Chestnut Grn Hlth Ctr Blakehur

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of employee health records and resident medical records; and staff interview, it was determined the facility failed to document residents and staff were offered and provided education regarding the benefits, risks, and potential side effects of receiving the COVID-19 vaccine to residents; and failed to maintain documentation related to COVID-19 vaccination in residents and staff records. This was evident for 3 of 5 residents (Resident #1, #4, #5) and 1 of 5 staff (Employee #21) reviewed during a recertification/complaint survey. The findings include: A COVID-19 vaccine is intended to provide acquired immunity against severe acute respiratory syndrome coronavirus 2, the virus that causes coronavirus disease. 1)The facility staff failed to maintain COVID-19 vaccination records for all residents. A)Review of Resident #1's medical record on 12/17/25 revealed the Resident was admitted to the facility on [DATE]. Further review of Resident #1's medical record revealed no documentation the Resident was offered and provided education on the COVID-19 vaccination; received or declined the COVID-19 vaccination since admission. B) Review of Resident #4's medical record on 12/17/25 revealed the Resident was admitted to the facility on [DATE]. Further review of Resident #4's medical record revealed no documentation the Resident was offered and provided education on the COVID-19 vaccination; received or declined the COVID-19 vaccination since admission. C) Review of Resident #5's medical record on 12/17/25 revealed the Resident was admitted to the facility in 2023. Further review of Resident #5's medical record revealed no documentation the Resident was offered and provided education on the COVID-19 vaccination; received or declined the COVID-19 vaccination in 2025. Interview with the Director of Nursing on 12/17/25 at 10:30 AM confirmed the Surveyor's findings for Residents #1, #4 and #5. 2)The facility staff failed to maintain COVID-19 vaccination records for all employees. Review of Employee #21 health record on 12/18/25 revealed Employee #21 was hired on 4/14/25. Further review of Employee #21 health record on 12/18/25 revealed no documentation the Employee was offered and provided education on the COVID-19 vaccination; received or declined the COVID-19 vaccination since hired. Interview with the Administrator on 12/18/25 at 11:30 AM confirmed the Surveyor's findings.

Based on interview, observation, and medical record review, it was determined the facility failed to ensure that the resident's call light was within reach, per the individualized care plans, to allow access to assistance when needed by staff. This was evident for 1 (Resident #7) of 12 residents interviewed during the recertification/complaint survey. The findings include: On 12/15/25 at 10:51 AM, while interviewing Resident #7, Resident #7 stated that he/she could not reach the call bell that was lying on the bed. Resident #7 was sitting in a reclining chair with his/her walker next to him/her on the right side. Resident #7's legs were reclined. The surveyor asked Resident #7 how he/she called the nurse and the response was, I just yell out for them. The surveyor went to get the nurse, Staff #4 who stated that Resident #7 normally had someone help him/her get out of bed into the chair. Staff #5 stated that the resident typically was gotten out of bed by the geriatric nursing assistant but at times would get out of bed without waiting for assistance. At that time, Staff #4 placed the call bell next to the resident. Review of Resident #7's care plan, at risk for falls had the intervention, place call system and most frequently used items within resident reach.On 12/17/25 at 2:27 PM the Director of Nursing was informed of the observation.

Based on medical record review and staff interview, it was determined the facility staff failed to ensure Minimum Data Set (MDS) assessments were accurately coded. This was evident for 7 (#12, #3, #7, #28, #22, #2, #4) of 23 residents reviewed during the recertification/complaint survey.
The findings include:
The MDS is part of the Resident Assessment Instrument that was Federally mandated in legislation passed in 1986. The MDS is a set of assessment screening items employed as part of a standardized, reproducible, and comprehensive assessment process that ensures each resident's individual needs are identified, that care is planned based on those individualized needs, and that the care is provided as planned to meet the needs of each resident.
1) On 12/17/25 at 10:12 AM a review of Resident #12's medical record was conducted and revealed the MDS assessment with an assessment reference date (ARD) of 11/9/25 Section M1200C, skin and ulcer/injury treatments, turning/repositioning program was checked as being performed. Review of Resident #12's medical record failed to produce documentation that the resident was on a turning and repositioning program.
On 12/18/25 at 8:33 AM an interview was conducted with Staff #16 (MDS Coordinator) and the Nursing Home Administrator (NHA). Staff #16 stated that she was aware that some of the MDS assessments were coded for turning and repositioning and should not have been, that it was an error.
2) On 12/17/25 at 10:30 AM a review of Resident #3's medical record was conducted and revealed the November 2025 Medication Administration Record (MAR) that documented Resident #3 received the medication Gabapentin and Amoxicillin. Gabapentin has a drug classification of anti-convulsant but can be used to treat pain. Amoxicillin is an antibiotic to treat infection.
Review of Resident #3's MDS assessment with an ARD of 11/12/25, documented in Section N, medications, that the resident was coded for no antibiotic and no anticonvulsant use. The MDS failed to capture the antibiotic and anticonvulsant.
Review of Resident #3's August 2025 MAR documented the resident received Gabapentin and Levaquin (antibiotic). Review of Resident #3's MDS assessment with an ARD of 8/12/25, Section N, medications, failed to capture the anticonvulsant and antibiotic.
The NHA was informed on 12/18/25 at 9:00 AM.
3) On 12/17/25 at 10:35 AM a review of Resident #7's medical record was conducted and revealed Resident #7 received bacitracin (antibiotic ointment) for a right thigh scratch on 8/27/25 to 9/2/25 per the August 2025 Treatment Administration Record (TAR).
Review of Resident #7's significant change MDS assessment with an ARD of 9/2/25, section N, Medications, failed to capture the use of the antibiotic ointment.
On 12/18/25 at 8:33 AM an interview was conducted with Staff #16 who confirmed the finding.
4) On 12/17/25 at 1:48 PM a review of Resident #28's medical record revealed the resident received Aspirin 81 mg. every morning. Review of Resident #28's quarterly MDS assessment with an ARD of 9/27/25, Section N, Medications, failed to capture the use of an antiplatelet, which was Aspirin, during the lookback period.
Further review of the 9/27/25 MDS assessment, Section M1200C, skin and ulcer/injury treatments, turning/repositioning program was checked as being performed. Review of the medical record failed to produce documentation that the resident was on a turning and repositioning program.
On 12/18/25 at 8:33 AM an interview was conducted with Staff #16 and the NHA. Staff #16 stated that she was aware that some of the MDS assessments were coded for turning and repositioning and should not have been, that it was an error.
5) Review of Resident #22's medical record on 12/16/25 revealed a MDS assessment with an assessment reference date (ARD) of 10/19/25 in Section P0100 Physical Restraints was coded for A. Bed rail. The MDS definition for Physical restraints is any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body.
Observation of Resident #22 on 12/16/25 at 9:13 AM and 11:22 AM revealed no bed rails in use and no restraints in place to restrict the Resident's movements.
Interview on 12/18/25 at 8:30 AM with Staff #16 (MDS Coordinator) confirmed Resident #22 should not have been coded for restraints on 10/19/25 MDS Section P0100.
Interview on 12/18/25 at 8:40 AM with the Administrator confirmed the Surveyor's findings.
6) Review of Resident #2's medical record on 12/15/25 revealed a MDS assessment with an assessment reference date (ARD) of 10/14/25 in Section P0100 Physical Restraints was coded for A. Bed rail. The MDS definition for Physical restraints is any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body.
Observation of Resident #2 on 12/15/25 at 12:39 PM and on 12/16/25 at 11:20 AM revealed the Resident was in a recliner next to the Resident's bed. At those times no bed rails were noted in use and no restraints in place to restrict the Resident's movements.
Interview on 12/18/25 at 8:30 AM with Staff #16 (MDS Coordinator) confirmed Resident #2 should not have been coded for restraints on 10/14/25 MDS Section P0100.
Interview on 12/18/25 at 8:40 AM with the Administrator confirmed the Surveyor's findings.
7) Review of Resident #4's medical record on 12/15/25 revealed a MDS assessment with an assessment reference date (ARD) of 11/5/25 in Section P0100 Physical Restraints was coded for A. Bed rail. The MDS definition for Physical restraints is any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body.
Observation of Resident #4 on 12/15/25 at 2:04 PM and on 12/16/25 at 11:21 AM revealed the Resident was in a wheelchair next to the Resident's bed. At those times no bed rails were noted in use and no restraints in place to restrict the Resident's movements.
Interview on 12/18/25 at 8:30 AM with Staff #16 (MDS Coordinator) confirmed Resident #4 should not have been coded for restraints on 11/5/25 MDS Section P0100.
Interview on 12/18/25 at 8:40 AM with the Administrator confirmed the Surveyor's findings.

Based on review of facility documentation and interview, it was determined that the facility failed to ensure a registered nurse was on duty of at least 8 consecutive hours 7 days a week. This was found to be evident for 2 of 14 days reviewed during a recertification/complaint survey. The findings include: A review was conducted on 12/16/25 of the daily staffing sheets from 12/1-12/14/25 provided by the Administrator. The review revealed there were 2 days (12/6 and 12/7/25) with no RN coverage for day, evening and night shifts. Interview with the Administrator on 12/17/25 at 3:02 PM confirmed there was no RN on duty for 12/6 and 12/7/25.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, interview, and review of facility policies and procedures, it was determined the facility failed to 1) timely respond to concerns noted on pharmacy reviews and, 2) have policies and procedures in place for monthly drug regimen review to include time frames for the different steps in the process. This was evident for 5 (#4, #6, #26, #28, #7) of 6 residents reviewed for monthly drug regimen review during a recertification/complaint survey.The findings include:
1) Review of Resident #4's medical record on 12/16/25 revealed the Resident was admitted to the facility on [DATE].
Further review of Resident #4's medical record the Pharmacist conducted a MRR (Monthly Regimen Review) on 11/13/25 and documented Irregularities (see consultant pharmacist report).
Further review of Resident #4's medical record revealed no consultant pharmacist report from 11/13/25.
On 12/17/25 at 10:42 AM the Director of Nursing (DON) was asked about the MRR for November, and she stated they were in her office.
Review of Resident #4's pharmacist MRR Note to Physician/Prescriber dated 11/13/25 revealed it stated Lidocaine patches should only be applied once daily with 12 hour on and 12 hour off period. Please clarify directions. There was no documented response from the Physician/Prescriber.
Review of Resident #4's physician orders on 12/17/25 revealed the Pharmacist's 11/13/25 recommendations had still not been addressed.
Interview with the Director of Nursing on 12/17/25 at 2:15 PM confirmed Resident #4's November MMR was not addressed by the physician/prescriber and was not in Resident #4's medical record.
2) Review of Resident #6's medical record on 12/16/25 revealed the Resident was admitted to the facility in 2024.
Further review of Resident #6's medical record the Pharmacist conducted a MRR (Monthly Regimen Review) on 11/13/25 and documented Irregularities (see consultant pharmacist report).
Further review of Resident #6's medical record revealed no consultant pharmacist report from 11/13/25.
On 12/17/25 at 10:42 AM the Director of Nursing (DON) was asked about the MRR for November, and she stated they were in her office.
Review of Resident #6's pharmacist MRR Note to Physician/Prescriber dated 11/13/25 revealed there was no documented response from the Physician/Prescriber.
Interview with the Director of Nursing on 12/17/25 at 2:15 PM confirmed Resident 6's November MMR was not addressed by the physician/prescriber and was not in Resident #6's medical record.
3) Review of Resident #26's medical record on 12/16/25 revealed the Resident was admitted to the facility in 2024.
Further review of Resident #26's medical record the Pharmacist conducted a MRR (Monthly Regimen Review) on 8/11/25 and 11/13/25 and documented Irregularities (see consultant pharmacist report).
Further review of Resident #26's medical record revealed no consultant pharmacist report from 8/11/25 and 11/13/25.
On 12/17/25 at 10:42 AM the Director of Nursing (DON) was asked about the MRR for August and November, and she stated they were in her office.
Review of Resident #26's pharmacist MRR Note to Physician/Prescriber dated 8/11/25 and 11/13/25 revealed there was no documented response from the Physician/Prescriber.
Interview with the Director of Nursing on 12/17/25 at 2:15 PM confirmed Resident 26's August and November MMR were not in Resident #26's medical record.
4) On 12/17/25 at 10:05 AM a review of Resident #28's medical record revealed on 11/13/25 the Pharmacist conducted a Monthly Regimen Review (MRR) and documented Irregularities (see consultant pharmacist report).
Further review of Resident #28's medical record revealed no consultant pharmacist report from 11/13/25.
On 12/17/25 at 10:42 AM the Director of Nursing (DON) was asked about the MRR for November, and she stated they were in her office.
The DON provided the 11/13/25 recommendation for Resident #28 that stated, Aspirin 81 mg. is not recommended for osteoarthritis as it is not an effective dose for pain. Please clarify diagnosis. The recommendation was not acted upon or reviewed by the physician as evidenced by a blank physician response as of 12/17/25.
5) On 12/17/25 at 10:10 AM a review of Resident #7's medical record revealed on 11/13/25 and 10/28/25 the Pharmacist conducted a Monthly Regimen Review (MRR) and documented Irregularities (see consultant pharmacist report).
Further review of Resident #7's medical record revealed no consultant pharmacist reports from 11/13/25 and 10/28/25.
On 12/17/25 at 10:42 AM the DON stated the MRRs were in her office. The DON provided the reviews for 11/13/25.
Review of the recommendation for 11/13/25: Bumetanide oral tablet 2 mg: give 2 mg. by mouth one time a day for edema hold for SBP (systolic blood pressure) less than 100. Please update MAR (Medication Administration Record) to include BP measurements so nursing knows when to hold bumetanide order when indicated per hold parameter. The recommendation was not reviewed or acted upon.
Review of the recommendation for 11/13/25: Metoprolol Succinate ER oral tablet extended releases 24-hour 25 mg; give 25 mg by mouth 2 times a day for HTN, hold for SBP less than 110, heart rate less than 60. Metoprolol succinate is recommended to be administered once daily. Metoprolol tartrate can be administered twice daily. Please consider decreasing frequency of metoprolol succinate order to once daily or changing to metoprolol tartrate. The recommendation was not reviewed by the physician.
On 12/17/25 at 12:25 PM a review of the Medication Regimen Reviews (MRR) Policy that was given to the surveyor by the Nursing Home Administrator (NHA) documented the following:
Timeframe for reporting: #1. Within 24 hours of the MRR, the consultant pharmacist provides a written report to the attending physicians for each resident identified as having a medication irregularity that is deemed not life threatening. #2. If the identified irregularity represents a risk to a person's life, health, or safety, the consultant pharmacist contacts the physician immediately (within one hour) to report the information to the physician verbally and documents the notification. #3. The consultant pharmacist provides the director of nursing services and medical director with a written, signed and dated copy of all medication regimen reports. #4. Copies of all medication regimen review reports, including physician responses, are maintained as part of the permanent medical record.
Physician response: #1: upon receiving the MRR report from the pharmacist, the attending physician reviews and responds to the report. The physician documents in the resident's medical record that the pharmacist's recommendations have been reviewed and what (if any) actions were taken to address them. #2. If the physician does not provide a timely or adequate response, or the consultant pharmacist identifies that no action has been taken he/she contacts the medical director of (if the medical director is the physician of record) the administrator.
There was no timeframe in the policy that stated within what timeframe the physician was notified and how long it would take from the time of notification to correct the concern and respond back.
On 12/17/25 at 2:27 PM the DON confirmed the consultant pharmacist reports for Residents #28 and Resident #7 were not in the residents' medical records. At that time the DON was asked about the process for pharmacy reviews. The DON stated the monthly reviews were done and she would receive the reports from the pharmacist. The DON would then give the recommendations to the Nurse Practitioner (NP) and either they would either agree or disagree with the recommendation. The DON stated she would send back copies to the pharmacist when complete. The DON stated she kept the recommendations in a binder in her office and not in the resident's medical record.
The Nursing Home Administrator was informed of the concern on 12/18/25 at 12:00 PM.

Based on medical record review and interview, it was determined the facility staff failed to ensure a resident's drug regimen was free from unnecessary drugs (Resident #7 and #36). This was evident for 2 of 6 residents reviewed during the recertification/complaint survey. The findings include:
1) The facility staff failed to monitor the blood pressure and heart rate prior to administering a blood pressure medication with physician ordered parameters.
On 12/17/25 at 10:05 AM Resident #7's medical record was reviewed and revealed a physician's order for Metoprolol Succinate ER 25 mg. to be given twice per day and to hold for the SBP (systolic blood pressure) if below 110 and heart rate less than 60. Systolic blood pressure is the top number of a blood pressure reading. Metoprolol is used to treat high blood pressure, chest pain, and heart failure.
Review of Resident #7's September 2025, October 2025, November 2025, and December 2025 Medication Administration Records (MAR) revealed the Metoprolol was given every morning at 9:00 AM and every evening at 5:00 PM. When the medication was administered it was indicated by nurses initialing and checking off that the medication was given. There was no place on the MAR where the blood pressure and heart rate was documented as being done and monitored prior to the administration of the medication.
Review of the vital sign section of Resident #7's medical record from September 2025 to December 2025 was inconsistent as to the days and times the vital signs were taken, and the vital signs were not taken every day and in the evening to correlate when the medication was administered.
The finding of the vital signs not being monitored prior to the administration of the Metoprolol was corroborated by the monthly medication record reviews (MRR) by the pharmacist. Cross Reference F756
On 12/17/25 at 2:27 PM the concern was discussed with the Director of Nursing who confirmed the finding, and she stated they had some education to do.
2) The facility staff failed to do a gradual dose reduction for Resident #36 who is taking a psychotropic medication.
Medical record review on 12/17/25 revealed on 2/10/20 Resident #36 was admitted to this facility. Resident #36 has a history of depression, falls, speech disturbance, Vascular dementia, asthma, pain the both shoulders from osteoarthritis and has been resistive to care in the past.
On 6/7/24 Resident #36 entered into hospice care at the facility. Since the Resident was on hospice care, the Resident no longer received psychiatric services. The Resident was ordered and was still taking quetiapine 12.5 mg every night for vascular dementia.
There was no gradual dose reduction done and nursing had not recorded any side effects of medications or any behaviors Resident #36 had, to determine if the Resident continued to need the medication. An interview with geriatric nursing assistant staff # 12 stated that when the Resident was first admitted here he/she was resisting care all the time, however now she/he is very cooperative with care. On 12/16/25 staff # 17 also stated that The Resident has been cooperative with care and does not resist care like he/she used to. Administrator and Director of Nursing are aware.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, it was determined that the facility staff failed to obtain laboratory tests as ordered by the nurse practitioner for a resident (Resident #4). This was evident for 1 of 23 residents reviewed during a recertification/complaint survey.The findings include:Review of Resident #4's medical record on 12/16/25 revealed the Resident was admitted to the facility on [DATE] following a hospitalization that included an orthopedic surgery.Further review of Resident #4's medical record revealed the Resident was seen by the Nurse Practitioner (Staff #18) on 11/11/25. At that time Staff #18 documented Will follow-up lab work on Thursday including Vitamin D level.Review of Resident #4's paper medical record revealed on 11/11/25 Staff #18 ordered a CBC (Complete Blood Count), CMP (Comprehensive Metabolic Panel) and Vitamin D level.Further review of Resident #4's medical record revealed the Resident did not have the laboratory tests as ordered.Interview with Administrator on 12/17/25 at 10:45 AM confirmed the facility staff failed to obtain laboratory tests as ordered by the nurse practitioner on 11/11/25.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, it was determined the facility staff failed to obtain timely radiology services for residents. This was evident for 1 (Resident #7) of 12 residents interviewed during a recertification/complaint survey.The findings include: On 12/15/25 at 10:55 AM an interview was conducted with Resident #7. Resident #7 stated that he/she was having difficulty lifting their left leg. Resident #7 stated, I can walk but just can't lift it. On 12/16/25 at 11:32 AM a review of Resident #7's medical record was conducted and revealed a 12/11/25 nursing note that documented the resident was evaluated by the Hospice nurse secondary to a call that was received from the facility day shift nurse assigned to the resident on 12/10/25 that documented, patient is unable to lift or move leg and previously was able. The note continued x-ray approved by Hospice. X-ray order placed with [name] at 3:30 pm. A 12/12/25 at 9:00 AM nurse practitioner note documented, x-ray of the left hip was ordered and currently pending. The note ended, will follow up on x-ray results. A 12/13/25 at 6:41 AM nursing note documented, resident was having left hip and leg pain. An x-ray was ordered several days ago. Several calls made to [name]. Sent an ETA of between 8 and 10:30 pm today for x-ray to be done. A 12/14/25 at 20:36 (8:36 PM) nursing note documented, [name] arrived at 11:45 am to perform scheduled x-ray of L hip and L fibula/tibula. X-ray is rescheduled for tomorrow morning due to resident not available today. A 12/15/25 at 19:24 (7:24 PM) note documented the x-ray was done, which was 4 days after ordered. On 12/16/25 at 12:10 PM an interview was conducted with the Director of Nursing (DON) who stated that the order should have been put in the computer first and then the x-ray company should have been called to schedule the x-ray. On 12/16/25 at 1:45 PM the DON and NHA (nursing home administrator) informed the surveyor that the x-ray request was called in and then put into the computer system later. The DON and NHA stated they did not know why it took the x-ray company so long to come to the facility. The NHA agreed that there should have been communication to the resident prior to the resident going out on 12/14/25, that the x-ray company would be coming to perform the x-ray that morning.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interviews, the facility failed to schedule a surgical follow-up appointment for a resident (Resident #4). This was evident for 1 of 23 residents reviewed during a recertification/complaint survey.The findings include:Review of Resident #4's medical record on 12/16/25 revealed the Resident was admitted to the facility on [DATE] following a hospitalization that included an orthopedic surgery.Review of Resident #4's hospital discharge instructions revealed it stated Follow-up: Surgeon in 6 weeks, or upon discharge from the rehab facility.During interview with Resident #4 on 12/17/25 at 8:59 AM, the Resident stated he/she does not have a follow-up appointment scheduled with the surgeon.Interview with the Scheduler (Staff #10) on 12/17/25 at 9:14 AM and review of the scheduling book for residents at that time, confirmed there is no follow-up appointment scheduled for Resident #4.Interview with the Administrator on 12/17/25 at 9:20 AM confirmed Resident #4 has been at the facility for 7 weeks; the Resident does not have an anticipated discharge date and there is no follow-up surgical appointment scheduled for Resident #4.After Surveyor intervention, a follow up surgical appointment was scheduled for the Resident on 1/5/25.

Based on medical record review and interview, it was determined that the facility failed to document residents were offered and provided education regarding the benefits, risks, and potential side effects of receiving the influenza and pneumococcal vaccines to residents; and failed to maintain documentation related to influenza and pneumococcal vaccination in residents' medical records. This was evident for 2 of 5 residents (Resident #4, #5) reviewed for influenza vaccination and 4 of 5 residents (Resident #1, #4, #5, #36) reviewed for pneumococcal vaccinations during a recertification/complaint survey. The findings include: 1.Review of Resident #1's medical record on 12/16/25 for influenza and pneumococcal vaccinations revealed no documentation of the Resident's pneumococcal vaccination status. After Surveyor intervention, the facility staff obtained Resident's #1 pneumococcal vaccination documentation on 12/17/25 from ImmuNet. ImmuNet is a confidential database that stores immunization records and makes them available to health care providers. 2. Review of Resident #4's medical record on 12/16/25 for influenza and pneumococcal vaccinations revealed no documentation the Resident was offered influenza vaccination in 2025 and no record of the Resident's pneumococcal vaccination.After Surveyor intervention, the facility staff obtained Resident #4's influenza and pneumococcal vaccination documentation from the Resident's Assisted Living on 12/17/25.3. Review of Resident #5's medical record on 12/16/25 for influenza and pneumococcal vaccinations revealed no documentation the Resident was offered influenza vaccination in 2025 and no record of the Resident's pneumococcal vaccination.Interview with the Director of Nursing on 12/17/25 at 10:42 AM stated the Resident's representative has declined vaccinations for Resident #5 for years. Interview with the Director of Nursing on 12/18/25 at 10:28 AM confirmed the facility staff failed to document they offered and the Resident's representative declined influenza and pneumococcal vaccinations for 2025 in the Resident's medical record.4.Review of Resident #36's medical record on 12/16/25 for influenza and pneumococcal vaccinations revealed no documentation the Resident's pneumococcal vaccination status.Interview with the Director of Nursing on 12/17/25 at 10:30 AM confirmed Resident #36's pneumococcal vaccination status is not documented in the Resident's medical record.

Based on observation, interview, and record review, it was determined that facility staff failed to treat residents with dignity. This was evident for 1 (Resident #12) of 6 residents observed during the recertification/complaint survey. The findings include:On 12/17/25 at 12:48 PM observation was made of Geriatric Nursing Assistant (GNA) #5 sitting in a chair next to Resident #12 on the left side of the bed. Prior to the surveyor knocking on the door to Resident #12's room, the surveyor observed, by the reflection in the glass of a picture on the right side of the wall (entrance), of GNA #5 sitting next to the resident. At the time of the observation, GNA #5 was looking down and not feeding Resident #12. The survey knocked on the door and entered and saw GNA #5 give a spoonful of pureed food. The surveyor observed a cell phone lying next to Resident #12 on the bed that was opened with a text message thread. On 12/17/25 at 2:30 PM the cell phone policy was reviewed after being received from the Nursing Home Administrator (NHA). The policy stated, to ensure residents are provided uninterrupted quality service, staff members are not permitted to use wireless communication devices (i.e. mobile phone, pagers, electronic listening devices, iPod, computer games, televisions, etc.) during scheduled work hours and/or in work areas. On 12/17/25 at 2:35 PM the NHA and the Director of Nursing (DON) were informed of the observation.

Based on record review, and interviews, it was determined the facility failed to provide written notice with the reason for transfer of a resident. This was found evident in 1 (Resident #45) of 3 residents reviewed for hospitalization during the survey.
The finding include:
On 7/17/24 8:54 AM, the surveyor reviewed Residents #45's medical record. The review revealed that Resident #45 was admitted to the facility in early February of 2024. Further review revealed Resident #45 was transferred to the hospital on 3/28/24, 4/4/24 and again on 5/1/24.
Progress notes written on 3/28/24, 4/4/24 and 5/1/24 all described that Resident #45 was being transferred to the hospital, however there was no document that indicated that Resident #45 was given a written notice for the reason of transfer.
On 7/17/24 at 12:12 PM, the surveyor interviewed the Director of Nursing (DON). In the interview the DON stated she was unable to provide documentation that the written notice was given to Resident #45 on the three occasions he/she was transferred to the hospital.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview with facility staff, it was determined that the facility failed to: 1) keep complete kitchen records and, 2) store food in accordance with professional standards for food service and safety. This was evident of 2 out of 3 observations of food storage during the annual survey.
The finding include:
1) On 7/15/24 at 8:58 AM, the surveyor took a tour of the first-floor kitchen with the Dietary Manager Staff #7. During the tour the surveyor reviewed the area where the three compartment sink and dishwasher were located. On further review of the area the temperature and chemical log was missing documentation on July 12 through July 15th. Staff #7 stated she was not sure why the temperatures and chemical levels were not recorded, and she would speak with the weekend staff and get back to the surveyor. She further stated the expectation is for the control measures to be recorded.
On 7/22/24 at 7:43 AM, the surveyor conducted a follow-up interview with Staff #7. During the interview staff #7 reported that she had spoken to the weekend dishwasher staff. He had reported to her that he must have overlooked recording the control measure and was very busy that weekend. She further stated she educated the staff on the importance of recording temperature and chemical levels. On review of the logs, the temperature and chemical levels were recorded completely for the following weekend dates July 19th, 20th and 21st .
2) On 7/15/24 at 8:18 AM, the surveyor took a tour of the first-floor kitchen.
On further observation the surveyor observed the contents in multiple refrigerators. In the refrigerator labeled HCK1 there were trays of individual packaged items. A label was noted on the tray with the item name and the date made. No labeling was noted on the individual packages. Jello, lemons, peaches/pears, apple sauce, coleslaw were all labeled on the trays respectively, however a few applesauce containers were moved to peaches/pear tray.
On review of the refrigerator labeled HCK7 a container labeled peaches was dated 7/6 and a container of what appeared to be mandarin oranges was dated but had no label.
On review of the refrigerator labeled HCK8 a container of corn muffins was dated 6/16 and a box of what appeared to be brownies was open to air and had no date or label.
On 7/15/24 at 8:36 AM, the surveyor observed three square vents in the ceiling of the kitchen that had condensation forming water droplets on the outer edges of the vents. On further observation the droplets were occasionally falling onto the floor in the area where the wheeled food transportation carts were being placed.
On 7/15/24 at 8:38 AM, the surveyor interviewed Certified Dietary Manager (CDM) Staff #13 who had just walked into the kitchen. During the interview Staff #13 stated a work order was put in for someone to look at the vents. She further stated the condensation was noted to have starred in the last week or two with the outside temperatures being especially hot. She explained that staff was aware and asked to keep the food transportation carts away from this area.
The surveyor reviewed the unlabeled and/or dated food concerns from the refrigerators with Staff #13. The surveyor showed Staff #13 refrigerator HCK1 where the trays were labeled and dated but the individual containers were not. The surveyor pointed out how containers of applesauce were moved to another tray which separated the apple sauce from the content label and the date it was made. The concern being the product could potentially be allowed to remain in the refrigerator beyond its expiration date with no way to identify when it was made. Staff #13 stated she understood the concern. She also stated she would toss the unlabeled and undated foods. She also would throw out the corn muffins and peaches as they were opened beyond acceptable time frame perishable foods.
On 7/15/24 at 8:46 AM, the surveyor and Staff #13 observed the first-floor kitchen dry storage area. The surveyor asked Staff #13 what was in the container. It was unlabeled and did not have a date. She stated it was dry granola and would get rid of the contents. Next to the dry granola container was an open package of grits without a date noted to indicate when the box was opened. Staff #13 stated the box should have been dated when it was opened, and she would get rid of it. Syrup and soy sauce also were noted to be opened with no date. Staff #13 stated she would remove those items as well. Staff #13 reported that the Dietary Manager Staff #7 was the manager and in charge of the kitchen.
On 7/15/24 at 8:58 AM, the surveyor continued the first-floor kitchen observation with Diet Manager Staff #7. During the tour the surveyor observed a metal ban on the floor just under the PVC piping next to the dishwasher. The pan was filled with a tan odorous liquid. Staff #7 stated that the facility was made aware of the leak and that she was not sure when the repair was due to be completed.
On 7/15/24 at 9:13 AM, the surveyor notified the Nursing Home Administrator (NHA) of the drops coming from kitchen vents. The NHA stated she would evaluate and make sure there were no food contamination concerns.
On 7/15/24 at 9:22 AM, the surveyor observed the 2nd level kitchen with the Food and Beverage Director Staff #11. Upon entry to the kitchen the surveyor observed refrigerator MK7. In the refrigerator was an open bottle of water along with a soda bottle opened with no cap on it. Staff #11 removed the contents of the refrigerator and tossed the items into the garbage.
On interview with Staff #11, he described that the chef is in charge of ordering and receiving foods. He further stated that deliveries come twice a week and that monthly reviews are performed for monitoring food storing practices.
Next the surveyor observed the dry storage area. Listed are the observations where the packaging was open and there was no date or legible date written to indicate when the contents were opened:
An opened bottle of honey.
A bag of bow tie pasta
A bag of elbow pasta. (dated but unable to make of date)
Two bags of egg noodles.
A bag of croutons.
A bag of dry gravy.
Staff #11 stated he would get rid of all the items identified as opened and not dated.
On 7/15/24 at 9:36 AM, the surveyor observed the freezer in the upper kitchen with Staff #11.
Upon observation the items below were noted to have no label indicated the contents as well as no date to indicate the age of the items:
A tray of egg rolls was observed laid out open to air.
A tray of (staff identified) spanakopita. (covered in plastic wrap)
Two long items wrapped in plastic wrap. (staff identified bread)
A package of what appeared to be garlic bread.
Two bags of salmon (located next to labeled salmon bags)
6 bags of cream corn per Staff #11.
Canadian bacon package per Staff #11.
A bag of patties (some type of meat).
The following items did not have a label but were dated:
A tray of bread slices.
Diced carrots.
Two bags of [NAME] (next to dated and labeled [NAME] bags).
Plastic wrapped turkey.
Plastic wrapped beef.
The following items were labeled but had no date on them:
A bag of meat sauce.
A bag of beef tips.
On interview Staff #11 stated he would be getting rid of all the identified items and anything that was unlabeled and/or not dated.
Next the surveyor and Staff #11 observed the upper-level kitchen walk-in refrigerator. Several times were noted not to be covered and were open to air. Two metal containers of soups, a tray of individual cups of aspic, and beef that was thawing on a tray on the lowest rack. Also, a container was noted unlabeled and not dated. The Executive Chef Staff #10 was present and stated it was fruit soup and it was on the menu yesterday. He further stated he would get rid of the container.
On 7/15/24 at 12:19 PM the surveyor interviewed the NHA and the Director of Nursing (DON). During the interview the NHA stated that when staff need to report or request maintenance, they email the maintenance administrator assistant and she then schedules a work order in their system. The NHA reported she would look to see when maintenance was updated on the needed repairs in the kitchen.
On 7/22/24 at 7:36 AM, the surveyor observed that the pan under the PVC pipe in the dishwashing room was removed and the floor was dry. On further observations the surveyor noted new vents were installed in the ceiling and no condensation was noted.
On 7/22/24 at 9:23 AM, the surveyor conducted a follow-up interview with the NHA. During the interview the administrator stated the drain was fixed by in-house staff on 7/16 and the vents were fixed by an outside contractor on 7/17. The NHA was able to produce the emails that were sent from Staff #11 asking for repairs on June 17th for the drain and on July 6th for the condensation. The NHA stated the facility attempted to fix these problems earlier but those repairs were unsuccessful.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 7/24/2024 at 10:00 AM, during a review of Resident #6's electronic and paper medical record, the Surveyor discovered Physicians Wound Evaluation and Management Summary notes from 1/02/2024 through 7/16/2024 which listed the resident had an indwelling catheter in the Review of Systems during each visit.
Further review of Resident #6's electronic medical record failed to reveal documentation that the resident had an indwelling catheter.
During an interview conducted with the Director of Nursing (DON) #2 on 7/24/2024 at approximately 10:30 AM, the Surveyor was informed that Resident #6 didn't have an indwelling catheter as stated in the Physician's wound notes.
On 7/24/2024 at 1:25 PM, the DON informed the Surveyor that the Wound Care Physician was made aware of the inaccurate documentation and would make the necessary corrections in Resident #6's Wound Evaluation and Management Summary notes.
Based on record review and staff interview, it was determined that the facility failed to maintain complete and accurate medical records in accordance with acceptable professional standards. This was evident for 2 (Resident #5 and #6) out of 21 resident records reviewed during the annual survey.
The findings include:
A medical record is the official documentation for a healthcare organization. As such, it must be maintained in a manner that follows applicable regulations, accreditation standards, professional practice standards, and legal standards. All entries to the record should be legible and accurate.
1. On 07/18/24 at 08:04 AM a review of Resident #5's medical record revealed that the resident was admitted to the facility on [DATE] with multiple diagnoses including Dementia, Depression, Hypertension, and Arthritis. The surveyor reviewed Resident #5's Influenza Immunization Informed Consent form located in the resident's hard chart at the nurse's station. At the bottom of the form Reason for Vaccine Decline, the words Got vaccine [DATE] was written. The document was signed by the resident's representative and witnessed by a facility staff on 03/08/24. The section identifying the name of the resident to whom the medical record referenced was left blank.
On 07/19/24 at 07:15 AM the Surveyor interviewed the Director of Nursing (DON) regarding omission of the resident's name on the Influenza Immunization Informed Consent form. The DON acknowledged the omission and stated that a correction would be made. Later, on 07/19/24 at 01:01 PM the DON informed the surveyor that she had identified the signature of the responsible party. It was for Resident #5 and the document was updated.
On 7/22/24 at 9.25AM the surveyor was given an updated copy of the document, Influenza Immunization Informed Consent by the DON with Resident #5's name on it.

Based on medical record review, and staff interviews, it was determined the facility failed to provide the Resident and/or Representative with a written notice of the facility's bed hold policy upon transfer to an acute care facility. This was evident for 1 (Resident #45) of 3 residents reviewed for hospitalization.
The findings include:
On 7/17/24 8:54 AM, the surveyor reviewed Resident #45's medical record. The review revealed that Resident #45 was admitted to the facility in early February 2024. Further review revealed Resident #45 was transferred to the hospital on 3/28/24, 4/4/24 and again on 5/1/24.
Progress notes written on 3/28/24, 4/4/24 and 5/1/24 all described that Resident #45 was being transferred to the hospital. Nowhere in the progress notes or medical record did it document that the bed hold policy was given to the resident.
On 7/17/24 at 12:12 PM, the surveyor interviewed the Director of Nursing (DON). In the interview the DON stated she was unable to provide documentation that the bed hold policy was given to Resident #45 on the three occasions he/she was transferred to the hospital.
The facility's bed hold policy states all residents/representatives are provided written information regarding the facility bed hold policies, which address holding or reserving a bed during a period of absence (hospitalization or therapeutic leave). Residents are provided written information about these policies at least twice; 1) well in advance of any transfer (admission packet) and 2) at the time of transfer (or, if the transfer was an emergency, within 24 hours).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and interviews, it was determined that the facility failed to accurately document oral assessments in a resident's medical record. This was found evident of 1 (Resident # 16) of 1 residents reviewed for dental concerns.
The findings include:
On 7/15/24 at 10:12 AM, the surveyor observed Resident #16 and during that observations it appeared that Resident #16 had no teeth.
On 7/15/24 at 2:08 PM, the surveyor reviewed Resident #16 's medical records. The review revealed that Resident #16 was admitted to the facility in November of 2022 and had a past medical history of, but not limited to, muscle weakness, dysphagia (difficulty swallowing), malignant neoplasm of the tongue, partial glossectomy (removal of part of the tongue) restlessness and agitation, and dementia.
Further review of Resident #16 's medical record revealed a care plan for nutrition, with a goal that Resident #16 will meet nutritional and hydration needs.
On 7/18/24 at 1:05 PM, the surveyor reviewed Resident #16's Minimum Data Set (MDS) assessment. The admission MDS assessment completed in November of 2022, in section L (assessment of oral and dental status) documented Resident #16 had broken or loosely fitting full or partial dentures (chipped, cracked, uncleanable, or loose). The next MDS assessments dated 2/17/23 and 5/20/23 had the same oral assessment. The admission MDS assessment dated [DATE] documented Resident #16 with none of the above are present.
Next the surveyor reviewed the nursing evaluation form from the admission assessment dated [DATE]. In the oral assessment the nurse documented Resident #16 had upper dentures.
On 7/18/24 at 2:40 PM, the surveyor interviewed the Director of Nursing (DON). During the interview the surveyor asked about the inconsistency in the oral assessments on 8/10/23 from the nursing admission assessment to the MDS admission assessment. The DON stated that Resident #16 did have dentures, but they did not fit well and the family chose to take them home. She further stated the option of no natural teeth or tooth fragment(s) (edentulous) would have been the accurate coding on the MDS not none of the above.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview with staff, it was determined that the facility failed to develop and implement a person-centered care plan for: 1) a resident with communication deficit, 2) a resident currently on a routine insulin regimen with frequent blood sugar monitoring, and 3) a resident receiving anticoagulation medication. This was evident for 3 (Resident #32, #10, #1) out of 21 residents with care plans reviewed during the annual survey.
The findings include:
1. On 7/15/2024 at 11:15 AM during an interview with Resident #32, the Surveyor discovered that the resident was hard of hearing and had impaired vision. In the resident's room, the Surveyor observed a large white board on the floor, that leaned on a chair in front of the resident's bed and a telephone with large, numbered buttons on the nightstand next to the bed. The Surveyor did not observe eyeglasses or hearing aids.
The MDS (Minimum Data Set) is a standardized, comprehensive assessment of a resident's functional, medical, psychosocial, and cognitive status to develop a plan of care based on the resident's individualized needs.
On 7/18/2024 at 10:33 AM, a review of Resident #32's electronic medical record revealed a Quarterly MDS assessment from 7/05/2024 which stated that the resident can sometimes understand verbal content and has impaired vision with no corrective lenses.
During further review of Resident #32's electronic medical record, the Surveyor discovered a note written by Social Worker #6 on 7/02/2024 which stated, [Resident #32] is very HOH (hard of hearing) and vision is impaired. Uses a magnifying glass to read.
During an interview with Licensed Practical Nurse (LPN) #14 on 7/19/2024 at 8:51 AM, the Surveyor was informed that Resident #32 is hard of hearing with impaired vision. LPN #14 explained that a person must look directly at the resident, take their time, and speak loudly to attempt to communicate with the resident. Resident #32 will not use hearing aides or eyeglasses. The resident uses a magnifying glass to read. The staff uses a white dry erase board to write in large print for the resident to see the writing.
A care plan is used to summarize a person's health conditions, specific care needs, and current treatments. It outlines what needs to be done to plan, assess, and manage care needs. This helps to evaluate the effectiveness of the resident's care.
Additional review of Resident #32's electronic medical record failed to reveal a care plan to address the resident's specific communication needs.
2. Insulin is an essential hormone that helps your body turn food into energy and controls your blood sugar levels to keep them in the normal range of 70 mg/dl and 100 mg/dl.
A sliding scale varies the dose of insulin based on the blood sugar level. The higher your blood sugar, the more insulin you receive.
On 7/17/2024 at 1:40 PM during review of Resident #10's electronic medical record, the Surveyor discovered that the resident was hospitalized [DATE]-[DATE] due to a hyperglycemic event. The resident returned to the facility and was placed on an insulin regimen which included blood sugar monitoring through daily finger stick checks and a sliding scale insulin dose.
Further review of Resident #10's electronic medical record failed to reveal a care plan to address insulin management on a sliding scale insulin dose.
During an interview with the Assistant Director of Nursing (ADON) #5 on 7/19/2024 at 10:32 AM, the Surveyor was informed that a person-centered care plan should have been developed and implemented for Resident #32, to address their communication deficit and specific communication needs, and for Resident #10, to address insulin management on a sliding scale insulin dose.
3. Eliquis (Apixaban) is an anticoagulant (blood thinner). It works by decreasing the clotting ability of the blood and helps to prevent harmful clots from forming in the blood vessels. Blood thinners can increase the risk of bleeding from falls or injuries.
On 07/16/24 at 12:48 PM a review of Resident #1's medical record revealed that resident was admitted to the facility on [DATE] with diagnoses including non-Hodgkin lymphoma, Repeated Falls, Congestive Heart Failure and Atrial Fibrillation. Resident #1 had an active physician's order dated 4/2/2024 for Eliquis for Atrial Fibrillation and the resident's medication administration record confirmed the resident was receiving the medication. There was no care plan for Resident #1 relating to the risks and interventions associated with anticoagulation therapy.
On 07/19/24 at 07:15AM in an interview with Director of Nursing (DON) the surveyor enquired about the plan of care for residents on anticoagulant therapy since the surveyor did not observe a plan of care in Resident #1's clinical record. The DON stated that she would address the issue.
On 07/22/24 at 09:25 AM the DON gave the surveyor a copy of a care plan for Resident #1 with the start date of 7/19/24. The care plan included interventions for bruising/bleeding which was consistent with risks for residents receiving anticoagulation therapy.

Based on observation, record review and interview with facility staff it was determined that the facility failed to obtain accurately documented informed consent prior to the use of the bed rails and updated bed rail assessments. This was evident of 2 (Resident #14 #16) of 2 residents reviewed for bed rails during an annual survey.
The findings include:
Bed rails also known as side rails are adjustable bars that attach to the bed. They vary in size, including full, half, and quarter lengths depending on their intended purpose. They can be used to prevent falls, help assist residents with movement, and provide a feeling of security. Bed rails also have potential risks associated with them, such as suffocation, entrapment, and psychological risks. A Resident or Resident's Representative should be provided with the risks and benefits along with a signed consent obtained before the use of bed rails.
1a) On 7/15/24 at 10:49 AM, the surveyor observed Resident #14's bed and noted 1/4 length bed rails up on both sides of the bed.
On 7/15/24 at 1:15 PM, the surveyor reviewed Resident #14 's medical records. The review revealed that Resident #14 was admitted to the facility in February of 2020 and had a past medical history of, but not limited to, difficulty in walking, muscle weakness, joint replacement, and vascular dementia.
Further review of Resident #14's medical record revealed a mobility care plan that stated, Resident #14 is at risk of self care deficit: bed mobility, transfers, hygiene, dressing grooming, feeling, toileting and locomotion on/off the unit. No interventions for bed rails were listed.
On 7/16/24 at 1:16 PM, the surveyor interviewed the Director of Nursing (DON). During the interview the DON described the process for bed rail use. She stated that nursing starts the bed rail assessment and the nurse would fill out an assessment form. She stated that therapies services also have input and their notes are uploaded and available. The DON stated that a consent for bed rails is also filled out before the use. The surveyor requested the facility's bed rail policy.
On 7/16/24 the surveyor reviewed the facility's bed rail policy. In the section titled use of bed rails (section 3) it stated; the use of bed rails or side rails (including temporarily raising the side rails for episodic use during cares) is prohibited unless the criteria for use of bed rails have been met, including attempts to use alternatives, interdisciplinary evaluation, resident assessment, and informed consent. (Section 8) stated; the bed rail assessment should be completed prior to use, reviewed and revised quarterly, and with significant changes in the resident(s) condition and/or changes in the type of bed rail being used.
On 7/17/24 at 7:08 AM, the surveyor conducted an interview with the DON. During the interview the surveyor requested bed rail evaluation/assessments and Resident #14's consent form for the use of bed rails.
On 7/17/24 at 9:32 AM, the survey conducted a follow-up interview with the DON. During the interview the DON stated that in 2020 the assessment form was on the same paper as the consent form. She further stated she found no other bed rail assessment completed for Resident #14 and further stated it is the expectation that bed rail assessments are completely quarterly. The DON confirmed that Resident #14 had a recent change of condition assessment done in June of 2024 and a bed rail assessment should have been completed at that time.
The surveyor next reviewed the consent form for bed rails for Resident #14, dated 2/28/20 with the DON. The signature of the representative was on the form however, neither box was checked that stated, I DO consent or I DO NOT consent .
1b) On 7/15/24 at 10:12 AM, the surveyor observed Resident #16's bed and noted the 1/4 length bed rails up on both sides of the bed.
On 7/15/24 at 2:08 PM, the surveyor reviewed Resident #16' medical records. The review revealed that Resident #16 was admitted to the facility in November of 2022 and had a past medical history of, but not limited to, muscle weakness, unsteadiness on feet, restlessness and agitation and dementia.
Further review of Resident #16's medical record revealed a fall care plan with multiple interventions to assist Resident #16 with mobility however, bed rails were not listed as an intervention throughout any of the care plans.
On 7/16/24 at 1:16 PM, the surveyor interviewed the Director of Nursing (DON). During the interview the DON described the process for bed rail use. She stated that nursing starts the bed rail assessment and the nurse would fill out an assessment form. She stated that therapies services also have input and their notes are uploaded and available. The DON stated that a consent for bed rail use is also filled out before the use. The surveyor requested the facility's bed rail policy.
On 7/16/24 the surveyor reviewed the facility's bed rail policy. In the section use of bed rails (section 3) stated; the use of bed rails or side rails (including temporarily raising the side rails for episodic use during cares is prohibited unless the criteria for use of bed rails have been met, including attempts to use alternatives, interdisciplinary evaluation, resident assessment, and informed consent. (Section 8) stated; the bed rail assessment should be completed prior to use, reviewed and revised quarterly, and with significant changes in the resident condition and/or changes in the type of bed rail being used.
On 7/17/24 at 7:08 AM, the surveyor conducted an interview with the DON. During the interview the surveyor requested bed rail evaluation/assessments for Resident #16 and the consent form for the use of bed rails.
On 7/17/24 at 9:32 AM, the surveyor conducted a follow-up interview with the DON. During the interview the DON provided assessments for bed rails used for Resident #16 dated 11/10/22 and 8/20/23. The DON reported no other bed rail assessments were found. The DON further stated it is the expectation that the bed rail assessment be completed quarterly. The DON confirmed that Resident #16 had a recent change of condition assessment done in June of 2024 and a bed rail assessment should have been completed at that time.
The surveyor next reviewed the consent form for bed rails for Resident #16, dated 11/10/22 with the DON. The signature of the representative was on the form however, neither box was checked that stated, I DO consent or I DO NOT consent .

Based on medical record review and interview it was determined the facility staff failed to
maintain a medical record in the most complete and accurate form (Resident #18). This was evident for 1 out of 18 residents reviewed during the annual survey.
The findings include:
A medical record is the official documentation for a healthcare organization. As such, it must be maintained in a manner that follows applicable regulations, accreditation standards, professional practice standards, and legal standards. All entries to the record should be legible, accurate and timely.
On 7-2-19 when reviewing Resident #18's electronic and paper medical record the last physician or nurse practitioner's note was 4-22-19. The Director of Nursing (DON) on 7-2-19 at 9:00 AM stated she/he would look to see if a physician visit still needed to be filed. On 7-2-19 at 9:10 AM the DON produced a physician visit note from 5-27-19 that had not been filed in the medical record.
On 7-3-19 at 8:00 AM the DON and Administrator confirmed Resident #18's medical record was not in it's most accurate form.

Based on medical record review and interview, it was determined that the facility failed to notify the resident or responsible party in writing of the reason for a Resident's (#26) transfer to the hospital. This was evident for 1 of 1 resident reviewed for hospitalization during the annual survey.
The findings include:
On 4-18-19 Resident #26 was transferred to the hospital for abdominal pain. The facility notified the responsible party verbally but did not send a written notice of the reason for the transfer.
This finding was confirmed by the Director of Nursing and the Administrator on 7-3-19 at 8:00 AM.