Mobile Nursing And Rehabilitation Center

Based on observation, interview, record review, and facility policy review, the facility failed to provide a private meeting space for the monthly Resident Council meeting that was attended to by 8 of 95 residents who resided in the facility.
Findings included:
A facility policy titled, Resident Council, dated 02/2017, revealed, 2. Monthly meetings be scheduled in an area that promotes privacy or per Resident request.
During an observation on 06/02/2025 at 2:32 PM, the surveyor noted residents participated in their monthly Resident Council meeting in the dining area. It was noted there was no signage posted on the door to inform staff that a meeting was in progress and staff entered the dining area to access the employees' break room. Two staff members entered the dining room and were within hearing distance of the residents' discussions.
During an interview on 06/03/2025 at 9:57 AM, the Activity Director (AD) stated the residents were required to meet in the dining room for their monthly Resident Council meeting. Per the AD, staff were able to enter and exit the dining room during the Resident Council Meeting and the kitchen staff continued to work in kitchen and kept the doors opened.
During the Resident Council meeting conducted by the survey team in the dining room on 06/03/2025 at 10:00 AM, with eight residents in attendance, staff were noted to enter and exit the dining room. The residents in the meeting reported they met once a month in the dining room, they did not know the meeting should be held in a private area and were not aware that staff were not able to enter the meeting area.
During an interview on 06/05/2025 at 8:44 AM, the Executive Director (ED) confirmed that Resident Council meetings were held in the dining room. The ED stated the facility would begin to in-service the staff on 06/05/2025 that they should not enter the dining room during the Resident Council meeting.
During an interview on 06/08/2025 at 8:31 AM, Resident #30 stated they informed the facility before that staff entered the dining room during the Resident Council meeting. Resident #30 stated the facility placed a sign on the door; however, staff still entered the dining room during the Resident Council meetings. Resident #3 stated the staff continued to enter the dining room where the Resident Council meetings were being held even though there had been a sign posted on the door. Resident #3 and Resident #30 both stated the meeting space was not private. A quarterly Minimum Data Set (MDS), with the Assessment Reference Date (ARD) of 03/11/2025, revealed Resident #30 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident had intact cognition. A quarterly MDS, with an ARD of 04/29/2025, revealed Resident #3 had a Staff Assessment for Mental Status (SAMS) that indicated the resident had modified independence in cognitive skills for daily decision making.
During an interview on 06/08/2025 at 10:34 AM, Resident #76 stated they attended the Resident Council meetings, which were held in the dining room. Resident #76 stated the kitchen staff usually worked in the kitchen and staff entered the dining room to eat their lunch while the Resident Council meeting was being held.
A quarterly MDS, with an ARD of 04/30/2025, revealed Resident #76 had a BIMS score of 10, which indicated the resident had moderate cognitive impairment.

Based on interview, record review, and facility policy review, the facility failed to monitor the side effects and efficacy of psychotropic medications for 1 (Resident #33) of 5 sampled residents reviewed for unnecessary medications.
Findings included:
A facility policy titled, Behavior Management and Psychopharmacological Medication Monitoring Protocol, dated 02/2025, specified, Residents who receive antipsychotic, anti-depressant, sedative/hypnotic, or anti-anxiety medications are to be maintained at the safest, lowest dosage necessary to manage the resident's condition. The policy specified, Residents will be reviewed routinely for effectiveness and monitored for side effects of these medications and will receive gradual dose reductions, unless clinically contraindicated.
An admission Record indicated the facility admitted Resident #33 on 05/08/2025. According to the admission Record, the resident had a medical history that included diagnoses of Bipolar disorder and Depressive episodes.
A Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/15/2025, revealed Resident #33 had a Brief Interview of Mental Status (BIMS) score of 14, which indicated the resident had intact cognition. The MDS indicated that the resident received antipsychotic, antianxiety, and antidepressant medication during the last seven days of the assessment period.
Resident #33's Order Summary Report that contained active orders as of 06/04/2025, revealed an order dated 05/08/2025, for clonazepam (a benzodiazepine medication) tablet 1 mg, give one tablet by mouth three times a day for anxiety; an order dated 05/08/2025, for escitalopram oxalate (an antidepressant medication) tablet 10 mg, give one tablet by mouth one time a day for depression; and an order dated 05/08/2025, for quetiapine fumarate (an antipsychotic medication) tablet 200 mg, give one tablet by mouth at bedtime for Bipolar disorder. The Order Summary Report revealed no evidence of an order for staff to monitor the efficacy of psychotropic medications until 06/04/2025. The Order Summary Report revealed an order dated 06/04/2025 that directed staff to observe the resident closely for side effects of antipsychotic, antianxiety, and antidepressant medications.
Resident #33's medication administration record (MAR) for the timeframe 05/01/2025 - 05/31/2025 and 06/01/2025 - 06/30/2025, revealed evidence to indicate staff administered clonazepam, escitalopram oxalate, and quetiapine fumarate as ordered by the physician. The MAR further revealed no evidence staff monitored the side effects and/or efficacy of these medication until 06/04/2025.
During an interview on 06/04/2025 at 10:36 AM, the Director of Nursing Services (DNS) stated there should have been an order to monitor psychotropic medications. Per the DNS, all monitoring would be documented on the MAR by the nurses. According to the DNS, Resident #33 did not have an order prior to 06/04/2025 to be monitored for psychotropic medications. The DNS stated it was important to monitor residents on those types of medications for any adverse reactions. The DNS confirmed there was no documentation on the MAR for Resident #33 that indicated there was monitoring of psychotropic medications since the resident began to receive the medications. The DNS stated she would expect residents who are prescribed psychotropic medications to be monitored for the medication effectiveness/side effects and that any monitoring would be documented on the resident's MAR.
During an interview on 06/07/2025 at 10:52 AM, the South Unit Manager (UM) stated she would monitor a resident's use of psychotropic medications based on the physicians' order. The South UM stated Resident #33 was ordered psychotropic medications on 05/08/2025; however, the resident did not have an order to monitor their use of psychotropic medications until 06/04/2025. The South UM stated she reviewed Resident #33's progress notes from 05/08/2025 until the order for monitoring was initiated on 06/04/2025 and found no evidence the resident was monitored for the medications side effects and/or efficacy.
During an interview on 06/07/2025 at 11:12 AM, Licensed Practical Nurse #29 stated Resident #33 should have been monitored for psychotropic medication use, but there was nothing documented in the resident's medical record prior to 06/04/2025.
During an interview on 06/07/2025 at 12:04 PM, the Executive Director stated he would expect any monitoring for psychotropic medication use to be documented according to the physician orders.

Based on interview, record review, document review, and facility policy review, the facility failed to ensure staff reported an allegation of abuse to the administrator that involved 1 (Resident #54) of 8 sampled residents reviewed for abuse.
Findings included:
The facility policy titled, Abuse Prevention, dated 01/2025, indicated, Alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours fi the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials,
An admission Record revealed the facility admitted Resident #54 on 07/12/2018. According to the admission Record, the resident had a medical history that included a diagnosis of dysarthria following cerebral infarction.
An annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/20/2025, revealed Resident #54 had a Staff Assessment for Mental Status (SAMS) that indicated the resident had modified independence in cognitive skills for daily decision making.
The Investigation Summary signed by the former Executive Director (ED) indicated on 07/27/2023 at 7:48 PM, Resident #54 alleged that Registered Nurse (RN) #23 abused them by pushing and cursing them. Per the Investigation Summary, Resident #54 reported the allegation to their family member (FM) and the FM reported the allegation to the former Unit Manger (UM). According to the Investigation Summary when RN #23 was interviewed, he stated on when he went to examine Resident #54's skin on 07/26/2023 at approximately 11:15 PM, the resident did not want him to, so he used a draw sheet to maneuver the resident and Resident #54 stated this is abuse and he replied, ma'am, that is [expective word]. The Investigation Summary indicated the facility notified the state survey agency (SSA) of the allegation of abuse on 07/27/2023 at 8:24 PM.
During an interview on 06/07/2025 at 8:26 AM, RN #23 stated he did not report what Resident #54 stated to anyone as he had been trained to do. RN #23 stated he was trained to report allegations of abuse to his supervisor/manager. RN #23 stated he did not think about reporting the incident, he just thought the resident was upset at him for doing his job.
During an interview on 06/07/2025 at 11:30 AM, ,the Director of Nursing Services (DNS) stated allegations of abuse were supposed to be reported to the SSA within two hours. The DNS stated Resident #54 made the allegation of abuse to RN #23 around 11:30 PM on 07/26/2023 and RN #23 did not report the allegation of abuse to anyone. Per the DNS, the facility became aware of the allegation once Resident #54's FM reported the allegation to a staff member during the morning hours of 07/27/2023. The DNS stated the allegation should have been reported to the SSA within two hours once it was made. The DNS stated she expected all allegations of abuse to be reported timely.
During an interview on 06/07/2025 at 12:00 PM, the Executive Director (ED) stated at the time of the allegation he was the DNS and did not remember what time he was informed of the allegation. Per the ED, RN #23 never reported the allegation of abuse to anyone and he expected all allegations of abuse to be reported timely.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, document review, and facility policy review, the facility failed to complete a thorough investigation for an allegation of sexual abuse that involved 1 (Resident #207) of 8 sampled residents reviewed for abuse.
Findings included:
A facility policy titled Abuse Prevention, dated 01/2025, revealed, Investigation: The facility will initiate at the time of any findings of potential abuse or neglect an investigation to determine cause and effect, and provide protections to any alleged victim to prevent harm during the continuance of the investigation.
An admission Record revealed the facility admitted Resident #207 on 03/13/2025. According to the admission Record, the resident had a medical history that included a diagnosis on acute chronic diastolic heart failure. Per the admission Record, the resident discharged to an acute care hospital on [DATE].
An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/20/2025, revealed Resident #207 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident had intact cognition.
The undated facility investigation summary signed by the Executive Director (ED) indicated on 05/07/2025, the Social Services Director (SSD) received a telephone call from the case manager at the local hospital, who stated Resident #207 alleged male staff member inserted his thumb into the resident's rectum several times and twisted it, all while a female staff member spanked the male staff member on their butt. Per the investigation summary, Resident #207 could not specify the exact date and time of the incident but indicated it occurred late at night.
The facility investigation file revealed no evidence to indicate any male staff were interviewed during the investigation.
The facility staff schedule for the timeframe 03/23/2025 to 03/29/2025 revealed a male certified nursing assistant (CNA) was assigned to care for Resident #207 on 03/24/2025 during the 3:00 PM-11:00 PM shift, 03/24/2025 during the 11:00 PM to 7:00 AM shift, and 03/25/2025 during the 3:00 PM to 11:00 PM shift and the 11:00 PM to 7:00 PM shift.
During an interview on 06/05/2025 at 10:09 AM, the ED stated that one male staff member had been identified in connection with the allegation reported by Resident #207; however, there was no documented evidence that this staff member was contacted. The ED explained that because he was unable to reach the male staff member, he did not document the attempts and did not include that information in the report.
During an interview on 06/05/2025 at 12:52 PM, CNA #22 stated he was a former employee who worked both the 3:00 PM-11:00 PM and 11:00 PM-7:00 AM shifts. CNA #22 reported that the ED had not contacted him regarding any investigation and that he was never informed of being involved in any abuse allegation.
During an interview on 06/06/2025 at 12:30 PM, the Director of Nursing Services stated she would have expected that any male staff involved should have been interviewed or contacted.

Based on interview, record review, and facility policy review, the facility failed to develop a comprehensive person centered care plan to address dialysis for 1 (Resident #48) of 1 sampled resident reviewed for dialysis and pain 1 for (Resident #158) of 3 sampled residents reviewed for pain management.
Findings included:
A facility policy titled, Comprehensive Person Centered Care Plans, revised 01/2025, indicated, Each resident will have a person-centered plan of care to identify problems, needs, strengths, preferences, and goals that will identify how the interdisciplinary team will provide care.
1. An admission Record indicated the facility admitted Resident #48 on 02/14/2025. According to the admission Record, the resident had a medical history that included diagnoses of end stage renal disease and dependence on renal dialysis.
An admission Minimum Data Set (MDS), with an Assessment Reference date of 02/21/2025, revealed Resident #48 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident had moderate cognitive impairment. The MDS indicated the resident received hemodialysis.
Resident #48's Order Summary Report that contained active orders as of 06/04/2025, revealed an order dated 02/14/2025, that specified the resident was to receive dialysis on Tuesdays, Thursdays, and Saturdays.
Resident #48's Care Plan Report, with an admission date of 02/14/2025, revealed no evidence of a care plan to address dialysis.
During an interview on 06/05/2025 at 9:21 M, the MDS Coordinator stated she usually completed a care plan for dialysis services, but was unsure why Resident #48's was missed
During an interview on 06/08/2025 at 11:42 AM, the Executive Director stated his expectation was for the resident to have a dialysis care plan in place.
2. An admission Record indicated the facility admitted Resident #158 on 08/16/2024. According to the admission Record, the resident had a medical history that included a diagnosis of chronic pain.
A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/21/2025, revealed Resident #158 had a Brief Interview for Mental Status (BIMS) score of 10, which indicated the resident had moderate cognitive impairment. The MDS indicated the resident received a scheduled pain medication regimen, as needed pain medications, and non-medication interventions for pain.
Resident #158's Order Summary Report that contained active orders as of 11/13/2024, revealed an order dated 10/04/2024, for oxycodone with acetaminophen tablet 10-325 milligrams (mg), give one table orally every six hours for pain and an order dated 11/13/2024, for oxycodone with acetaminophen 10-325 mg, give one tablet by mouth every six hours as needed for pain.
Resident #158's comprehensive care plan with an admission date of 08/16/2024, revealed no care plan to address the resident's pain.
During an interview on 06/08/2025 at 11:36 AM, the MDS Coordinator stated she could find a care plan related to pain for Resident #158 and did not know how it was missed.
During an interview on 06/08/2025 at 11:42 AM, the Executive Director stated his expectation was for the resident to have a care plan related to pain.
During an interview on 06/08/2025 at 2:43 PM, the Director of Nursing Services (DNS)stated her expectation was for the care plans to be completed to meet the needs of the residents. The DNS stated a care plan for pain should have been developed for Resident #158.

Based on observation, interview, record review, and document review, the facility failed to ensure staff transferred a resident, who was at risk for falls, with the use of a mechanical lift and two-person staff assistance. Specifically, on 06/11/2024, failed to follow the resident's care plan and daily care guide when she assisted the resident with a transfer from their wheelchair to the bed. During the transfer, Resident #6 fell to the floor and sustained a right femur fracture. This deficient practice affected 1 (Resident #6) of 4 sampled residents reviewed for accidents.
Findings included:
An admission Record revealed the facility admitted Resident #6 on 04/10/2024. According to the admission Record, the resident had a medical history that included diagnoses of autistic disorder, cerebral palsy, age-related osteoporosis, a history of falling, and morbid obesity.
An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/17/2024, revealed Resident #6 had a Brief Interview for Mental Status (BIMS) score of 11, which indicated the resident had moderate cognitive impairment. The MDS indicated the resident required partial/moderate assistance with roll left to right, sit to lying, lying to sitting on side of bed and sit to stand and was dependent on staff for chair/bed-to chair transfers and toilet transfers.
Resident #6's Care Plan included a problem statement initiated 04/19/2024, that indicated the resident had a potential for future falls due to a history of falls, weakness, impaired mobility, cognitive deficit, and unawareness of safety boundaries. Interventions directed the staff to provide a two person assist with mechanical lift for transfers.
The undated Daily Care Guide, indicated Resident #6 was a 2 person assist with transfers using mechanical lift.
Resident #6's progress note signed by Licensed Practical Nurse (LPN) #2 and dated 06/11/2024 at 3:29 PM, indicated LPN #2 was informed by a certified nursing assistant (CNA) that the resident fell to the floor while being transferred from a wheelchair to their bed. The progress note revealed the resident initially complained of left lower extremity pain and had a reddened area on their left lower extremity. Per the progress note, the physician was notified and gave an order to x-ray the resident's left and right tibia, fibula, and foot, The progress noted indicated the x-ray revealed the resident had a fractured right femur and orders were received to send the resident to the emergency room (ER) for further evaluation and treatment.
Resident #6's x-ray report dated 06/11/2024 indicated the resident was found to have an oblique mildly displaced, apex ventro-lateral angulated mid-diaphyseal fracture of the right femur noted.
A handwritten statement written by CNA #32 and dated 06/11/2024, indicated after Resident #6 got dressed, CNA #32 brought the mechanical lift pad to the resident's room and Resident #6 began to panic and stated they did not want to use the mechanical lift that they could stand to get in their wheelchair. According to the handwritten statement, CNA #32 indicated the first time the resident stood, the resident sat back down by their bed, but when the resident stood the second time, the resident pivoted a little bit, tried to turn then fell. Per the handwritten statement, CNA #32 stated she held onto the back of Resident #6's pants.
During an interview on 06/05/2025 at 5:05 PM, LPN #2 stated Resident #6 was a two-person assist and did not like the mechanical lift. LPN #2 stated there should have been two people to assist the resident with the transfer on 06/11/2024 with the mechanical lift.
During an interview on 06/06/2025 at 9:57 AM, the Quality Assurance/Infection Preventionist (QA/IP) stated Resident #6 required the use of a mechanical lift with a two-person assist for transfers at the time of the incident on 06/11/2024. The QA/IP stated to her knowledge Resident #6 was not capable to stand by themselves. Per the QA/IP, there should have been another person with CNA #32 when she attempted to transfer the resident on 06/11/2024.
On 06/07/2025 at 9:08 AM, 06/07/2025 at 6:08 PM, and 06/08/2025 at 8:20 AM, the surveyor attempted to conduct a telephone interview with CNA #32; each time the surveyor left a voicemail message and no return call was received.
During a follow-up interview on 06/07/2025 at 9:46 AM, the QA/IP stated during the course of the investigation into Resident #6's fall on 06/11/2024, CNA #32 informed her that it was just her in the resident's room at the time of the fall. The QA/IP stated CNA #32 was terminated because she did not follow the resident's care guide, which indicated the resident was a two-person transfer with a mechanical lift. The QA/IP stated as the result of the incident, education was done with the staff, staff were observed to ensure they followed the resident's care plan/guide, and Resident #6's care plan was updated to reflect that if the resident refused to be transferred with the mechanical lift, the staff should notify the nurse. The QA/IP stated it was poor judgement and understanding by CNA #32 that led to the resident's fall.
During an interview on 06/07/2025 at 12:03 PM, the Director of Nursing Services (DNS) stated CNA #32 was terminated for failure to follow protocol.
During an interview on 06/07/2025 at 1:49 PM, the Executive Director (ED) stated he was made of the incident and the DNS informed him that CNA #32 did not follow the process. The ED stated the DNS addressed the issue with CNA #32, training was done with the staff and observation/monitoring of resident transfers were implemented. Per the ED, since the incident on 06/11/2024, there had not been another incident in which staff did not follow a resident's care plan during transfers, so the facility felt the retraining/education and monitoring worked.
During a follow-up interview on 06/08/2025 at 12:19 PM, the DNS stated she expected the CNAs to follow the pocket care guide when they provided care to the residents.
During a follow-up interview on 06/08/2025 at 1:48 PM, the ED stated he expected the staff to follow the resident's pocket care guide.
The facility's actions to correct the identified deficient practice related to falls during a transfer with a mechanical lift revealed:
- The facility terminated CNA #32's employment on 06/13/2024.
- The facility revised the care plan for Resident #6.
- The facility completed in-service education with the nursing staff, to include all CNAs on resident transfers.
- The facility reviewed the resident incident during their weekly risk management meeting.
- The facility monitored resident transfers and interventions implemented and determined no other falls occurred in the facility related to a resident transfer.
Verification of corrective actions taken by the facility revealed the following:
- The personnel file for CNA #32 revealed a hire date 04/1/2024 and a termination date of 06/13/2024 for failure to follow policy and procedure.
- Resident #6's revised care plan interventions included the resident was a two-person assist with transfers using a mechanical lift, and if the resident refused to transfer with the lift the certified nursing assistant was to notify a nurse and not attempt to transfer without using the lift.
- Training of 100% of nursing staff and competencies were conducted for 100% of the CNAs between 06/12/2024 and 06/17/2024.
- Observation of transfers for two residents including Resident #6 on 06/08/2025 with no concerns noted.
- Multiple interviews with staff revealed their knowledge to utilize the pocket care guide for daily care instructions for each resident, including whether a resident was a two person assist. All staff interviewed stated if a mechanical lift was to be used for a resident that it required two people.
- Observation of the pocket care guide for Resident #6 revealed the resident was a two-person assist with a mechanical lift.
- Multiple interviews with staff revealed monitoring was in place of the CNAs for transfers utilizing a mechanical lift.
- Interview with the Executive Director revealed ongoing discussion of falls and transfers during the weekly risk management calls and monthly quality assurance meetings.
- Review of the incident log revealed no other falls with a fracture related to a transfer utilizing a mechanical lift since 06/11/2024.
Based on verification of the facility's corrective action, the severity of harm was determined to be past noncompliance.

Based on interview, record review, document review, and facility policy review, the facility failed to order prescribed medication for 1 (Resident #308) of 20 sampled residents.
Findings included:
A facility policy titled, Ordering and Receiving Medications from Pharmacy, dated 03/2025, revealed, Medications are ordered and received from the pharmacy in a timely manner. The facility maintains accurate records of medications ordered and their receipt.
An admission Record revealed the facility admitted Resident #308 on 03/18/2025. According to the admission Record, the resident had a medical history that included a diagnosis of anxiety disorder.
Resident #308's Order Recap Report, dated 03/01/2025 - 03/31/2025, revealed an order dated 03/19/2025, for alprazolam tablet 0.5 milligram, give one tablet by mouth at bedtime for anxiety.
Resident #308's medication administration record (MAR) for the timeframe 03/01/2025 - 03/31/2025, revealed staff documented a code of 9 on the MAR for the administration of alprazolam at bedtime on 03/19/2025, 03/22/2025, 03/24/2025, and 03/26/2025 - 03/28/2025. Per the MAR, a code of 9 indicated other, see progress notes.
Resident #308's progress note created by Licensed Practical Nure (LPN) #7 and dated 03/19/2025 at 9:19 PM, indicated for the alprazolam the staff were awaiting the medication from the pharmacy.
Resident #308's progress note created by LPN #21 and dated 03/22/2025 at 8:54 PM, indicated for the alprazolam the medication was ordered.
Resident #308's progress note created by LPN #20 and dated 03/24/2025 at 9:10 PM, indicated the alprazolam medication was not in stock.
Resident #308's progress note created by LPN #18 and dated 03/26/2025 at 10:47 PM, indicated the alprazolam medication was not available.
Resident #308's progress note created by LPN #18 and dated 03/27/2025 at 9:28 PM, indicated the alprazolam medication was not available.
Resident #308's progress note created by LPN #19 and dated 03/28/2025 at 9:12 PM, indicated the staff was awaiting the alprazolam medication.
The pharmacy delivery sheet dated 03/15/2025, 03/18/2025, 03/19/2025, and 03/21/2025, revealed no evidence the facility received alprazolam for Resident #308 from the pharmacy.
During an interview on 06/04/2025 at 3:05 PM, LPN #7 stated she did not think Resident #308 had any alprazolam in the cart on 03/19/2025. LPN #7 stated the medication would not be found in the emergency kit because all drugs were not in there. According to LPN #7, awaiting on pharmacy popped up on the MAR and was entered into the progress notes. LPN #7 stated she did not contact anyone, she just waited for the medication.
During an interview on 06/05/2025 at 12:38 PM, LPN #18 stated the medication was already ordered, it just had not been delivered to the facility
On 06/04/2025 at 3:11 PM and 06/05/2025 at 10:25 AM, the surveyor attempted to interview LPN #20, but there was no answer and unable to leave a message on the voicemail.
On 06/05/2025 at 1:42 PM and 06/08/2025 at 10:45 AM, the surveyor attempted to interview LPN #21; however, the number was disconnected.
During an interview on 06/05/2025 at 10:14 AM, the Pharmacist stated the pharmacist never received an order to fill a prescription of alprazolam for Resident #308; therefore, they never provided alprazolam to the facility for the resident.
During an up interview on 06/07/2025 at 12:39 PM, the Director of Nursing Services (DNS) stated the pharmacy did not get the prescription for the routine order for alprazolam for Resident #308. Per the DNS, the order was never faxed to the pharmacy.
During an interview on 06/06/2025 at 2:41 PM, the Executive Director (ED) stated he would expect the nurses to call the pharmacy and see what the problem was and then they could talk to the physician. The ED stated he expected the nurses to report to the DNS if a resident was missing their medication for an extended time period.

Based on interview, record review, and facility policy review, the facility failed to monitor the side effects and efficacy of an anticoagulant medication for 1 (Resident #33) of 5 sampled residents reviewed for unnecessary medications.
Findings included:
An admission Record indicated the facility admitted Resident #33 on 05/08/2025. According to the admission Record, the resident had a medical history that included diagnoses of venous insufficiency and thrombocytopenia.
A Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/15/2025, revealed Resident #33 had a Brief Interview of Mental Status (BIMS) score of 14, which indicated the resident had intact cognition. The MDS indicated that the resident received an anticoagulant medication during the last seven days of the assessment period.
Resident #33's Order Summary Report that contained active orders as of 06/04/2025, revealed an order dated 05/08/2025 for apixaban (an anticoagulant medication) oral tablet, 5 milligrams (mg) give one table two times a day for blood clot prevention for 30 days. The Order Summary Report revealed no evidence of an order for staff to monitor the side effects and/or efficacy of anticoagulant medication until 06/04/2025. The Order Summary Report revealed an order dated 06/04/2025 that directed staff to observe the resident closely for side effects of anticoagulant medications.
Resident #33's medication administration record (MAR) for the timeframe 05/01/2025 - 05/31/2025 and 06/01/2025 - 06/30/2025, revealed evidence to indicate staff administered apixaban as ordered by the physician. The MAR further revealed no evidence staff monitored the side effects and/or efficacy of these medication until 06/04/2025.
During an interview on 06/04/2025 at 10:36 AM, the Director of Nursing Services (DNS) stated there should have been an order to monitor anticoagulants medications. Per the DNS, all monitoring would be documented on the MAR by the nurses. According to the DNS, Resident #33 did not have an order prior to 06/04/2025 to be monitored for anticoagulants medications. The DNS stated it was important to monitor residents on those types of medications for any adverse reactions. The DNS confirmed there was no documentation on the MAR for Resident #33 that indicated there was monitoring of anticoagulants medications since the resident began to receive the medications. The DNS stated she would expect residents who are prescribed anticoagulant medications to be monitored for the medication effectiveness/side effects and that any monitoring would be documented on the resident's MAR.
During an interview on 06/07/2025 at 10:52 AM, the South Unit Manager (UM) stated she would monitor a resident's use of anticoagulant medications based on the physicians' order. The South UM stated Resident #33 was ordered an anticoagulant medications on 05/08/2025; however, the resident did not have an order to monitor their use of anticoagulant medications until 06/04/2025. The South UM stated she reviewed Resident #33's progress notes from 05/08/2025 until the order for monitoring was initiated on 06/04/2025 and found no evidence the resident was monitored for the medications side effects and/or efficacy.
During an interview on 06/07/2025 at 11:12 AM, Licensed Practical Nurse #29 stated Resident #33 should have been monitored for anticoagulant use, but there was nothing documented in the resident's medical record prior to 06/04/2025.
During an interview on 06/07/2025 at 12:04 PM, the Executive Director stated he would expect any monitoring for anticoagulant medication use to be documented according to the physician orders.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and facility policy review, the facility failed to ensure staff documented the condition of a resident's skin for 1 (Resident #157) of 20 sampled residents.
Findings included:
A Face Sheet indicated the facility admitted Resident #157 on 08/12/2024. According to the Face Sheet, the resident had a medical history that included diagnoses of hemiplegia following cerebral infarction affecting left side, congested heart failure, diabetes mellitus, atrial fibrillation, and other diseases of stomach and duodenum.
Resident #157's Baseline Care Plan, dated 08/12/2024, indicated the resident's skin was intact.
An admission Minimum Dat Set (MDS), with an Assessment Reference Date (ARD) of 08/19/2024, revealed Resident #157 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident had intact cognition. The MDS indicated that the resident had no unhealed pressure ulcers/injuries.
Resident #157's medical record revealed no evidence to indicate any skin concerns related to the resident's perineal area.
Resident #157's local hospital admission history and physical dated 09/02/2024 at 5:08 PM, revealed the resident admitted to the hospital and was noted to have a perineal area rash.
Contained within the facility's investigation file was a written statemen from Certified Nursing Assistant (CNA) #40 dated 09/03/2024 that indicated when CNA #40 provided care to Resident #157 she noticed a white rash between the resident's legs and notified Licensed Practical Nurse (LPN) #41, who looked at the resident and gave the CNA some cream to apply to the area. The written statement revealed that on another occasion CNA #40 observed the same area was white and pinkish red, she reported her observations to LPN #42, who looked at it and gave CNA #40 some cream to put on the area.
During an interview on 06/07/2025 at 2:45 PM, CNA #40 confirmed her statement she had written on 09/03/2024. The CNA stated Resident #157 had a white rash around their perineal area and she reported it to LPN #41 because it was an issue that needed to be addressed. CNA #40 stated LPN #41 gave her some [NAME] to apply to the white rash. The CNA stated on a different occasion they saw the rash around the resident's perineal area that was white and pinkish red. The CNA stated she reported it to LPN #42, and LPN #42 gave her some cream to apply. The CNA stated she did not take care of the resident often and did not remember the time frame or dates of the two observations.
During an interview on 06/05/2025 at 3:50 PM, LPN #41 stated she did not see any issues that needed to be addressed with Resident #157. LPN #41 stated the resident did not have any opened areas and barrier cream was only applied to protect the resident's skin. LPN #41 stated she did not remember any skin issues or a need to notify the physician. She stated the CNAs were good about reporting any changes. Per LPN #41, if there had been a rash, she would have notified the physician and received a treatment order.
During an interview on 06/08/2025 at 9:46 AM, LPN #42 stated she did not recall the resident or the event that was referenced by CNA #40.
During an interview on 06/08/2025 at 10:20 AM, the Director of Nursing Services (DNS) stated she expected if a CNA reported to a nurse that they had noticed a change in a resident's skin they should have assessed the resident and called the physician if needed. The DNS stated she did not find any documentation related to skin issues around the resident's perineal/groin area.
During an interview on 06/08/2025 at 11:56 AM, the Executive Director stated he expected the nurses to have documentation to support how they responded to what the CNAs reported to them.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure a resident's call light was within reach for 1 (Resident #6) of 20 sampled residents.
Findings included:
A facility policy titled, Resident [NAME] of Rights, dated 01/2023, revealed, facility residents shall have the right to 10. Reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents.
An admission Record revealed the facility admitted Resident #6 on 04/10/2024. According to the admission Record, the resident had a medical history that included a diagnosis of autistic disorder.
An annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/09/2025, revealed Resident #6 had a Brief Interview for Mental Status (BIMS) score of 7, which indicated the resident had severe cognitive impairment.
Resident #6's Care Plan included a problem statement initiated 04/19/2024, that indicated the resident had a potential for future falls due to a history of falls. Interventions directed staff to keep the resident's call light within reach of the resident and encourage the resident to call for assistance.
During a concurrent interview and observation on 06/03/2025 at 3:37 PM, Resident #6 was in bed, and the resident's call light was wrapped around the bed enabler on the right side of the bed. Resident #6 stated they could not reach their call light. Resident #6 stated they used their call light. Resident #6 stated if they needed help they would call out to staff.
During a concurrent observation and interview on 06/04/2025 at 9:47 AM, Certified Nursing Assistant (CNA) #31 stated Resident #6 used their call light. CNA #31 observed Resident #6's call light wrapped around the right enabler, out of reach of the resident, and stated it should not be there.
During a concurrent observation and interview on 06/04/2025 at 9:53 AM, Resident #6 was in bed and their call light was wrapped around the enabler. Resident #6 stated the staff normally wrapped their call light around the right enabler. Resident #6 stated they could not reach their call light. CNA #31 confirmed the call light was wrapped around the right enabler on the resident's bed.
During an interview on 06/04/2025 at 10:48 AM, Licensed Practical Nurse (LPN) #30 stated a fall intervention for Resident #6 was to keep the call light within reach for Resident #6. LPN #30 stated sometimes the resident would use the call light and sometimes the resident would holler out. LPN #30 stated the call light was supposed to be in the resident's hand or clothing and that the resident would not be able to wrap the call light around the enabler.
During an interview on 06/08/2025 at 9:17 AM, the Director of Nursing Services stated she expected residents to have their call lights within reach.
During an interview on 06/08/2025 at 10:50 AM, the Executive Director stated he expected the call lights to be within reach of residents and that every time staff went into a resident's room they should look to ensure the call light was in place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record review and review of facility policies titled, CONTACT PRECAUTIONS and ENTERAL TUBE MEDICATION ADMINISTRATION PROCEDURES, the facility failed to ensure:
1) a Contact Isolation sign was posted on Resident Identifier (RI) #49's door on three of three days of the survey; and
2) a medication nurse did not clean RI #29's feeding syringe with a paper towel after administering medications to RI #29 during the evening medication pass on 08/21/19.
These deficient practices affected RI #49, one of one resident on isolation precautions; and RI #29, one of one resident observed with a feeding tube during the medication pass administration.
Findings Include:
1) Review of a facility policy titled CONTACT PRECAUTIONS, with a date of 10/09, revealed:
POLICY: Contact Precautions are a transmission based precaution that will be utilized to reduce the risk of transmission of epidemiologically important micro-organisms by direct or indirect contact .
RESPONSIBILITY:
All staff.
EQUIPMENT:
1. Door sign that reads Contact Precautions or Visitors Must See Nurse Before Entering or notifies visitors to check at front desk .
RI #49 was admitted to the facility on [DATE], with a diagnosis pf Hypertensive Heart Disease Without Heart Failure.
A review of RI #49's urine culture, with a collection date of 08/12/19, revealed the following:
. 4+ PROTEUS MIRABILIS ESBL (Extended Spectrum Beta-Lactamase) **CONTACT ISOLATION INDICATED** .
RI #49's Physician's Telephone Orders dated 08/15/19, documented:
. Isolation Precaution .
RI #49's INSTANT CARE PLAN dated 08/15/19, documented:
. UTI (Urinary Tract Infection) ESBL IN URINE CONTACT ISOLATION .
On 08/20/19 at 10:08 a.m., the surveyor observed there was no sign on RI #49's room door indicating the type of isolation RI #49 was on.
On 08/21/19 at 7:54 a.m., RI #49's room door remained without an isolation sign.
On 08/22/19 at 10:35 a.m., the surveyor observed RI #49's room door to remain without an isolation sign.
On 08/22/19 at 10:43 a.m., the surveyor conducted an interview with Employee Identifier (EI) #1, the Registered Nurse (RN) Unit Manager for the unit RI #49 resided on. The surveyor asked EI #1 what type isolation was RI #49 on. EI #1 said Contact isolation for ESBL in the urine. The surveyor asked EI #1 how would visitors know the type isolation RI #49 was on. EI #1 said there was a sign on the door that told visitors to come to the desk.
On 08/22/19 at 10:48 a.m., the surveyor accompanied EI #1 to RI #49's room. When asked where the sign was, EI #1 said she did not see one.
On 08/22/19 at 11:36 a.m., the surveyor conducted an interview with EI #2, the Infection Control Nurse. The surveyor asked EI #2 what type isolation was RI #49 on. EI #2 said Contact isolation. The surveyor asked EI #2 should there be a sign on RI #49's door indicating the type isolation RI #49 was on. EI #2 said yes. When asked why there should be a sign on the door, EI #2 said so visitors and staff will know the type precautions to take.
2) Review of the facility policy titled, ENTERAL TUBE MEDICATION ADMINISTRATION PROCEDURES, with a date of 02/18, revealed:
. RESPONSIBILITY:
All Licensed Nursing Personnel .
PROCEDURE: .
11. Clean feeding syringe .
RI #29 was admitted to the facility on [DATE], with a diagnosis of Gastrostomy Status.
A review of RI #29's August 2019 physician's orders revealed RI #29 received the following medications during the evening medication pass administration:
. LAMOTRIGINE 100 MG (Milligrams) TABLET GIVE ONE TABLET PER TUBE TWICE A DAY
TOPAMAX 200 MG TABLET GIVE ONE TABLET PER TUBE TWICE A DAY . CRANBERRY 450 MG TABLE (Tablet) GIVE 900 MG PER TUBE TWICE A DAY .
On 08/21/19 at 4:32 p.m., the surveyor observed EI #3, a Licensed Practical Nurse (LPN)/medication nurse, prepare the above medications for RI #29. After administering the medications through RI #29's syringe, EI #3 removed the tip of the syringe from RI #29's feeding tube and wiped the inside of the syringe with a Kleenex. EI #3 then wiped the inside of the syringe with a paper towel, wiped the plunger with a paper towel and placed the syringe/plunger back in a plastic bag.
On 08/22/19 at 10:58 a.m., the surveyor conducted an interview with EI #3. The surveyor asked EI #3, after administering medications to a resident with a feeding tube, what is the proper way to clean the syringe. EI #3 said rinse the syringe and dry it with a paper towel. The surveyor asked EI #3 how did she clean RI #29's syringe on 08/21/19. EI #3 said she cleaned it with a paper towel. When asked did she rinse the syringe before storing it, EI #3 said no.
On 08/22/19 at 12:00 p.m., the surveyor conducted an interview with EI #2, the Infection Control Nurse. The surveyor asked EI #2 what was the proper way to clean a syringe after medications have been administered to a resident. EI #2 said the nurse should take the syringe to the rest room and rinse it in the sink and dry it with a clean paper towel before placing the syringe back in the bag. When asked what was there a potential for when not cleaned this way, EI #3 said infection.

Based on interview, review of the Controlled Record of Medication Destruction sheets and review of a facility policy titled MEDICATION DESTRUCTION, the facility failed to ensure the required signatures were on one of five Controlled Record of Medication Destruction sheets for the months of January and February 2018, and one of five Controlled Record of Medication Destruction sheets for the month of February 2018 had a date of disposal on the sheet.
This affected two of 12 months of Controlled Record of Medication Destruction Records reviewed.
Findings Include:
A facility policy titled MEDICATION DESTRUCTION, dated
12/13, documented:
. RESPONSIBILITY:
All Licensed Personnel / Director of Nursing Services . CONTROLLED MEDICATIONS . 4. Medication destruction occurs only in the presence of two licensed nurses and/or a licensed nurse and a pharmacist or as required by state regulations. 5. The following information is entered on the Medication Destruction Record - Controlled Medication sheet . g. The date of disposal
h. The signatures of the persons conducting the disposal of the medication .
On 06/28/18 at 3:56 p.m., the surveyor reviewed the Record of Medication Destruction sheets for the Controlled medications. A review of the January and February 2018 Controlled Medication Destruction sheets revealed one of five sheets for each of the months did not contain the required signatures, and one of five sheets for February 2018, did not have the date of disposal on the sheet.
On 06/28/18 at 4:35 p.m., the surveyor conducted an interview with Employee Identifier (EI) #1, the Director of Nursing. The surveyor asked EI #1, what information should be on the Controlled Medication Drug Destruction sheets. EI #1 replied, the resident's name or the drug label with the name, the name of the medication and strength, the date, the quantity that you are destroying, the destruction code, three signatures, the name of the facility, the type of the medication and the date and method of destruction. The surveyor asked EI #1 who was responsible for ensuring the Controlled Medication Destruction sheets were filled out completely. EI #1 said she and the pharmacist. The surveyor asked EI #1, on her review of the January 2018 Controlled Drug Medication Destruction sheets, how many signatures did she observe. EI #1 said her signature was missing on one of the five sheets. EI #1 said on the February 2018 Controlled Drug Medication Destruction sheets, her signature was also missing on one of five of the sheets. When asked how many signatures should there be on the Controlled Medication Drug Destruction sheets, EI #1 replied three.