Holiday Manor Care Center

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to notify a physician of elevated blood sugar (BS) levels and a refused laboratory test for a resident with multiple complex medical conditions. The resident was originally admitted on 2/20/2026 and readmitted later with diagnoses including diabetes mellitus, hemiplegia and hemiparesis following a stroke, chronic kidney disease, and psychosis. An MDS dated 2/24/2026 documented that the resident’s cognition was intact and that the resident required moderate assistance with several ADLs but was independent with eating. A physician order dated 4/1/2026, effective 4/2/2026, directed staff to check BS twice daily before breakfast and dinner and to notify the physician when BS exceeded 200 mg/dl. Review of the April 2026 MAR showed BS checks at 6:30 a.m. and 4:30 p.m. with multiple readings over 200 mg/dl, including 239, 498, 205, 226, and 389 mg/dl on various days. During interviews and concurrent record reviews, RNs confirmed that there was no documentation that the physician had been notified of these elevated BS results, despite the explicit order to do so. One RN acknowledged documenting BS readings of 239 and 498 mg/dl and stated that the physician was not notified and that they could not find documentation that any other licensed nurse had notified the physician. The report also notes that the facility failed to notify the physician when the resident refused a complete blood count (CBC) ordered to evaluate anemia on 4/6/2026, although specific documentation details for that refusal are not provided in the excerpt. The deficient practice centers on the lack of required physician notification for both the elevated BS readings and the refused CBC test for this resident.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Licensed nurses failed to accurately and completely perform fall risk evaluations for two residents, resulting in incomplete and inaccurate assessments of fall risk. For the first resident, who had diagnoses including diabetes mellitus, hemiplegia and hemiparesis following a cerebral infarction, chronic kidney disease, and psychosis, the initial Fall Risk Evaluation dated 2/20/2026 was left incomplete. In the History, Current Status, Predisposing Conditions section, systolic blood pressure and several other items were not marked. In the Gait and Balance section, no items were marked to describe the resident’s abilities, including the option indicating the resident was not able to perform the function. In the Medications section, no medications were documented and the option indicating no relevant medications was also left blank. This incomplete evaluation was marked as “in progress” with a total fall score of eight, which did not place the resident in the high-risk category. On 3/25/2026, the same resident experienced a fall in the bathroom, as documented on an SBAR communication form, which stated that the fall was reported by the family and that two staff members assisted the resident back to bed. A subsequent Fall Risk Evaluation completed that same date documented “no falls in the past three months” in the History, Current Status, and Predisposing Conditions section, despite the fall that had just occurred. The vision status section was left blank, and the predisposing disease section was marked as “none present,” even though the resident had a diagnosis of cerebrovascular accident. The fall score on this evaluation was five, again indicating the resident was not considered at high risk for falls. During interview, the RN who completed the evaluation acknowledged not including the fall that occurred that day, leaving the vision status blank, and marking no predisposing disease because she did not see the CVA diagnosis, and stated that the evaluation was incomplete. For the second resident, who had diagnoses including pneumonitis, diabetes mellitus, Alzheimer’s disease, and anemia, and whose MDS showed severely impaired cognition and a need for staff assistance with multiple ADLs and transfers, the Fall Risk Evaluations also contained omissions. On the 2/21/2026 evaluation, the Medications section had no items marked, including the option indicating that none of the listed medications were taken in the prior seven days, although the overall fall score was recorded as 12. On the 3/29/2026 evaluation, the Gait and Balance section had no items marked, including the option indicating the resident was not able to perform the function, and the Medications section again had no items marked, including the “none” option. This evaluation recorded a fall score of 10, indicating the resident was not considered at high risk for falls. During interview, the RN who completed these evaluations stated that they were not completed accurately and emphasized the importance of correct and complete information to implement appropriate interventions. The DON also stated that licensed nurses should complete Fall Risk Evaluations accurately and thoroughly to properly assess residents’ risk for falls, consistent with the facility’s Fall Risk Assessment policy, which requires nursing staff and other disciplines to identify and document fall risk factors and use assessment data, including medications and functional factors, to establish a resident-centered falls prevention plan. The facility’s written policy on Fall Risk Assessment, last reviewed on 1/28/2026, specified that nursing staff, in conjunction with the attending physician, consultant pharmacist, therapy staff, and others, would identify and document resident risk factors for falls and establish a resident-centered falls prevention plan based on relevant assessment information. The policy further required review of medications or medication combinations that could relate to falls, and use of assessment data to identify underlying medical conditions and functional and psychological factors that may increase fall risk, including ambulation, mobility, gait, balance, ADL capabilities, activity tolerance, continence, and cognition. The incomplete and inaccurate completion of the Fall Risk Evaluations for both residents, including missing documentation of clinical conditions, gait and balance, and medications, did not follow these policy requirements and resulted in fall risk scores that did not reflect the residents’ actual fall histories and conditions.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Licensed nurses failed to follow a physician’s order for a resident with diabetes mellitus, hemiplegia, hemiparesis following cerebral infarction, chronic kidney disease, and psychosis. The physician’s order, dated 2/20/2026, directed staff to check the resident’s blood sugar (BS) two times a day for diabetes management, specifically before breakfast and before dinner, and to notify the physician when BS levels exceeded 200 mg/dl. The resident’s MDS indicated intact cognition and a need for moderate assistance with several ADLs, while being independent with eating. Review of the Medication Administration Record (MAR) for March 2026 showed that licensed nurses documented BS checks at 9 a.m. and 6 p.m., which were after meals rather than before meals as ordered. The MAR further showed numerous BS readings over 200 mg/dl on multiple dates, including several readings in the 300–400 mg/dl range. Despite these elevated values, there was no documentation that the physician was notified when BS levels exceeded 200 mg/dl, as required by the physician’s order. During interviews, RN 1 acknowledged documenting several very high BS readings and stated that BS was checked after meals instead of before meals and that the physician was not notified regarding BS levels exceeding 200 mg/dl. LVN 1 stated that the MAR had been incorrectly transcribed to 9 a.m. and 6 p.m. after meals, and that this error was followed; LVN 1 also stated the physician was probably called once or twice but could not recall specific dates or times, and there was no documentation of such calls in the progress notes. RN 3 similarly stated that the order to check BS before meals and to notify the physician for BS levels greater than 200 mg/dl was missed, that BS was checked after meals, and that the physician was not consistently notified, with any possible contacts not documented. The facility’s policies on diabetes clinical protocol and administering medications required that physician-ordered monitoring and reporting parameters be incorporated into the MAR and care plan, and that concerns about medication or potential adverse consequences be communicated to the prescriber.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to ensure a resident’s call light was kept within reach as required by the resident’s care plan and facility policy. The resident, who had intact cognition but required moderate assistance with multiple ADLs including toileting, personal hygiene, showering, lower body dressing, bed mobility, and transfers, had diagnoses including DM, hemiplegia and hemiparesis following a stroke, chronic kidney disease, and psychosis. The resident’s care plan, initiated on 4/1/2026, identified ADL deficits and included an intervention to ensure the call light was within reach and that staff responded promptly to calls and requests. The facility’s policy on answering call lights required that the call light be accessible to the resident when in bed, from the toilet, from the shower or bathing facility, and from the floor. During an observation and interview in the resident’s room, the resident was seen sitting on the bed while the call light cord and button were hanging over a bulletin board under an overhead wall-mounted lamp, out of the resident’s reach and sight. The resident stated that the call light should be within reach but was unable to access or see it and therefore could not obtain staff assistance if needed at that time. CNA 1 confirmed that the call light should be kept within reach at all times and acknowledged that if the resident could not reach the call light, the resident might attempt to move without assistance. The DON stated that the resident had one documented fall since initial admission and also stated that the call light should be kept within reach at all times, consistent with facility policy.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Surveyors identified a deficiency related to the facility’s failure to maintain required physician progress notes for a resident. The resident was originally admitted with multiple diagnoses including DM, hemiplegia and hemiparesis following a stroke, chronic kidney disease, and psychosis, and had intact cognition per the MDS. The MDS also documented that the resident required moderate assistance with several ADLs but was independent with eating. On a later date, an SBAR form documented that the resident verbalized statements about believing they were going to die and reported feelings of hopelessness, as relayed by the resident’s family. In response, a physician’s order was written for a psychiatry evaluation to be conducted by a psychiatrist. During a concurrent interview and record review with an RN, surveyors were unable to locate any physician progress notes in the resident’s clinical record related to the psychiatry evaluation following the order. The RN confirmed that the psychiatry consultation note could not be found and stated that follow-up for the resident’s mood changes should have occurred the same day or by the following day. The DON later stated that the facility received the psychiatry progress notes from the psychiatrist several weeks after the examination and acknowledged that some physicians do not consistently provide documentation on the same day services are rendered. Facility policies titled “Physician Services” and “Physician Progress Notes” required that physician orders and progress notes be maintained in accordance with OBRA regulations and that progress notes be maintained for each resident to reflect the resident’s progress and response to the care plan and medications, but the required psychiatry progress notes were not present in the resident’s record at the time of the survey.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that a copy of Resident 49's Advance Directive was readily available in the resident's medical record. Despite the resident's admission record indicating the presence of an Advance Directive, the document was not found in the medical record during a review. Interviews with the Registered Nurse and Social Services Designee confirmed the absence of the document and the lack of follow-up to obtain it. This oversight could lead to the facility not being aware of or able to carry out the resident's healthcare wishes in an emergency. Additionally, the facility did not provide two residents, Resident 20 and Resident 291, with written information concerning their rights to refuse or accept medical or surgical treatments and to formulate an Advance Directive upon admission. Resident 20's Advance Directive Acknowledgement form was blank, and there was no evidence that the resident or their conservator was informed of their rights. Similarly, Resident 291's form was also blank, and there was no documentation that the resident received the necessary information upon admission. The facility's policy and procedure on Advance Directives require that residents or their representatives be provided with written information about their rights concerning medical treatment and Advance Directives upon admission. The failure to adhere to this policy for the sampled residents could result in their healthcare wishes not being honored, as the necessary documentation and communication were not completed as required.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to develop comprehensive, person-centered care plans for several residents, leading to deficiencies in addressing their specific needs. Resident 49, diagnosed with PTSD, did not have a care plan that addressed her condition, despite the facility's policy requiring trauma-informed care plans. The Director of Nursing acknowledged the importance of identifying triggers for PTSD to avoid re-traumatizing the resident, yet no such plan was in place. Resident 47, who required RNA therapy for mobility issues, also lacked a care plan addressing his prescribed treatments. Despite having physician orders for passive range of motion exercises and ambulation assistance, the facility did not develop a care plan to ensure these treatments were provided consistently. The Director of Nursing confirmed that a care plan should have been created to address these needs. Additionally, Resident 85's refusal of Covid-19 and influenza vaccinations was not documented in a care plan, leaving the resident without monitoring for potential complications. Resident 63's activity preferences were not considered in his care plan, despite his expressed interest in watching television. Lastly, Resident 21, who required oxygen therapy, did not have a care plan addressing his oxygen use, which could lead to inadequate care. The facility's failure to develop these care plans was contrary to their policy, which mandates comprehensive, person-centered care plans for all residents.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that licensed nurses attempted nonpharmacological interventions before administering PRN morphine sulfate to a resident with severe pain. The resident, who had moderately impaired cognition and was dependent on staff for most activities of daily living, was admitted with diagnoses including polyneuropathy and spinal enthesopathy in the lumbar region. Despite having an order for nonpharmacological interventions, the facility's Medication Administration Record showed multiple instances where morphine was administered without documentation of attempted nonpharmacological interventions. During interviews, the Registered Nurse and the Director of Nursing acknowledged the lack of documentation and the importance of attempting nonpharmacological interventions before administering opioid medications. The facility's policy on pain assessment and management, last reviewed in February 2025, indicated that nonpharmacological interventions might be appropriate alone or in conjunction with medications. This oversight had the potential to increase the resident's risk of experiencing adverse side effects from the medication.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that licensed nurses attempted nonpharmacological interventions before administering PRN lorazepam to a resident with anxiety disorder. The resident, who had intact cognition and required supervision for most activities of daily living, received lorazepam on multiple occasions without documentation of nonpharmacological interventions being attempted first. This was confirmed during an interview with a registered nurse and a review of the resident's medication administration record. The facility's policy indicated that nonpharmacological approaches should be used to minimize medication use, but this was not followed. Additionally, the facility did not ensure that a physician's order for another resident's PRN lorazepam included a stop date. The resident, who had moderately impaired cognition and was dependent on staff for most activities of daily living, had an order for lorazepam without a stop date, contrary to the facility's policy that PRN orders for psychotropic medications should be limited to 14 days. The Director of Nursing confirmed that PRN lorazepam should have a stop date after 14 days, and the physician should reevaluate the need for continued medication use.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to develop a complete and accurate baseline care plan for a resident within 48 hours of admission, as required. The baseline care plan for the resident, who was admitted with acute respiratory failure, hypoxia, difficulty in walking, dementia, and a history of falling, was missing critical information. Specifically, the sections on oxygen use, pain, safety risks, and skin risk were incomplete. This oversight was identified during a review of the resident's records and an interview with the Assistant Director of Nursing (ADON), who acknowledged the omission and stated it was a mistake on her part. The resident's Minimum Data Set (MDS) indicated moderate cognitive impairment and a need for partial assistance with daily activities, as well as the use of oxygen therapy. Despite these needs, the baseline care plan did not reflect the necessary care instructions. The Director of Nursing (DON) confirmed that the baseline care plan was not completed thoroughly, which could lead to an inability to meet the resident's immediate care needs. The facility's policy requires a comprehensive baseline care plan to be developed within 48 hours of admission to ensure effective and person-centered care, but this was not adhered to in this case.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to update and revise a resident's care plan following a change in the resident's condition. The resident, who was admitted with diagnoses including type 2 diabetes mellitus, paranoid schizophrenia, and encephalopathy, experienced a change in behavior on February 17, 2025, as documented in the SBAR communication form. The resident exhibited behavioral symptoms such as throwing things and banging doors, which was a significant deviation from their baseline condition. Despite this change, the care plans for mood problems and behavioral symptoms related to schizophrenia, both initiated on February 12, 2025, were not updated to reflect the resident's new condition. The care plans initially included interventions such as administering medications, providing meaningful activities, and monitoring for signs of depression and anxiety. However, these plans were not revised to address the resident's new behavioral symptoms, as confirmed by Licensed Vocational Nurse 3 and the Director of Nursing during interviews. The facility's policy and procedure require that care plans be reviewed and revised following a resident's change of condition. However, this was not done for the resident in question, potentially leading to inadequate care and supervision. The Director of Nursing acknowledged that the care plans were not updated, which is contrary to the facility's policy that mandates prompt notification and revision of care plans in response to significant changes in a resident's condition.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure the low air loss mattress (LALM) was set correctly for a resident, which had the potential to place the resident at risk for discomfort and development of pressure ulcers. The resident was admitted with diagnoses including metabolic encephalopathy, acute respiratory failure, and chronic kidney disease. The resident's Minimum Data Set indicated severely impaired cognition and dependence on assistance for various activities. The resident's care plan noted potential impairment to skin integrity due to fragile skin and incontinence, with an intervention to follow facility protocol for treatment of injury. During an observation, it was noted that the LALM setting was at seven for 300 lbs, while the resident's current weight was 236 lbs. The physician's order indicated the LALM should be set based on comfort and/or resident weight for skin management. The Treatment Nurse confirmed the correct setting for the resident's weight was five. The facility's policy on support surface guidelines emphasized the importance of appropriate pressure reducing and relieving devices for residents at risk of skin breakdown. The LALM user manual also indicated that the comfort setting controls the air pressure output based on the resident's weight.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that a resident received the necessary treatment and services to prevent a decline in range of motion (ROM). The resident, who was admitted with conditions including metabolic encephalopathy, type 2 diabetes mellitus, and difficulty in walking, had a physician's order for a Restorative Nursing Assistant (RNA) program. This program was intended to assist the resident with ambulation using a front wheel walker five times a week with two-person assistance. However, the Treatment Administration Record for the specified period showed no entries for the RNA treatment, indicating that the program was not implemented. Interviews and record reviews revealed that the RNA was unaware of the order due to a failure in transferring the physician's order to the RNA task flowsheet in the Electronic Health Record (EHR). Consequently, the RNA program was not initiated, and a care plan was not created. The Director of Rehabilitation confirmed that the resident had been discharged to the RNA program after reaching maximal potential with skilled services, but the licensed staff did not follow through with the physician's order. The Director of Nursing acknowledged the oversight and emphasized the importance of creating a person-centered care plan to monitor the resident's progress and prevent functional decline.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide trauma-informed care to a resident diagnosed with post-traumatic stress disorder (PTSD). The resident was admitted on January 31, 2025, with a diagnosis of PTSD, and the Minimum Data Set (MDS) dated February 4, 2025, indicated moderately impaired cognition and a need for moderate assistance with activities of daily living. Despite these indicators, the facility did not complete a timely trauma-informed care assessment or conduct an interdisciplinary team (IDT) meeting to address the resident's specific needs related to PTSD. Interviews with facility staff revealed gaps in the process. A Licensed Vocational Nurse from the regional office completed the trauma-informed care assessment only after a medical records audit prompted it, indicating it should have been done upon admission. The Director of Nursing acknowledged that social services should have completed the assessment and facilitated an IDT meeting to discuss the resident's specific triggers. The Social Services Designee admitted to lacking experience in conducting these assessments, as her predecessor was responsible for them. The facility's policy on trauma-informed care emphasized the importance of minimizing triggers and re-traumatization, which was not adhered to in this case.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to conduct a social service assessment for Resident 18 within 14 days of admission, as required by their policy and procedure titled 'Social Assessment.' Resident 18 was admitted with diagnoses including type 2 diabetes mellitus, paranoid schizophrenia, and encephalopathy. Despite the resident's cognitive skills being moderately impaired, as indicated in the Minimum Data Set, no social service assessment was conducted from the time of admission on February 12, 2025, to March 12, 2025. The Social Services Designee (SSD) acknowledged the oversight, stating that although another social worker was initially responsible, she should have followed up to ensure the assessment was completed. The Director of Nursing confirmed that the social worker should have conducted the assessment within the specified timeframe to address psychosocial concerns and assist with the resident's adjustment to the facility. The facility's policy, last reviewed on February 26, 2025, mandates that a social assessment be completed within 14 days of admission to identify the resident's personal and social situation, needs, and problems. This deficiency had the potential to delay the delivery of care and services necessary for the resident's well-being.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that licensed nurses documented the administration of PRN medications on the Medication Administration Record (MAR) for two residents. For Resident 29, who was admitted with conditions including polyneuropathy and bilateral osteoarthritis, there was a failure to document the administration of tramadol on the MAR, despite it being recorded on the Record of Controlled Substances. This discrepancy was identified during a review of the resident's records, where it was noted that the tramadol was taken from the bubble pack but not documented as administered on the MAR. Similarly, for Resident 8, who had diagnoses including idiopathic peripheral autonomic neuropathy and chronic ulcer, the administration of oxycodone was not documented on the MAR, although it was recorded on the Record of Controlled Substances. This occurred on two separate occasions. The lack of documentation on the MAR for both residents posed a risk of double dosing, as subsequent nurses would not have a complete record of medication administration. The facility's policy requires that the individual administering the medication initials the MAR after each administration, which was not adhered to in these cases.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that a resident was free from significant medication errors by not administering clozapine as ordered. The resident, who was admitted with diagnoses including encephalopathy, paranoid schizophrenia, and major depression, was prescribed clozapine orally disintegrating tablets (ODT) 200 mg to be taken once daily. During a medication administration observation, a Licensed Vocational Nurse (LVN) administered two 100 mg tablets of clozapine to the resident without explaining the proper method of administration, which involves allowing the tablets to disintegrate in the mouth before swallowing. The LVN admitted to not knowing the meaning of the abbreviation ODT or the correct administration method for ODT medication. The Assistant Director of Nursing confirmed that the medication should dissolve in the mouth before swallowing, and emphasized that licensed staff should be knowledgeable about the correct route of medication administration. The facility's policy on medication administration, last reviewed in February 2025, also indicated that medications should be administered safely and as prescribed, including the correct method of administration.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to properly store unopened insulin pens for two residents, Resident 80 and Resident 391, which could potentially lead to the insulin losing its efficacy. Resident 80, who was originally admitted on January 21, 2024, and readmitted on December 16, 2024, had a diagnosis of type 2 diabetes mellitus with ketoacidosis and required insulin glargine injections. During an observation on March 12, 2025, it was noted that Resident 80's unopened insulin pen was stored in Medication Cart A instead of the refrigerator, contrary to the manufacturer's guidelines. Licensed Vocational Nurse 1 confirmed that the insulin should be refrigerated and acknowledged the potential need to discard the medication if not stored properly. Similarly, Resident 391, who was originally admitted on January 30, 2020, and readmitted on January 26, 2025, also had a diagnosis of type 2 diabetes mellitus and required insulin glargine injections. On March 11, 2025, an observation revealed that Resident 391's unopened insulin pen was stored in Medication Cart B instead of being refrigerated. The Director of Nursing confirmed that unopened insulin should be stored in the refrigerator to maintain its efficacy, as per the manufacturer's guidelines. The facility's policy on medication storage also indicated that medications requiring refrigeration should be stored in a secured refrigerator, which was not adhered to in these cases.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to adhere to safe food handling practices when a dietary aide was observed wearing an uncovered, dangling bracelet in the kitchen. This observation was made during a concurrent interview and record review with the Dietary Supervisor. The dietary aide was seen taking plates from the steam table and placing them into a delivery cart while wearing the bracelet, which was not covered by the gloves. The facility's policy, titled 'Dress Code for Women and Men' and dated 2018, specifies that no excessive jewelry should be worn in the kitchen, allowing only wedding rings, non-dangling earrings, and wristwatches, which must be covered with gloves when handling food. The Dietary Supervisor acknowledged that the dress code should be followed to maintain cleanliness in the kitchen. This deficiency had the potential to place 89 out of 90 residents at risk for foodborne illnesses.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to implement its Enhanced Barrier Precautions (EBP) policy for a resident with a colostomy bag, which is a medical device that collects stool from a surgical opening in the abdomen. The resident, who was admitted and readmitted with diagnoses including metabolic encephalopathy and urinary tract infections, was not placed on EBP despite the facility's policy indicating that residents with indwelling medical devices require such precautions. Observations revealed no EBP signs or personal protective equipment (PPE) outside the resident's room, and the Infection Preventionist (IP) was unaware of the need for EBP in this case. Additionally, the facility did not ensure that a resident's urinal was labeled with a resident identifier, which is crucial for infection control. The unlabeled urinal was observed at the resident's bedside, and the Certified Nursing Assistant confirmed the lack of labeling. The Director of Nursing (DON) acknowledged the absence of a specific policy for labeling urinals, while the IP emphasized the importance of labeling to prevent cross-contamination among residents. The facility's policies on Enhanced Barrier Precautions and Standard Precautions were reviewed, indicating the necessity of using standard precautions in all situations to prevent the transmission of infectious diseases. However, the failure to adhere to these policies in the cases of the resident with a colostomy bag and the unlabeled urinal highlights lapses in infection control practices within the facility.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to protect a resident's right to be free from verbal abuse when one resident verbally abused another. Resident 50, who had intact cognition and was dependent on staff for most activities of daily living, was subjected to verbal abuse by Resident 15. The incident occurred when Resident 50 attempted to stop Resident 15 from moving a personal protective equipment bin outside his room, leading to Resident 15 responding with derogatory language. This incident was witnessed by several staff members, including a Registered Nurse and the Director of Staff Development, who confirmed the verbal exchange. In another incident, the facility failed to protect a resident from physical abuse when Resident 18 pushed Resident 61, causing her to fall. Resident 61, who had moderately impaired cognitive skills and required assistance for daily activities, was pushed by Resident 18 in the hallway. This incident was witnessed by another resident, Resident 53, who reported the altercation to the nursing staff. The facility's records indicated that Resident 18 had a history of behavioral symptoms and was known to exhibit aggressive behavior. The facility's policies on abuse prevention and resident-to-resident altercations were not effectively implemented, as evidenced by these incidents. The Administrator and Director of Nursing acknowledged the incidents as abuse, with the verbal abuse being confirmed by the facility's policy definition. The physical altercation was substantiated by witness accounts and the facility's own investigation, highlighting a failure to maintain a safe environment for residents.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that Fall Risk Evaluations were completed accurately for a resident, which placed the resident at risk of not receiving appropriate care and services after a fall incident. The resident, who was originally admitted on 9/3/2021 and readmitted on 2/1/2025, had diagnoses including metabolic encephalopathy, Alzheimer's disease, and generalized muscle weakness. The Minimum Data Set (MDS) indicated that the resident was dependent on staff for most activities of daily living. On 3/11/2025, the resident was found on the floor next to her bed, and she stated she did not know what happened and was just trying to get comfortable. During a review of the resident's Fall Risk Evaluations, it was found that the evaluation dated 2/1/2025 had incomplete sections, specifically the Gait/Balance and Medications sections. Treatment Nurse 1 acknowledged that these sections should have been completed. Additionally, the Fall Risk Evaluation dated 3/11/2025 incorrectly indicated that the resident had no falls within the past three months, despite the fall occurring on the morning of 3/11/2025. The Director of Nursing emphasized the importance of accurately completing Fall Risk Evaluations to assess the resident's risk of falling and to provide effective care. The facility's policy on managing falls and fall risk, last revised on 2/26/2025, requires staff to identify interventions based on evaluations and current data to prevent falls.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure a resident was free of unnecessary psychotropic drugs by not summarizing the resident's monthly behavior and side effects. This deficiency was identified for a resident who had been admitted with diagnoses including a left hip fracture, schizoaffective disorder, and major depressive disorder. The resident's Minimum Data Set indicated severely impaired cognitive skills and a need for total assistance with daily activities. Physician orders included Trazodone for depression and Risperdal for schizoaffective disorder. However, the Behavior Summary Side Effects forms for these medications were blank for two months, lacking documentation of episodes of sadness or adverse reactions. Interviews with facility staff, including an LVN and the DON, confirmed that the monthly behavior summaries for the resident's psychotropic medications were not completed. The staff acknowledged that without this data, it would be challenging to assess the effectiveness of the medications or proceed with a gradual dose reduction. The facility's policy on psychotropic medication use emphasized the need for comprehensive review and documentation to ensure medications are clinically indicated and to monitor for adverse consequences. The lack of documentation hindered the facility's ability to evaluate the necessity and impact of the psychotropic drugs administered to the resident.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain complete and accurate medical records for a resident, identified as Resident 1, by not documenting on the resident's Activities of Daily Living (ADL) Flow Sheet. This deficiency was identified during a review of Resident 1's records, which showed multiple instances in December 2022 where essential care activities such as bowel function, personal hygiene, bathing, transfer, and locomotion were left undocumented. Additionally, there were no initials from Certified Nursing Assistants (CNAs) on several dates, indicating a lack of accountability for the care provided. Resident 1, who was readmitted to the facility with a history of a left hip fracture, osteoporosis, and diabetes mellitus, was assessed to have severely impaired cognitive skills and required total assistance with daily activities. The absence of documentation on the ADL Flow Sheet meant that there was incomplete information regarding the care provided to the resident, which could lead to confusion about the resident's care needs. Interviews with CNA 3 and the Director of Nursing confirmed the importance of proper documentation and acknowledged the gaps in the records, emphasizing that without documentation, it is unclear what services were provided to the resident.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to notify the physician and the resident's family about a skin discoloration on a resident's coccyx, which was reported by a CNA on 9/9/2022. The resident, who had a history of a left hip fracture, osteoporosis, and diabetes mellitus, was severely cognitively impaired and required total assistance with daily activities. Despite the CNA's report, the facility did not inform the physician or the family until 9/16/2022, when a physician order was received to treat the skin condition. This delay in communication was confirmed during interviews with the Treatment Nurse and the Director of Nursing, who were unable to find documentation of timely notification. The facility's policy requires prompt notification of changes in a resident's condition to the physician and family, ideally within 24 hours. However, in this case, the notification was delayed by several days, which could have impacted the resident's care. The Director of Nursing acknowledged the lack of documentation and stated that the physician and family should have been notified on the same day the skin discoloration was observed. The facility's failure to adhere to its policy on notifying changes in a resident's condition led to this deficiency.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to complete a neurological assessment for a resident after an unwitnessed fall, which is a requirement according to the facility's policy. The resident, who had a history of encephalopathy, lack of coordination, and schizophrenia, was found on the floor near the dietary department. The resident's Minimum Data Set indicated moderately impaired cognitive skills for daily decision-making, and the care plan included interventions for falls, such as frequent neurological and bleeding evaluations. However, the Neurological Assessment Flow Sheet for the resident was incomplete, with no documented evidence of an assessment being done at the specified time. Licensed Vocational Nurse 1 confirmed during an interview and record review that the neurological assessment was not completed as required. The facility's policy, reviewed in July 2024, mandates neurological assessments following an unwitnessed fall, but this was not adhered to in this instance. The lack of documentation and completion of the neurological assessment could lead to confusion in care and services, potentially placing the resident at risk of not receiving appropriate care due to incomplete medical information.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure proper use of low air loss mattresses (LALM) for two residents, leading to potential risks of skin breakdown. Resident 2, admitted with diagnoses including gangrene and dementia, was observed on a LALM set to static mode instead of the ordered alternating mode. The resident was also lying on multiple layers of linen, contrary to the facility's policy of using no more than two layers. Certified Nursing Assistant 1 (CNA 1) admitted to forgetting to remove the extra cloth incontinence pad, which contributed to the improper setup. Similarly, Resident 3, who was readmitted with chronic obstructive pulmonary disease and dementia, was found on a LALM set to static mode with multiple layers of linen. CNA 2 acknowledged the oversight of not removing the extra cloth incontinence pad, resulting in four layers of linen. Both CNAs stated that they were instructed not to adjust the LALM settings, which were supposed to be checked every shift according to the physician's orders. The facility's policies and procedures emphasized the importance of using the LALM correctly to prevent pressure ulcers, including maintaining the alternating mode and limiting linen layers. The failure to adhere to these guidelines for both residents increased the risk of skin breakdown, as the LALM's effectiveness was compromised by the static setting and excessive linen layers.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that the actual hours worked by licensed and unlicensed nursing staff responsible for resident care were posted daily, as required. On two consecutive days, the facility displayed projected nursing hours instead of actual hours worked. Observations and interviews revealed that the posted nursing hours in the facility's lobby were based on expected staffing rather than the actual hours worked by the staff. The Director of Nursing (DON) and Payroll personnel confirmed that the actual nursing hours were calculated the day after the shifts occurred, which led to the posting of projected hours instead of actual hours. Interviews with the DON and Payroll staff indicated a lack of adherence to the facility's policy, which mandates the posting of actual nursing hours within two hours of the beginning of each shift. The DON acknowledged that the posted hours were projections and not actual hours, and Payroll staff confirmed that the actual hours for the days in question had not been calculated at the time of the survey. This practice potentially kept residents and visitors unaware of the actual staffing levels in the facility.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to obtain a physician's order before applying zinc oxide cream to a resident's skin, which is a requirement for medication administration. The resident, who was admitted with conditions including a left hip fracture, osteoporosis, and diabetes mellitus, had severely impaired cognitive skills and required total assistance for daily activities. On 9/9/2022, a CNA reported skin discoloration on the resident's coccyx, and zinc oxide cream was applied without a physician's order. A physician's order for the cream was not obtained until 9/16/2022. During interviews and record reviews, it was confirmed that there was no documentation of notifying the resident's physician or family about the skin discoloration on 9/9/2022. The facility's policy requires that medications and treatments be administered only upon a written order from a licensed practitioner. The Director of Nursing acknowledged the lack of a physician's order and the absence of documentation regarding the notification of the physician or family, confirming the deficiency in following the facility's medication and treatment order policy.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to promptly notify the physician of the results of a STAT X-ray for a resident, leading to a delay in necessary care. The resident, who had a history of a left hip fracture, osteoporosis, and diabetes mellitus, was readmitted to the facility with severe cognitive impairment and required total assistance for daily activities. On 9/29/2022, after the resident slid from a chair, a STAT X-ray was ordered to rule out a fracture in the left hip and femur. The X-ray was performed on the same day at 11:22 p.m., and the results were emailed to the facility at 12:50 a.m. on 9/30/2022. However, the facility staff did not promptly relay the results to the physician. The mobile diagnostic company attempted to call the facility multiple times during the early hours of 9/30/2022, but there was no answer. It was not until 7:35 a.m. that the results were communicated to the physician, who then ordered the resident to be transferred to the hospital for further evaluation. Interviews with the facility staff revealed that there was a lack of proper communication and follow-up between the nursing staff during shift changes. The Licensed Vocational Nurse acknowledged that the 11 p.m.-7 a.m. shift should have followed up on the STAT X-ray results and documented their attempts. The Director of Nursing, who was not present at the time of the incident, stated that the staff should have contacted the diagnostic company sooner to prevent the delay in care. The facility's policy required prompt communication of test results to the attending physician, especially for STAT orders, but this procedure was not adequately followed.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to report an allegation of sexual abuse involving two residents within the required two-hour timeframe, as mandated by Section 1150B of the Act. The incident involved Resident 1, who was found half-naked in their room with Resident 2, also half-naked, by a Certified Nursing Assistant (CNA 1) on 11/11/2024. Despite witnessing the situation, CNA 1 did not report the incident to any facility staff until 11/22/2024, leading to a significant delay in reporting the alleged abuse to the State Survey Agency (SSA). Resident 1, who has a history of epilepsy and schizoaffective disorder, was assessed to have moderately impaired cognitive skills and required assistance with daily activities. Resident 2, diagnosed with psychosis and mood disorder, was also cognitively impaired and needed maximum assistance with certain tasks. The failure to report the incident promptly resulted in a delay of an onsite inspection by the SSA, which was necessary to ensure the safety of other residents and to investigate the potential abuse. Interviews with facility staff revealed that CNA 1 and CNA 2, who also witnessed the incident, did not fulfill their responsibility to report the situation immediately. CNA 1 assumed nothing inappropriate had occurred and did not inform anyone until questioned by the Director of Nursing (DON) on 11/22/2024. CNA 2, believing CNA 1 had already reported the incident, also failed to notify any licensed nurse. The facility's policy requires all allegations of abuse to be reported within two hours, but this protocol was not followed, leading to the deficiency.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to implement proper infection control practices in two significant instances. Firstly, a resident with chronic obstructive pulmonary disease and Alzheimer's disease was found to have their nebulizer mouthpiece and tubing improperly stored in a nightstand without a protective bag or date label. This was against the facility's policy, which requires such equipment to be stored in a plastic bag with the resident's name and date to prevent the spread of germs. The Licensed Vocational Nurse acknowledged the oversight and confirmed that the equipment should have been stored correctly. In another instance, the facility did not report suspected cases of scabies for two residents. One resident, who was dependent on staff for personal care, exhibited dry, flaky skin and crusted palms, which were itchy. The Treatment Nurse confirmed there were no treatment orders in place and subsequently notified the physician. Another resident, also dependent on staff for personal care, had dry, flaky skin on the right palm and reported itching. The Certified Nursing Assistant had reported this condition to the Treatment Nurse two weeks prior, but no action was taken until the survey. The facility's failure to report these suspected scabies cases and to store medical equipment properly posed a risk of cross-contamination and infection spread among residents and staff. The facility's policies on infection control and outbreak management were not adhered to, as evidenced by the lack of timely reporting and appropriate storage practices.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to notify the physicians of two residents when there were changes in their skin conditions. Resident 2, who has chronic obstructive pulmonary disease and pruritis, was observed with dry, flaky skin and crusted palms, which he reported as itchy. Despite being dependent on staff for personal hygiene, there were no treatment orders in place for his condition, and the physician was not notified until the surveyor's visit. Similarly, Resident 3, diagnosed with Alzheimer's disease and type two diabetes mellitus, had dry, flaky skin on the right palm and reported itchiness. Although a CNA reported this change to a treatment nurse about two weeks prior, the nurse did not receive the report until the day before the surveyor's visit, delaying notification to the physician and treatment initiation. The Director of Nursing acknowledged that the facility's staff failed to complete the Stop and Watch form, an early warning tool for communicating changes in a resident's condition, which led to the omission of necessary follow-up actions. The facility's policy requires prompt notification of changes in a resident's condition to the resident, their physician, and their representative, but this was not adhered to in these cases. The lack of documentation and communication resulted in a delay in medical care and treatment for both residents, potentially impacting their well-being.

Penalty

Fine: $18,057

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to protect a resident from neglect during a discharge process. The resident, who had a history of chronic obstructive pulmonary disease, type 2 diabetes mellitus, schizoaffective disorder, and psychosis, was discharged from a locked skilled nursing facility (SNF 1) to an unlocked facility (SNF 2) without proper procedures. The resident exhibited behaviors that made him a danger to himself and others, requiring one-to-one supervision. Despite this, the discharge was conducted without a physician's order, and the necessary discharge summary and recapitulation of stay were not provided to the receiving facility. The facility staff did not conduct a hand-off communication to ensure continuity of care for the resident. The receiving facility, SNF 2, was not informed of the resident's arrival and did not receive the necessary medical information to provide appropriate care. The resident was transported using a non-medical transport service, despite being identified as a danger to himself and others, which was against the facility's policy for safe and orderly discharge services. The facility's actions were deemed neglectful as they failed to provide the necessary care and services to ensure the resident's safety during the discharge process. The lack of communication, documentation, and appropriate transportation contributed to the resident's increased risk of harm, ultimately leading to the resident's death shortly after arriving at SNF 2.

Removal Plan

• Resident 1 was discharged to SNF 2 and is no longer a resident of the facility (SNF 1).
• The DON in-serviced RN 2 to enter physician orders for discharge only after speaking to the physician.
• The DON in-serviced the facility Marketer 1 (MTR 1) to no longer arrange resident transportation.
• The DON in-serviced RN 2 regarding giving report to the nurse at the receiving facility of SNF 2.
• Medical Director Medical Doctor 1 (MDMD 1) in-serviced the ADM, DON, Assistant Director of Nursing (ADON), SSD, and all other Department Heads regarding ensuring all residents are free of neglect related to discharge services to ensure resident's safety and promote their (resident) highest well-being from the time residents enter the facility to the time residents leave the facility.
• The DON continued providing in-services to admissions office staff, nursing staff, and social services staff regarding the facility's current policies and procedures for the prevention of Neglect related to Discharge/Transfer services.

Penalty

Fine: $18,057

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure a safe and orderly discharge for a resident who was a danger to himself and others. The resident was transferred from a locked facility to a non-locked facility without obtaining a proper physician order for discharge. The registered nurse entered a verbal order for discharge without actually speaking to the attending physician, which was a deviation from the standard procedure. This lack of communication and proper authorization contributed to the unsafe discharge process. Additionally, the facility did not provide the receiving facility with the necessary discharge summary and recapitulation of stay, only sending a summary of physician orders. The receiving facility was not informed in advance about the resident's arrival, and attempts to contact the discharging facility for more information were unsuccessful. This lack of communication and documentation transfer hindered the continuity of care and left the receiving facility unprepared to meet the resident's needs. Furthermore, the facility did not conduct a proper hand-off communication to ensure the receiving facility was aware of the resident's medical and behavioral needs. The resident, who required one-to-one supervision and was at risk for wandering and falls, was transported using a non-medical transport service, despite being identified as a danger to himself and others. This inappropriate mode of transportation further compromised the resident's safety during the discharge process.

Removal Plan

• Resident 1 was discharged to SNF 2 and is no longer a resident of the facility (SNF 1).
• The DON in-serviced RN 2 to enter physician orders for discharge only after speaking to the physician.
• The DON in-serviced the facility Marketer 1 (MTR 1) to no longer arrange resident transportation.
• The DON in-serviced RN 2 regarding giving report to the nurse at the receiving facility of SNF 2.
• Medical Director Medical Doctor 1 (MDMD 1) in-serviced the ADM, DON, Assistant Director of Nursing (ADON), SSD, regarding ensuring all residents receive all discharge services (providing and completed needed discharge documentations and conducting hand off report to receiving facility) needed to ensure the resident's safety and promote the resident's highest well being from the time of discharge.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide resident-centered care for a resident who sustained a fall. On the morning of 6/15/2024, a Licensed Vocational Nurse (LVN 2) did not inform another nurse (LVN 1) or the Registered Nurse Supervisor (RNS 1) that the resident had fallen. This oversight led to a delay in the resident receiving necessary care and services. The resident, who had been admitted with multiple diagnoses including chronic obstructive pulmonary disease, chronic kidney disease, anxiety disorder, lack of coordination, and major depressive disorder, was found on the floor by a Certified Nursing Assistant (CNA 2) and was assisted back to bed by LVN 2 and CNA 2. Despite the resident's moderate cognitive impairment and requirement for supervision with activities of daily living, the fall was not immediately reported or documented by LVN 2. The resident later complained of leg pain, which led to an x-ray revealing an acute minimally displaced intertrochanteric fracture of the left femur. The resident's physician was eventually notified, and the resident was transferred to a General Acute Care Hospital. Interviews with the staff revealed that LVN 2 acknowledged the failure to report the fall due to being busy, and the facility lacked a specific policy related to quality of care.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that a resident was provided with activities of daily living (ADL) assistance, resulting in a delay in delivering necessary care and services. The resident, admitted with diagnoses including atrial fibrillation and heart failure, had the capacity to understand and make decisions. The resident's Minimum Data Set (MDS) indicated the need for setup or clean-up assistance for various ADLs, and the care plan specified that the resident's ADL needs should be met daily. However, the Certified Nurse Assistant (CNA) Functional Abilities Flowsheet for a specific day in April 2024 was found to be blank, indicating that no ADL assistance was documented as provided during the day shift. During an interview and record review, the Director of Staff Development (DSD) confirmed that CNAs are required to document on the CNA Functional Abilities Flowsheet after providing ADL assistance. The DSD emphasized the importance of documentation to ensure care is provided and to notify licensed nurses of any changes in the resident's needs. The facility's policy on ADLs, last revised in March 2018, stated that residents should be provided with care, treatment, and services to maintain or improve their ability to carry out ADLs. The lack of documentation suggested that the necessary care was not provided to the resident on the specified day.