HIGHLINE POST ACUTE

A complaint survey, prompted by #CO2709603, #CO2709691? and #CO2728272? was conducted on 1/29/26. No deficiencies were cited.

A survey with #CO2709604 was completed on 1/29/26. No deficiencies were cited.

A complaint survey, prompted by #CO2573935, #CO2598759, #CO2636489, #CO2662210 and #CO2678229 was conducted on 12/8/25 to 12/11/25. One deficiency was cited.

Based on interviews and record review, the facility failed to ensure residents were free from any significant medication errors, affecting one (#1) of three residents out of 10 sample residents. Specifically, the facility failed to provide Resident #1 with the physician-prescribed medication for human immune deficiency virus (HIV) disease. Resident #1 was admitted to the facility on 2/19/25 with a physician’s order to receive the HIV medication Biktarvy. Biktarvy consists of three components, bictegravir, emtricitabine & tenofovir alafenamide (tenofovir). On 2/19/25, the nurse who admitted Resident #1 transcribed the Biktarvy order as tenofovir alafenamide only. The nurse did not recall why the order was changed, and there was no evidence that the pharmacist or the medical director reviewed the order before it was changed. Resident #1 continued on tenofovir only from 2/19/25 until 11/9/25 when the prescription read to discontinue. On 11/9/25, neither the facility nursing staff, the facility pharmacist who performed a monthly medication review prior to the medication being discontinued, nor the medical director reordered the medication for Resident #1. Antiretroviral (ART) therapy for HIV is a lifelong medication. From 11/9/25 until 11/21/25, Resident #1 did not receive any HIV medications. On 11/20/25, Resident #1 went to a local hospital to undergo his approximately every six to nine month viral load blood test. (Viral load blood test for HIV is used to determine how well the ART is working) The viral load blood work documented Resident #1 had a viral load of 65,900. According to the hospital gerontologist, had Resident #1 received his HIV medications as ordered, his viral load numbers would be approximately zero, an undetectable level that meant the virus was suppressed, preventing disease progression and transmission. Also on 11/20/25, when Resident #1 went to the hospital for his bloodwork, his medication orders sent from the facility did not include Biktarvy as prescribed in February 2025. The hospital physician wrote a medication order for Biktarvy on 11/20/25, and on 11/21/25, Resident #1 began taking Biktarvy, the medication he should have been on since 2/19/25 for his HIV.The facility's failure to administer Biktarvy as ordered created the likelihood for serious resident harm. According to the hospital gerontologist, tenofovir was not sufficient to treat HIV on its own. Serious harm was also likely due to the resident's exposure since February 2025 to an incomplete medication regimen, which can create an even greater drug resistance to Biktarvy for HIV (meaning Resident #1 may develop a resistance to the HIV drug Biktarvy due to it not being administered since February 2025). Findings include:I. Findings of immediate jeopardyA. Failure to administer medications as orderedThe facility failed to accurately transcribe the physician’s order for a compound anti-viral medication for HIV, which led to Resident #1 not receiving the correct combination medication from 2/19/25 until 11/9/25. When the incorrect medication order expired on 11/9/25, the medical director and the facility pharmacist were not consulted, and the medication was not renewed. The resident did not receive any anti-viral medications in the compound for HIV from 11/9/25 to 11/21/25. B. Facility notice of immediate jeopardyOn 12/9/25 at 2:50 p.m., the nursing home administrator (NHA), the director of nursing (DON), and clinical resource #1 were notified of the facility’s failure to prevent a significant medication error by not ensuring Resident #1 received his HIV medication as prescribed. The medication error created a situation of immediate jeopardy for serious harm. C. Facility plan to remove immediate jeopardyOn 12/11/25, the NHA, DON, and clinical resource #1 presented the following plan to address the immediate jeopardy situation. It read in pertinent part,“Immediate Action Done:“On 12/9/25, Resident #1’s medication list was printed and reviewed with the facility physician for accuracy.“On 12/9/25, the hospital’s infectious disease office (for Resident #1) was contacted regarding follow-up appointment recommendations for lab monitoring.“Beginning 12/9/25, the DON or designee will prioritize reviewing current residents who are receiving clinically significant medications such as insulin, anticoagulants, cancer agents, antivirals, and medications for multiple sclerosis or Parkinson's. This review will focus on order accuracy. Once those residents are completed, the DON/designee will review all remaining residents. This plan will be completed by 12/12/25.“On 12/9/25, the DON or designee reviewed all resident orders with a discontinuation date using the order listing report to ensure accuracy. This was completed on 12/9/25.“Plan:“(Facility name) Medication policy was reviewed on 12/9/25 by the NHA, the DON, and the medical director.“Beginning 12/9/25, new admission orders will be reviewed against the discharge orders to ensure transcription accuracy. Any discrepancies identified will be clarified with the attending physician. This process will be ongoing.“Beginning 12/9/25, the primary physician will review new admission orders in conjunction with the history and physicals to ensure accuracy. This will be an ongoing process.“Beginning 12/10/25, consultant pharmacists will complete a review of new admissions for clinically significant risk within 72 hours of admission. This review will include assessment of high-risk medications, potential interactions, contraindications, missing indications, and duplicate therapies. Any concerns identified will be communicated to the facility immediately.“On 12/9/25, the licensed practical nurse (LPN) who may not have transcribed the original order correctly was re-educated via phone by the assistant director of nursing (ADON). Education included the facility’s policy regarding medication administration and reconciliation guidelines of noting who medications were verified with and any changes made during reconciliation.“Beginning 12/9/25, the staff development coordinator (SDC) or designee re-educated all licensed nurses on the facility's medication administration and reconciliation policy. Education included documenting who was verified for each medication, noting any changes made during reconciliation, completing a two-nurse verification of order accuracy, and clarifying when a long-term medication has a stop date. “Education was completed by 12/11/25 for 43 of 57 licensed nurses through in-person or phone education. Any nurse who has not yet received (the) education will not work the floor until training is completed. Licensed nurses who have not worked within the last 60 days have been terminated.“Licensed nurses on a leave of absence will be educated upon their return and prior to working on the floor. Eleven licensed nurses were unable to be reached by the SDC or designee and will not be scheduled (to work) until the required education is completed.“Beginning 12/9/25, the SDC/designee will educate agency licensed nurses on the facility’s policy regarding medication administration and reconciliation guidelines. Education was uploaded to the agency portal on 12/10/25. The agency platform requires the agency nurse to complete training before they can confirm the shift.“On 12/9/25, the regional director of clinical services notified the pharmacy account representative of the error. A meeting has been scheduled with (pharmacy name) for 12/18/25 to review the error in detail and establish an ongoing plan for medication monitoring. D. Removal of immediate jeopardyOn 12/11/25 at 2:11 p.m., the NHA and clinical resource #1 were notified that, based on the plan for removal of immediate jeopardy, the plan was accepted and the immediate jeopardy situation removed. However, deficient practice remained at a G scope and severity, isolated, actual harm. II. Professional referenceAccording to the 9/25/25 guidelines for the use of antiretroviral agents in adults and adolescents with HIV, retrieved on 12/15/25 from https://clinicalinfo.hiv.gov/en/guidelines/hiv-clinical-guidelines-adult-and-adolescent-arv/initiation-antiretroviral-therapy,“The primary goals of antiretroviral therapy (ART) are to prevent HIV-associated morbidity and mortality and to prevent transmission of HIV to others. Durable viral suppression lowers the risk of both AIDS-defining and other HIV-related complications, improves immune function and overall health, and allows people with HIV to live a lifespan approaching that of people without HIV. High plasma viral load is a major risk factor for HIV transmission.“The Panel on Antiretroviral Guidelines for Adults and Adolescents (the Panel) recommends ART for all people with HIV to reduce the morbidity and mortality associated with HIV infection (AI) and to prevent HIV transmission to sexual partners and infants. ART should be initiated as soon as possible after HIV diagnosis.“The key to successfully maintaining viral suppression is continuous access to ART and full adherence to the prescribed regimen. Lack of adherence or intermittent access to ART can result in treatment failure and the emergence of drug resistance mutations that may compromise future treatment options.”III. Facility policy and proceduresThe Administering Medication policy, revised 2019, was provided on 12/9/25 at 6:09 p.m. by the DON. It read in pertinent part,“Medications are administered in a safe and timely manner, and as prescribed.“The director of nursing services supervises and directs all personnel who administer medications and/or have related functions.“Medications are administered in accordance with prescriber orders, including any required time frame.”IV. Resident #1A. Resident statusResident #1, age less than 70, was admitted on 2/19/25. According to the December 2025 computerized physician orders (CPO), diagnoses included human immune deficiency virus (HIV) disease, psychotic disorder with delusions, dementia, depression and pain. The 8/28/25 minimum data set (MDS) assessment revealed the resident had mild cognitive impairment with a brief interview for mental status (BIMS) score of 11 out of 15. He required set-up or clean-up assistance with eating, toileting, oral hygiene and dressing. He required supervision with showers. He did not reject care from staff. The medication, Biktarvy, was not documented on the MDS assessment. B. Resident #1’s interviewResident #1 was interviewed on 12/8/25 at 3:00 p.m. Resident #1 said he took whatever medication the nurses gave him at the facility. Resident #1 said he did not remember missing any medications, nor did he refuse any medications to his memory. C. Record reviewThe medication administration record (MAR) for Resident #1’s HIV medication from 2/20/25 (Resident #1 was admitted on 2/19/25) until 11/21/25 revealed:February 2025: Resident #1 received Tenofovir Alafenamide Fumarate, one oral tablet 25 mg (milligram) in the morning for HIV. The start date was 2/20/25. The end date for the medication documented both 11/9/25 and 2/20/26. The March 2025, April 2025, May 2025, June 2025, July 2025, August 2025, September 2025, October 2025, and November 2025 MARs (until 11/9/25) revealed Resident #1 received Tenofovir Alafenamide Fumarate, one oral tablet 25 mg (milligram) in the morning for HIV. The end date for the medication was 11/9/25.-Resident #1 did not receive Tenofovir, or any HIV medications from 11/10/25 through 11/20/25. The comprehensive care plan, initiated on 3/8/25, revealed Resident #1 had a diagnosis of HIV and was at risk for complications manifested by a decreased white blood count, fatigue, fluid volume deficit, nutrition, impaired skin integrity, infection, pain, and weight loss. The planned intervention was to administer medications as ordered. On 11/20/25, Resident #1 went to the hospital for routine HIV blood work. The hospital laboratory documented that the virus was detected above maximum quantitative range. The viral load (VL) was documented at 65,900. (See the hospital gerontologist's interview below; the resident’s VL should have read approximately zero). The hospital documented it was unclear how long the resident had been without antiretrovirals. The hospital records documented Resident #1 stated it had been a few days since he received his HIV medication, but his viral load suggested longer. Biktarvy did not appear on his medication list for the hospital when he came from the facility. The hospital gerontologist for Resident #1 wrote a prescription on 11/20/25 for the resident to resume the medication Biktarvy. While at the hospital on 11/20/25, Resident #1 had a CBC (complete blood count) with WBC (white blood count) comprehensive blood test to count the red cells, platelets, and total white blood cells. The results indicated low and out of range for Resident #1. On 11/21/25, Resident #1 began Biktarvy oral tablet 50-200-25 mg (milligrams) (Bictegravir-Emtricitabine-Tenofovir Alafenamide Fumarate), one tablet by mouth one time a day for HIV. These were the three compounds in the medication Biktarvy that Resident #1 was to have received upon his admission on 2/19/25. The November 2025 CPO documented Resident #1’s medication Biktarvy was revised on 11/20/25 with a start date of 11/21/25. The 11/25/25 physician’s assistant (PA) note documented that Resident #1 had a history of HIV and had a history of being non-compliant with Biktarvy. However:-See above; the resident was not offered Biktarvy for approximately ten months, from the time of his admission into the facility in February 2025 until he received the medication on 11/21/25. -See above; the MDS assessment documented that the resident did not reject care from staff, and the November 2025 and December 2025 MAR did not document any refusals of Biktarvy. -See below; interview with LPN #1 and LPN #2, on 12/9/25 at 10:20 a.m., revealed that Resident #1 was cooperative with care. Further, a 12/2/25 nursing progress note documented that the resident continued to take medications as ordered and was cooperative with care. V. Action taken after immediate jeopardy was identifiedThe 12/9/25 nursing progress note (during survey) documented that the ADON called and notified Resident #1’s family member of a medication error involving Biktarvy that occurred upon admission in February 2025. The family member was informed that the error was identified during the resident's appointment at the hospital on 11/20/25 and that the correct medication had resumed since that time. The family member was also informed that corrective actions had been implemented to prevent recurrence of the error. VI. InterviewsThe hospital gerontologist was interviewed on 12/9/25 at 9:55 a.m. via telephone. The hospital gerontologist said when Resident #1 came to the hospital on 11/20/25, his VL blood work was over 65,000, and it should have been around zero had he received Biktarvy. The hospital gerontologist said it was unlikely the reason for the high bloodwork numbers was because the medication was not working, but rather because Resident #1 had not received his medication. The hospital gerontologist said he had seen Resident #1 for almost two years, since January 2024. The hospital gerontologist said if the resident missed only a few days, it would be okay, but Resident #1’s medication was critical for him to take. The hospital gerontologist said when Resident #1 came to the hospital on 11/20/25, his medication list from the facility did not have Biktarvy on it. LPN #1 and LPN #2 were interviewed on 12/9/25 at 10:20 a.m. Both LPNs said recently in November 2025, Resident #1 went to a follow-up appointment at the hospital, and after that appointment, he started the medication (Biktarvy). LPN #1 said Resident #1 did not reject medications that the nurses provided. Both said the resident was cooperative with care. The DON was interviewed on 12/9/25 at 1:28 p.m. The DON said Resident #1 was admitted to the facility in February 2025 with a physician’s order for a medication called Biktarvy. The DON said Biktarvy was made of three components bictegravir, emtricitabine and tenofovir alafenamide. The DON said she thought that when the LPN entered the medication, it was entered as only tenofovir. The DON said she did not know why it was ordered incorrectly, or if anyone else reviewed the medication order prior to it being changed. The DON said she did not know if the LPN did not transcribe the order correctly, or the pharmacy had. The DON said she spoke to the LPN today (12/9/25) about the day Resident #1 was admitted on 2/19/25. The DON said the LPN did not remember what happened that long ago, or which provider or source was used to verify the medication. The DON said that the medication was not transcribed correctly, which was a medication error. The DON said after Resident #1 went to the hospital for his blood work on 11/20/25, the hospital gerontologist wrote an order for Biktarvy, and it was provided to Resident #1 starting on 11/21/25. The DON said Resident #1 did not receive his correct medication from the date he was admitted on 2/19/25 until 11/21/25. The facility’s medical director (MD) was interviewed on 12/9/25 at 1:50 p.m. The MD said she did not know how it was that Resident #1 did not receive the medication he was supposed to receive 10 months ago for HIV. The MD said the situation was like Swiss cheese that had a lot of holes. The MD said the situation had a lot of holes as to why or who missed the medication’s correct physician order. The MD said she could not say whether or not Resident #1 would be affected by not having received his HIV medication. On 12/10/25 at 11:22 a.m., the facility pharmacist was interviewed via the telephone. The facility pharmacist said she had begun on 11/1/25 as the facility pharmacist. The facility pharmacist said the process for a newly admitted resident to the facility was for the nurse on duty to call or notify the pharmacist consultant, who would verify the physician’s orders. The facility pharmacist said after that, a pharmacist assigned to the facility would perform monthly reviews of a resident’s medications. The facility pharmacist said when she read residents' medications, she kept a lot in balance, including fall risks, and then made recommendations. The facility pharmacist said she reviewed the medications for the residents in the facility in the first part of November 2025. The facility pharmacist said she did not know why Resident #1’s HIV medication was not reordered. The facility pharmacist said she would do a review of her work and then return the call with follow-up information about Resident #1’s medication. -However, the facility pharmacist did not call back as of 12/11/25, the end of the survey. On 12/10/25 at 2:32 p.m., the hospital gerontologist wrote via email, “Missed HIV medications cause (s) the HIV viral load to rise and the patient’s immune system to worsen (as measured by the CD4 count). This increases the risk of infections, certain types of cancers, and even common conditions like heart disease. When someone misses medications regularly, they can also develop resistance to those medications.“It's actually a little worse that (Resident #1) was on tenofovir alone (one of the three components in Biktarvy). Tenofovir by itself is not sufficient to treat HIV. Exposure to an "incomplete" regimen like this creates an even greater opportunity for drug resistance to develop (in addition to not fully treating the HIV).“So, while Resident #1 was completely off medicines for only a short time (11/9/25 to 11/21/25), he was not being fully treated since February 2025. This mistake should have been caught by his clinicians and/or pharmacy, even if they were not very familiar with HIV treatment options.”The NHA and the DON were interviewed together on 12/11/25 at 2:20 p.m. The NHA and the DON both said the situation with Resident #1 happened prior to their employment in the facility as NHA and DON. Both the NHA and the DON said they were aware of the critical nature of the situation with Resident #1. Both the NHA and the DON said the situation with the wrongly transcribed medication would not happen again with the new systems put in place during the survey.

A survey prompted by complaint #CO2687255 was completed on 12/8/25 to12/11/25. One deficiency was cited.

Based on interviews and record review, the facility failed to ensure residents were free from any significant medication errors, affecting one (#1) of three residents out of 10 sample residents. Specifically, the facility failed to provide Resident #1 with the physician-prescribed medication for human immune deficiency virus (HIV) disease. Resident #1 was admitted to the facility on 2/19/25 with a physician’s order to receive the HIV medication Biktarvy. Biktarvy consists of three components, bictegravir, emtricitabine & tenofovir alafenamide (tenofovir). On 2/19/25, the nurse who admitted Resident #1 transcribed the Biktarvy order as tenofovir alafenamide only. The nurse did not recall why the order was changed, and there was no evidence that the pharmacist or the medical director reviewed the order before it was changed. Resident #1 continued on tenofovir only from 2/19/25 until 11/9/25 when the prescription read to discontinue. On 11/9/25, neither the facility nursing staff, the facility pharmacist who performed a monthly medication review prior to the medication being discontinued, nor the medical director reordered the medication for Resident #1. Antiretroviral (ART) therapy for HIV is a lifelong medication. From 11/9/25 until 11/21/25, Resident #1 did not receive any HIV medications. On 11/20/25, Resident #1 went to a local hospital to undergo his approximately every six to nine month viral load blood test. (Viral load blood test for HIV is used to determine how well the ART is working) The viral load blood work documented Resident #1 had a viral load of 65,900. According to the hospital gerontologist, had Resident #1 received his HIV medications as ordered, his viral load numbers would be approximately zero, an undetectable level that meant the virus was suppressed, preventing disease progression and transmission. Also on 11/20/25, when Resident #1 went to the hospital for his bloodwork, his medication orders sent from the facility did not include Biktarvy as prescribed in February 2025. The hospital physician wrote a medication order for Biktarvy on 11/20/25, and on 11/21/25, Resident #1 began taking Biktarvy, the medication he should have been on since 2/19/25 for his HIV.The facility's failure to administer Biktarvy as ordered created the likelihood for serious resident harm. According to the hospital gerontologist, tenofovir was not sufficient to treat HIV on its own. Serious harm was also likely due to the resident's exposure since February 2025 to an incomplete medication regimen, which can create an even greater drug resistance to Biktarvy for HIV (meaning Resident #1 may develop a resistance to the HIV drug Biktarvy due to it not being administered since February 2025). Findings include:I. Failure to administer medications as orderedThe facility failed to accurately transcribe the physician’s order for a compound anti-viral medication for HIV, which led to Resident #1 not receiving the correct combination medication from 2/19/25 until 11/9/25. When the incorrect medication order expired on 11/9/25, the medical director and the facility pharmacist were not consulted, and the medication was not renewed. The resident did not receive any anti-viral medications in the compound for HIV from 11/9/25 to 11/21/25. On 12/9/25 at 2:50 p.m., the nursing home administrator (NHA), the director of nursing (DON), and clinical resource #1 were notified of the facility’s failure to prevent a significant medication error by not ensuring Resident #1 received his HIV medication as prescribed. The medication error created a situation for serious harm. On 12/11/25, the NHA, the DON, and clinical resource #1 presented the following plan to address the situation of serious harm. It read in pertinent part,“Immediate Action Done:“On 12/9/25, Resident #1’s medication list was printed and reviewed with the facility physician for accuracy.“On 12/9/25, the hospital’s infectious disease office (for Resident #1) was contacted regarding follow-up appointment recommendations for lab monitoring.“Beginning 12/9/25, the DON or designee will prioritize reviewing current residents who are receiving clinically significant medications such as insulin, anticoagulants, cancer agents, antivirals, and medications for multiple sclerosis or Parkinson's. This review will focus on order accuracy. Once those residents are completed, the DON/designee will review all remaining residents. This plan will be completed by 12/12/25.“On 12/9/25, the DON or designee reviewed all resident orders with a discontinuation date using the order listing report to ensure accuracy. This was completed on 12/9/25.“Plan:“(Facility name) Medication policy was reviewed on 12/9/25 by the NHA, the DON, and the medical director.“Beginning 12/9/25, new admission orders will be reviewed against the discharge orders to ensure transcription accuracy. Any discrepancies identified will be clarified with the attending physician. This process will be ongoing.“Beginning 12/9/25, the primary physician will review new admission orders in conjunction with the history and physicals to ensure accuracy. This will be an ongoing process.“Beginning 12/10/25, consultant pharmacists will complete a review of new admissions for clinically significant risk within 72 hours of admission. This review will include assessment of high-risk medications, potential interactions, contraindications, missing indications, and duplicate therapies. Any concerns identified will be communicated to the facility immediately.“On 12/9/25, the licensed practical nurse (LPN) who may not have transcribed the original order correctly was re-educated via phone by the assistant director of nursing (ADON). Education included the facility’s policy regarding medication administration and reconciliation guidelines of noting who medications were verified with and any changes made during reconciliation.“Beginning 12/9/25, the staff development coordinator (SDC) or designee re-educated all licensed nurses on the facility's medication administration and reconciliation policy. Education included documenting who was verified for each medication, noting any changes made during reconciliation, completing a two-nurse verification of order accuracy, and clarifying when a long-term medication has a stop date. “Education was completed by 12/11/25 for 43 of 57 licensed nurses through in-person or phone education. Any nurse who has not yet received (the) education will not work the floor until training is completed. Licensed nurses who have not worked within the last 60 days have been terminated.“Licensed nurses on a leave of absence will be educated upon their return and prior to working on the floor. Eleven licensed nurses were unable to be reached by the SDC or designee and will not be scheduled (to work) until the required education is completed.“Beginning 12/9/25, the SDC/designee will educate agency licensed nurses on the facility’s policy regarding medication administration and reconciliation guidelines. Education was uploaded to the agency portal on 12/10/25. The agency platform requires the agency nurse to complete training before they can confirm the shift.“On 12/9/25, the regional director of clinical services notified the pharmacy account representative of the error. A meeting has been scheduled with (pharmacy name) for 12/18/25 to review the error in detail and establish an ongoing plan for medication monitoring. On 12/11/25 at 2:11 p.m., the NHA and clinical resource #1 were notified that the facility's plan was accepted. II. Professional referenceAccording to the 9/25/25 guidelines for the use of antiretroviral agents in adults and adolescents with HIV, retrieved on 12/15/25 from https://clinicalinfo.hiv.gov/en/guidelines/hiv-clinical-guidelines-adult-and-adolescent-arv/initiation-antiretroviral-therapy,“The primary goals of antiretroviral therapy (ART) are to prevent HIV-associated morbidity and mortality and to prevent transmission of HIV to others. Durable viral suppression lowers the risk of both AIDS-defining and other HIV-related complications, improves immune function and overall health, and allows people with HIV to live a lifespan approaching that of people without HIV. High plasma viral load is a major risk factor for HIV transmission.“The Panel on Antiretroviral Guidelines for Adults and Adolescents (the Panel) recommends ART for all people with HIV to reduce the morbidity and mortality associated with HIV infection (AI) and to prevent HIV transmission to sexual partners and infants. ART should be initiated as soon as possible after HIV diagnosis.“The key to successfully maintaining viral suppression is continuous access to ART and full adherence to the prescribed regimen. Lack of adherence or intermittent access to ART can result in treatment failure and the emergence of drug resistance mutations that may compromise future treatment options.”III. Facility policy and proceduresThe Administering Medication policy, revised 2019, was provided on 12/9/25 at 6:09 p.m. by the DON. It read in pertinent part,“Medications are administered in a safe and timely manner, and as prescribed.“The director of nursing services supervises and directs all personnel who administer medications and/or have related functions.“Medications are administered in accordance with prescriber orders, including any required time frame.”IV. Resident #1A. Resident statusResident #1, age less than 70, was admitted on 2/19/25. According to the December 2025 computerized physician orders (CPO), diagnoses included human immune deficiency virus (HIV) disease, psychotic disorder with delusions, dementia, depression and pain. The 8/28/25 facility assessment revealed the resident had mild cognitive impairment. He required set-up or clean-up assistance with eating, toileting, oral hygiene and dressing. He required supervision with showers. He did not reject care from staff. The medication, Biktarvy, was not documented on the facility assessment. B. Resident #1’s interviewResident #1 was interviewed on 12/8/25 at 3:00 p.m. Resident #1 said he took whatever medication the nurses gave him at the facility. Resident #1 said he did not remember missing any medications, nor did he refuse any medications to his memory. C. Record reviewThe medication administration record (MAR) for Resident #1’s HIV medication from 2/20/25 (Resident #1 was admitted on 2/19/25) until 11/21/25 revealed:February 2025: Resident #1 received Tenofovir Alafenamide Fumarate, one oral tablet 25 mg (milligram) in the morning for HIV. The start date was 2/20/25. The end date for the medication documented both 11/9/25 and 2/20/26. The March 2025, April 2025, May 2025, June 2025, July 2025, August 2025, September 2025, October 2025, and November 2025 MARs (until 11/9/25) revealed Resident #1 received Tenofovir Alafenamide Fumarate, one oral tablet 25 mg (milligram) in the morning for HIV. The end date for the medication was 11/9/25.-Resident #1 did not receive Tenofovir, or any HIV medications from 11/10/25 through 11/20/25. The comprehensive care plan, initiated on 3/8/25, revealed Resident #1 had a diagnosis of HIV and was at risk for complications manifested by a decreased white blood count, fatigue, fluid volume deficit, nutrition, impaired skin integrity, infection, pain, and weight loss. The planned intervention was to administer medications as ordered. On 11/20/25, Resident #1 went to the hospital for routine HIV blood work. The hospital laboratory documented that the virus was detected above maximum quantitative range. The viral load (VL) was documented at 65,900. (See the hospital gerontologist's interview below; the resident’s VL should have read approximately zero). The hospital documented it was unclear how long the resident had been without antiretrovirals. The hospital records documented Resident #1 stated it had been a few days since he received his HIV medication, but his viral load suggested longer. Biktarvy did not appear on his medication list for the hospital when he came from the facility. The hospital gerontologist for Resident #1 wrote a prescription on 11/20/25 for the resident to resume the medication Biktarvy. While at the hospital on 11/20/25, Resident #1 had a CBC (complete blood count) with WBC (white blood count) comprehensive blood test to count the red cells, platelets, and total white blood cells. The results indicated low and out of range for Resident #1. On 11/21/25, Resident #1 began Biktarvy oral tablet 50-200-25 mg (milligrams) (Bictegravir-Emtricitabine-Tenofovir Alafenamide Fumarate), one tablet by mouth one time a day for HIV. These were the three compounds in the medication Biktarvy that Resident #1 was to have received upon his admission on 2/19/25. The November 2025 CPO documented Resident #1’s medication Biktarvy was revised on 11/20/25 with a start date of 11/21/25. The 11/25/25 physician’s assistant (PA) note documented that Resident #1 had a history of HIV and had a history of being non-compliant with Biktarvy. However:-See above; the resident was not offered Biktarvy for approximately ten months, from the time of his admission into the facility in February 2025 until he received the medication on 11/21/25. -See above; the facility documented that the resident did not reject care from staff, and the November 2025 and December 2025 MAR did not document any refusals of Biktarvy. -See below; interview with LPN #1 and LPN #2, on 12/9/25 at 10:20 a.m., revealed that Resident #1 was cooperative with care. Further, a 12/2/25 nursing progress note documented that the resident continued to take medications as ordered and was cooperative with care. V. Action taken after immediate jeopardy was identifiedThe 12/9/25 nursing progress note (during survey) documented that the ADON called and notified Resident #1’s family member of a medication error involving Biktarvy that occurred upon admission in February 2025. The family member was informed that the error was identified during the resident's appointment at the hospital on 11/20/25 and that the correct medication had resumed since that time. The family member was also informed that corrective actions had been implemented to prevent recurrence of the error. VI. InterviewsThe hospital gerontologist was interviewed on 12/9/25 at 9:55 a.m. via telephone. The hospital gerontologist said when Resident #1 came to the hospital on 11/20/25, his VL blood work was over 65,000, and it should have been around zero had he received Biktarvy. The hospital gerontologist said it was unlikely the reason for the high bloodwork numbers was because the medication was not working, but rather because Resident #1 had not received his medication. The hospital gerontologist said he had seen Resident #1 for almost two years, since January 2024. The hospital gerontologist said if the resident missed only a few days, it would be okay, but Resident #1’s medication was critical for him to take. The hospital gerontologist said when Resident #1 came to the hospital on 11/20/25, his medication list from the facility did not have Biktarvy on it. LPN #1 and LPN #2 were interviewed on 12/9/25 at 10:20 a.m. Both LPNs said recently in November 2025, Resident #1 went to a follow-up appointment at the hospital, and after that appointment, he started the medication (Biktarvy). LPN #1 said Resident #1 did not reject medications that the nurses provided. Both said the resident was cooperative with care. The DON was interviewed on 12/9/25 at 1:28 p.m. The DON said Resident #1 was admitted to the facility in February 2025 with a physician’s order for a medication called Biktarvy. The DON said Biktarvy was made of three components bictegravir, emtricitabine and tenofovir alafenamide. The DON said she thought that when the LPN entered the medication, it was entered as only tenofovir. The DON said she did not know why it was ordered incorrectly, or if anyone else reviewed the medication order prior to it being changed. The DON said she did not knowif the LPN did not transcribe the order correctly, or the pharmacy had. The DON said she spoke to the LPN today (12/9/25) about the day Resident #1 was admitted on 2/19/25. The DON said the LPN did not remember what happened that long ago, or which provider or source was used to verify the medication. The DON said that the medication was not transcribed correctly, which was a medication error. The DON said after Resident #1 went to the hospital for his blood work on 11/20/25, the hospital gerontologist wrote an order for Biktarvy, and it was provided to Resident #1 starting on 11/21/25. The DON said Resident #1 did not receive his correct medication from the date he was admitted on 2/19/25 until 11/21/25. The facility’s medical director (MD) was interviewed on 12/9/25 at 1:50 p.m. The MD said she did not know how it was that Resident #1 did not receive the medication he was supposed to receive 10 months ago for HIV. The MD said the situation was like Swiss cheese that had a lot of holes. The MD said the situation had a lot of holes as to why or who missed the medication’s correct physician order. The MD said she could not say whether or not Resident #1 would be affected by not having received his HIV medication. On 12/10/25 at 11:22 a.m., the facility pharmacist was interviewed via the telephone. The facility pharmacist said she had begun on 11/1/25 as the facility pharmacist. The facility pharmacist said the process for a newly admitted resident to the facility was for the nurse on duty to call or notify the pharmacist consultant, who would verify the physician’s orders. The facility pharmacist said after that, a pharmacist assigned to the facility would perform monthly reviews of a resident’s medications. The facility pharmacist said when she read residents' medications, she kept a lot in balance, including fall risks, and then made recommendations. The facility pharmacist said she reviewed the medications for the residents in the facility in the first part of November 2025. The facility pharmacist said she did not know why Resident #1’s HIV medication was not reordered. The facility pharmacist said she would do a review of her work and then return the call with follow-up information about Resident #1’s medication. -However, the facility pharmacist did not call back as of 12/11/25, the end of the survey. On 12/10/25 at 2:32 p.m., the hospital gerontologist wrote via email, “Missed HIV medications cause (s) the HIV viral load to rise and the patient’s immune system to worsen (as measured by the CD4 count). This increases the risk of infections, certain types of cancers, and even common conditions like heart disease. When someone misses medications regularly, they can also develop resistance to those medications.“It's actually a little worse that (Resident #1) was on tenofovir alone (one of the three components in Biktarvy). Tenofovir by itself is not sufficient to treat HIV. Exposure to an "incomplete" regimen like this creates an even greater opportunity for drug resistance to develop (in addition to not fully treating the HIV).“So, while Resident #1 was completely off medicines for only a short time (11/9/25 to 11/21/25), he was not being fully treated since February 2025. This mistake should have been caught by his clinicians and/or pharmacy, even if they were not very familiar with HIV treatment options.”The NHA and the DON were interviewed together on 12/11/25 at 2:20 p.m. The NHA and the DON both said the situation with Resident #1 happened prior to their employment in the facility as NHA and DON. Both the NHA and the DON said they were aware of the critical nature of the situation with Resident #1. Both the NHA and the DON said the situation with the wrongly transcribed medication would not happen again with the new systems put in place during the survey.

A survey prompted by complaint #CO2567760 was completed on 6/30/25 to 7/14/25. One deficiency was cited.

Based on observations, record review and interviews the facility failed to ensure an environment free of accident hazards for two (#1 and #19) of nine residents reviewed for accident hazards out of 21 sample residents. On 5/18/25 Resident #1 requested certified nurse aide (CNA) #1 to heat up an egg roll from his personal refrigerator in a microwave that was at the nurses’ station. After heating up the egg roll, CNA #1 gave the egg roll to Resident #1, without using a thermometer to check the temperature of the egg roll, and told the resident not to touch the egg roll because it was very hot. However, Resident #1 immediately picked up the egg roll after CNA #1 gave it to him. Hot liquid came out of the egg roll and dropped on the resident’s leg causing a second degree burn to Resident #1’s left thigh..On 5/19/25 the facility implemented a plan of correction in response to the incident which caused Resident #1’s left thigh burn. The corrective actions included placing thermometers and temperature logs at each nurses’ station for staff to take the temperatures of heated up food for residents and logging the temperatures prior to giving the food to the residents. However, on 6/30/25, during the survey, observations revealed the corrective actions implemented by the facility on 5/19/25 were not in place and none of the facility’s three microwaves at the nurses’ stations had a thermometer or a temperature log for staff to utilize. Additionally, on 6/19/25 Resident #19 was in the facility van, in his wheelchair, for an activity outing. Resident #19 was supposed to be secured in the van with a shoulder harness seatbelt placed across his chest, which also included a seatbelt extender attached to the seatbelt. The seatbelt extender was to be secured into a hook on the van floor. However, the seat belt was not secured properly on Resident #19. During the outing, another driver in front of the van made an abrupt turn which caused the transportation driver to quickly utilize the brakes. When the transportation driver suddenly stepped on the brakes, Resident #19 fell forward out of his wheelchair, onto his knees, and scraped his forearm which caused bleeding. Resident #19 sustained a 4 centimeter (cm) by 7 cm by 0.1 cm skin tear to his right forearm. The facility investigated the incident and determined the transportation driver did not fully secure Resident #19’s seatbelt, which resulted in the fall. The facility implemented a plan of correction in response to the incident on 6/19/25, immediately after Resident #19 sustained the fall in the facility van and no other incidents in the van occurred following implementation of the plan of correction. -While the facility identified and corrected the deficient practice regarding the incident with Resident #19, it was identified during the survey that the facility continued to have current deficient practice related to accident hazards due to corrective actions not being in place for the incident with Resident #1 (see above). Specifically, the facility failed to:-Ensure staff checked microwaved food for safe temperature prior to serving the food to residents, which resulted in Resident #1 sustaining a second degree burn to his left thigh; and,-Ensure Resident #19 was secured properly in the facility’s van, which resulted in the resident sustaining an abrasion to his right forearm after he fell out of his wheelchair when the van abruptly stopped. Findings include: I. Burn incident with Resident #1 on 5/18/25A. Facility policy and procedureThe Hot Liquid Safety policy, dated 2025, was provided by the nursing home administrator (NHA) on 7/1/25 at 1:37 p.m. via email. It revealed in pertinent part, “Hot liquids are to be served at proper (safe and appetizing) temperatures using appropriate safety precautions.“Proper (safe and appetizing) temperature means both appetizing to the resident and minimizing the risk for scalding and burns.“Scalding is a burn caused by spills, immersion, splashes, or contact with hot water, food and hot beverages, or steam.“Hot liquids can cause scalding and burns. The degree of injury depends on the temperature, the amount of skin exposed, and the duration of exposure.“The temperatures of hot liquids will be checked in the dietary department or at the nurses' station if the microwave is in place before distribution to the nursing units. If the temperature is greater than 140 degrees Fahrenheit (F), hold the liquid in the dietary department until it reaches an appropriate temperature.”II. Resident #1 A. Resident statusResident #1, age less than 65, was admitted on 5/2/24 and readmitted on 6/3/25 According to the June 2025 computerized physician orders (CPO), diagnoses include type 2 diabetes mellitus, dependence on renal dialysis, morbid obesity, peripheral vascular disease, history of falling, acquired absence of the right leg above the knee and acquired absence of the left leg below the knee. The 4/4/25 facility assessment revealed the resident was cognitively intactHe required set up or clean up assistance with eating. He required partial moderate assistance with toileting. B. ObservationsOn 6/30/25, beginning at 2:00 p.m., three microwaves were observed in the facility, one at each of the two nurses’ stations and one in the activity room. None of the three microwaves had thermometers or a food temperature log for staff to utilize. On 6/30/25 facility staff said all three of the microwaves were used to heat residents’ foods, but none of the staff members could provide thermometers to check the temperatures of the microwaved food items (see staff interviews below). C. Resident interviewResident #1 was interviewed on 6/30/25 at 3:20 p.m. Resident #1 said the egg roll item was from his own personal refrigerator. He said he asked CNA #1 to heat the egg roll (on 5/18/25) in the nurses’ station microwave. Resident #1 said after CNA #1 gave the food to him, he picked up the egg roll and dropped it immediately because it was too hot to hold, and it fell on his leg. Resident #1 said he thought it was the liquid inside the egg roll that burned his leg. Resident #1 said the burn hurt and he had a lot of pain. He said the physician saw him and told him the burn would heal and he was given some cream that stopped the pain. Resident #1 said he still had a small scar on his leg from the incident. D. Facility investigation of Resident #1’s burn incident and corrective actionsThe facility’s investigation and corrective actions implemented in response to the incident were provided on 6/30/25 at 11:00 a.m. by the corporate consultant (CC) and the NHA. The facility’s investigation documented that on 5/18/25 Resident #1 had food (from his personal room refrigerator) heated up in the microwave (at the nurses’ station) by CNA #1. According to the resident, the food rolled onto his leg causing a burn. The temperature of the food was not checked prior to giving the heated food (from the microwave) to Resident #1. The facility implemented the following action plan in response to the incident. However, on 6/30/25, during the survey, observations revealed the corrective actions implemented by the facility on 5/19/25 were not in place and none of the facility’s three microwaves at the nurses’ stations had a thermometer or a temperature log for staff to utilize. Corrective Action: The staff immediately assessed the resident. Nursing management started educating staff on 5/19/25 on the policy and safe handling of food with microwaves. This education was provided by the assistant director of nursing (ADON). The education included what temperature the food needed to be, how to properly assess the temperature of food and log (how to document the food temperatures). The nursing administration put out thermometers and a food temperature log at each nurses’ station on 5/19/25. On 5/19/25 a one-to-one education was provided to CNA #1 regarding proper safe handling procedures for food and drinks. Identification of others: All residents had the potential to be affected. The regional director of clinical services (RDCS) reviewed risk management from the last three months for any residents with burns and none were noted. Systematic changes: The ADON started education with staff on 5/19/25 on the policy for heating food/beverages per regulation. Monitoring: The director of nursing (DON)/designee would conduct twice weekly audits of designated microwaves (and) ensure that a temperature log was being used to document residents’ food/beverages (or items residents requested to be heated in a microwave, not meal service). The DON/designee would audit twice weekly that a thermometer and a temperature log was at the designated area where microwaves were located. The DON/designee would present all findings of audits to the quality assurance and performance improvement (QAPI) committee for a minimum of 12 weeks and would continue until substantial compliance was met. E. Record reviewThe 5/18/25 nursing progress note documented Resident #1 sustained a burn injury to the left thigh from an egg roll that was heated in the microwave (at the nurses’ station). A 2 cm by 4 cm superficial burn was noted on Resident #1’s leg. Resident #1 reported that while attempting to open his egg roll, it slipped and fell onto his thigh and caused a burn. The incident was reported to the on-call physician and a physician’s order was received for silver sulfadiazine cream (an antibiotic cream used to treat second and third degree burns). The 5/20/25 wound care physician note documented Resident #1 received a second degree burn on 5/18/25. The note documented the burn was on the resident’s left anterior thigh and it received a status of not healed. The initial wound encounter measurements were 2 cm length by 6.5 cm width by 0.1 cm depth. Resident #1 reported a pain level of zero out of 10. The wound bed had 100 percent (%) epithelialization (a new layer of tissue formed over the damaged area). The periwound skin exhibited edema. The 5/27/25 wound care physician note documented Resident #1’s wound was improving and not healed. The left anterior thigh had a burn and encounter measurements were 1.5 cm length by 2.3 cm width by 0.1 cm depth. The resident reported a wound pain of level zero out of 10. The wound bed had 100% epithelialization. The wound was improving. The periwound skin exhibited scarring. The 6/10/25 wound care physician note documented Resident #1’s burn on his left anterior thigh was resolved. F. Staff interviewsThe DON was interviewed on 6/30/25 at 5:05 p.m. The DON said after the incident on 5/18/25 with Resident #1, she and the ADON educated all the staff and put thermometers at every nurses’ station where there was a microwave. The DON said as of today (6/30/25), she did not know where the thermometers went that were placed at the nurses’ station on 5/19/25. The DON said Resident #1 did not go to the hospital for his burn. The corporate nurse (CN) was interviewed on 6/30/25 at 5:20 p.m. The CN said any microwaves at nurses’stations and the activity room would be removed immediately per the management's decision because all three of the microwaves were used to heat and reheat residents' food. CNA #1 was interviewed on 7/1/25 at 11:20 a.m. via the telephone. CNA #1 said she was the one who served Resident #1 the egg roll (on 5/18/25). CNA #1 said almost every night Resident #1 asked for items to be heated in the microwave. CNA #1 said Resident #1 liked his food items very hot. CNA #1 said she should have only heated up the egg roll for about two minutes, but instead heated the egg roll for five or six minutes. CNA #1 said she did not use a thermometer to check the temperature of the egg roll. CNA #1 said she did not remember if there were any thermometers by the microwave on the nurses’station. CNA #1 said the egg roll was taken out of the microwave and immediately placed on Resident #1’s bed side table. CNA #1 said she told Resident #1 to wait a few minutes for the egg roll to cooldown because it was very hot. CNA #1 said she did not see Resident #1 drop the food item on his leg. CNA #1 said she was educated by the ADON after the incident about how to correctly heat foods in a microwave and how to use a thermometer. CNA #1 said she thought microwaved foods should only be heated to 140 degrees Fahrenheit. Licensed practical nurse (LPN) #5 was interviewed on 7/1/25 at 1:15 p.m. LPN #5 said the microwaves at the nurses’ stations were used sporadically by the residents and Resident #1 asked for microwaved items only at night. LPN #5 said there were thermometers placed by the microwaves after Resident #1 was burned and the staff was educated on how to heat foods properly. G. Facility follow-upOn 6/30/25, the NHA and the maintenance director (MTD) took the microwaves out of the nurses’ stations and the activity room. On 6/30/25 at 5:20 p.m. the NHA said since no thermometers were near the microwaves at the nurses' stations and activity room, he decided to remove the three microwaves. The NHA said the microwaves would be removed while the facility continued to review and revise the policy on safe food handling with heating up food and/or beverages. The NHA said new education would be provided to staff, which included that only the kitchen would have a microwave to reheat residents’ food items. On 6/30/25 the ADON began re-educating all staff on microwaves and food service temperatures. The re-education also included where the thermometers and temperature log were to be kept. The re-education included how to perform a temperature check and what degrees foods needed to be served to the residents. Effective on 6/30/25, only one microwave in the main kitchen would be designated for all facility units staff to heat residents’ food. A full house audit was completed by the CN on 6/30/25 at 6:15 p.m. on any burns in the last 90 days. No other residents were affected. II. Van incident with Resident #19 on 6/19/25A. Facility policy and procedureThe Transporting A Resident (Facility Van) policy, dated March 2025, was provided by the CN on 7/14/25 at 12:31 p.m. via email. It revealed in pertinent part,“It is the policy of this facility to provide residents with safe, non-emergency transportation to doctor’s appointments, activity outings, and any other trips the facility deems necessary.“The van will be well-maintained and equipped with safety features. Each resident will be secured in a seat with a seatbelt or in their wheelchair secured with wheelchair tie-downs.“Staff authorized to drive the van will have the necessary training and licensure to operate the vehicle as well as knowledge of van safety features. Copies of any necessary documentation will be kept in each employee’s personnel file.”B. Resident statusResident #19, age 81, was admitted on 8/16/24. According to the July 2025 CPO, diagnoses included Parkinson's disease, vascular dementia, unsteadiness on his feet, chronic obstructive pulmonary disorder (COPD), cognitive communication disorder, need for assistance with personal care, amputation of (a) great toe, obesity and hypertension (high blood pressure). The 5/23/25 facility assessment revealed the resident had moderate cognitive impairments. He required supervision/ touch assistance with oral hygiene, toileting and upper body dressing. C. Facility investigation of Resident #19’s van incident and corrective actionsThe facility’s investigation and corrective actions implemented in response to the incident were provided on 7/1/25 at 10:00 a.m by the CC.The investigation documented on 6/19/25, while out on an activity outing, Resident #19 did not have a seat belt (secured) across his lap in the facility van. Resident #19 said he fell out of his wheelchair because the truck in front of the van slammed on their brakes, and the facility van had to come to a sudden stop to avoid an accident. The facility implemented the following action plan in response to the incident:Resident #1 was returned to the facility after the fall and was assessed by the registered nurse (RN). Treatment was provided by a facility nurse. The staff present in the facility van at the time of the incident were immediately educated on 6/19/25 by the DON. The education included ensuring all residents were always secured appropriately with a seat belt while in the facility van. All residents had the potential to be affected. The DON conducted an audit of risk management over the last 60 days and no other residents were identified. The interdisciplinary team (IDT) completed a root cause analysis which was completed on 6/19/25. On 6/19/2025 the regional director of plant operations performed a safety check on the van. On 6/19/25 a training was provided by the regional director of plant operations to the DON and ADON (about van safety). On 6/19/2025 a training was provided by the regional director of plant operations to the facility’s director of maintenance (MTD) regarding safety checks (of the facility van). The transportation driver was trained on 6/19/25 to ensure all residents were always secured appropriately with a seat belt while in the facility van. Additionally, any new employees that would provide transport would be educated prior to the start of their first transport. On 6/23/2025 additional coaching (van safety) was provided to the transportation driver by the NHA.The DON/designee would audit all transports prior to leaving the facility to see that the residents were secured appropriately with their seat belts. The audit would continue for 12 weeks minimum. The DON/designee would present audits to the QAPI committee monthly for a minimum of 12 weeks or until substantial compliance was achieved. The MTD would audit the van twice per week to ensure the safety of the van, and the audit would be recorded on a paper audit tool for 12 weeks minimum. The administration would present audits to the QAPI committee monthly for a minimum of 12 weeks and until substantial compliance will be achieved.-While the facility identified and corrected the deficient practice regarding the incident with Resident #19, it was identified during the survey that the facility continued to have current deficient practice related to accident hazards due to corrective actions not being in place for the incident with Resident #1 (see above). D. Record review The fall risk assessment, dated 3/22/25, documented Resident #19 was a moderate fall risk. The comprehensive care plan 8/22/24 revealed Resident #1 was at risk of falls related to Parkinson disease, amputation of the great toe, and muscle weakness. The interventions documented the resident needed a safe environment with even floors free from spills and/or clutter, adequate glare-free light, a working and reachable call light, and personal items within reach. The nursing progress note, dated 6/19/25 (after the fall) and written by the ADON, documented Resident #19 was going on outings in the facility bus when he fell out of his wheelchair to his knees, then fell back and hit his head on his wheelchair. Resident #19 was observed to have two skin tears measuring 2.5 cm by 1.5 cm and 4 cm by 0.5 cm to his right arm, an abrasion to his right knee and a bruise to his nose. Resident #19 said he fell out of his wheelchair to his knees and hit the back of his head on the wheelchair. The resident was assessed by a RN and assisted back to his wheelchair. Neurological check(s) were initiated and wound treatment was placed. The 6/19/25 physician’s progress note documented a verbal physician’s order was given for wound care instructions to clean Resident #19’s right arm wounds with cleanser, pat dry, skin prep the periwound (protect the skin surrounding the wound), apply a gauze dressing to the wound bed, and cover with bordered gauze as needed and QOD (every other day). The 7/1/25 wound care physician’s note documented Resident #19 had a skin tear to the right forearm with dimensions of 4 cm by 5 cm by 0.1 cm. The drainage was scant and the periwound was pink in color. The 7/8/25 wound care physician’s note documented the skin tear for Resident #19 was resolved. E. Staff interviewsThe transportation driver was interviewed on 7/10/25 at 11:43 a.m. The transportation driver said she put Resident #19 in the facility van. The transportation driver said she thought she had correctly secured Resident #19 with wheelchair tie downs to the wheels of the wheelchair and a seatbelt, which had an extender that was to be locked, to the van floor. The transportation driver said a driver in front of the van made a quick move that caused her to slam on the brakes. The transportation driver said when the brakes were abruptly stepped on, the activity assistant (AA) said Resident #19 had fallen. The transportation driver said she drove the van over to the side of the road, parked the van and put on the emergency lights. The transportation driver said she gave Resident #19 basic first aid placed Resident #19 back into his wheelchair, and because of blood, she bandaged the skin tear on his arm. The transportation driver said she called the DON and returned to the facility, which was about five to eight minutes away from where the incident occurred. The transportation driver said she only saw blood on Resident #19’s arm. The transportation driver said the DON and a facility nurse took Resident #19 off of the van and took over the care of Resident #19. The transportation driver said no other residents were hurt that were in the van on 6/19/25. The transportation driver said the van worked correctly but she did not strap in Resident #19’s seatbelt correctly. The transportation driver went into the van during the interview and demonstrated how the incident happened. The transportation driver said Resident #19’s wheelchair wheels were properly secured on the van floorboard. The transportation driver said she then put a shoulder harness seatbelt across his chest, and added a seatbelt extender that was approximately two to three feet long. The extender was to buckle into the seat belt at one end, and at the other end of the extender was a hook that latched onto a metal loop on the floorboard to secure Resident #19 in place. The transportation driver said she did not know which part of the seatbelt was not secured. The transportation driver said it was either the extender end was not secured onto the seat belt, or it was the extender hook which was not latched onto the floor board of the van. The transportation driver said when she helped Resident #19 back into his wheelchair the entire seatbelt and extender were off which was why Resident #19 was able to fall forward out of his wheelchair. The transportation driver said she was educated the day of the incident by the DON. The transportation driver said the following day, the DON had her do a return demonstration in the van to show how to correctly secure residents. The DON was interviewed on 7/10/25 at 12:30 p.m. The DON said the transportation driver was educated prior to being allowed to drive residents in the van. The DON said it was a one time mistake and there had been no falls in the facility van since the incident on 6/19/25. The DON said Resident #19 did not need to go to the hospital after the fall. The DON said the facility’s wound nurse and the facility’s wound physician cared for the skin tear. The DON said only Resident #19’s arm had a skin tear, and he had no other bruises or wounds after he was assessed. The DON said on 7/8/25 the wound physician documented that the skin tear was resolved. The DON said for several weeks, she or a designee would check the residents who attended field trips to ensure all of the residents on the van were secured correctly.

A complaint survey, prompted by #CO1936080, #CO1936085, #CO1936087, #CO1936088, #CO1936090, #CO1936091, #CO1936092, #CO1936093 and Incident #1936089 was conducted on 6/30/25 to 7/14/25. One deficiency was cited.

Based on observations, record review and interviews the facility failed to ensure an environment free of accident hazards for two (#1 and #19) of nine residents reviewed for accident hazards out of 21 sample residents. On 5/18/25 Resident #1 requested certified nurse aide (CNA) #1 to heat up an egg roll from his personal refrigerator in a microwave that was at the nurses’ station. After heating up the egg roll, CNA #1 gave the egg roll to Resident #1, without using a thermometer to check the temperature of the egg roll, and told the resident not to touch the egg roll because it was very hot. However, Resident #1 immediately picked up the egg roll after CNA #1 gave it to him. Hot liquid came out of the egg roll and dropped on the resident’s leg causing a second degree burn to Resident #1’s left thigh..On 5/19/25 the facility implemented a plan of correction in response to the incident which caused Resident #1’s left thigh burn. The corrective actions included placing thermometers and temperature logs at each nurses’ station for staff to take the temperatures of heated up food for residents and logging the temperatures prior to giving the food to the residents. However, on 6/30/25, during the survey, observations revealed the corrective actions implemented by the facility on 5/19/25 were not in place and none of the facility’s three microwaves at the nurses’ stations had a thermometer or a temperature log for staff to utilize. Additionally, on 6/19/25 Resident #19 was in the facility van, in his wheelchair, for an activity outing. Resident #19 was supposed to be secured in the van with a shoulder harness seatbelt placed across his chest, which also included a seatbelt extender attached to the seatbelt. The seatbelt extender was to be secured into a hook on the van floor. However, the seat belt was not secured properly on Resident #19. During the outing, another driver in front of the van made an abrupt turn which caused the transportation driver to quickly utilize the brakes. When the transportation driver suddenly stepped on the brakes, Resident #19 fell forward out of his wheelchair, onto his knees, and scraped his forearm which caused bleeding. Resident #19 sustained a 4 centimeter (cm) by 7 cm by 0.1 cm skin tear to his right forearm. The facility investigated the incident and determined the transportation driver did not fully secure Resident #19’s seatbelt, which resulted in the fall. The facility implemented a plan of correction in response to the incident on 6/19/25, immediately after Resident #19 sustained the fall in the facility van and no other incidents in the van occurred following implementation of the plan of correction. -While the facility identified and corrected the deficient practice regarding the incident with Resident #19, it was identified during the survey that the facility continued to have current deficient practice related to accident hazards due to corrective actions not being in place for the incident with Resident #1 (see above). Specifically, the facility failed to:-Ensure staff checked microwaved food for safe temperature prior to serving the food to residents, which resulted in Resident #1 sustaining a second degree burn to his left thigh; and,-Ensure Resident #19 was secured properly in the facility’s van, which resulted in the resident sustaining an abrasion to his right forearm after he fell out of his wheelchair when the van abruptly stopped. Findings include: I. Burn incident with Resident #1 on 5/18/25A. Facility policy and procedureThe Hot Liquid Safety policy, dated 2025, was provided by the nursing home administrator (NHA) on 7/1/25 at 1:37 p.m. via email. It revealed in pertinent part, “Hot liquids are to be served at proper (safe and appetizing) temperatures using appropriate safety precautions.“Proper (safe and appetizing) temperature means both appetizing to the resident and minimizing the risk for scalding and burns.“Scalding is a burn caused by spills, immersion, splashes, or contactwith hot water, food and hot beverages, or steam.“Hot liquids can cause scalding and burns. The degree of injury depends on the temperature, the amount of skin exposed, and the duration of exposure.“The temperatures of hot liquids will be checked in the dietary department or at the nurses' station if the microwave is in place before distribution to the nursing units. If the temperature is greater than 140 degrees Fahrenheit (F), hold the liquid in the dietary department until it reaches an appropriate temperature.”II. Resident #1 A. Resident statusResident #1, age less than 65, was admitted on 5/2/24 and readmitted on 6/3/25 According to the June 2025 computerized physician orders (CPO), diagnoses include type 2 diabetes mellitus, dependence on renal dialysis, morbid obesity, peripheral vascular disease, history of falling, acquired absence of the right leg above the knee and acquired absence of the left leg below the knee. The 4/4/25 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. He required set up or clean up assistance with eating. He required partial moderate assistance with toileting. B. ObservationsOn 6/30/25, beginning at 2:00 p.m., three microwaves were observed in the facility, one at each of the two nurses’ stations and one in the activity room. None of the three microwaves had thermometers or a food temperature log for staff to utilize. On 6/30/25 facility staff said all three of the microwaves were used to heat residents’ foods, but none of the staff members could provide thermometers to check the temperatures of the microwaved food items (see staff interviews below). C. Resident interviewResident #1 was interviewed on 6/30/25 at 3:20 p.m. Resident #1 said the egg roll item was from his own personal refrigerator. He said he asked CNA #1 to heat the egg roll (on 5/18/25) in the nurses’ station microwave. Resident #1 said after CNA #1 gave the food to him, he picked up the egg roll and dropped it immediately because it was too hot to hold, and it fell on his leg. Resident #1 said he thought it was the liquid inside the egg roll that burned his leg. Resident #1 said the burn hurt and he had a lot of pain. He said the physician saw him and told him the burn would heal and he was given some cream that stopped the pain. Resident #1 said he still had a small scar on his leg from the incident. D. Facility investigation of Resident #1’s burn incident and corrective actionsThe facility’s investigation and corrective actions implemented in response to the incident were provided on 6/30/25 at 11:00 a.m. by the corporate consultant (CC) and the NHA. The facility’s investigation documented that on 5/18/25 Resident #1 had food (from his personal room refrigerator) heated up in the microwave (at the nurses’ station) by CNA #1. According to the resident, the food rolled onto his leg causing a burn. The temperature of the food was not checked prior to giving the heated food (from the microwave) to Resident #1. The facility implemented the following action plan in response to the incident. However, on 6/30/25, during the survey, observations revealed the corrective actions implemented by the facility on 5/19/25 were not in place and none of the facility’s three microwaves at the nurses’ stations had a thermometer or a temperature log for staff to utilize. Corrective Action: The staff immediately assessed the resident. Nursing management started educating staff on 5/19/25 on the policy and safe handling of food with microwaves. This education was provided by the assistant director of nursing (ADON). The education included what temperature the food needed to be, how to properly assess the temperature of food and log (how to document the food temperatures). The nursing administration put out thermometers and a food temperature log at each nurses’ station on 5/19/25. On 5/19/25 a one-to-one education was provided to CNA #1 regarding proper safe handling procedures for food and drinks. Identification of others: All residents had the potential to be affected. The regional director of clinical services (RDCS) reviewed risk management from the last three months for any residents with burns and none were noted. Systematic changes: The ADON started education with staff on 5/19/25 on the policy for heating food/beverages per regulation. Monitoring: The director of nursing (DON)/designee would conduct twice weekly audits of designated microwaves (and) ensure that a temperature log was being used to document residents’ food/beverages (or items residents requested to be heated in a microwave, not meal service). The DON/designee would audit twice weekly that a thermometer and a temperature log was at the designated area where microwaves were located. The DON/designee would present all findings of audits to the quality assurance and performance improvement (QAPI) committee for a minimum of 12 weeks and would continue until substantial compliance was met. E. Record reviewThe 5/18/25 nursing progress note documented Resident #1 sustained a burn injury to the left thigh from an egg roll that was heated in the microwave (at the nurses’ station). A 2 cm by 4 cm superficial burn was noted on Resident #1’s leg. Resident #1 reported that while attempting to open his egg roll, it slipped and fell onto his thigh and caused a burn. The incident was reported to the on-call physician and a physician’s order was received for silver sulfadiazine cream (an antibiotic cream used to treat second and third degree burns). The 5/20/25 wound care physician note documented Resident #1 received a second degree burn on 5/18/25. The note documented the burn was on the resident’s left anterior thigh and it received a status of not healed. The initial wound encounter measurements were 2 cm length by 6.5 cm width by 0.1 cm depth. Resident #1 reported a pain level of zero out of 10. The wound bed had 100 percent (%) epithelialization (a new layer of tissue formed over the damaged area). The periwound skin exhibited edema. The 5/27/25 wound care physician note documented Resident #1’s wound was improving and not healed. The left anterior thigh had a burn and encounter measurements were 1.5 cm length by 2.3 cm width by 0.1 cm depth. The resident reported a wound pain of level zero out of 10. The wound bed had 100% epithelialization. The wound was improving. The periwound skin exhibited scarring. The 6/10/25 wound care physician note documented Resident #1’s burn on his left anterior thigh was resolved. F. Staff interviewsThe DON was interviewed on 6/30/25 at 5:05 p.m. The DON said after the incident on 5/18/25 with Resident #1, she and the ADON educated all the staff and put thermometers at every nurses’ station where there was a microwave. The DON said as of today (6/30/25), she did not know where the thermometers went that were placed at the nurses’ station on 5/19/25. The DON said Resident #1 did not go to the hospital for his burn. The corporate nurse (CN) was interviewed on 6/30/25 at 5:20 p.m. The CN said any microwaves at nurses’stations and the activity room would be removed immediately per the management's decision because all three of the microwaves were used to heat and reheat residents' food. CNA #1 was interviewed on 7/1/25 at 11:20 a.m. via the telephone. CNA #1 said she was the one who served Resident #1 the egg roll (on 5/18/25). CNA #1 said almost every night Resident #1 asked for items to be heated in the microwave. CNA #1 said Resident #1 liked his food items very hot. CNA #1 said she should have only heated up the egg roll for about two minutes, but instead heated the egg roll for five or six minutes. CNA #1 said she did not use a thermometer to check the temperature of the egg roll. CNA #1 said she did not remember if there were any thermometers by the microwave on the nurses’station. CNA #1 said the egg roll was taken out of the microwave and immediately placed on Resident #1’s bed sidetable. CNA #1 said she told Resident #1 to wait a few minutes for the egg roll to cool down because it was very hot. CNA #1 said she did not see Resident #1 drop the food item on his leg. CNA #1 said she was educated by the ADON after the incident about how to correctly heat foods in a microwave and how to use a thermometer. CNA #1 said she thought microwaved foods should only be heated to 140 degrees Fahrenheit. Licensed practical nurse (LPN) #5 was interviewed on 7/1/25 at 1:15 p.m. LPN #5 said the microwaves at the nurses’ stations were used sporadically by the residents and Resident #1 asked for microwaved items only at night. LPN #5 said there were thermometers placed by the microwaves after Resident #1 was burned and the staff was educated on how to heat foods properly. G. Facility follow-upOn 6/30/25, the NHA and the maintenance director (MTD) took the microwaves out of the nurses’ stations and the activity room. On 6/30/25 at 5:20 p.m. the NHA said since no thermometers were near the microwaves at the nurses' stations and activity room, he decided to remove the three microwaves. The NHA said the microwaves would be removed while the facility continued to review and revise the policy on safe food handling with heating up food and/or beverages. The NHA said new education would be provided to staff, which included that only the kitchen would have a microwave to reheat residents’ food items. On 6/30/25 the ADON began re-educating all staff on microwaves and food service temperatures. The re-education also included where the thermometers and temperature log were to be kept. The re-education included how to perform a temperature check and what degrees foods needed to be served to the residents. Effective on 6/30/25, only one microwave in the main kitchen would be designated for all facility units staff to heat residents’ food. A full house audit was completed by the CN on 6/30/25 at 6:15 p.m. on any burns in the last 90 days. No other residents were affected. II. Van incident with Resident #19 on 6/19/25A. Facility policy and procedureThe Transporting A Resident (Facility Van) policy, dated March 2025, was provided by the CN on 7/14/25 at 12:31 p.m. via email. It revealed in pertinent part,“It is the policy of this facility to provide residents with safe, non-emergency transportation to doctor’s appointments, activity outings, and any other trips the facility deems necessary.“The van will be well-maintained and equipped with safety features. Each resident will be secured in a seat with a seatbelt or in their wheelchair secured with wheelchair tie-downs.“Staff authorized to drive the van will have the necessary training and licensure to operate the vehicle as well as knowledge of van safety features. Copies of any necessary documentation will be kept in each employee’s personnel file.”B. Resident statusResident #19, age 81, was admitted on 8/16/24. According to the July 2025 CPO, diagnoses included Parkinson's disease, vascular dementia, unsteadiness on his feet, chronic obstructive pulmonary disorder (COPD), cognitive communication disorder, need for assistance with personal care, amputation of (a) great toe, obesity and hypertension (high blood pressure). The 5/23/25 MDS assessment revealed the resident had moderate cognitive impairment with a BIMS score of 12 out of 15. He required supervision/ touch assistance with oral hygiene, toileting and upper body dressing. C. Facility investigation of Resident #19’s van incident and corrective actionsThe facility’s investigation and corrective actions implemented in response to the incident were provided on 7/1/25 at 10:00 a.m by the CC.The investigation documented on 6/19/25, while out on an activity outing, Resident #19 did not have a seat belt (secured) across his lap in the facility van. Resident #19 said he fell out of his wheelchair because the truck in front of the van slammed on their brakes, and the facility van had to come to a sudden stop to avoid an accident. The facilityimplemented the following action plan in response to the incident:Resident #1 was returned to the facility after the fall and was assessed by the registered nurse (RN). Treatment was provided by a facility nurse. The staff present in the facility van at the time of the incident were immediately educated on 6/19/25 by the DON. The education included ensuring all residents were always secured appropriately with a seat belt while in the facility van. All residents had the potential to be affected. The DON conducted an audit of risk management over the last 60 days and no other residents were identified. The interdisciplinary team (IDT) completed a root cause analysis which was completed on 6/19/25. On 6/19/2025 the regional director of plant operations performed a safety check on the van. On 6/19/25 a training was provided by the regional director of plant operations to the DON and ADON (about van safety). On 6/19/2025 a training was provided by the regional director of plant operations to the facility’s director of maintenance (MTD) regarding safety checks (of the facility van). The transportation driver was trained on 6/19/25 to ensure all residents were always secured appropriately with a seat belt while in the facility van. Additionally, any new employees that would provide transport would be educated prior to the start of their first transport. On 6/23/2025 additional coaching (van safety) was provided to the transportation driver by the NHA.The DON/designee would audit all transports prior to leaving the facility to see that the residents were secured appropriately with their seat belts. The audit would continue for 12 weeks minimum. The DON/designee would present audits to the QAPI committee monthly for a minimum of 12 weeks or until substantial compliance was achieved. The MTD would audit the van twice per week to ensure the safety of the van, and the audit would be recorded on a paper audit tool for 12 weeks minimum. The administration would present audits to the QAPI committee monthly for a minimum of 12 weeks and until substantial compliance will be achieved.-While the facility identified and corrected the deficient practice regarding the incident with Resident #19, it was identified during the survey that the facility continued to have current deficient practice related to accident hazards due to corrective actions not being in place for the incident with Resident #1 (see above). D. Record review The fall risk assessment, dated 3/22/25, documented Resident #19 was a moderate fall risk. The comprehensive care plan 8/22/24 revealed Resident #1 was at risk of falls related to Parkinson disease, amputation of the great toe, and muscle weakness. The interventions documented the resident needed a safe environment with even floors free from spills and/or clutter, adequate glare-free light, a working and reachable call light, and personal items within reach. The nursing progress note, dated 6/19/25 (after the fall) and written by the ADON, documented Resident #19 was going on outings in the facility bus when he fell out of his wheelchair to his knees, then fell back and hit his head on his wheelchair. Resident #19 was observed to have two skin tears measuring 2.5 cm by 1.5 cm and 4 cm by 0.5 cm to his right arm, an abrasion to his right knee and a bruise to his nose. Resident #19 said he fell out of his wheelchair to his knees and hit the back of his head on the wheelchair. The resident was assessed by a RN and assisted back to his wheelchair. Neurological check(s) were initiated and wound treatment was placed. The 6/19/25 physician’s progress note documented a verbal physician’s order was given for wound care instructions to clean Resident #19’s right arm wounds with cleanser, pat dry, skin prep the periwound (protect the skin surrounding the wound), apply a gauze dressing to the wound bed, and cover with bordered gauze as needed and QOD (every other day). The 7/1/25 wound care physician’s note documented Resident #19 had a skin tear to the right forearm with dimensions of 4 cm by 5 cm by 0.1 cm. The drainage was scant and the periwound was pink in color. The 7/8/25 wound care physician’s note documented the skin tear for Resident #19 was resolved. E. Staff interviewsThe transportation driver was interviewed on 7/10/25 at 11:43 a.m. The transportation driver said she put Resident #19 in the facility van. The transportation driver said she thought she had correctly secured Resident #19 with wheelchair tie downs to the wheels of the wheelchair and a seatbelt, which had an extender that was to be locked, to the van floor. The transportation driver said a driver in front of the van made a quick move that caused her to slam on the brakes. The transportation driver said when the brakes were abruptly stepped on, the activity assistant (AA) said Resident #19 had fallen. The transportation driver said she drove the van over to the side of the road, parked the van and put on the emergency lights. The transportation driver said she gave Resident #19 basic first aid placed Resident #19 back into his wheelchair, and because of blood, she bandaged the skin tear on his arm. The transportation driver said she called the DON and returned to the facility, which was about five to eight minutes away from where the incident occurred. The transportation driver said she only saw blood on Resident #19’s arm. The transportation driver said the DON and a facility nurse took Resident #19 off of the van and took over the care of Resident #19. The transportation driver said no other residents were hurt that were in the van on 6/19/25. The transportation driver said the van worked correctly but she did not strap in Resident #19’s seatbelt correctly. The transportation driver went into the van during the interview and demonstrated how the incident happened. The transportation driver said Resident #19’s wheelchair wheels were properly secured on the van floorboard. The transportation driver said she then put a shoulder harness seatbelt across his chest, and added a seatbelt extender that was approximately two to three feet long. The extender was to buckle into the seat belt at one end, and at the other end of the extender was a hook that latched onto a metal loop on the floorboard to secure Resident #19 in place. The transportation driver said she did not know which part of the seatbelt was not secured. The transportation driver said it was either the extender end was not secured onto the seat belt, or it was the extender hook which was not latched onto the floor board of the van. The transportation driver said when she helped Resident #19 back into his wheelchair the entire seatbelt and extender were off which was why Resident #19 was able to fall forward out of his wheelchair. The transportation driver said she was educated the day of the incident by the DON. The transportation driver said the following day, the DON had her do a return demonstration in the van to show how to correctly secure residents. The DON was interviewed on 7/10/25 at 12:30 p.m. The DON said the transportation driver was educated prior to being allowed to drive residents in the van. The DON said it was a one time mistake and there had been no falls in the facility van since the incident on 6/19/25. The DON said Resident #19 did not need to go to the hospital after the fall. The DON said the facility’s wound nurse and the facility’s wound physician cared for the skin tear. The DON said only Resident #19’s arm had a skin tear, and he had no other bruises or wounds after he was assessed. The DON said on 7/8/25 the wound physician documented that the skin tear was resolved. The DON said for several weeks, she or a designee would check the residents who attended field trips to ensure all of the residents on the van were secured correctly.

A revisit survey was completed on 5/21/25 for all previous deficiencies cited on 4/7/25. The facility is in compliance with all regulations surveyed.

A complaint survey, prompted by #CO39689, Incident #39505 and Incident #39631 was completed on 4/3/25 to 4/7/25. One deficiency was cited.

Based on observations, record review and interviews, the facility failed to ensure one (#10) of three residents reviewed for falls out of 10 sample residents received adequate supervision and services to prevent an accident. Specifically, the facility failed to:-Ensure a root cause was identified for Resident #10's fall on 3/16/25; and, -Ensure Resident #10's care plan was reviewed for appropriate fall interventions after a fall. Findings include:I. Facility policy and procedureThe Safety and Supervision of Residents policy and procedure, reviewed 4/4/25, was provided by the nursing home administrator (NHA) on 4/8/25 at 12:02 p.m. It read in pertinent part, "Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities."Our individualized, resident-centered approach to safety addresses safety and accident hazards for individual residents. The interdisciplinary care team (IDT) shall analyze information obtained from assessments and observations to identify any specific accident hazards or risks for individual residents. The care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices."Implementing interventions to reduce accident risks and hazards shall include the following: communicating specific interventions to all relevant staff, assigning responsibility for carrying out interventions, providing training, as necessary, ensuring that interventions are implemented and documenting interventions."Monitoring the effectiveness of interventions shall include the following: ensuring that interventions are implemented correctly and consistently, evaluating the effectiveness of interventions, modifying or replacing interventions as needed and evaluating the effectiveness of new or revised interventions. II. Resident #10A. Resident statusResident #10, age greater than 65, was admitted on 3/9/18. According to the April 2025 computerized physician orders (CPO), diagnoses included type 2 diabetes mellitus (DM), dementia, chronic obstructive pulmonary disease (COPD), unsteadiness on feet and chronic kidney disease. The 3/10/25 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of six out of 15. He required substantial/maximal assistance with showers/bathing. He required partial/moderate assistance with toileting hygiene, upper and lower body dressing, personal hygiene, putting on/off footwear, and walking 50 feet with two turns. He required supervision/touching assistance with bed mobility, toileting and sit to stand transfers, shower transfers and walking 10 feet. The resident used a manual wheelchair. The assessment revealed he exhibited no behavioral symptoms or rejection of care. B. Record reviewReview of Resident #10's fall care plan, revised 6/6/18, revealed the resident was at risk for falls related to COPD, dementia, DM type 2, chronic kidney disease, hyperlipidemia, nicotine dependence, GERD (gastroesophageal reflux disease), neuropathy, HTN (hypertension), depression, BPH (benign prostatic hyperplasia) and history of falls. Interventions included encouraging the resident to wear shorts/pants with appropriate length, ensuring the resident's call light was within reach and encouraging the resident to use it for assistance as needed, providing a prompt response to all requests for assistance, educating and encouraging the resident to call for assistance with picking up items from the floor, educating the resident/family/caregivers about safety reminders and what to do if a fall occurred, encouraging the resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility, ensuring the resident was wearing non-skid shoes, rearranging the resident's room as needed and ensuring the bedside phone was within reach, therapy screening for restorative nursing program and therapy to evaluate and treat as indicated.-Review of the fall interventions revealed there had been no revisions to the care plan since 6/1/23. Review of Resident #10's secondary fall care plan, revised 7/25/24, revealed the resident had an unwitnessed fall and was at risk for recurring falls and unsteady gait related to cognitive impairment. Interventions, initiated 7/25/24, included medication regimen review as indicated, monitoring for complications related to the fall (change in neurological status, evidence of injury, loss of range of motion, pain) and notifying the physician promptly if observed, occupational therapy (OT) to screen for wheelchair management and smoking safety, keeping personal/frequently used items within reach, anticipating and meeting the resident's needs, educating/reminding the resident to call for assistance, encouraging activity as tolerated with rest periods between activities as needed, evaluation of medications for side effects that may increase fall risk, explaining all procedures and providing reassurance during mobility tasks to alleviate the fear of falling, keeping bed in low position with brakes locked, keeping the resident's call light within reach and initiating a restorative nursing program (initiated 9/19/23). -Review of the interventions revealed there had been no updates to the fall care plan since 7/25/24. -There was no documentation to indicate Resident #10's care plan was reviewed for the effectiveness of his fall interventions after his fall on 3/16/25. The 3/16/25 at 4:40 p.m. nurse's note revealed the certified nurse aide (CNA) called the nurse and said Resident #10 was on the ground in the main courtyard. The nurse went to the area and found the resident sitting down next to his wheelchair. Upon assessment, no apparent injuries were noted. The resident denied hitting his head, his pupils were equal, round, reactive to light and accommodation and his range of motion and vital signs were within normal limits. The resident was transferred to his wheelchair, with a maximum of two people safely. Neurological checks were initiated by the floor nurse.-The progress note did not identify a root cause for the resident's fall. The 3/17/25 at 11:32 a.m. physician's note revealed the reason for the physician's visit was follow up to a fall. Resident #10 was seen in his room, lying in bed comfortably and in no acute distress. The resident had a recent fall with no injuries. The physical examination did not show any trauma or bumps. Vital signs were stable. Resident #10 had a fall on 3/16/25 where he was found sitting next to his wheelchair in the courtyard. The note indicated staff were to continue follow-up with fall and neuroprotocol per facility. The 3/17/25 at 1:50 a.m. weekly nurse summary note revealed there had been no resident fall incident that week. -However there had been a fall the day before, on 3/16/25. -Review of the resident's progress notes revealed there was no further documentation of Resident #10's fall incident.-Review of Resident #10's EMR revealed there was no documentation to indicate a root cause for the resident's fall had been identified by the nurse on duty at the time of the fall or by the IDT.-Additionally, there was no documentation to indicate Resident #10's fall interventions had been reviewed for effectiveness or to determine if new fall interventions were needed. III. Staff interviewsThe director of nursing (DON) and the regional clinical resource (RCR) were interviewed together on 4/7/25 at 12:46 p.m. The DON said the facility's process after a fall depended upon if it was witnessed or not, but the nurse would be called and a RN would do an assessment before the resident would get up. The DON said if a resident hit their head or if it was unwitnessed, the nurses would do neurological assessments and notify physicians and residents' representatives. The DON said the facility would do an IDT meeting after the fall on the following business day to prevent a recurrence. The DON said IDT included herself, the director of rehabilitation (DOR), social services and the NHA. The DON said IDT would meet to discuss and determine the root cause of the fall. The DON and the RCR said they were not aware that Resident #10 had a fall on 3/16/25. They said they did not see an IDT note/assessment and said the fall had not been documented into their risk management system. The DON said the nurse on duty at the time of Resident #10's fall did not enter the fall into risk management and therefore the facility did not have an IDT meeting to determine the root cause because they were not aware of the fall. The DON said that Resident #10 had not been assessed for the root cause of his fall and the resident's care plan had not been reviewed to determine if new fall interventions were needed. The DON said the risk management entry was important so that it could trigger the next steps for fall review. The DON said it looked like it was an agency nurse that did not enter the information and she said she would call and educate the agency nurses and re-educate the staff nurses regarding the appropriate fall process. The DON said since Resident #10 had not had an IDT review of his 3/16/25 fall, she would talk with the resident, the physician and the nurse and find out the root cause of the fall and update the resident's care plan appropriately.

A revisit survey was completed on 4/3/25 for all previous deficiencies cited on 2/27/25. The facility is in compliance with all regulations surveyed.

A revisit survey was completed on 4/3/25 for all previous deficiencies cited on 2/27/25. The facility is in compliance with all regulations surveyed.