact the family was made. The on-call physician was contacted. The on-call physician agreed with the plan of care and asked to be notified of any change in condition. 04/24/23 at 21:12 (9:12 p.m.) - Resident continues 72-hour post fall monitoring. He had bruising on the right side of his forehead. He complained of pain in his head and was given acetaminophen at dinner time to good effect. Neuro checks were within normal limits at this time. Monitoring will continue. 04/25/23 at 22:09 (10:09 p.m.) - Resident continues 72-hour post fall monitoring. He had new bruising developed on bilateral eyes from fall which happened Sunday afternoon. His family member pointed out that he had bruising around both eyes. He denied any facial pain and had not complained of pain during this shift. He was taking scheduled acetaminophen to good effect every 6 hours. 04/26/23 at 22:20 (10:20 p.m.) - Resident #37 continues 72-hour post fall monitoring. He had facial bruising around both eyes and bruising on his forehead, he denied any pain. Neuro checks were within normal limits. 04/28/23 at 21:07 (10:07 p.m.) - Resident #37 returned from the hospital. His family member and hospital staff reported the resident had a fracture of cervical spine (C1) and will require cervical collar to be worn at all times for 2 months at least. The Fall Scale with an effective date of 04/20/23 showed Resident #37 had intermittent confusion. He had fallen before and had 1-2 falls in the past 3 months. His vision was poor. Resident #37 overestimates or forgets the limits of his ability to ambulate safely. He had a score of 18 which indicated a low risk of falls. This form was dated 05/15/23 and signed by the Risk Manager. The Fall Scale with an effective date of 04/23/23 showed Resident #37 was disoriented. He had fallen before, and he had 3 or more falls in the past 3 months. His vision was poor, and his gait was weak. Resident #37 overestimates or forgets the limits of his ability to ambulate safely. He had a score of 21 which indicated a moderate risk of falls. This form was dated 04/23/23 and signed by Staff B, Licensed Practical Nurse (LPN). The Nursing Home Transfer and Discharge Notice dated 04/28/23 showed the resident was transferred to a local hospital due to increased confusion. The care plan with a focus area related to falls showed Resident #37 had multiple falls and continues to be a fall risk related to having poor safety awareness due to impaired cognition and weakness with decreased mobility and balance (falls may be unavoidable due to multiple risk factors). The intervention initiated after the fall on 04/20/23 was the care plan to discuss the resident's progression of disease and safety. The intervention initiated after the fall on 04/23/23 was a lap buddy should be placed on his wheelchair when in his chair. Resident #37 was preoccupied with anything on the floor. An appropriate intervention to prevent Resident #37 from falling was not implemented after the fall on 04/20/23. On 09/19/23 at 1:50 p.m., Staff B, LPN, reported on the day of the fall, the resident was trying to stand. His head was observed on the floor. He assessed him. He was not complaining of pain at the time. No one witnessed the fall. The resident could not what happened. He did not go out to the hospital on that day. On 09/20/23 at 9:09 a.m., the Assistant Director of Nursing (ADON) reported they have a post fall monitoring sheet that was utilized to monitor the resident for 72 hours. They reviewed falls in morning meetings and discuss interventions to put in place. Sometimes they would put the new intervention in the Certified Nursing Assistant (CNA) task, if it looked like an infection they would do labs, and therapy was involved. They would send a resident out to the hospital depending on the situation. Resident #37 looked like he had a headache because he was holding his forehead. One time he said he was trying to pick up a shoe. He liked to be to himself. In an emergency, they must contact the doctor to get further directions about sending a resident out to the hospital. The doctor was notified of the fall. He was continuing to have headaches prior to being sent out to the hospital. He was later discharged to the hospital and was found to have a C1 fracture. The fall was unwitnessed, and his head was on the floor. On 09/20/23 at 9:25 a.m., the Director of Nursing (DON) stated they did an interdisciplinary review with the team. Resident #37 spent much of his day in the dining room because he had a significant history of falls. One of the falls happened after lunch while staff were prepping, and one was after lunch while staff was doing their after-lunch routine. They generally lay him down after lunch and get him back up for dinner. Staff heard a sound that was suspicious, and Resident #37 was found on the floor. He was responsive, alert, and wanted to get up. He was assessed and a hematoma was observed on his head and ice was applied to it. Staff notified the physician. Resident #37 was not on any blood thinners. If he was on blood thinners, they would have sent him out immediately. No post fall huddle form, Situation Background Assessment Recommendation (SBAR), or Change in Condition (CIC) form was completed. The DON stated they generally just chart in the chart and notify family. If there was loss of consciousness or an obvious injury, they would send a resident out to the hospital. With a head injury, they don't automatically send them out and the doctor made that determination unless the family or the resident said they want to go out to the hospital. Resident #37 had a fall on 04/20 and a second fall on 04/23. He did not have a head injury on the second fall. While monitoring him, he was holding his head and they became concerned. He was not as active as he normally was, and they wanted to have him evaluated due to the back-to-back falls. The DON stated he just was not acting himself. They did not send a resident out to the hospital unless there were neurological changes. He only complained that his head hurts which she would expect. The resident required three people to get him up. They always talk to staff to get statements and follow up after a fall. The root cause was he was probably trying to go back to bed after lunch. The second fall was three days later just before lunch. The fall was unwitnessed, and they really did not know what happened. When asked what kind of intervention was put in place after the first fall, the DON stated she believed they had a care plan meeting and tried to figure out other things from an Interdisciplinary Team (IDT) standpoint. They were questioning if they should put a helmet on him because they were starting to see more of him coming forward when falling. Having an IDT meeting was standard stated the DON. This meeting was held with a family member. Prior to these two falls, they moved him to the dining setting to have more opportunities to see him. The procedure provided by the facility Prevention of Falls Program revised 06/09/22 revealed the following: Intent Care plans will be created and implemented based on the individual's risk factors to aid in the prevention of falls. II. Quality Assurance/Risk Management Guidelines A. Responsibility of Risk Manager/Designee Care plan is to be updated with any new interventions. B. The Interdisciplinary Plan of Care (IPOC) team will meet within the same period of time and discuss the causative factors, interventions to prevent another fall, make therapy referral as necessary and revise the care plan if necessary.

Based on record review, interview, and observation, the facility failed to assess and develop a comprehensive care plan related to side rails for two (Residents #12 and #18) out of twenty-eight sampled residents. Findings Included: 1. On 9/18/23 at 1:33 p.m., an observation was conducted of Resident #12's bed. The observation showed a mattress that was bolstered at the head of bed (HOB) and end of bed (EOB) with 1/4 rails lowered in a manner that produced a 1/2 rail covering the distance in between the two bolsters. A review of Resident #12's Admission Record showed the resident was admitted on [DATE] and readmitted on [DATE]. The record included diagnoses not limited to unspecified severity unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, Post-Traumatic Stress Disorder (PTSD), and Parkinson's Disease. A review of the annual comprehensive assessment, dated 7/22/23, showed Resident #12 had a Brief Interview of Mental Status score of 4, indicative of severe cognition impairment. A review of Resident #12's Side Rail Evaluation and Consent, dated 8/18/23, revealed the plan for 1/2 side rails was to enable positional changes and improve bed mobility and for use during resident care/mobility. The evaluation did not show a physician's order was obtained or the resident's representative signed the consent. Review of Resident #12's care plan identified the following: - was a fall risk related to requiring extensive to total assistance by staff, poor safety awareness, and poor balance. The interventions did not include the use of side rails. - very limited mobility with poor coordination and balance related to weakness and Parkinson's disease. The interventions associated with this focus did not include the use of side rails. - need for Activities of Daily Living (ADL) assist due to weakness and cognitive deficits. The interventions did not include the use of side rails for positioning assistance. 2. On 9/18/23 at 9:30 AM, Resident #18, was observed in bed with a side rail up on each side of bed. Resident #18 was asking for help in a low voice, stating she wanted to go home because she must take care of her bills. The resident was neatly groomed, she was clothed in day attire, her hair was brushed, her glasses were on, and a lift sling was underneath her. A review of the electronic medical record) revealed Resident #18 was admitted to the facility with an initial admitted [DATE] with diagnoses to include essential hypertension, atrial fibrillation, major depressive disorder, and chronic renal disease, stage three. Resident #18 had a readmitted [DATE] with additional diagnoses of unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety, malignant neoplasm of the cecum (anatomically part of the gastrointestinal system assisting in digestion), and anxiety disorder. A record review of Resident #18's Minimum Data Set (MDS), dated [DATE], showed in Section C - (Cognitive Patterns) a Brief Interview for Mental Status (BIMS) score of four which indicated severe impaired cognition. Upon further review of the MDS, Section E -(Behavior) showed no potential indicators for psychosis, wandering, or rejection of care. Review of Section G -(Functional Status) had Resident #18 as requiring total assistance (two + persons physical assist) for bed mobility, transfers, dressing, toilet use, personal hygiene and locomotion on unit and set up (help only) for eating. The answer was not used for the MDS Section P - (Restraints and Alarms) for P0100, Bed Rails. An observation on 9/19/23 at 11:30 a.m. of Resident #18's room revealed the right side rail in an upright vertical position and the left side rail in a horizontal position parallel to the bed in the upright position (Photographic Evidence Obtained.) Resident was not present. An interview was conducted with Staff C, Certified Nursing Assistant (CNA) on 9/19/23 at 9:44 a.m. Staff C confirmed Resident #18 required total care related to toileting, bathing, transferring and required some assistance with eating and minor ADLs (Activities of Daily Living). She was verbal and could ask for things usually by a one-word request. Staff C stated Resident #18 might have mild verbal outbursts but was cooperative with bathing and transfers to her wheelchair. Staff C stated Resident #18 had a [spouse] who was a resident here at some point in time but stated she had never seen him come to visit the resident. Staff C stated the resident had a [family member] who would visit. Staff C stated Resident #18 had not tried to get out of bed on her own. A record review of Resident #18's physician orders for the month of September showed no current orders for side rails. A review of the most recent care plan, dated 8/31/23, showed no care plan areas identified for utilization of side rails. A record review of Nursing Side Rail Evaluation and Consent in Resident #18's electronic medical records, dated 8/11/23, documented side rails (enablers) were indicated to enable positional changes and improve bed mobility and for use during resident care/mobility. There was no resident or resident representative documented as being involved in the consenting process. An interview with the Director of Nursing (DON) was conducted on 9/19/23 at 3:00 p.m. The DON stated residents should have a care plan for side rails. The DON stated the residents should be evaluated, consented to and care planned for the side rails. The DON agreed Resident #18 was not properly care planned for the use of siderails. A review of the facility's policy titled, Comprehensive Care Plans, implemented on 10/17/2018 and revised on 01/23/2021, documented, It is the policy of this facility to develop and implement a comprehensive person- centered care plan for each resident, consistent with resident rights, includes measurable objectives and timeframes to meet our resident's medical, nursing, and mental and psychosocial needs are identified and the resident's comprehensive assessment. Policy explanation and compliance guidelines included the following items: 1. The care planning process will include an assessment of the resident's strengths and needs and will incorporate the residents [sic] personal and cultural preferences in developing goals of care. Services provided or arranged by the facility, as outlined by the comprehensive care plan, shall be culturally competent and trauma induced . 5. The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment. 6. The comprehensive care plan will include measurable objectives and time frames to meet the residents' needs as identified in the residence comprehensive assessment. The objectives will be utilized to monitor their resident's progress. Alternative interventions will be documented, as needed. 7. The physician, other practitioner or professional will inform the resident and/ or resident's representative of the risks and benefits of proposed care, of treatment, and treatment alternatives options. The facility will attempt alternate methods for refusal of treatment and services and document such attempts in the clinical record including discussions with the resident and or resident representative. 8. Qualified staff responsible for carrying out interventions specified in the care plan will be notified of their roles and responsibilities for carrying out the interventions, initially and when changes are made. 48441

Based on observation, record review, and interview, the facility failed to protect the Private Healthcare Information and personal data for three (Residents #55, #46, and #54) of 28 sampled residents as evidence by conversations held at the receptionist desk with a visitor standing nearby and with resident documents left unattended at the receptionist desk. Findings included: On 9/18/23 at 2:50 p.m., Staff D, Executive Assistant/Receptionist, was talking on the telephone at the reception desk making an appointment for a walker to be delivered to an unknown resident's home address. The name, date of birth, and home address of the resident was given to the recipient of the phone call. This information was overheard by this writer as well as other team members from the conference room across the hallway, approximately 12 feet, from the receptionist's desk. On 9/19/23 at 10:45 a.m., Staff D was sitting at the receptionist's desk while a female visitor was standing directly in front of the desk. The staff member was speaking to an unknown person on the telephone and provided the Medicare or Medicaid number of a resident to the recipient of the call. On 9/19/23 at 4:52 p.m., Staff D was sitting at the reception desk on the telephone making a follow up appointment for Resident #55. The staff member provided the recipient of the call with the name and date of birth of the resident, Medicare Part A number of the resident, and identified the secondary insurance held by the resident. This information was overheard while this writer was sitting in the conference room across from the reception desk. On 9/20/23 at 1:58 p.m., the Nursing Home Administrator reported that Staff D was at lunch. An observation at that time showed the reception desk in the front lobby of the facility was unoccupied and unattended. On 9/20/23 at 2:01 p.m., the reception desk was observed, still unoccupied. On top of the desk, in front of the computer keyboard was Resident #54's Photo and Other Media Release Form, dated 9/20/23 and signed by the resident's emergency contact. Next to Resident #54's form was a pad of paper listing several residents' names. On the other side of the form was a piece of yellow paper that showed Resident #46 had an appointment with a Primary Care Physician, date of the appointment, and specific information regarding the appointment. The observation revealed an open yellow binder with the Vaccine Consent Form for Resident #54 on top of contents. The consent was filled out and signed by the resident's representative on 9/20/23 and showed the vaccine consents for the Flu, Pneumonia, and COVID vaccines. (Photographic Evidence Obtained) An interview was conducted on 9/20/23 at 4:03 p.m. with Staff D. She stated the receptionist desk was her office. She reported receiving HIPAA (Health Insurance Portability Accountability Act) training upon hire, two (2) years ago. Staff D stated appointments and transportation needs were regularly made from the reception desk and when making an appointment the provider would ask for the resident's name and date of birth. Staff D reviewed the photographic evidence obtained and stated normally turns it over and said it was her fault. An interview was conducted on 9/20/23 at 4:24 p.m., with the Nursing Home Administrator (NHA). The NHA said HIPAA meant Privacy of Protected Information and included everything, name, medication information, date of birth, and Medicare/Medicaid numbers. The observation and overheard conversations were reviewed and discussed with the NHA who stated that it was inappropriate (to be seen and overheard). The NHA agreed that visitors and other residents could hear Protected Health Information (PHI) from the reception desk. The Admission Handbook, which the facility identified as being given to each resident at the time of his/her admission identified in the section - Confidentiality/HIPAA, All your healthcare information is considered protected healthcare information. To maintain continuity of care, it is only disclosed in the course of normal health care operations. Except for normal healthcare operations your healthcare information can only be assessed with your permission. The policy - HIPAA Security Measures, implemented 10/21/22 revealed, It is the facility's policy to implement reasonable and appropriate measures to protect and maintain the confidentiality, integrity, and availability of the resident's identifiable information and/or records that are in electronic format. The policy did not address the protection of written Protected Health Information (PHI). The policy's Explanation and Compliance Guidelines included the following: - Facility leadership will ensure the implementation of policies and procedures to prevent, detect, contain, and correct any security violations. - Security measures will be implemented to manage risk and vulnerabilities as identified in the risk analysis. - Only appropriate employees will have access to electronic protected health information (EPHI). These employees will receive appropriate training related to the security of the information for which they have access. - The facility will perform a periodic technical and non-technical evaluation of its security plans and procedures to ensure it continued compliance in response to environmental or operational changes that affect the security of EPHI. - The facility will implement policies and procedures that specify the proper functions to be performed, the manner in which those functions are to be performed, and the physical attributes of the surroundings of a specific workstation or class of workstation that can access EPHI. All workstations that access EPHI will have restricted access.

Based on observation, record review, and interview, the facility failed to ensure two (Resident #103 and #13) of twenty-two sampled residents were assessed for the self-administration of medications. Findings included: 1. An observation and interview was conducted on 9/18/23 at 11:29 a.m., with Resident #103. An over-bed table was positioned in front of the resident and a medication cup containing two white round tablets was within reach of the resident. The resident identified the tablets as Xanax then said they were a name brand pain reliever/anti-inflammatory. A review of Resident #103's New Admission Evaluation, dated 9/14/23 at 3:45 p.m., revealed the resident had not expressed a desire to self-administer medications. The review of the resident's evaluations on 9/18/23 at 12:53 p.m. showed the resident had not been evaluated for self-administration of medications. (Photographic Evidence Obtained) The Order Summary Report, active as of 9/19/23 at 7:37 p.m., for Resident #103 did not include a physician order allowing the resident to self-administer any medications. A review of Resident #103's care plan on 9/18/23 at 3:27 p.m. included a focus area that showed the resident had episodes of pain and the interventions were, Staff will administer medications as per MD order. 2. An observation was conducted with Staff B, Licensed Practical Nurse (LPN) of administration of medications for Resident #13. The staff member dispensed oral medications and removed a bottle of Artificial Tears for the resident. Staff B administered the oral medications and informed the resident of the application of eye drops. The resident and a family member (who was at bedside) reported Resident #13 had a bottle of eye drops in a small black pouch hanging from the residents neck. The resident stated that the eye drops were needed every 4 hours and there was no one at the facility to give them every 4 hours. The family member reported supplying the eye drops, in various brands, to Resident #13 for about ten (10) years. The resident has had them in the pouch, which the family member made, since the resident's admission to the facility. The family member removed a bottle of Artificial Tears from the resident's black pouch. A review of the Admission Record for Resident #13 showed an admitted [DATE] and included diagnoses not limited to unspecified dementia. A review of the Order Summary Report, active as of 9/19/22 at 7:45 p.m., included an order, dated 4/12/23 for Artificial Tears Ophthalmic solution 0.2-0.2-1% - Instill one drop in both eyes two times a day for dry eyes. The Order Summary did not include an order from the physician allowing the resident to self-administer any medication. A review of Resident #13's September Medication Administration Record (MAR) showed staff had administered the resident's Artificial Tears twice daily except for the refusal that was observed. The MAR showed the resident did not self-administer the ophthalmic solution every 4 hours as reported. Review of Resident #13's progress notes revealed the following: - 9/19/23 at 8:02 a.m., Resident declined for resident self-medicating self at bedside with own artificial tears. MD to be notified and resident need to be evaluated if resident can be administered correctly. Family member at bedside stated that family supplying medication. - 9/19/23 at 6:11 p.m., an Administration note for Artificial Tears identified supervised self-administration. - 9/19/23 at 7:55 p.m., the Director of Nursing (DON) noted Resident verbalized a desire to self-administer her eye drops earlier today during medication pass. Eye drops are an over-the counter (OTC) item, however, there is concern regarding (re:) resident's ability to properly store and access the medication as she is not able to independently retrieve items stored in her bedside table. Will collaborate with (w/) resident, physician, Interdisciplinary team (IDT) and request Occupational Therapy (OT) input. A review of Resident #13's New Admission Data Collection and Observation, dated 9/14/22, showed the resident had not expressed a desire to self-administer medications. A review of Resident #13's care plan included a focus that showed the resident had a vision deficit and required glasses. The interventions associated with this focus instructed staff to Administer eye drops as ordered. The care plan did not show the resident had the ability to self-administer eye drops or any other medication. A review of Resident #13's evaluations revealed one Medication Self-Administration Safety Screen, dated 9/19/23, which was the initial screen, was not locked (completed), and had errors. The instructions for the Safety Screen instructed to Complete this assessment prior to resident initiating self administration of medication and with any medication order changes, change in function/condition that might affect the residents ability to safely self-administer medications. Ongoing assessment should occur at a minimum of quarterly. Use clinical judgment with section B to determine if or what level of self-administration will be allowed. The Self-Administration screen showed the resident was being considered for the self-administration of Artificial Tears Ophthalmic Solution and the medication would be kept at the residents bedside. The evaluation portion of the screening showed the resident required assistance with reading the label and/or identifying the medication, was unable to demonstrate secure storage of medications kept in room, and required assistance with correctly administer eye drops or eye ointments correctly. The approval portion of the evaluation was incomplete and did not identify if the physician order had been obtained for unsupervised administration, with supervision administration, or may not self-administer medications. On 9/19/23 at 9:30 a.m., the Director of Nursing (DON) reported that no resident had been evaluated for self-administration of medications, however; Resident #13 had asked to be evaluated this morning. The DON stated on 9/20/23 during an interview that began at 2:22 p.m., leaving Resident #103's medication unattended at bedside was a big no no. The policy - Resident Self-Administration of Medication, implemented 10/24/22, revealed It is the policy of this facility to support each resident's right to self administer medication. A resident may only self administer medications after the facility's interdisciplinary team has determined which medications may be self administered safely. The policy explanation and compliance guidelines revealed that Each resident is offered the opportunity to self administer medications during the routine assessment by the facilities interdisciplinary team. The Residents preference will be documented on the appropriate form and placed in the medical record. Review of the explanation and guidelines revealed the following: 3. When determining if self administration is clinically appropriate for a resident the interdisciplinary team should at a minimum consider the following: - a. The medications appropriate and safe for self administration; - b. The residence physical capacity to swallow without difficulty, open medication bottles, (and) administer injections; - d. The residents capability to follow directions until time to know when medications need to be taken; - g. The residents ability to ensure that medication is stored safely and securely. 4. The results of the interdisciplinary team assessment are recorded on the medication self administration assessment form which is placed in the residence medical record. 8. All nurses and aides are required to report to the charge nurse on duty any medication found at the bedside not authorized for bedside storage. Unauthorized medications are given to the charged nurse for return to the family or responsible party. Families are responsible parties are reminded of the policy and procedures regarding resident submission when necessary. 13. The care plan must reflect resident self administration and storage arrangements for such medications.

Based on observation, interview and record review the facility failed to maintain a clean and comfortable environment on 1 (west) of 2 resident hallways. Findings included: An observation of the facility's physical environment on 9/8/21 from 10:37 AM to 10:50 AM revealed the following: -Room 14 was noted to have a bathroom door that was soiled, scrapped, and disintegrating on the bottom portion of the door. -Room 15 was noted to have peeling paint on the hallway door. -Room 17 was noted to have peeling paint on the hallway door. -Room 17 was noted to have missing closet doors. -Room 17 was noted to have missing wall molding behind bed A. -Room 17 was noted to have 2 doors in their adjoined bathroom. Both doors were noted to be disintegrating on the bottom of the doors. -The hallway outside of rooms 15-18 was noted to have 3 doors and a wall with peeling paint. Photographic evidence was obtained. An observation on 9/10/21 at 9:47 AM revealed Room 15 had a closet with missing doors. Photographic evidence was obtained. An interview with the Maintenance and Environmental Director on 9/10/21 at 10:00 AM revealed there is a resident in the building who has trouble sleeping at night and will wheel himself around the building at night and peels off the paint with his hands. The Maintenance Director was unable to verbalize the last time the walls and doors were painted. An interview with the Director of Nursing on 9/10/21 at 10:18 AM revealed there is a resident who peels the paint, and the staff clean it up and re-paint the areas, The DON reported peeling of the paint is therapy for the client, and she would rather him peel the paint than have to increase his medications. Review of the facility policy titled Safe and Homelike Environment with an effective date of May 20, 2017 revealed that 3. Housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly and comfortable environment.

Based on observations, interview and record review the facility failed to ensure each resident was provided with dignity related residents exposed body and confidentiality regarding resident's bodily functions for 2 (#30 and #39) of 27 sampled residents. Findings included: 1. Observations on 9/09/21 at 7:46 AM from the hallway outside the resident's room, Resident#30 was noted to be in her room moving around organizing her closet. The resident was noted to be wearing a hospital gown that was open in the back exposing her bare back and her incontinent brief. It was also noted the curtain to the window that looks out to the enclosed patio was open about 2 feet and a staff member was noted to be walking back and forth on the patio repeatedly passing the resident's window. Continued observation at this time revealed that Staff A, Certified Nursing Assistant (CNA) was standing in the hallway and said good morning to the resident from the hallway and explained to this surveyor that the resident was going home today. Continued interview during the observation with Staff A at this time revealed staff probably opened the resident's window curtain so the resident could see while moving around her room. Staff A proceeded to walk down the hall to obtain towels from a bin in the center hallway. She did not attempt to close the window curtain, the privacy curtain, or the door to allow for privacy for Resident #30. During an interview on 9/09/21 at 7:48 AM, Resident#30 reported she is scheduled to go home today and is excited. The resident reported she did not open the window curtain and did not ask anyone to open them and does not know who opened them or when they were opened. She reported she does not like to be exposed but the gown does not close in the back. An interview on 9/09/21 at 7:50 AM with Staff A, CNA revealed she was aware the resident had on a gown which exposed her back and her incontinent brief. The staff reported she should have helped cover her up or close the window and door, and that she was sorry for that. She reported the resident's aide probably opened the curtain for the resident because she likes it open. An interview on 9/09/21 at 7:52 AM with Staff B, CNA revealed he is assigned to the resident and the resident is going home today. He reported he did not open the residents window curtain this morning and the resident will request when she wants the window curtain open, which is usually after she gets dressed. On 9/09/21 at 7:54 AM an interview with the Director of Nursing (DON) revealed if residents are exposed staff are to offer help and ensure privacy. On 9/09/21 at 8:07 AM an Interview with the DON revealed all staff are to intervene timely to protect all resident's dignity and offer help. she stated she will speak to all staff regarding resident privacy and dignity. Review of Resident #30's record revealed a Minimum Data Set (MDS) for a 5-day admitted d 8/2/21, which indicated that the resident has a Brief Review for Mental Status (BIMS) score of 14 (cognitively intact); feels that it is very important to choose what to wear and very important to take care of her personal belongings. 2. Observations on 9/10/21 at 8:08 AM revealed that while seated in the work area room which was in the front of the building adjacent to the lobby a transport vehicle was observed to pull in front of the building and the driver came into the building and requested a resident. On 9/10/21 at 8:11 AM while in the work area Staff A, CNA was heard talking loud in the lobby and indicated that Resident #39 can't come now she's on the toilet she's got diarrhea, he has to wait. The lobby area instantly became quiet, Staff A then passed the door to the work area and stated, Oh I'm sorry. On 9/10/21 at 8:13 AM an interview with the DON revealed she was present when Staff A was speaking loudly about Resident #39, and she has already spoken to her. She reported that all the residents should be protected, and resident conditions should be reported to the nurse in a manner to protect privacy. Review of the Resident #39's record revealed a Quarterly MDS dated [DATE] which indicate that she has a BIMS score of 13 (Cognitively intact) 3. Review of the facility policy titled Promoting/Maintaining Resident Dignity with a review date of 10/14/2020 revealed that It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident's quality of life by recognizing each resident's individuality. Continued review of the policy found that under the sub-section titled Compliance Guidelines: included the following: 1. All staff members are involved in providing care to residents to promote and maintain resident dignity and respect resident rights. 10. Speak respectfully to residents; avoid discussions about residents that may be overheard. 12. Maintain resident privacy. Review of the facility policy titled Confidentiality of Personal and Medical Records with an effective date of October 13, 2019 revealed that Employees should not discuss resident information in public or semi-public areas.

Based on observation, interview and record review, the facility failed to ensure wound care orders and consistent treatment were in place for one Resident (#40) of three residents reviewed. Findings Included: During an interview and observation of Resident #40 on 9/8/21 at 10:52 a.m. she stated she had a fall recently and sustained a skin tear to the left arm and left lower leg. The resident stated someone changed the dressing and pulled up her left sleeve which revealed an oval shaped white dressing with illegible writing on her left arm and left leg. During an interview with Staff Member E, Licensed Practical Nurse (LPN) on 9/9/21 at 3:49 p.m. she stated the resident had a fall a few weeks ago and scraped her left arm and left leg. [NAME] said a dressing was applied for pressure and protection as the scrapes were scabbed over. Staff Member E, LPN stated she did not document what the wounds looked like and called them 'scabs.' Staff Member E, LPN stated she did not get an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . During observation of Resident #40 on 9/9/21 at 4:29 p.m. with Staff Member E, LPN and Staff member C, Registered Nurse (RN), Staff Member C, RN removed the resident's left lower leg dressing. The wound was observed with slough, redness and slightly swollen with drainage. Staff Member E, LPN conveyed the wounds were from the August fall to Staff member C, RN. Staff member C, RN stated the wound was moist from the scab falling off and stated the wound was red but did not appear infected. The resident pulled up her sleeve to look at her left arm. The left arm did not reveal a dressing, blood was observed on the resident's sweater and a skin tear was observed on the left arm. Staff Member E, LPN stated she did have a dressing on the residents left arm and was not sure what happened to it. She confirmed it was bleeding and said they would clean and dress the wounds and obtain a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of a health status note dated 9/9/21 at 5:28 p.m. included the resident had a skin tear to left lower extremity that scab had come off. Dressing was removed, small amount of serosanguineous drainage on dressing. Also noted skin tear to left forearm with moderate amount of serosanguineous drainage noted. Both skin tears documented as occurring during a prior fall. Nurse Practitioner notified. Skin tear cleansed with normal saline, triple antibiotic ointment applied and covered dressing. Treatment orders placed on the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] A review of an Infection Note dated 8/22/21 at 5:02 a.m. included, Dressing remains intact, clean, and dry to left arm and left leg. A review of an Infection Note dated 8/10/21 at 4:23 p.m. included skin tear to left top forearm. A review of an Infection note dated 8/10/21 at 2:54 p.m. included Resident received two skin tears. Physician notified. A continued review of the health status note dated 8/9/21 at 7:50 p.m. revealed the resident was found on the floor in front of her wheelchair and next to the sink. Large skin tear found on left lateral lower leg and one large skin tear on left forearm. Nurse applied [MEDICATION(S)], steristrips, pads and [MEDICATION(S)] to both skin tears. Physician called. Review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the care plan revealed a focus area for risk of skin tears initiated on 3/13/18 included interventions to maintain clutter free environment, moisturize skin implemented 3/13/18. Focus area risk for infection related to arthritis initiated 9/29/17. Interventions included monitor resident for any signs and symptoms of infection and notify physician as indicated, initiated on 9/29/17. Review of the treatment administration record (TAR) included skin check by licensed nurse every Saturday on evening shift. Start date 5/25/19 last completed on 9/4/21. Review of the wound/skin evaluation dated 9/4/21 included [CONDITION(S)] to lower extremities on antibiotics. No dressing medically required. Review of the Minimum Data Set (MDS) revealed a Brief interview for mental status (BIMS) of 13, no cognitive impairment dated 8/12/21. During an interview with the Director of Nursing (DON) on 9/9/21 at 3:56 p.m. she stated that anytime a dressing is in place there should be a treatment ordered, skin sheets should be charted, and orders should be obtained. Review of facility policy for wound management dated 6/10/18, two pages, revealed: 5. Weekly during the scheduled weekly skin evaluation the nurse responsible for that week's evaluation will document the wounds on the weekly skin check. When there is noted deterioration in the wound the nurse will notify the physician and consult for additional treatment orders. The nurse will notify the resident's responsible party regarding the change in condition, and this will be documented in the resident's record. This process will continue weekly until the wound is healed. Review of facility policy for wound prevention dated 6/10/18, two pages, revealed: The purpose of this program is to assist the facility in the care, services and documentation related to the occurrence, treatment, and prevention of pressure as well as, non-pressure related wounds. Review of facility policy for skin integrity dated 6/10/18 page one revealed: It is the policy of the facility to ensure that the residents receive care and services to prevent the development and promote the healing of pressure sores, in accordance with State and Federal Regulations.

Based on interview and record review the facility failed to inform all residents, representatives, and families by 5:00 p.m. the next calendar day following a COVID-19 outbreak of 18 residents and 12 employees. Findings included: Review of the facility's Line Listing COVID 19 dated, Dec-20, revealed that one resident tested positive for Coronavirus (COVID-19) on 12/19/2020, another resident tested positive for COVID-19 on 12/20/2020, and 16 residents tested positive for COVID-19 on 12/21/2020. Review of the facility's Employee COVID-19 documentation dated, Dec-20, revealed seven staff members were positive for COVID-19 on 12/18/2020, one staff member became positive for COVID-19 on 12/20/2020, and four staff members tested positive for COVID-19 on 12/21/2020. Review of the facility's documentation of resident, family, and resident representative notifications titled, COVID-19, revealed there was a notification sent out on 12/16/2020, time of notification not documented. The next notification was sent out on 12/24/2020, time of notification not documented. The documentation indicated that there was not a timely notification sent to all residents, families, and representatives to inform them of the facility's COVID-19 outbreak. An interview with the Nursing Home Administrator was conducted on 1/4/2020 at 12:45 p.m. He stated he was unaware that he had to notify all residents, their representatives, and families by 5:00 p.m. the next day following even one positive COVID-19 case. He stated he had only notified the families of the positive residents and doing weekly updates to the resident representatives and resident families.

Based on observation, interview and policy review, the facility did not ensure that infection control standards were consistently applied during meal tray pass on the west wing, and in the assisted dining room for three (Staff B, C, & D) of nine staff reviewed. Findings included: On 02/17/20 at 11:55 AM, observation of the mid-day meal tray pass began on the west wing. Staff B, Staff C, and Staff E, all CNAs, were passing the mid-day meal trays. At 11:58 am, Staff C walked out of a resident's room with her gloves on carrying a used brief that was wrapped around itself in her right hand, above her head. She told Staff E, Let me throw this away and I'll be right there. As Staff C was talking, Staff [NAME] was pushing the meal cart down the hallway, passing Staff C while she held the used brief in her hand. At 12:01 pm Staff B, walked into an isolation room with a meal tray. She did not put on any personal protective equipment (PPE) before entering. At 12:05 pm Staff C walked out of a room with her gloves on into the hallway. After exiting the room, she stopped, removed her gloves, and walked back into the room. She then exited the room and walked to the meal tray cart. During observation of meal tray pass of the assisted dining room on 02/17/20 at 12:37 pm, Staff D, RN, was observed fixing empty meal trays on top of the meal tray delivery cart. She was observed multiple times removing dirty trays from the resident tables and then placing them on top of the cart. She would then retrieve a new tray from the cart to provide a meal to another resident seated in the dining room. At one point, Staff D was observed touching a small open, used carton of milk a resident had been drinking out of before meal trays were available. She then went on to check a meal ticket on a new unserved tray before passing the tray to a resident. Hand hygiene was not performed between these actions. At 12:43 pm, Staff D walked out of the dining room to get a resident a cup of coffee. On her way back to the dining room, she dropped dry non-dairy creamer packets onto the floor. She bent over, picked them up, walked into the dining room where the resident was sitting, opened the packets, and poured and stirred them into the resident's coffee. On 02/17/20 at 1:00 pm in a double interview with Staff B, CNA and Staff C, CNA, Staff C she said that did not think about it when she walked out of the room both times. Staff B said that she didn't think she had to get another tray for the resident because she didn't put the tray down inside of the room or take the cover off. She said that she didn't need PPE in the isolation room because she didn't touch anything. At 4:30 pm, the DON added to the interview that she holds agency staff to the same standards as her facility hired staff. She also reiterated that the facility does include agency staff in their education and in-services. Review of the facility policy titled Infection prevention and control and surveillance program with the date of 6/20/2017 under Procedure #3 The facility will provide personal protective equipment (PPE) to support compliance with standard and transmission-based precautions and ensure that it is readily available for staff use. Staff are required to adhere to standard precautions and use PPE according to standard precautions. Under #5 The facility will require staff to perform hand hygiene as indicated by national guidelines. Review of the Centers for Disease Control and Prevention's hand hygiene for providers revealed that hand hygiene should be performed after touching a patient (resident) or the patient's (resident's) immediate environment.

Based on interview and facility record review, the facility failed to provide the Skilled Nursing Facility Advanced Beneficiary Notice (form CMS- ) to two (Residents #8 and #15) of three residents reviewed for notification of potential liability of skilled services and the right to appeal the Medicare Non- Coverage. Findings included: 1. A brief interview was conducted on 02/19/20 at 08:57 a.m. with the Social Services Director. The Social Work Director stated she completed the request for residents selected for the Beneficiary Protection Notification. Three residents were selected for the review. 2. A review of the Skilled Nursing Facility Beneficiary Protection Notification document revealed Resident #8's Medicare Part A Skilled Services episode start date was on 9/5/2019. The last day covered was 11/25/2019. The facility initiated the discharge from Medicare Part A services when benefit days were not exhausted. The Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage - Form CMS (SNF ABN) was not provided to the resident. She transitioned to long term care under Medicaid. Further review revealed the resident's daughter/Health Care Proxy was contacted by phone on 11/22/19 at 1:55 p.m. and was explained the notice of non-coverage and appeal rights as documented on the CMS- -Notice of Medicare Non-Coverage (NOMNC) form. The resident remained in the facility. 3. A review of the Skilled Nursing Facility Beneficiary Protection Notification document revealed Resident #15's Medicare Part A Skilled Services Episode start date was on 12/11/2019. The last day covered was 12/30/19. The Social Services Director revealed on the worksheet that Resident #15 was switched from Medicare Part A to Veteran's Administration (VA) skilled services. The resident did not receive Form CMS- (SNF ABN). Form CMS- (NOMNC) was not provided as the discharge from Medicare Part A was family initiated. He remained in the facility. There was no break in skilled service when resident went from Medicare A to VA Skilled Services. A review of resident's hospital patient registration form revealed Resident #15 was covered by the Veterans Administration Tri West PCCC insurance and Medicare. The resident's census sheet revealed the resident was covered by Medicare Part A on 12/11/19 to 12/31/19. From 12/31/19 to 2/10/20, resident was covered by Veteran's Administration RUGS. An interview was conducted on 02/20/20 at 10:42 a.m. with the Social Services Director. For Resident #15, she stated, the daughter did not want to incur the co-pay after 20 days of resident's admission. It was decided prior to admission that resident would use Medicare Part A to day 20 and on day 21, access his VA benefits. She stated there was no break in services, as the rehabilitation department re-evaluated the resident and was submitted to the VA for continued skilled care. The Social Services Director stated the Pre-Admission Nurse completed the documentation prior to resident's admission into the facility and she verified the resident did not receive the CMS- and the NOMNC. The surveyor requested a copy of the pre-admission documentation. The Social Services Director did not provide the pre-admission documentation with daughter's request. 4. Further interview with Social Services Director revealed Resident #8 was transferred into long-term (section of the facility). She verified resident/family representative was not provided the CMS- - Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage Form. 5. An interview was conducted on 02/20/20 at 12:02 p.m. with the Administrator. He stated the facility does not have a policy on beneficiary notices. The Administrator verified Resident #8 remained in the facility and was on Medicaid following the Part A services. The facility did not provide the CMS- - Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage form and her daughter was contacted via phone. The Administrator verified Resident #15 was on Medicare Part A for 20 days and then day 21 on Veterans Administration (VA) Insurance. He stated resident remained in the facility on the VA Insurance from 12/31/19 to 2/10/20 and was then discharged to home. The Administrator stated resident did not receive the CMS- - Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage form.

Based on observation and interview, the facility failed to ensure four staff members (A, B, C, and D) knocked, announced themselves, and/or requested permission to enter resident occupied rooms during three of three days (11/19/2018, 11/20/2018 and 11/21/2018) of the survey. Findings included: 1. On 11/19/2018 at 11:19 am, a Certified Nursing Assistant (CNA)/Staff A walked directly in to Resident #29's room without knocking and/or announcing herself. Resident #29 and another resident were in the room and unaware that Staff A was entering their room. 2. On 11/19/2018 at 12:09 p.m., Staff A was observed to come down the hall and brought a meal tray to Resident #18's room. Staff A walked right into the room and did not first knock or announce herself. Resident #18 and another resident were present in the room at the time of the observation. 3. On 11/19/2018 at 12:14 p.m., Staff B was observed to walk right into Resident #18's room without first knocking or announcing herself. There were two residents in the room at the time. 4. During a random follow-up observation on 11/20/2018 at 10:58 am, two CNA's, Staff C and Staff D, were observed to walk into Resident #29's room without knocking on the door and or announcing themselves to the two residents present in the room at the time. 5. On 11/21/2018 during the lunch tray delivery, Staff A was observed to walk into Resident #30's room to deliver her meal. Staff A did not knock, announce herself, or ask permission before entering the room. At the time of this observation, two residents were present in the room. An interview was conducted on 11/21/2018 at 9:14 am with Staff C regarding the facility's policy and procedure before entering a resident's room. Staff C stated First I knock to see if it is okay to come in to the room, introduce myself to resident to assist them, and explain what I am going to do. I ask for consent from them and take it from there. During interview with Staff B on 11/21/2018 at 9:18 am at the nurse's station, she stated the facility's procedure for entering a room is to knock, announce myself, and ask if I can come in. An interview was conducted with Staff A on 11/21/2018 at 8:52 am regarding her procedure for entering a resident's room. Staff A stated, when I enter a room to help a resident, I get my towels and things, put gloves on and change them, take dirty briefs out in a tied up bag, go to the linen room to dispose of it, and wash my hands. Staff A did not mention knocking, announcing herself, or requesting permission from a resident prior to entering their living space. An interview was conducted with the Director of Nursing (DON) on 11/21/2018 at 9:46 am. The DON was informed of the observations. The DON stated that her expectation of all staff in the facility was that We have to knock, announce ourselves and ask permission to come in. The DON related that the facility does not have a specific policy regarding procedures for entering rooms, but does maintain and follow The Agency for Health Care Administration's regulations.

Based on record review and interview, the facility did not ensure that they provided a 30 day written notice for a facility initiated discharge, failed to notify the local Ombudsman Council's office of the transfer, and failed to follow the facility policy related to physician documentation of an emergency hospital transfer for one (#101) of one resident reviewed for an emergency transfer to the hospital. Findings included: During record review for Resident #101 it was determined that he was sent to the local hospital as an emergency transfer on 7/13/18 and did not return to the facility. The record did not contain a transfer notice provided to the resident at the time the resident was moved to a higher level of care. An interview was conducted with the administrator on 11/20/18 at 10:20 a.m. who confirmed that the facility did not have a social services director on staff at the time of survey, and could not locate the Nursing home transfer and discharge form for Resident #101 at time of his emergency hospital transfer. The administrator was also unable to provide evidence that a written 30 day notice or transfer form was given to the Local Ombudsman Council as required. Continued interviews with the Director of Nursing (DON) and Social Services Consultant on 11/20/18 at 1:35 p.m. confirmed that there was no record that Resident #101 had been given a transfer or 30 day notice of discharge at the time of his hospitalization . In addition, there was, no record that the primary physician for the resident had documented the reason for the emergency transfer. Record review of the undated current facility policy titled Transfer and Discharge Requirements revealed that under the section PR[NAME]EDURE : 4. The resident's physician will also document in the clinical record when the transfer or discharge is necessary. An interview with the DON on 11/20/18 confirmed that the policy was current and there was no written proof that the physician for Resident #101 had documented in his clinical record the reasons for the emergency hospital transfer.

Based on record review and interview with the Director of Nurses, the facility failed to ensure, that for one (#1) of five sampled residents of a total facility census of 53 residents, admission orders [REDACTED]. Findings include: Resident #1 was admitted to the facility on [DATE] after a hospitalization for a fall at his home, in which he reported he had hit his head. review of the resident's medical record revealed [REDACTED]. Contained in the admitting paper work to the facility was an order for [REDACTED]. Further review of the Physician's note, dated 01/02/14, revealed the resident had multiple diagnosis, had difficulty articulating but was alert and oriented x three, could answer and respond appropriately, and followed commands. The resident had been given loading doses of [MEDICATION NAME] (medication for [MEDICAL CONDITION]) , a total of four units of fresh frozen plasma, and daily [MEDICATION NAME] for A fib. The resident was evaluated by a Neurosurgeon at the hospital, and the physician commented that the resident was fortunate that no surgical intervention was required. The interim care plan developed for this resident included "altered gait and balance, at risk for falls, need for Activities of Daily Living (ADL) assist and retraining, need for staff to assist to the toilet, and occasionally incontinent of bladder." Nurses' notes were reviewed for the resident's stay from 12/31/13 through 01/09/14 and found to document the resident's need for one person to assist in transfers, two people to assist with bed mobility, usually continent and used the urinal, but had been educated on using the call bell to request assistance for toileting. He was noted to be alert and oreiented confused at times. Because the resident had been identified as a fall risk, a clip alarm was in use. The resident was documented as being able to feed himself and usually ate more than 75% at meals. He participated in both Speech and Occupational Therapy. On 01/10/14 at 5:00 a.m. , nurses' notes began to identify that the resident had gotten up out of bed unassisted, had removed his clip alarm, and included that the resident seemed very confused. On 01/11/14 the nurses' note written at 1:00 p.m. included: "alert, lethargic, requested bedrest, feeds self less than 75 %, requiring one person for transfers and two for bed mobility." On 01/12/14 at 1:00 p.m. the nurses' note indicated, "alert/lethargic, confused, pleasant, fed by staff more than 75%, bed mobility times two and transfers times one, extensive assist with ADLs." On 01/13/14 on the 11p to 7a shift, the nurse documented that the clip alarm was sounding as the resident was ambulating to the bathroom without assistance. The nurses note on 01/13/14 at 9:00 a.m. documented "increased confusion, unable to stand, unable to feed self", with reference to a call having been made to the Nurse Practioner to obtain labs. At 11:00 a.m. on 01/13/14 the Nurse Practioner was notified of the patient's condition and the order to send to the emergency room was given. At 12:00 p.m. on 01/13/14 the nurses note indicated, "resident in bed, nonverbal, resident opens eyes when spoken to." There were no nurses' notes or documentation of an assessment indicating that the nurses had identified the resident's change in condition from early on 01/10/14 until he was transferred to the hospital on [DATE]. The resident had been alert, oriented, able to feed himself, answer questions, and needing only one person to assist with transferring. The last nurses note on 01/13/14 identified the resident as being unable to feed himself, unable to stand, and nonverbal. Review of the Treatment Administration Record for January 2014 revealed an order had been transcribed to "make arrangements for CT brain without contrast in one week", but there was no indication that the appointment had been made. Review of the nurses notes did not refer to obtaining the appointment and the nurses notes on 01/07/14 did not refer to the resident leaving the facility for the CT scan of the brain. Interview with the Director of Nurses (DON) on 02/03/14 beginning at 3:00 p.m. revealed that as part of her review of patient care, she reviews all unplanned transfers to the hospital. She reported that when she reviewed this resident's unplanned transfer to the hospital, she discovered that the order for the CT scan of the brain had not been obtained. Per the interview, upon review of the nurses notes for resident #1, the DON revealed that she identified a change in condition for this resident beginning on 01/10/14, when the nurses identified the resident's confusion and then on 01/11/14 when nurses documented the resident's lethargy and inability to feed himself. Review of Hospital Notes, dated 01/13/14 at 1525 (3:25 p.m.), revealed the resident was arousable, would open his eyes to verbal and tactile stimuli, responded to only two questions with a one word answer, and was not following commands. A CT scan of the brain was obtained on 01/13/14 at 1555 (3:55 p.m.) with the Impression of "mostly chronic - appearing right sided subdural hematoma with significant leftward subfalcine shift." A Neurosurgical consult was recommended. In a summary of procedure results the CT scan was identified as "chronic subdural - size greater than previous scans."