Pacific Care Nursing Center

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to implement infection control measures for one of two sampled residents (Resident 2) by failing to:1. Ensure Certified Nursing Assistant (CNA)1 and Registered Nurse (RN)1 wore required personal protective equipment (PPE- clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) before entering Resident 2's room who was on contact isolation ( a set of safety steps used in the facility to stop the spread of germs that are passed by touching a patient or contaminated items in the resident's room).This failure had the potential to spread and transmit infections to all residents, staff and visitors.Findings:During an observation and interview on 2/4/2026 in Resident 2's room with CNA1, CNA 1 and RN 1 were inside the room without wearing an isolation gown, and gloves. Resident 2 was observed sitting on his wheelchair while CNA1 and RN 1 held the wheelchair with their bare hands. A sign for Contact Isolation was observed posted on the wall before entering Resident 2's room. CNA 1 stated they were about to put Resident 2 back to bed. CNA 1 stated Resident 2 was on contact precautions because of an urinary tract infection (UTI- an infection in the bladder/ urinary tract).During a review of Resident 2's admission Record, the admission Record indicated the Resident 2 was initially admitted on [DATE] and was readmitted on [DATE] to the facility. Resident 2 had diagnoses including UTI, extended spectrum beta lactamase (ESBL-group of bacteria that are resistant to common antibiotic and difficult to treat), depression (common, serious medical illness characterized by a persistent low mood, sadness, and loss of interest in daily activities) and chronic obstructive pulmonary disease(COPD-progressive lung disease that causes inflammation, damaging the airway and make it difficult to breathe).During a review of Resident 2's Minimum Data Set (MDS- resident assessment tool) dated 12/30/2025, the MDS indicated Resident 2 had moderately impaired cognitive skills ( a person had trouble remembering, learning, making decisions which make daily life challenging) and required substantial/ maximal assistance ( helper does more than half the effort) with transferring to and from a bed to a chair, bathing and toileting hygiene. The MDS indicated Resident was incontinent (unable to control bladder or bowels resulting in leaking urine accidentally) of urine.During a review of Resident 2's Care Plan titled, Resident on Isolation Precautions related to ESBL, dated 2/2/2026, the Care Plan interventions included maintaining contact isolation precautions as indicated and monitoring for signs and symptoms of infection.During a review of Resident 2 SBAR (Situation, Background, Assessment, Recommendation- provides a framework for communication between members of the healthcare team about a resident's condition) Communication Form dated 2/2/2026, the SBAR Communication Form indicated Resident 2 urine culture (a laboratory test that detects and identifies bacteria or yeast in a urine sample to diagnose UTI) was positive for ESBL and the physician was notified.During an interview on 2/4/2026 at 2:42 p.m. with CNA 1, CNA 1 stated he forgot Resident 2 was on contact isolation that's why he did not wear the isolation gown and gloves in the room. CNA1 stated the staff should wear an isolation gown, gloves and mask before entering Resident 2's room because he was on contact isolation.During an interview on 2/4/2026 at 2:59 p.m. with RN 1, RN 1 stated she forgot Resident 2 was on contact isolation and it was a mistake not wearing the proper PPE. RN 1 stated Resident 2 was on contact isolation because of the presence of ESBL in the urine.During a concurrent interview and record review on 2/4/2026 at 3:10 p.m. with the Infection Preventionist Nurse (IPN), Resident 2's urine culture and SBAR dated 2/2/2026 were reviewed. The IPN stated Resident 2's urine culture had ESBL in the urine and required contact isolation. The IPN stated CNA 1 and RN 1 should have worn PPE like gloves and isolation gown before entering the room. The IPN stated every time a staff member enters Resident 2's room, the staff should practice hand hygiene, wear isolation gown and gloves to prevent cross contamination (the transfer of bacteria, viruses, microorganisms, or other harmful substances from one surface to another through improper or unsanitary equipment, procedures, or products) and spread of infection among residents and staff. During an interview on 2/4/2026 at 5:00 p.m. with the Director of Nursing (DON), the DON stated not practicing contact precautions on Resident 2 could cause spread of infection to other residents and can result in an outbreak (sudden, unexpected increase in the number of disease cases in a specific localized area or group).During a review of facility's policy and procedure (P&P) titled, Infection Control- Transmission Based Precautions, revised 2/2018,the P&P indicated Contact Precautions are intended to prevent transmission of infections that are spread by direct ( person-to-person) or indirect contact with the resident or environment and require the use of gown and gloves upon entering the resident's room.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1), who had an existing pressure ulcer ([PU] localized damage to the skin and/or underlying tissue usually over a bony prominence) was turned and repositioned at least every two hours. This deficient practice resulted in Resident 2 being left in the same position on his left side for over four hours and had the potential for new PUs to develop and a delay in healing for Resident 1's existing PU.Findings: During a review of Resident 2's admission Record (Face Sheet) the Face Sheet indicated Resident 2 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including type 2 diabetes mellitus ([DM] a disorder characterized by difficulty in blood sugar control and poor wound healing) without complications, unspecified (a condition where symptoms match a general category, but there is insufficient information or documentation to classify it more specifically) severe protein-calorie malnutrition (inadequate intake of protein and calories causing muscle weakness), and a stage 4 PU (a full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone) in the sacral region (area above the buttocks). During a review of Resident 2's Minimum Data Set ([MDS] a resident assessment tool) dated 6/27/2025, the MDS indicated Resident 2 was dependent (resident does none of the effort to complete the activity) on staff to roll from left to right. During a review of Resident 2's Braden Scale for Predicting Pressure Sore Risk assessment dated [DATE] and 12/25/2026, the Braden Scale for Predicting Pressure Sore Risk assessment indicated Resident 2 scored nine (a score of 12 or below represent a high risk of developing PUs, placing Resident 2 at high risk for PUs. During a review of Resident 2's Weekly Pressure Injury Record dated 1/27/2026, the Weekly Pressure Injury Record indicated Resident 2 had a PU to the sacrococcyx measuring 5.7 centimeters ([cm] a unit of measurement) x 3.6 cm x 2.5 cm. During a review of Resident 2's Care Plan dated 2/4/2026, the Care Plan indicated Resident 1 had an alteration in skin integrity with an actual stage 4 pressure injury to the sacrococcyx (area above the buttock) related to immobility. The Care Plan's interventions indicated to turn and reposition Resident 2 at least every two hours and to utilize pillows as repositioning devices. During an observation of Resident 2 on 2/3/2026 at 10:25 a.m., 12:30 p.m., 1:30 p.m., 2:30 p.m., and 2:45 p.m., Resident 2 was observed lying on a low air loss mattress (a specialized therapeutic support surface often featuring alternating, inflating, and deflating air cells, designed to prevent and treat pressure ulcers) positioned on his left side and a wedge under his right buttock. During an interview on 2/3/2026 at 2:45 p.m., Certified Nursing Assistant (CNA) 1 stated Resident 1 could not turn himself and relied on him (CNA 1) to assist him to turn and reposition at least every two hours to prevent skin breakdown. During an interview on 2/3/2026 at 3:30 p.m., Licensed Vocational Nurse (LVN) 1 stated the Treatment Nurse (TN) and the Charge Nurses (CN) were responsible to make sure the residents were turned and repositioned every two hours and as needed. During an interview on 2/4/2026 at 4:12 p.m., the Director of Nursing (DON) stated licensed nurses were responsible for making sure CNAs turn residents every two hours. The DON stated turning was important to prevent pressure ulcers from getting worse and preventing new ones from occurring. During a review of the facility's Policy and Procedure (P&P) dated 5/2019, titled Prevention of Pressures Ulcers the P&P indicated for a resident in bed: a. Change position at least every 2 hours or more frequently as needed:

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure grievances (a perceived wrong or other cause for complaint or protest, especially unfair treatment) made during resident Council (an independent organized group of residents of that facility who meet to discuss concerns, develop suggestions on improving services, and plan social activities) meetings regarding slow call-light response from the 11 p.m. to 7 a.m., shift was promptly addressed and did not negatively affect four of four sampled residents (Resident 1, Resident 2, Resident 3, and Resident 4).This deficient practice had the potential to cause delays in care and as a result of the deficient practice Resident 1, Resident 2, Resident 3, and Resident 4 continued to experience slow response times when pressing the call light during the 11 p.m. to 7 a.m. shift. Resident 1 felt pissed and Resident 2 felt scared due to the slow response times.Findings:1. During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including Hemiplegia (can't move one side of the body) affecting the left dominant side, contracture of muscle (the permanent shortening and stiffening of muscles, which limits the normal movement of a joint or body part), and osteoporosis (a condition in which there is a decrease in the amount and thickness of bone tissue).During a review of Resident 1's care plan dated 9/9/2024 titled Resident prefers the following, the care plan indicated a goal of Resident 1 adopting healthy coping practices and interventions that included ensuring Resident 1's call light was within reach and answered promptly.During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool) dated 6/2/2025, the MDS indicated Resident 1 was cognitively (relating to or involving the processes of thinking and reasoning) intact. The MDS indicated Resident 1 required a wheelchair and was dependent (helper does all the effort) for toileting hygiene.2. During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE] with diagnoses of history of falling and absence of right leg below the knee (right leg missing below the knee).During a review of Resident 2's MDS dated [DATE], the MDS indicated Resident 2 was cognitively intact. The MDS indicated Resident 2 required a wheelchair and needed supervision or touching assistance (resident requires verbal queues or touching/ steadying while the resident performs the task) for toileting and chair to bed transfers.3. During a review of Resident 3's admission Record, the admission Record indicated Resident 3 was admitted to the facility on [DATE] with diagnoses of injury in a motor-vehicle accident and depression (persistent feelings of sadness that can interfere with daily activities).During a review of Resident 3's care plan titled Activities of Daily Living (ADL, activities related to personal care) Function revised on 6/25/2025, the care plan indicated Resident 3 had general weakness and was dependent on staff for toilet use. The goals for Resident 3 included reducing the risk for fall and skin impairments. Interventions for Resident 3 included placing the call light within reach and answering the call light promptly.During a review of Resident 3's MDS dated [DATE], the MDS indicated Resident 3's cognition was mildly impaired. The MDS indicated Resident 3 required a wheelchair and required substantial/ maximal assistance (helper does more that half the effort) for toileting hygiene.4. During a review of Resident 4's admission Record, the admission Record indicated Resident 4 was admitted to the facility on [DATE] with diagnoses of multiple sclerosis (a disease in which the immune system eats away at the protective covering of nerves) and neuromuscular dysfunction of bladder (the nerves that carry messages back and forth between the bladder and the spinal cord and brain don't work the way they should, often leading to being unable to control urine).During a review of Resident 4's MDS dated [DATE], the MDS indicated Resident 4 had mild cognitive impairment. The MDS indicated Resident 4 required substantial/ maximal assistance for toileting.During a review of Resident 4's care plan titled ADL Functional dated 8/5/2025, the care plan goals were reducing the risk for fall and skin impairments, the interventions included ensuring the call light was within reach and answering the call light promptly.During a review of the facility's grievances, a grievance was filed on 6/30/2025 by Resident 2. The grievance indicated Resident 2 raised concerns regarding delayed answering of call lights especially right during the 11 p.m. to 7 a.m. shift.During a review of the facility's Resident Council minutes dated 7/24/2025, the Resident Council minutes indicated the month prior (June 2025) during the Resident Council meeting the resident's brought concerns regarding slow call light response especially during the 11 p.m. to 7 a.m. shift. During the July 2025 meeting the resident were asked are call lights being answered in a timely manner? and the residents responded call lights were slow to be answered during the 11 p.m. to 7 a.m. Shift. The Resident Council minutes indicated Resident 2 complained she was not getting help to go to the toilet.During an interview on 8/20/2025 at 12:04 p.m., Resident 3 stated there were always issues with the call light being answered during the 11 p.m. to 7 a.m. shift. Resident 3 stated she had waited up to two hours for someone to answer her call light (unknown date) and when the staff (unknown) finally came in, Resident 3 asked what were you doing, sleeping? Resident 3 stated the long call light wait times were frustrating because she can't get out of the bed by herself and she wouldn't be pressing the call light if she did not need something. Resident 3 stated the long call light wait times had been discussed during multiple Resident Council meetings and it was still an ongoing issue.During an interview on 8/20/2025 at 12:41 p.m., Resident 1 stated there is a long call light response time for the 11 p.m. to 7 a.m. shift and sometimes she waited an hour or more to get help when she pressed the call light. Resident 1 stated the medication she takes gives her diarrhea, so she gets pissed that no one answers the call light, and she has to sit and wait in her shit. Resident 1 stated she starts phone calling up to the front desk during the 11 p.m. to 7 a.m. shift when the staff are not answering call lights. Resident 1 stated she was not going to the Resident Council meetings anymore because residents always had the same complaints (about 11 p.m. to 7 a.m. shift) and nothing was changing.During an interview on 8/21/2025 at 12 p.m., Resident 2 stated she was a high fall risk because she only had one leg, and the staff were supposed to supervise her while she tried to get up to the toilet. Resident 2 stated she presses the call light, but the staff take too long to come during the 11 p.m. to 7 a.m. shift, so she gets up to use the restroom by herself. Resident 2 stated she felt scared she might fall because she is getting up alone due to staff taking a long time to answer the call light. Resident 2 stated she made a grievance as well as the residents had made complaints about the 11 p.m. to 7 a.m. shift call lights during Resident Council meeting but it was still happening as recently as last night. Resident 2 stated she waited 45 minutes last night during the 11 p.m. to 7 a.m. shift to get help when she pressed her call light.During an interview on 8/21/2025 at 12:45 p.m., Resident 4 stated the call light waiting times during the 11 p.m. to 7 a.m. shift was long, and she wore diapers, so she had to wait in her dirty diaper until someone finally came to change her. Resident 4 stated the facility was aware of the complaints against the 11 p.m. to 7 a.m. shift but it was still an ongoing issue.During an interview on 8/21/2025 at 3 p.m., the director of staff development (DSD) stated she attended the Resident Council meetings and was aware of the issue with delayed response time to call lights during the 11 p.m. to 7 a.m. shift. The DSD stated she had been working at the facility for four months and when she started the complaints about call light response times were really bad and now, they are just bad not really bad. The DSD stated the expectation for answering call lights when residents needed something was right away or at least within 10 minutes. The DSD stated the potential outcome of not answering a resident's call light right away was falls, the resident could be sitting in urine or poop for extended periods of time, and the residents may feel terrible.During an interview on 8/21/2025 at 4:10 p.m., the director of nursing (DON) stated she was aware of complaints regarding the 11 p.m. to 7 a.m. call light wait times. The DON stated the potential outcome of extended wait times for call lights was the resident's needs were not being met, patient satisfaction goes down, and increased risk for falls so it was very important to answer call lights right away. The DON stated her staff were in-serviced regarding the long wait times during the 11 p.m. to 7 a.m. shift and the issue still continued. The DON stated her staff were not competent in answering the call lights in a timely manner or the importance of answering the call lights within a timely manner.During a review of the facility's policy and procedure (P&P) titled Call Lights and dated 1/2017, the P&P indicated it was the facility's policy to respond to the resident's requests and needs and call lights should be answered promptly.

Based on interview and record review, the facility failed to ensure an annual performance evaluation (a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics in performing that an individual needs to perform work roles or occupational functions successfully) was performed every year for Certified Nursing Assistant (CNA ) 2. This deficient practice had the potential for the facility not be able to assess the skills necessary for CNA 2 to provide nursing services to assure resident safety and to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Findings:During a concurrent interview and record review on 7/18/2025 at 12:01 PM with the Director of Staff Development (DSD), Certified Nursing Assistant (CNA) 2's employee file with a date of hire on 10/6/2010 was reviewed. CNA 2's employee file indicated the last performance evaluation was done on 10/15/2021. The DSD stated performance evaluations should be done yearly to talk about improvements and how to exceed expectations and to make sure the employee can perform their job duties or may need a review. The DSD stated if the annual performance evaluation was not done it could jeopardize the care of the residents.During an interview on 7/18/2025 at 3:46 PM with the Director of Nursing (DON), the DON stated the annual performance evaluations need to be done annually to let us know how the certified nurses are doing. DON stated we need to do the annual performance to get feedback on how they are doing and if nurses need room for improvement to grow as an employee.During a review of facility's Certified Nursing Assistant (CNA) Job Description (undated), the Certified Nursing Assistant (CNA) Job Description indicated CNA Must demonstrate the knowledge and skills necessary to provide care appropriate to the age-related needs of the residents served.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow infection control precautions for three of four sampled residents (Resident 100, Resident 8 and Resident 40) when:1a.Certified Nursing Assistant (CNA) 2 picked up a pillow and bed linen from the floor and placed it on Resident 100's lower extremities (lower legs, feet).1b.CNA 2 did not follow the standard of practice of wiping front to back when cleaning Resident 100's rectum. 1c.CNA 2 did not perform hand hygiene after providing perineal ( the area of the body between the anus and the external genitalia) care on Resident 100.1d.CNA 2 failed to doff (remove) personal protective equipment (PPE) before leaving Resident 100's room.2. Infection control precautions were not observed while administering Resident 8's medications via gastrostomy tube (g-tube - a surgically placed tube used to administer mediations or food directly into the stomach)3.Licensed Vocational Nurse (LVN) 4 failed to wash hands before administering Resident 40's eye drops, during medication administration. These deficient practices placed Resident 100, 8 and 40 at risk of infection, cross contamination (process by which bacteria or other microorganisms are unintentionally transferred from one substance or object to another) and contamination of medications. Findings:
1.During a review of Resident 100’s admission Record, the admission Record indicated Resident 100 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including fracture (broken bone) of right humerus (long bone in the upper arm, extending from shoulder to elbow) and right radius (one of two long bones in the forearm, located on the thumb side), infection and inflammatory reaction due to internal right knee prosthesis (artificial internal body part), osteomyelitis (inflammation of bone or bone marrow, usually due to infection) of right tibia (the shinbone, the larger of the two bones in the lower leg between the knee and ankle) and right fibula (the calf bone, located on the outer side of the lower leg between the knee and ankle), infection of the skin and subcutaneous tissue (layer of fat and tissue under the skin).
During a review of Resident 100’s Minimum Data Set ([MDS] resident assessment tool) dated 7/17/2025, the MDS indicated Resident 100’s cognition was severely impaired. The MDS also indicated Resident 100 was dependent (helper does all the work) with activities of daily living (ADLs- activities such as toileting and personal hygiene a person performs daily).The MDS also indicated Resident 100 had a multi-drug -resistant organism (MDRO- microorganisms that are resistant to at least one class of antibiotics).
During a review of Resident 100’s History and Physical (H&P) dated 7/11/2025, the H&P indicated that Resident 100 had fluctuating capacity to understand and make decisions for herself.
During a review of Resident 100’s Order Summary Report dated 7/18/25, the Order Summary Report indicated Resident 100 was on enhanced barrier precautions (EBP- an infection control strategy primarily used in nursing homes, to reduce the spread of MDRO’s) for Candida Auris (C-Auris type of yeast that can cause severe illness and spreads easily among patients in healthcare facilities), Carbapenem-Resistant Acinetobacter baumanni (CRAB- a type of antibiotic resistant bacteria that causes serious infections in healthcare facilities). The Order Summary Report also indicated Resident100 was taking Cephalexin (antibiotic used to treat bacteria) 250 milligrams (mg- unit of measure) every 12 hours one capsule through a gastrostomy tube (g-tube- tube inserted through the abdominal wall directly into the stomach) for right elbow infection.
During a review of Resident 100’s Care plan titled on Enhanced Barrier Precaution related to (r/t) C-auris and CRAB dated 7/10/25, the care plan interventions indicated staff were to use personal protective equipment (PPE-gloves, gown, mask) when providing care to Resident 100, to keep PPE cart outside resident’s room with proper disposable materials and staff need to do frequent hand washing.
During an observation on 7/16/25 at 11:11am in Resident 100’s room , CNA2 was assisting Treatment Nurse 1 (TXN1) with wound care on Resident 100. CNA 2 was observed placing a wet towel on Resident 100’s bed on a dirty chux (absorbent pads used to protect bedding from bodily fluids like urine and blood). CNA 2 was also observed cleaning Resident 100’s rectum using the same towel that was on the dirty chux and wiping from back to front. CNA 2 was also observed picking up a pillow and bed linen off the floor and placing it back on Resident 100’s bed touching her lower extremities. CNA 2 was also observed taking dirty linen out of Resident 100’s room and failing to doff his PPE (gown, gloves). CNA 2 proceeded to grab a pillowcase and returned to Resident 100’s room wearing the same gown. CNA 2 was then observed putting on gloves and completed Resident100 care. CNA 2 did not do hand hygiene when providing Resident 100’s personal care.
During an interview on 7/16/25 at 1:32 pm with CNA 2,CNA 2 stated that he was aware he should have used a basin with soap and water when providing care for Resident 100, but he did not see one in her bedside drawer. CNA 2 also stated that when he was cleaning Resident 100’s bottom he should have cleaned from front to back not back to front and changed his gloves and washed his hands after cleaning Resident 100’s bottom, because there was a potential for Resident 100 to have cross contamination from feces causing her to have an infection. CNA 2 stated when the pillow and bed linen touched the floor he should not have put it back on Resident 100’s bed because the pillow and bed linen were contaminated. CNA 2 also stated that Resident 100 was on EBP for her infections and that he should have taken off his PPE before exiting Resident 100’s room to prevent cross contamination.
During an interview on 7/16/25 at 4:04 pm with TXN 1, TXN 1 stated Resident 100 was on EBP because of her infected wounds. TXN 1 stated she did see CNA 2 place the wet towel on Resident 100’s dirty chux and that he did clean Resident 100’s bottom from back to front and that she did not see CNA 2 wash his hands or change his gloves after cleaning Resident 100’s bottom. TXN 1 stated she saw CNA 2 pick up the pillow and bedlinen off the floor and place it back on Resident 100’s bed and that the linen was contaminated and should not have been put back on Resident 100’s bed. TXN 1 the reason she did not correct CNA 2 was because she was focusing on Resident 100’s wound treatment.
During an interview with the Director of Staff Development (DSD) on 7/17/25 at 4:18 pm, the DSD stated when providing any kind of perineal care on the residents the CNA needs to get two basins, one for clean and one for dirty water and six towels, they need to wipe and dump meaning, that you should wipe from front to back then toss the towel and get a new one. The DSD stated CNA needs to change their gloves and wash their hands after cleaning residents bottoms, to prevent the spread of infection from cross contaminations. The DSD also stated that any time a pillow or bedlinen touches the floor the CNA was to get a clean set of bedlinens and place the linen that fell on the ground in the dirty linen barrel to prevent the spread of infection. The DSD stated that anytime the CNAs wear PPE they need to take it off before leaving the residents’ room and they need to wash their hands and put on new PPE before reentering residents’ room when providing the residents with care to protect the residents from infection.
During an interview on 7/18/25 at 12:26 pm with the Director of Nursing (DON), the DON stated Resident 100 was on EBP and the staff need to wear PPE when providing direct care to Resident 100. The DON stated she was made aware of CNA 2 failure to follow infection control practices. The DON stated Resident 100 was at risk for worsening infection and rehospitalization.
During a review of the facility’s policy and procedures (P&P) titled Hand Hygiene, dated 7/2019 the P&P indicated “It is the policy of the facility that all staff members perform hand hygiene before and after direct resident care and after contact with potentially contaminated substances to prevent, to the extent possible, the spread of infection. Hand hygiene will be performed by staff as follows, before taking care of susceptible residents such as those who are severely immunosuppressed. During care when moving from a contaminated activity to a clean activity (for example after assisting a resident with toileting, before assisting with clean clothing). Immediately after glove removal, After taking care of an infected resident or one who is likely to be colonized with micro-organisms of special clinical or epidemiologic significance (e.g., multiple resistant bacteria, MRSA); and before and after giving personal care to residents and/or self. If gloves are worn for a procedure, hand hygiene is to be performed before putting gloves on and after removal and disposal of gloves.
During a review of the facility’s policy and procedures (P&P) titled Perineal Care dated 10/2018, the P&P indicated, “Wash perineal area with the washcloth or personal cleansing cloths, wiping from front to back. Wash the rectal area thoroughly, wiping from the base of the labia towards and extending over the buttocks. Do not reuse the same washcloth or water to clean the labia or use the same personal cleansing cloth.”
2.During a review of Resident 8’s admission Record, dated 7/16/2025, the admission Record indicated, Resident 8 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included but not limited to, sepsis (a life-threatening blood infection), chronic kidney disease (a condition where the kidneys are damaged and cannot filter blood as well as they should), gastrostomy status, personal history of urinary tract infections (infection in any part of the urinary system), pneumonia (an infection/inflammation in the lungs) and history of other infectious and parasitic diseases.
During a review of Resident 8’s History and Physical (H&P), dated 2/4/2025, the document indicated Resident 8 did not have the capacity to understand and make decisions.
During a review of Resident 8’s Minimum Data Set (MDS-resident assessment tool), dated 4/21/2025, the MDS indicated Resident 8 was on g-tube feedings, fully dependent on facility staff for Activities of Daily Living (ADLs) such as oral hygiene, toileting hygiene, showering, upper and lower body dressing, putting on or taking off footwear and personal hygiene.
During a concurrent observation and interview on 7/16/2025 at 9:00 a.m. with Licensed Vocational Nurse (LVN) 4, LVN 4 prepared six medications and supplements by crushing them individually using a crushing device to be administered to Resident 8 via g-tube. LVN 4 stated he used five to 10 mL water to dissolve each medication separately. LVN 4 started to administer medications one by one using gravity method followed by water in between each medication. LVN 4 then stepped away from the bedside with the syringe in his hand that was used to administer water and g-tube medications, and walked to the medication cart, which exposed the syringe to other factors in the environment. LVN 4 returned to bedside with the same syringe and resumed medication administration.
During an interview on 7/16/2025 at 2:47 p.m. with LVN 4, LVN 4 stated he should not have taken the syringe used for g-tube medication administration with him to the medication cart. LVN 4 stated he should have changed gloves and sanitized hands if he needed to move away from the resident. LVN 4 stated there was a risk of contamination when he removed the syringe away from the resident's area. LVN 4 could not say that it was important to take precautions to prevent infection but stated to prevent any bacteria and prevent contamination.
During an interview on 7/17/2025 at 11:48 a.m. with the Director of Nursing (DON), the DON stated nurses should not have brought the syringe that was used to administer g-tube medications away from the resident care area to medication cart because that would increase the risk for contamination and infection when the syringe was reintroduced to administer g-tube medications.
3. During a review of Resident 40’s admission Record, dated 7/16/2025, the admission Record indicated Resident 40 was originally admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including tracheostomy (a surgical procedure to create an opening in the neck and into the trachea [windpipe] to allow for breathing when the upper airway is blocked or when prolonged breathing assistance is needed) status and unspecified glaucoma (an eye condition that increased eye pressure).
During a review of Resident 40’s MDS, dated [DATE], the MDS indicated Resident 40’s cognition (ability to think, understand, learn, and remember) was intact. The MDS indicated Resident 40 needed setup or clean-up assistance from the facility staff for activities of daily living (ADLs) such as eating, supervision assistance for oral hygiene, moderate assistance for upper body dressing and personal hygiene, maximal assistance for lower body dressing, putting on or taking off footwear, and dependent for toileting hygiene.
During a concurrent observation and interview on 7/16/2025 at 9:45 a.m. with LVN 4, LVN 4 prepared six medications to be administered to Resident 40 which included artificial tears eye drops. LVN 4 stated Resident 40 was supposed to receive one drop of artificial tears into the right eye four times a day for dryness. LVN 4 was not observed washing hands after preparing medications, before wearing gloves and before administering artificial tears eye drops to Resident 40.
During a medication reconciliation review on 7/16/2025 at 1:12 p.m., Resident 40’s Order Summary Report, dated 6/1/2025 and 7/17/2025 indicated the following physician order:
“Artificial Tears Ophthalmic (eye) Solution (carboxymethylcellulose sodium) instill 1 drop in right eye four times a day for dry eyes/itchiness, order date 4/4/2023, start date 4/4/2023.”
During an interview on 7/16/2025 at 2:05 p.m. with LVN 4, LVN 4 stated he should have washed his hands before administering artificial tears eye drops to Resident 40 to prevent contamination and infection.
During an interview on 7/17/2025 at 11:48 a.m. with the DON, the DON stated it was very important for nurses to wash their hands before putting on gloves and before administering eye drops to prevent infection.
During a review of the facility’s policy and procedure (P&P) titled, “Hand Hygiene,” dated 7/2019, the P&P indicated, “It is the policy of the facility that all staff members perform hand hygiene before and after direct resident care and after contact with potentially contaminated substances to prevent, to the extent possible, the spread of infection. Hand hygiene will be performed by staff as follows: during care when moving from a contaminated activity to a clean activity (for example .clothing).”
During a review of the facility’s P&P titled, “Medication Administration,” dated 4/2025, the P&P indicated, “Staff shall follow facility infection control procedures, i.e., handwashing, antiseptic techniques, gloves, isolation precautions, etc. as applicable.”

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement and follow its protocol for antibiotic (medicine used to kill bacteria and treat infections) use on one of four sampled residents (Resident 55).This failure had the potential for Resident 55 to receive an inappropriate antibiotic which could lead to antibiotic resistance (occurs when bacteria evolve and develop the ability to withstand the effects of antibiotics, rendering these drugs ineffective).Findings:During a review of Resident 55's admission Record, the admission Record indicated the resident was admitted on [DATE] to the facility with diagnoses including methicillin resistant staphylococcus aureus infection (MRSA- caused by a type of staph bacteria that's become resistant to many of the antibiotics used for staph infections), obstructive and reflux uropathy(blockage in the urinary tract that prevents normal urine flow and backward flow of urine from the bladder towards the kidneys), chronic kidney disease( long term decline in kidney function) and benign prostatic hyperplasia (BPH-common condition in older men where the prostate gland gets bigger and the enlargement can put pressure on the urethra [tube that carries urine from the bladder] causing problems with urination).During a review of Resident 55's Minimum Data Set (MDS- a resident assessment tool) dated 6/30/2025, the MDS indicated the resident had intact cognition (thought process) and required partial/moderate assistance ( helper does less than half the effort) with personal hygiene, bed mobility and upper body dressing. The MDS indicated the resident was on an antibiotic.During a review of Resident 55's urine culture (laboratory test that checks a urine sample for bacteria, yeast or other microorganisms and helps determine what type of germ is causing the infection) collected on 6/25/2025 , the urine culture indicated the resident had greater than 100,000 cfu (colony forming units-refers to estimated number of viable bacteria or fungi in a urine sample)/milliliter( ml.-a unit of volume) of Escherichia coli ( bacteria). The urine culture indicated Escherichia Coli is sensitive ( effective in inhibiting the growth of bacteria)to Macrobid. During a review of Resident 55's Physician's Order dated 7/3/2025, the Physician Order indicated an order of Macrobid (antibiotic that treats urinary tract infection [UTI-infection in the bladder/urinary tract ) oral capsule 100 milligrams (mgs- unit of measurement) two times a day for UTI for 5 days.During a review of Resident 55's Licensed Personnel Progress Notes dated 7/3/2025 at 10:30 p.m., the Licensed Personnel Progress Notes indicated the resident was being monitored for adverse reaction related to Macrobid administration. During a review of Resident 55's SBAR (a structured communication tool that stands for situation, background, recommendation, assessment used for relaying information in a resident's condition) dated 7/2/2025 timed at 6:30 p.m. , the SBAR indicated the resident had an ESBL ( Extended -Spectrum Beta Lactamase - bacteria that produces enzyme which makes them resistant to certain antibiotics and can be harder to treat) in the urine and had no pain. The SBAR indicated that the physician and family representative were notified, and the facility was awaiting orders from the physician.During a concurrent interview and record review on 7/18/2025 at 11:50 a.m. with Infection Preventionist Nurse (IPN), Resident 55's Surveillance Data Collection form (data collection that helps healthcare facilities monitor antibiotic usage, identify areas where stewardship efforts can be improved and track the development of antibiotic resistance) and Progress Notes were reviewed. The IPN stated Resident 55 had cloudy urine with sediments and the urine culture had E. coli. The IPN stated the facility used McGeer criteria (a set of guidelines used to ensure consistent surveillance, reporting of infections and as well appropriate treatment and antibiotic use) for their antibiotic use and the use of Macrobid for the UTI did not meet the criteria of Mcgeer. The IPN stated Resident 55 had an indwelling catheter (flexible tube inserted into the bladder to drain urine) and was not showing any symptoms of infection, just sediments in the urine. The IPN stated the physician should have been notified if the resident was not meeting the McGeer's Criteria. The IPN verified through record review of Progress Notes, there was no documentation the physician was notified about the use of Macrobid not meeting the McGeer Criteria. The IPN stated the licensed nurses and IPN are responsible in making sure the usage of antibiotics is meeting the McGeer criteria. The IPN stated, the licensed nurses should have followed up with the physician if the resident still need the antibiotic because it did not meet the Mcgeer. The IPN stated Resident 55 can be at risk for antibiotic resistance and development of MDRO (multi-drug-resistant organisms- a germ that is resistant to many antibiotics).During an interview on 7/18/2025, at 3:10 p.m. with the Director of Nursing (DON), the DON stated her responsibility in antibiotic stewardship (coordinated interventions designed to improve and optimize antibiotic use, ensuring they are used appropriately, safely and effectively) is to ensure the antibiotic prescribed by the physician meets the McGeer's criteria to prevent giving unnecessary antibiotics to the residents. The DON stated giving unnecessary antibiotics to the resident could lead to MDRO and antibiotic resistance.During a review of facility's policy and procedure (P&P) titled, Infection Control-Antibiotic Stewardship, revised 1/2018, the P&P indicated it is the policy of the facility to establish an antibiotic stewardship that promotes the appropriate use of antibiotics and to have a system of monitoring that will improve resident outcomes and reduce antibiotic resistance. The P&P indicated the IPN, DON and pharmacy consultant will review, monitor antibiotic usage on a regular basis , monitor antibiotic resistance patterns and maintain a separate report for the number of residents that did not meet the McGeer's criteria.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that staff used a communication board (tool used for communicating with residents that speak another language) for one of four sampled residents (Resident 100) as written in her care plan. This deficient practice had a potential for staff to ineffectively communicate with Resident 100's care and had a potential to delay medicating Resident 100 when she complained of being in pain. Findings: During a review of Resident 100's admission Record , the admission Record indicated Resident 100 was originally admitted to the facility on [DATE] with diagnoses including cerebrovascular accident (CVA- stroke, loss of blood flow to part of the brain) and tracheostomy (surgically created opening in the neck that extends into the windpipe) with ventilator (a medical device to help support or replace breathing) dependence. During a review of Resident 100's History and Physical (H&P) dated 7/11/2025, the H&P indicated that Resident 100 was hospitalized on [DATE] for sepsis (life-threatening blood infection) from infected right elbow fracture and infected right knee replacement and was readmitted to the facility on [DATE]. The H&P indicated Resident 100 has a fluctuating capacity to understand and make decisions. During a review of Resident 100's Minimum Data Set (MDS- resident assessment tool) dated 7/17/2025, the MDS indicated Resident 100 was dependent (helper does all the effort or two or more helpers is required for the resident to complete the activity) on staff for bed mobility, moving from sitting on side of bed to lying flat on bed, toileting hygiene, bathing, dressing, personal hygiene, and oral hygiene. The MDS indicated that Resident 100's primary language is Spanish. During review of Resident 100's Care Plan titled Impaired Communication dated 7/13/2025, the Care plan interventions indicated Do not hurry when trying to communicate (with resident). During a concurrent observation and interview on 7/15/2025 at 10:38 a.m. with Resident 100, observed Resident 100 grimacing and uncomfortable in bed. A communication board with Spanish words and phrases hanging on the wall was used to communicate with Resident 100. Resident 100 stated she was in pain and would like pain medication. During an observation on 7/15/2025 at 10:43 a.m. in Resident 100's room, Licensed Vocational Nurse (LVN) 4 instructed Resident 100 that Tylenol was administered at 8:45 a.m. and to wait for the medication to kick in about 45 minutes to an hour in English. Resident 100 shook her head and mouthed, No se (I don't understand). LVN 4 replied, No pain? Okay and left the room. During an interview on 7/15/2025 at 10:50 a.m. with LVN 4, LVN 4 stated that he did not use the communication board to assess Resident 100's uncontrolled pain. During a subsequent observation on 7/15/2025 at 10:52 a.m. with LVN 4 and Resident 100 in Resident 100's room, Resident 100 stated she was in ten-out-of-ten pain in her right leg. LVN 4 asked Resident 100, Are you sure you're in pain? I just gave you medicine at 8:45 (a.m.) Resident 100 was grimacing and nodded her head. During an interview on 7/17/2025 at 2:31 p.m. with Register Nurse Supervisor (RNS) 3, RNS 3 stated that staff should be using the communication board when communicating with Resident 100 because it was important for her to make her needs known. RNS stated that staff was trained in how to use the communication board and what it was part of new hire orientation. RNS 3 stated that LVN 4 did not try to understand Resident 100 and this had the potential for Resident 100 to continue being in pain. During an interview on 7/18/2025 at 12:26 p.m. with the Director of Nursing (DON), the DON stated that staff can neglect residents' needs when they don't use the communication board and that is why all staff should be using it. During a review of Resident 100's Policy and Procedures (P&P) titled, Activities of Daily Living, Quality of Care, Routine Resident Monitoring, and Scope of Services dated 6/2022, the P&P stated, The facility will provide. communication (speech, language and other means such as a communication board) to residents assessed to require these services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure one of one sample resident (Resident 53) received rehabilitation services or Restorative Nursing Aide ([RNA] nursing aide program that helps residents to maintain their function and joint mobility) services for the right-hand contracture. (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints).This failure had the potential to result in Resident 53 being at risk for further range of motion (ROM - the extent of movement of a joint) decline and contracture.Findings:During a review of Resident 53's admission Record, the admission Record indicated, Resident 53 was admitted to the facility on [DATE] with diagnoses including dysarthria (a speech disorder that occurs when muscles used for speaking become weak or are unable to coordinate properly), muscle weakness, hemiplegia (paralysis of one side of the body) and hemiparesis (weakness of one side of the body) affecting the right dominant side.During a review of Resident 53's History and Physical, dated 6/25/2025, the H&P indicated Resident 53 did not have the capacity to understand and make decisions.During a review of Resident 53's Minimum Data Set (MDS-a resident assessment tool), dated 7/12/2025, the MDS indicated Resident 53 was dependent on nursing staff for toileting, showering, dressing, sitting, lying down and transferring. The MDS indicated Resident 53 needed partial to moderate assistance from nursing staff with personal and oral hygiene.During a concurrent observation and interview on 7/15/2025 at 10:38 am with Resident 53 in Resident 53's room, observed Resident 53's right wrist and right hand were contracted. Resident 53 stated she does not know if she was getting therapy for the contractures on the right wrist and right hand.During a concurrent interview and record review on 7/17/2025 at 9:48 am with Licensed Vocational Nurse (LVN) 2, Resident 53's Care Plan, titled cerebral vascular accident (CVA- lack of adequate blood supply to the brain ), dated 6/24/2025 was reviewed. The Care Plan indicated Resident 53 was at risk for development of joint limitation/contracture secondary to decreased mobility related to right side weakness and a right arm contracture. The Care Plan indicated the goal was to minimize the risk of further joint limitation in the next three months. The Care Plan indicated to provide restorative activities as ordered. LVN 2 stated Resident 53 was admitted to the facility with a right upper extremity contracture with moderate to severe limitations. During a concurrent interview and record review on 7/07/17/2025 at 11:52 AM with the Director of Rehabilitation (DOR), Resident 53's Joint Mobility Assessment, dated 6/24/2025, was reviewed. The Joint Mobility Assessment indicated Resident 53 had right shoulder moderate to severe joint mobility limitation. The Joint Mobility assessment indicated Resident 53 had right elbow moderate to severe joint mobility limitation. The Joint Mobility assessment indicated, Resident 53 had right wrist severe joint mobility limitation. The Joint Mobility assessment indicated Resident 53 had right hand and fingers with moderate joint mobility limitation. The DOR stated the PT focus was on bed mobility. The DOR stated the OT focus was on upper body dressing, transferring and personal hygiene. The DOR stated he does not know when Resident 53 developed contractures to the right elbow, right shoulder and right hand. The DOR stated there are no goals for the right-hand contracture. The DOR stated typically a splint should be given to residents with contractures on the hand. The DOR stated interventions for contractures are active ROM, passive range of motion ([PROM] the range of motion that is achieved when an outside force such as a therapist causes movement of a joint and is usually the maximum range of motion that a joint can move) and strengthening and preventative measures. The DOR stated no preventative measures were done for Resident 53. The DOR stated Resident 53 should have received preventive measures for the right-hand contracture to prevent further decline and contractures.During an interview on 7/17/2025 at 3:51 pm with Registered Nurse Supervisor (RNS) 1, RNS 1 stated Resident 53's right hand was contracted, and no nursing services were being provided to maintain or improve mobility on the right hand. RNS 1 stated Resident 53's contracture would worsen and more limitation to hand mobility if Resident 53 was not receiving any preventive services (RNA services).During an interview on 7/18/2025 at 3:36 pm with the Director of Nursing (DON), the DON stated residents admitted to the facility with contractures need rehabilitation services to prevent further decline in function and to maintain function and prevent further contractures.During a review of the facility's policy and procedure (P&P), titled Limitations in Range of Motion and Mobility and Referrals for Therapy, , date revised 10/2017, the P&P indicated, It is the policy of the facility that a resident who enters the facility without limited range of motion does not experience reduction in range of motion unless the resident's clinical condition demonstrates that the reduction in range of motion is unavoidable. A resident with limited range of motion will be assessed and provided appropriate treatment and services in an attempt to increase range of motion and/or prevent a fll11her decrease in range of motion. A resident with limited mobility will receive appropriate services, equipment and assistance to maintain or improve mobility in an attempt to maintain or improve mobility unless the resident's reduction in mobility is demonstrated to be unavoidable. The facility will ensure that ongoing communication and caregiver training takes place between

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure one of one sampled resident (Resident 66) was not left un-attendant in bed prior to transfer to a mechanical lift (Hoyer lift- (a device used to assist with transferring and moving individuals who have limited mobility) and bed should be locked.This failure had the potential for Resident 66 to fall out of bed and sustain injuries that require hospitalization. Findings:During a review of Resident 66's admission Record, the admission Record indicated Resident 66 was admitted to the facility on [DATE] with diagnoses including intracranial hemorrhage (brain bleed), cervical osteomyelitis (infection of the bone) , cervical discitis (an infection of the intervertebral discs in the neck), and cervical spondylolisthesis ( a condition where one of the vertebrae in your neck (cervical spine) slips forward, backward, or onto the vertebra below it).During a review of Resident 66's Care Plan, titled Risk for Fall, dated 4/27/2025, the Care Plan indicated, Resident 66 had poor safety awareness, episodes of placing the bed up high despite explanations of risk and benefits. During a review of Resident 66's Care Plan, titled High Risk for Injury, dated 4/27/2025, the Care Plan indicated, Resident 66 had generalized muscle weakness. The Care Plan indicated to implement fall precautions with frequent visual checks, call for safety with Hoyer lift transfer. During a review of Resident 66's History and Physical (H&P), dated 4/28/2025, the H&P indicated, Resident 66 had the capacity to understand and make decisions.During a review of Resident 66's Minimum Data Set (MDS- a resident assessment tool), dated 5/3/2025, the MDS indicated, Resident 66 needed substantial to maximal assistance with toileting, showering, dressing, sitting, standing, and transferring.During an observation on 7/15/2025 at 10:40 a.m., in Resident 66's room, observed two wheelchairs were positioned in front of Resident 66's bed blocking the entrance into the room. Resident 66 was lying flat on her back in bed with a Hoyer lift pad underneath. Resident 66's bed was elevated, the side rails were down, the breaks at the foot of the bed were off. Resident 66's foley catheter bag was on top of Resident 66's bed next to Resident 66.During a concurrent observation and interview on 7/15/2025 at 10:44 a.m., with Certified Nursing Assistant (CNA) 4, CNA 4 and another certified nursing assistant (unknown) went to Resident 66 bedside with a Hoyer lift wearing gowns and gloves. CNA 4 connected Resident 66 to the Hoyer lift using the strap from the Hoyer lift pad. CNA 4 stated the breaks at the foot of the bed were not locked and should always be locked. CNA 4 locked Resident 66's brakes on at the foot of the bed. CNA 4 and another CNA transferred Resident 66 off the bed into a wheelchair. During an interview on 7/16/2025 at 1:31 p.m., with CNA 4, CNA 4 stated it was documented in Resident 66's Care Plan that the resident likes to raise her bed. CNA 4 stated Resident 66 was not on any fall precaution measures. CNA 4 stated before the transfer of Resident 66 with the Hoyer lift the brakes at the foot of the bed were not locked. CNA 4 stated the bed should have been in the lowest position before transferring Resident 66 to the wheelchair to prevent Resident 66 from falling.During a concurrent interview and record review on 7/17/2025 at 10:56 a.m., with Licensed Vocational Nurse, (LVN) 5, Resident 66 Care Plan, dated 4/27/2025 was reviewed. The Care Plan indicated on 4/27/2025 Resident 66 had episodes of putting bed up in a high position and the risk and benefits were explained. The Care Plan indicated frequent visual checks and providing a safe environment. LVN 5 stated the brakes should be locked at all times while Resident 66 was in bed as Resident 66 could fall.During an interview on 7/17/2025 at 3:48 p.m., with Registered Nurse Supervisor (RNS) 1, RNS 1 stated Resident 66 was a high risk for falls. RNS 1 stated if Resident 66 was left unattended with the bed in a high position and the brakes were not locked Resident 66 could fall in bed and sustain injury. During an interview on 7/18/2025 at 3:35 p.m., with the Director of Nursing (DON), the DON stated the brakes on Resident 66's bed should be locked. The DON stated the nursing staff were not supposed to leave the residents unattended when the bed was in a high position. The DON stated someone should have stayed with Resident 66 for safety and to prevent risk of falling.During a review of the facility's policy and procedure (P&P), titled Falling Star Program, , date revised 7/2018, the P&P indicated, Purpose: .To attempt to increase supervision for residents assessed to be at high risk for falls. General safety precautions and interventions should be used for residents and may include: Maintaining the bed in the lowest position.Locking brakes on beds, gurneys, or wheelchairs.Keep the resident's environment free of unnecessary obstacles.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure one of one sample resident (Resident 47) was provided with indwelling urinary catheter (a flexible tube inserted into the bladder to drain urine) care based on professional standards of practice and Resident 47's physician order. This failure had the potential for Resident 47 to develop a urinary tract infection (UTI- an infection in any part of the urinary system, the kidneys, bladder or urethra) and unable to assess Resident 47's intake and output.Findings:During a review of Resident 47's admission Record, the admission Record indicated, Resident 47 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including end stage renal disease (the final stage of chronic kidney disease (CKD) where the kidneys have significantly lost their ability to function adequately), hydronephrosis (a condition where one or both kidneys swell due to a backup of urine), retention of urine and diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing).During a review of Resident 47's Minimum Data Set (MDS- a resident assessment tool), dated 5/20/2025, the MDS indicated, Resident 47 was dependent on nursing staff for toileting, showering, dressing and transferring. The MDS indicated Resident 47 had an indwelling urinary catheter.During a review of resident 47's Physician Orders, dated 6/26/2025, the Physician Orders indicated, Resident 47 had an order to monitor urinary output every shift.During a review of Resident 47's History and Physical (H&P), dated 6/27/2025, the H&P indicated, Resident 47 had the capacity to understand and make decisions.During a review of Resident 47's Care Plan, dated 6/27/2025, the Care Plan indicated Resident 47 was at risk of developing a UTI. The Care Plan interventions indicated to monitor intake and output (I&O) every shift.During an interview on 7/15/2025 at 1:53 p.m., with Resident 47, Resident 47 stated her urinary indwelling catheter bag was not being emptied every shift. Resident 47 stated his urinary bag was being emptied in the mornings and afternoons.During an interview on 7/16/2025 at 2:49 p.m., with Certified Nursing Assistant (CNA) 5, CNA 5 stated Resident 47 was a dialysis (a treatment that replaces kidney function when kidneys fail, removing waste and excess fluid from the blood) resident. CNA 5 stated Resident 47 has a indwelling urinary catheter and should be emptied one time per shift. CNA 5 stated she documents the urinary output on the TASK section in the residents' health record and informs the licensed vocational nurses (LVN) of the urinary output every shift. CNA 5 stated it was important to empty Resident 47's urinary bag to see if the resident was having urinary retention or if there were any problems. CNA 5 stated the urine needs to be emptied because it can cause backflow and Resident 47 can develop a UTI.During a current interview and record review on 7/17/2025 at 10:14 a.m., with LVN 2, Resident 47's Medication Administration Record (MAR), dated July 2025 was reviewed. The MAR indicated there was no documentation of the licensed nurses to demonstrate the amount of urine output measured in milliliters on the following days:7/2/2025, for night shift (11 p.m. to 7 a.m.)7/4/2025, for night shift7/5/2025, for evening shift (3 p.m. to 11 p.m. shift) and night shift7/6/2025, for night shift 7/7/2025, for night shift7/8/2025, for night shift7/11/2025, for night shift7/12/2025, for night shift7/13/2025, for evening shift and night shift7/14/2025, for night shift7/16/2025, for night shift LVN 2 stated Resident 47 was a dialysis resident and uses a indwelling urinary catheter due to urinary retention. LVN 2 stated Resident 47's urinary output should be monitored, emptied and measured once per shift and as needed to prevent urine backflow. LVN 2 stated Resident 47 could develop a UTI or kidney infection. During a concurrent interview and record review on 7/17/2025 at 3:31 PM with Registered Nurse Supervisor (RNS) 1, Resident 47's Physician Order, dated 6/26/2025, was reviewed. The Physician Order indicated to monitor Resident 47's output every shift. RNS 1 stated every shift the nurses need to empty the indwelling urinary catheter and document the amount of output in milliliters in the resident's health record. RNS 1 stated if the urinary catheter output was not documented we cannot have an accurate monitoring of the urine output for a resident on dialysis, to know if the resident was having retention or any fluid buildup or needs extra dialysis, and to assess renal function.During an interview on 7/18/2025 at 3:12 p.m., with the Director of Nursing (DON), the DON stated the nurses should have documented the measured urine output in milliliters in the resident's health record. DON stated it is important to know the urine output to make sure the resident is not retaining fluid. During a review of facility's policy and procedure (P&P) titled Intake and Output revised 05/2016, the P&P indicated It is the policy of the facility to record fluid and intake and output in accordance with the following: If ordered by the physician; and for each resident admitted with an indwelling catheter.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident with a gastrostomy tube (GT-a tube that is passed through the abdominal wall to the stomach used to provide nutrition) site was not leaking from January 2025 to present for one out of eight residents (Resident 8). This deficient practice resulted in continuous leakage of tube feeding formula around Resident 8's stoma (surgically created opening on the abdomen that allows waste to exit the body) site with Resident 8 being transferred to the General Acute Care Hospital (GACH) and had the potential to cause skin breakdown around the site, lead to malnutrition, infection and Resident 8 not receiving the volume of tube feeding formula ordered by the physician.Findings:During a concurrent observation and interview on 7/16/2025 at 2:46 p.m., with Treatment Nurse (TN 1), Resident's 8 g-tube dressing was observed leaking out through the g-tube dressing. TN1 stated it was observed today that the g-tube was leaking.During a review of Resident 8's admission Record/Face sheet ( a document that summaries key information about a person, thing or situation), the admission Record indicated Resident 8 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including, gastrostomy status (the presence of a gastrostomy tube, which is a surgical procedure that creates an opening in the stomach through the abdominal wall.), dysphagia ( a medical term for difficulty swallowing. ), tracheostomy ( a surgical procedure that creates an opening in the trachea [windpipe]to help with breathing).During a review of the care plan (CP) titled, Alteration in skin integrity dated 2/01/25, the CP indicated the interventions included to notify MD for G-tube leakage if no progress was made towards healing or any signs or symptoms of decline. During a review of Resident's 8 Significant Change in Status Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 04/21/2025, the MDS indicated the resident had severely impaired cognitive (process of thinking) skills for daily decision making. The MDS also indicated the Resident's 8 was totally dependent (helper does all the effort) on bed mobility, transfer, locomotion, dressing, tube feeding, toilet use, and personal hygiene.During a record review on 7/17/24 of Resident 8's transfer record, the transfer record indicated to send Resident 8 to the GACH for a G-tube evaluation and management related to the stoma site leaking. During an interview on 7/17/25 at 10:39am with TN1. TN1 stated she called the doctor because the g-tube was leaking excessively. TN1 stated she thinks the stoma was too large, and that is why the g-tube was leaking. During a concurrent interview and record review on 7/17/225 at 2:23 pm with The Assistant Director of Nursing (ADON), the ADON stated Resident 8's was transferred to the GACH today because the G-tube was leaking with excess amounts of caramel colored fluid. The ADON stated the doctor was called and gave an order to transfer Resident 8 to the GACH for a g-tube replacement. The ADON stated Resident 8'medical records indicated the G-tube was leaking since 1/31/25. The ADON stated the evaluation of g-tube should have been done by the doctor and the licensed nurses should have follow up. The ADON stated the leaking of the g-tube can cause skin irritation, redness and could make Resident 8 uncomfortable. During a concurrent interview and record review on 7/17/25 at 3:13 pm with TN2 of Resident 8's weekly skin assessment was reviewed. TN2 stated she should have called and followed up with the doctor that g-tube was still leaking with no progress. TN 2 stated, this was a delay in treatment. During a review of Resident 8's weekly skin assessment, the following measurements of the G-tube were documented: -On 7/6/25 1x1centimeter ([cm] unit of measurement) in size with redness.-On 7/16/25 2x2 cm in size with redness and leaking. During a concurrent interview and record review on 7/17/25 at 3:46 pm with the Director of Nursing (DON), the DON stated Resident 8 should have been evaluated earlier for G-tube leaking because it can cause skin irritation and redness. The DON stated licensed nurses in the facility should report any abnormal changes to the doctor. During a review of the facility's policy and procedure (P&P) titled, Gastrostomy Tube Feeding via Continuous Pump dated 1/2017, the P&P indicated to Report complications promptly to the supervisor and the attending physician.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure resident's pain was managed for one of two sampled residents (Resident 100); who had multiple pressure ulcers (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence), a healing right arm fracture, and right knee surgical site. Specifically, the facility failed to:1. Ensure that staff followed Resident 100's care plan titled, Alteration in Comfort - Pain which indicates to provide nursing measures that will provide comfort and lessen intensity of pain by repositioning, offering pain medication, and reassessing effectiveness of pain medication after 30 minutes.2. Ensure that Treatment Nurse (TN) 1 did not continue providing wound care treatment when Resident 100 had facial grimacing (a facial expression where the mouth and face are twisted, often to indicate disgust, disapproval, or pain) and complained of having severe pain (a pain rating of seven to ten in the numeric pain scale) during the care.3. Ensure Licensed Vocational Nurse (LVN) 6 followed the physician's orders to give two tablets of Norco (pain medication) 5/325 milligrams (mg- a unit of measurement) for severe pain when Resident 100 complained of having a seven-out-of-ten pain. 4. Ensure that staff medicated Resident 100 with Tylenol (pain medication) 500 mg 30 minutes prior to wound care treatment as ordered by the physician.These deficient practices had a potential for Resident 100 experiencing unrelieved and uncontrolled pain manifested by facial grimacing, stiffening, and verbalizing having severe pain when treatment nurses provided wound care treatment. Findings:During a review of Resident 100's admission Record (AR), the AR indicated Resident 100 was originally admitted to the facility on [DATE] with diagnoses including fracture of right humerus (long bone in the upper arm, extending from shoulder to elbow) and right radius (one of two long bones in the forearm, located on the thumb side), infection and inflammatory reaction due to internal right knee prosthesis (artificial internal body part), osteomyelitis (inflammation of bone or bone marrow) of right tibia (the shinbone, the larger of the two bones in the lower leg between the knee and ankle) and right fibula (the calf bone, located on the outer side of the lower leg between the knee and ankle), tracheostomy (surgically created opening in the neck that extends into the windpipe) with ventilator (a medical device to help support or replace breathing) dependence, infection of the skin and subcutaneous tissue (layer of fat and tissue under the skin), and myositis (inflammation of the muscles that causes weakness and pain) of the right thigh. During a review of Resident 100's History and Physical (H&P) dated 7/11/2025, the H&P indicated that Resident 100 was hospitalized on [DATE] for sepsis (life-threatening blood infection) from infected right elbow fracture and infected right knee replacement and was readmitted to the facility on [DATE]. The H&P indicated Resident 100 has a fluctuating capacity to understand and make decisions. During a review of Resident 100's Minimum Data Set ([MDS] resident assessment tool) dated 7/17/2025, the MDS indicated Resident 100 was dependent (helper does all the effort or two or more helpers is required for the resident to complete the activity) on staff for bed mobility, moving from sitting on side of bed to lying flat on bed, toileting hygiene, bathing, dressing, personal hygiene, and oral hygiene. The MDS indicated Resident 100 has a deep tissue injury (pressure ulcer where damage occurs to the underlying soft tissues often beneath intact skin) on the left heel and a stage 2 pressure ulcer (partial-thickness loss of skin, presenting as a shallow open wound) on the right heel. The MDS indicated that Resident 100's primary language is Spanish.During review of Resident 100's Care Plan (CP) titled Impaired Communication dated 7/13/2025, the CP states, Do not hurry when trying to communicate (with resident). 1. During a concurrent observation and interview on 7/15/2025 at 10:38 a.m. with Resident 100, Resident 100 was grimacing in bed. A communication board with Spanish words and phrases hanging on the wall was used to communicate with Resident 100. Resident 100 stated she was in pain and would like pain medication.During an observation on 7/15/2025 at 10:43 a.m. in Resident 100's room, LVN 4 instructed Resident 100 (in English) that Tylenol was administered at 8:45 a.m. and to wait for the medicine to kick in about 45 minutes to an hour. Resident 100 shook her head and mouthed, No se (I don't understand). LVN 4 replied, No pain? Okay and left the room. During an interview on 7/15/2025 at 10:50 a.m. with LVN 4, LVN 4 stated that he did not use the communication board to assess Resident 100's uncontrolled pain. During a subsequent observation on 7/15/2025 at 10:52 a.m. in Resident 100's room with LVN 4 and Resident 100, Resident 100 stated she was in ten-out-of-ten pain in her right leg. LVN 4 asked Resident 100, Are you sure you're in pain? I just gave you medicine at 8:45 (a.m.) Resident 100 was grimacing and nodded her head. During an interview on 7/15/2025 at 11:05 a.m. with LVN 4, LVN 4 stated he was not aware that two hours had passed since he gave Resident 100 Tylenol 500 mg. LVN 4 stated that he did not do a follow up pain assessment after giving Resident 100 Tylenol at 8:45 a.m. because we don't do follow up (assessments) for routine medications. LVN 4 stated that it's important to give pain medication and provide non-medication interventions when a resident asks for it to manage the resident's pain. During a review of the facility's Policy and Procedure (P&P) titled Pain Management Protocol dated 10/2017, the P&P indicated to assess effectiveness of pain medication with routine and PRN (as needed) pain medication approximately 30 minutes after administration.During review of Resident 100's CP titled Alteration in Comfort - Pain dated 7/10/2025, the CP indicated to:a. Assess non-verbal resident for possible signs and symptoms of pain ex. Grimacesb. Administer pain medication per physician's order c. Re-assess for pain after 30 minutes and notify physician for possible need for increased pain medicationd. Provide nursing measures that will provide comfort and lessen intensity of painDuring a review of Resident 100's Pain Level Summary (PLS) dated 7/18/2025, the PLS indicated that no pain assessments were done for Resident 100 between 7/14/2025 at 9:21 p.m. and 7/15/2025 at 11:15 a.m. The PLS indicated LVN 4 did not do a pain assessment for the Tylenol given at 8:45 a.m. and did not reassess the resident to measure its effectiveness. During an interview on 7/18/2025 at 9:44 a.m. with Resident 100, translation services by telephone were used to communicate with Resident 100. Resident 100 stated that she is not happy with her care in the facility and her pain is not managed well.During an interview on 7/18/2025 at 1:13 p.m. with the Director of Nursing (DON), the DON stated improper pain assessments lead to inadequate interventions for residents experiencing pain like Resident 100. The DON stated improper pain assessments are a competency issue for better and thorough assessments. 2. During a concurrent observation and interview on 7/16/2025 at 11:15 a.m. with TN 1, Certified Nursing Assistant (CNA) 2, and Resident 100 during Resident 100's wound care treatment, Resident 100 was noted grimacing and bucking the ventilator (when a patient is not synchronized with the ventilator's breaths due to pain, anxiety, or other factors that disrupt the normal breathing pattern) when CNA 2 lifted Resident 100's right leg to turn her. During a subsequent observation and interview with TN 1 on 7/16/2025 at 11:27 a.m., TN 1 stated, We are going to continue (the wound care treatment). [Resident 100] has a post-op appointment in an hour and needs to get cleaned. Resident 100 was grimacing, stiffening her body when being moved, and bucking the ventilator while TN 1 and CNA 2 continued wound care treatment. Resident 100 stated her pain was seven-out-of-ten during wound treatment.During an interview on 7/16/2025 at 4:45 p.m., LVN 4 reported that when TN 1 informed him of Resident 100's pain during wound care treatment, he instructed TN 1 to assess whether Resident 100 could tolerate completing the treatment. LVN 4 also mentioned that he gave Resident 100 pain medication only after the treatment was finished. During an interview on 7/16/2025 at 4:16 p.m. with TN 1, TN 1 stated that the wound care treatment should have been stopped when Resident 100 showed signs of discomfort and reported pain. TN 1 indicated that LVN 4 should have administered pain medication immediately rather than waiting until after the treatment. TN 1 noted that continuing the treatment resulted in additional pain for Resident 100.During a concurrent interview and record review on 7/17/2025 at 2:31 p.m. with Registered Nurse Supervisor (RNS) 3, Resident 100's H&P was reviewed. RNS 3 stated the reason Resident 100 was hospitalized on [DATE] was because of uncontrolled pain in her right leg and right arm. RNS 3 stated that pain management has been an ongoing issue for Resident 100.During a review of the facility's P&P titled Wound Care, dated 4/2017, the P&P indicated to assess any change in the resident's condition, how the resident tolerates the procedure, and to report other information in accordance with facility policy and professional standards of practice. 3. During an observation on 7/18/2025 at 9:58 a.m. in Resident 100's room, LVN 6 asked Resident 100 if she had pain but did not ask where the location of the pain was. During a concurrent observation and interview on 7/18/2025 at 10:06 a.m. with LVN 6, LVN 6 administered one tablet of medication via Resident 100's gastrostomy (a surgical opening into the stomach for feeding and medications) tube (g-tube). LVN 6 stated he gave one tablet of Norco 5-325 mg. He mentioned that he did not ask Resident 100 about the location of her pain because it was difficult to communicate with her at that time since she is Spanish speaking and the CNA who usually translates was busy. LVN 6 stated that Resident 100 has a communication board but did not use it when he should have. LVN 6 stated it's important to effectively communicate with the resident so the resident can properly express their needs and it's important to determine the location of the resident's pain because it can be a new onset of pain or an emergency like chest pain which could indicate a heart attack. LVN 6 stated, I did not do an accurate pain assessment.During an interview on 7/18/2025 at 10:36 a.m. with Resident 100, Resident 100 stated she was still experiencing seven-out-of-ten pain 30 minutes after receiving her pain medication. During a concurrent interview and record review on 7/18/2025 at 10:37 a.m. with LVN 6, Resident 100's Medication Administration Record (MAR) dated 7/18/2025 was reviewed. The MAR indicated the following: a. Norco 5-325 mg give one tablet via g-tube every six hours as needed for moderate pain (four to six)b. Norco 5-325 mg give two tablets via g-tube every six hours as needed for severe pain (seven to ten) LVN 6 stated, [Resident 100] complained of seven-out-of-ten pain and I should have given her two tablets (of Norco 5-325 mg) instead of one. Following the physician's order is important for resident safety. If not, the resident may continue to experience pain and discomfort. During a review of the facility's P&P titled Medication Administration, dated 4/2025, the P&P indicated Medications must be administered in accordance with the physician orders, including any required time frame.During review of Resident 100's CP titled Alteration in Comfort- Pain, dated 7/10/2025, the CP indicated to determine location of the resident's pain.4. During a review of Resident 100's Order Summary Report (OSR) dated 7/18/2025, the OSR indicated the following physician's order: a. Acetaminophen (Tylenol) oral tablet: Give 500 mg via g-tube every day shift for pain management, give one tablet 30 minutes prior to wound care every day, not to exceed three grams (g- a unit of measurement) in 24 hours. During a concurrent interview and record review on 7/16/2025 at 4:16 p.m. with TN 1, Resident 100's MAR and Treatment Administration Record (TAR) dated 7/18/2025 were reviewed. The MAR and TAR indicated that Tylenol was not administered 30 minutes prior to wound care treatment as follows:a. On 7/12/2025, MAR indicated Tylenol 500 mg administered at 12:55 p.m., and the TAR indicated wound care treatment was provided at 12:44 p.m.b. On 7/13/2025, the MAR indicated Tylenol 500 mg administered at 2:14 p.m., and the TAR indicated wound care treatment was provided at 4:36 p.m.c. On 7/14/2025, MAR indicated Tylenol 500 mg administered at 11:59 a.m., and TAR indicated wound care treatment was provided at 6:38 p.m.d. On 7/15/2025, MAR indicated Tylenol 500 mg administered at 8:54 a.m., and TAR indicated wound care treatment was provided at 5:31 p.m.TN 1 stated that LVN 4 did not coordinate when to give Tylenol 500 mg on 7/15/2025 and therefore the medication was given earlier than it should have been on that day. TN 1 stated, The pain medication and when the treatment is done does not coincide with the order.During an interview on 7/18/2025 at 10:24 a.m. with Resident 100's family member (FM 2), FM 2 stated the facility is not doing their best because the facility told him that Resident 100 would be taken care of when she left the hospital, but Resident 100 was reinfected at this facility. FM 2 stated the facility mistook Resident 100's grimacing for smiling which caused her pain to be untreated. FM 2 stated, [Resident 100] was showing her teeth like she was grimacing and to me, she just didn't look good. She was in a lot of pain. I don't feel like her pain is managed well there (in the facility). [The facility] did not have strong enough pain medication for her, and they couldn't understand that she was constantly in pain. There was a communication barrier because she's Spanish speaking and on top of that, she can't really talk because of the breathing tube (tracheostomy).During a review of the facility's P&P titled Wound Care, dated 4/2017, the P&P indicated to review the resident's plan of care for any special needs of the resident, including pain medication to be administered prior to wound care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain accurate documentation on accountability record or controlled medication count sheet/controlled drug record ([CDR] - a document indicating perpetual inventory and administration of controlled substances affecting three residents (Residents 66, 76 and 90) in one of three inspected medication carts (Middle Medication Cart Skilled Nursing Facility [SNF] side).1.Resident 76's Pregabalin (a controlled medication [medications that the use and possession of are controlled by the federal government] used to treat fibromyalgia [pain in muscles and soft tissues] related pain, neuropathic (nerve related) pain and a subset of seizures [a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness]).2.Resident 66's Clonazepam (a controlled medication used to treat panic disorder and seizure [a medical term used to describe sudden, uncontrolled burst of electrical activity in the brain]).3. Resident 90's Pregabalin.These deficient practices of failing to maintain accurate documentation of controlled medications had the potential to result in medication errors, controlled medication loss and/or drug diversion for Residents 66, 76 and 90. Findings:1a. During a review of Resident 76's admission Record, dated 7/17/2025, the admission Record indicated Resident 76 was admitted to the facility on [DATE] with diagnoses including muscle weakness and type 2 diabetes mellitus ([DM]-a disorder characterized by difficulty in blood sugar control and poor wound healing).During a review of Resident 76's History and Physical (H&P), dated 1/30/2025, the H&P indicated Resident 76 had the capacity to understand and make decisions.During a review of Resident 76's Minimum Data Set (MDS -resident assessment tool), dated 5/5/2025, the MDS indicated, Resident 76's cognition (ability to think, understand, learn, and remember) was intact. The MDS indicated Resident 76 was independent in performing activities of daily living (ADLs) such as eating, oral hygiene and personal hygiene, needed clean-up assistance from the facility staff for upper body dressing, supervision or touching assistance for toileting hygiene and showering and moderate assistance for lower body dressing and putting on or taking off footwear.During a concurrent observation, interview and record review on 7/17/2025 at 1:29 p.m. with Licensed Vocational Nurse (LVN) 5 of Middle Medication Cart SNF, Resident 76's medication card / bubble pack (a card that packages doses of medication within small, clear, plastic bubbles), facility's controlled medication count sheet (CDR) and the medication administration details in electronic Medication Administration Record (eMAR) for pregabalin 25 milligrams ([mg] a unit of measurement for mass) and pregabalin 100 mg were reviewed. Resident 76's medication card / bubble pack for pregabalin 25 mg contained a quantity of nine capsules remaining, with instructions as take one capsule (with 100 mg total dose of 125 mg) by mouth two times a day for neuropathic (nerve) pain, fill date 7/7/2025. The facility's CDR indicated a quantity of 10 capsules remaining with the last dose administered on 7/16/2025 at 3:00 p.m. Resident 76's medication card / bubble pack for pregabalin 100 mg contained a quantity of nine capsules remaining, with instructions as take one capsule with 25 mg (total dose of 125 mg) by mouth two times a day for neuropathic pain, fill date 7/7/2025. The facility's CDR indicated a quantity of 10 capsules remaining with the last dose administered on 7/16/2025 at 7/16/2025 at 3:00 p.m. The administration details in eMAR indicated the instructions as Lyrica (pregabalin) capsule 25 mg, give 5 capsules (125 mg) by mouth two times a day for neuropathic pain and the last dose of 5 capsules of pregabalin 25 mg was documented as administered on 7/16/2025 at 5:31 p.m. LVN 5 stated she forgot to document the pregabalin 25 mg and pregabalin 100 mg after they were administered to Resident 76 on 7/17/2025 at morning time in CDR and in eMAR. During a concurrent interview and record review on 7/17/2025 at 2:01 p.m. with Registered Nurse Supervisor (RNS) 2, the order details for Resident 76's pregabalin and physician orders for pregabalin 100 mg and pregabalin 25 mg were reviewed. The order details in Resident 76's medical record indicated only Lyrica oral capsule 25 mg (pregabalin) controlled drug, give 5 capsules by mouth two times a day for neuropathic pain, give 5 capsules of 25 mg ( total of 125 mg). The physician order for pregabalin 100 mg, give 1 capsule by mouth two times a day for neuropathic pain was discontinued on 6/16/2025 with the reason indicated as increased to 125 mg two times a day. The document contained a new order for pregabalin oral capsule 25 mg, give 5 capsules by mouth two times a day for neuropathic pain. Give 5 capsules of 25 mg (total of 125 mg). RNS 2 stated he could not speak much of the order because he did not administer the medications for Resident 76. During an interview on 7/17/2025 at 2:06 p.m. with LVN 5, LVN 5 stated she should have informed pharmacy about the changes in how Resident 76's pregabalin order was written by the physician to be five capsules of 25 mg instead of 1 capsule of 25 mg and 1 capsule of 100 mg for a total dose of 125 mg, to prevent medication errors and to maintain accurate documentation in the medical records. During a review of Resident 76's Order Summary Report, dated 7/17/2025, the Order Summary Report indicated the following physician orders: Lyrica oral capsule 25 mg (pregabalin), give five capsules by mouth two times a day for neuropathic pain, give 5 capsules of 25 mg (total of 125 mg), order date 6/16/2025, start date 6/17/2025 Lyrica oral capsule 100 mg (pregabalin), give 1 capsule by mouth two times a day for neuropathic pain, give 1 capsule of 100 mg with 1 capsule of 25 mg to total 125 mg, order date 7/17/2025, start date 7/17/2025 Lyrica oral capsule 25 mg (pregabalin), give 1 capsule by mouth two times a day for neuropathic pain, give 1 capsule of 25 mg with 1 capsule of 100 mg to total 125 mg, order date 7/17/2025, start date 7/17/2025During a review of Resident 76's Medication Administration Report (MAR) dated 7/1/2025 to 7/31/2025, the MAR indicated, Lyrica 25 mg (pregabalin), give 5 capsules by mouth two times a day for neuropathic pain, give five capsules of 25 mg ( total of 125 mg), start date 6/17/2025, discontinue date (d/c) 7/17/2025 was documented as administered 29 times.During a review of Resident 76's MAR, dated 6/1/2025 to 6/30/2025, the MAR indicated, a. Pregabalin was administered under physician order that indicated, Lyrica oral capsule 100 mg (pregabalin), give 1 capsule by mouth two times a day for neuropathic pain, start date 6/11/2025, discontinue (d/c) date 6/16/2025 from 6/11/2025 to 6/16/2025.b. Pregabalin was administered under physician order that indicated, Lyrica oral capsule 25 mg (pregabalin), give five capsules by mouth two times a day for neuropathic pain, give 5 capsules of 25 mg (total of 125 mg), start date 6/17/2025, d/c date 7/17/2025 from 6/17/2025 to 6/30/2025.2. During a review of Resident 66's admission Record, dated 7/17/2025, the admission Record indicated Resident 66 was admitted to the facility on [DATE] with diagnoses including osteomyelitis (bone infection) of the vertebrae ( back bone), DM, and dysphagia ( difficulty swallowing). During a review of Resident 66's MDS, dated [DATE], the MDS indicated Resident 66's cognition was moderately impaired. The MDS indicated Resident 66 needed supervision assistance from the facility staff for eating, moderate assistance for oral hygiene and upper body dressing, maximal assistance for showering, lower body dressing and putting on or taking off footwear, and dependent on facility staff for toileting hygiene. During a concurrent observation, interview and record review on 7/17/2025 at 1:29 p.m. with LVN 5 of Middle Medication Cart SNF, Resident 66's medication card / bubble pack, facility's CDR and the medication administration details in eMAR for clonazepam 0.5 mg were reviewed. Resident 66's medication card / bubble pack for clonazepam 0.5 mg contained a quantity of eight tablets remaining. The facility's CDR indicated a quantity of nine tablets remaining with the last dose administered on 7/16/2025 at 5:00 p.m. The administration details in eMAR indicated the last dose of one tablet of clonazepam 0.5 mg for Resident 66 was documented as administered on 7/17/2025 at 9:36 a.m. LVN 5 stated she forgot to document in CDR after administering clonazepam 0.5 mg to Resident 66. LVN 5 stated she documented in electronic medical records but did not document in the controlled drug record so the quantity on medication card and CDR did not match.During a review of Resident 66's Order Summary Report, dated 7/17/2025, the Order Summary Report indicated, but not limited to the following physician order: Clonazepam tablet 0.5 mg, give 1 tablet by mouth two times a day for anxiety manifested by (m/b) verbalization of being anxious, order date 5/26/2025, start date 5/27/2025.3. During a review of Resident 90's admission Record, dated 7/17/2025, the admission Record indicated Resident 90 was admitted to the facility on [DATE], with diagnoses that included but not limited to, type 2 diabetes mellitus with diabetic neuropathy (nerve damage caused by diabetes, often affecting the legs and feet ).During a review of Resident 90's History and Physical (H&P), dated 12/19/2024, the H&P indicated Resident 90 had the capacity to understand and make decisions.During a review of Resident 90's MDS, dated [DATE], the MDS indicated Resident 90's cognition was moderately impaired. The MDS indicated Resident 90 needed setup or clean-up assistance from the facility staff for eating and oral hygiene, moderate assistance for personal hygiene, maximal assistance for toileting hygiene, showering, upper body dressing, and dependent on facility staff for lower body dressing and putting on or taking off footwear.During a concurrent observation, interview and record review on 7/17/2025 at 1:29 p.m. with LVN 5 of Middle Medication Cart SNF, Resident 90's medication card / bubble pack, facility's CDR and the medication administration details in eMAR for pregabalin 75 mg were reviewed.Resident 90's medication card / bubble pack for pregabalin 75 mg contained a quantity of nine capsules remaining. The facility's CDR indicated a quantity of 10 capsules remaining with the last dose administered on 7/16/2025 at 5:00 p.m. The administration details in eMAR indicated the last dose of one tablet of pregabalin 75 mg for Resident 90 was documented as administered on 7/17/2025 at 11:48 a.m. LVN 5 stated she forgot to document in CDR after administering pregabalin 75 mg to Resident 90. LVN 5 stated she documented in electronic medical record but did not document in the controlled drug record so the quantity on medication card and CDR did not match. LVN 5 stated she should have documented all the controlled medications immediately after they were administered to residents to ensure accuracy and safety of residents, and to prevent medication errors, drug diversion and misuse.During an interview on 7/17/2025 at 5:14 p.m. with the Director of Nursing (DON), the DON stated the licensed nurses should sign the CDR and electronic medical record after the controlled substances were administered to maintain accuracy of the medications being given. The DON stated it was very important to account for the controlled medications, to prevent medication errors and drug diversion. The DON stated for Resident 76, the licensed nurse should have sent the physician order that indicated five capsules of 25 mg Lyrica instead of the current medication cards as one capsule of 25 mg and one capsule of 100 mg to maintain accuracy and to match the physical medication cards and quantities with corresponding physician orders.During a review of the facility's policy and procedure (P&P) titled, Controlled Medications, dated 4/20028, the P&P indicated, Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, storage, disposal, and recordkeeping in the facility, in accordance with federal and state laws and regulations. C. When a controlled medication is administered, the licensed nurse administering the medication immediately enters the following information on the accountability record and the medication administration record (MAR): 1) Date and time of administration, 2) amount administered, 3) signature of the nurse administering the dose on the accountability record at the time the medication is removed from the supply, 4) Initials of the nurse administering the dose on the MAR after the medication is administered.

Based on interview and record review, the facility's Quality Assessment and Assurance Committee (QAA) failed to ensure effective oversight and implementation of the facility's plan of correction (POC) of the deficient practices identified during the last recertification survey in 2024.This failure resulted in the facility to have repeat deficiencies in pharmacy services, quality of care and infection control.Findings:During a review of the facility's Statement of Deficiencies for the 2024 Recertification survey indicated the following repeat deficiencies in pharmacy services, quality of care and infection control.During a concurrent interview and record review on 7/18/2025 at 3:27 pm with the Administrator (ADM), the Quality Assurance Performance Improvement (QAPI- a data driven proactive approach to improvement used to ensure services are meeting quality standards) was reviewed. The ADM stated that QAPI was an ongoing program in the facility where the QAPI team analysis data and statistics to evaluate and identify concerns in the building to improve the quality of care for the residents. The ADM stated she was not sure what happened, she only started working at the facility two months ago.During a review of the facility's policy and procedure (P&P), titled Quality Assurance and Performance Improvement (QAPI) Program, dated, 12/2024, the P&P indicated, It is the policy of this facility to provide a process to evaluate and monitor the ongoing quality of services and care provided to residents through the facility's quality assessment and assurance committee, which will be referred to by the facility as the Quality Assurance Performance Improvement (QAPI) committee. The QAPI committee identifies and addresses specific care, and quality issues and implements an action plan to resolve these issues. The goal of the QAPI committee is to promote excellence in quality of care, quality of life, resident choice, person directed care and resident transitions. All systems that affect resident and family satisfaction, quality of care and services provided, and all areas that affect the quality of life for residents and employees will be addressed.

Based on interview and record review the facility failed to ensure five of five sampled employees Certified Nursing Assistant (CNA) 2, CNA 5, , CNA 6, Licensed Vocational Nurse (LVN) 4, Director of Rehabilitation (DOR) and CNA 4 were offered the Covid-19 (an infectious disease caused by the SARS-CoV-2 virus) vaccine (a substance that is put into the body of a person to protect them from a disease) .This failure had the potential to place all residents and staff at risk for infection of Covid 19.Findings:During an interview on 7/18/2025 at 10:17 a.m., with the Infection Preventionist Nurse, (IPN), the IPN stated upon hire she makes sure employees have their Covid 19 immunization (the process of making a person resistant to a disease, typically through the administration of a vaccine) and any other immunizations. The IPN stated she offers employees the flu vaccine, Covid 19 vaccine, hepatitis vaccine and TDAP (a vaccine that protects against three diseases: tetanus, diphtheria, and pertussis). The IPN stated if the employee declines a vaccine the employee will sign the employee declination form. The IPN stated she provides education about the vaccine and re-offers the vaccine to staff. The IPN stated if the employee wants the vaccine facility will administer the vaccine to the employee. The IPN stated she had a Covid 19 clinic in June and July 2025 and offered the Covid-19 vaccine to employees. The IPN stated she does not have documentation of employees declining the COVID 19 vaccine. The IPN stated she should have documented if the employees were offered the Covid 19 vaccine. The IPN stated it was important to offer the vaccines for the prevention of flu, Covid 19, and pneumonia. The IPN stated it was important to offer vaccines to staff to protect residents, lessen the severity of illness, and prevent potential outbreaks. During an interview on 7/18/2025 at 3:44 p.m., with the Director of Nursing (DON), the DON stated the IPN needs to document if staff was offered the Covid-19 vaccine and should be offered upon hire. The DON stated vaccination was to protect staff and resident and prevent them from getting sick from Covid 19.During a review of facility's policy and procedure (P&P) titled Coronavirus Vaccine Policy dated 02/2025, the P&P indicated COVID 19 vaccinations will be offered to all staff and residents.unless such immunizations are medically contraindicated, the individual has already been immunized during this time period or the individual refuses to receive the vaccine. The facility will maintain documentation for all residents and staff on COVID 19 vaccinations status.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to:1. Store, label and/or discard Resident 41 or 42's Epogen ([generic name - epoetin alfa] a medication used to treat anemia [low red blood cell count]) and Resident 100's Retacrit ([generic name - epoetin alfa-epbx] a medication used to treat anemia) in accordance with manufacturer's specifications and facility's policy and procedure (P&P) titled, Vials and Ampules of Injectable Medications, dated 4/2008, affecting one of one inspected medication room (Medication Room).2. Ensure removal of expired docusate sodium (a medication used to relieve constipation), Resident 55's latanoprost (a medication used to treat high eye pressure) eye drops from the medication cart, and ensure Resident 76's Basaglar ([generic name - insulin glargine] a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication), Resident 63's insulin lispro pen and Resident 77's insulin lispro pen were labeled with an open date, in accordance with manufacturer's specifications and facility's policy and procedure (P&P) titled, Storage of Medications, dated 4/2008, affecting two of three inspected medication carts inspected (Middle Medication Cart Skilled Nursing Facility [SNF] side and Medication Cart 2 Subacute).3. Ensure the facility's licensed nursing staff did not leave Resident 40's medications unattended, that included artificial tears eye drops, calcium carbonate (a supplement used to relieve acid reflux), prednisone (a medication used to treat inflammation), Eliquis ([generic name - apixaban] a medication used to prevent blood clots, midodrine (a medication used to treat low blood pressure) and levetiracetam (a medication used to treat seizure [a medical term used to describe sudden, uncontrolled burst of electrical activity in the brain] oral solution, affecting one of seven residents observed during medication administration (Resident 40).4. Maintain a clean and safe environment for medication storage in two out of three inspected medication carts, by failing to remove and dispose of medications, discarded and used vials that were stored in unsealed red biohazard containers in an irretrievable manner (Medication Cart 2 Subacute and Medication Cart 3 Subacute). These deficient practices resulted in an unclean and unsecure environment for medication storage, had the potential to result in medication errors, and Residents 40, 41 or 42, 55, 63, 76 and 77 receiving medications that were discontinued, expired, ineffective, or toxic due to improper storage and labeling possibly leading to adverse health consequences such as anemia, eye complications, abnormal blood glucose levels and hospitalization. Findings:1. During a concurrent observation and interview on [DATE] at 4:43 p.m. with Registered Nurse Supervisor (RNS) 3, in Medication Room Refrigerator Subacute, the medication refrigerator contained the following medications that were found stored in a manner contrary to manufacturer requirements:a. One open multidose vial of Epogen 20,000 units per milliliters ([mL] a unit of measurement for volume) with no opened date label for Resident 41 or 42.b. Two unopened multidose vials of Epogen 20,000 units/mL for Resident 41 or 42.According to the manufacturer's product labeling, a multidose vial would be stable for up to 21 days when stored at 2-to-8 degrees Celsius ([ C] is a unit of temperature [36-to-46 degrees Fahrenheit ([ F] is a unit of temperature) after it was opened.c. One open single dose vial of Retacrit 10,000 units/mL for Resident 100.d. One unopened single-use or single dose vial of Retacrit 10,000 units/mL for Resident 100.According to the manufacturer's product labeling, unopened single-use vials should be stored between 2 and 8 C (36 and 46 F) and unused portions of single-use should be discarded and not reused.RNS 3 stated the licensed nurse staff should have discarded the partial dose from the single use vial because the single dose vials should not be reused because it would increase the risk for infection. RNS 3 stated the single dose vial would not be safe or effective for residents to treat anemia.2a. During a concurrent observation and interview on [DATE] at 12:39 p.m. with Licensed Vocational Nurse (LVN) 5 of Middle Medication Cart SNF, the medication cart contained the following medications either expired, or stored and labeled in a manner contrary to the facility's P&P titled, Storage of Medications and manufacturer requirements:a. One opened bottle of docusate sodium 100 milligrams ([mg] a unit of measurement for mass) with an expiration date of 7/2025.LVN 5 stated it would not be safe for facility residents to receive an expired medication, and docusate sodium should have been removed from the medication cart three months before its expiration date.b. One bottle of opened latanoprost eye drops with an opened date of [DATE] for Resident 55.According to the pharmacy label on latanoprost eye drops, the unused portion of the medication was supposed to be discarded after 28 days.LVN 5 stated Resident 55's latanoprost eye drops should have been removed from the medication cart after 28 days, on [DATE], for the resident's safety. LVN 5 stated there was a risk for eye irritation, and the medication would not be effective for treating glaucoma.c. One unopened Basaglar 100 units/mL KwikPen with no open date or date it was removed from the refrigerator for Resident 76.According to the manufacturer's product labeling, the unopened / not in-use prefilled pen should be stored at 36 F to 46 F (2 C to 8 C) and opened / in-use prefilled pen, if stored at room temperature (up to 30 C [86 F]) must be discarded after 28 days. LVN 5 stated Resident 76's Basaglar was not opened but should have been labeled with an opened date when it was removed from refrigerator to be able to determine its expiration date. LVN 5 stated the medication would not be safe or effective in controlling blood glucose levels for Resident 76.2b. During a concurrent observation and interview on [DATE] at 2:23 p.m. with LVN 3, of Medication Cart 2 Subacute, the medication cart contained the following medications stored and labeled in a manner contrary to the facility's P&P titled, Storage of Medications and manufacturer requirements:a. One opened insulin lispro kwikpen 100 units/mL with no open date for Resident 77.b. One insulin lispro kwikpen 100 units/mL with no open date for Resident 63.According to the manufacturer's product labeling, once opened / in-use or once stored at room temperature, insulin lispro must be used within 28 days or be discarded.LVN 3 stated i would say dangerous and in other words, it would not be safe or effective to give expired or insulin with no opened date to the residents. LVN 3 stated it would not help manage blood glucose levels for the residents.During an interview on [DATE] at 5:14 p.m. with the Director of Nursing (DON), DON stated she would need to double check with the pharmacy, but facility staff should have discarded the multidose vials after they were opened. DON stated the medications should have been removed from the medication cart before they expired at least one month before the expiration date. DON stated those medications requiring refrigeration such as insulin and some eye drops should have an open date to be able to determine their expiration date after they were removed from the refrigerator.3. During a concurrent observation and interview on [DATE] at 9:45 a.m. with LVN 4, LVN 4 prepared the following six medications to be administered to Resident 40:a. A vial of artificial tears (a medication used to treat dry eyes) eye drops to administer one drop for the right eyeb. One tablet of calcium carbonate (a medication used to treat symptoms of acid reflux) 500 milligrams ([mg] a unit of measurement for mass)c. One tablet of prednisone (a medication used to treat inflammation and pain) 5 mgd. One tablet of Eliquis ([generic name - apixaban] a medication used to treat blood clots) 2.5 mge. One tablet of midodrine 2.5 mgf. 7.5 milliliters ([mL] a unit of measurement for volume) of levetiracetam (a medication used to treat seizures [sudden, uncontrolled electrical disturbances in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness]) 100 mg per mLLVN 4 entered Resident 40's room, placed the medications on the bedside cart and stepped away to go to the medication cart and observed looking for something. LVN 4 returned to the resident's bedside and resumed medication administration.During an interview on [DATE] at 2:05 p.m. with LVN 4, LVN 4 stated it was important to secure and keep the medications safe and should not have left them unattended. LVN 4 stated he should not have turned around to get the alcohol wipes to sanitize the tip of the artificial tears eye drops bottle.During an interview on [DATE] at 11:48 a.m. with DON, DON stated the licensed nursing staff should have been careful not leaving medications unattended for safety reasons and to prevent accidental ingestion. 4a. During a concurrent observation and interview on [DATE] at 2:42 p.m. with LVN 3, of Medication Cart 2 Subacute, the medication cart contained one red container with a transparent/clear open lid, filled with several retrievable empty looking Heparin (a medication administered as an injection to prevent blood clots) vials and other medication vials in the bottom drawer. LVN 3 stated there was a risk that someone could reach in and misuse the vials and it was a potential hazard. LVN 3 stated the vials should have been thrown in the Sharps container on the side of the cart which would be more secure and irretrievable.4b. During a concurrent observation and interview on [DATE] at 2:55 p.m. with LVN 8, of Medication Cart 3 Subacute, the medication cart contained one red container with transparent/clear open lid, filled with several retrievable unlabeled/unidentified tablets, capsules, empty looking shells of capsules in the bottom drawer. LVN 8 stated she should have disposed of the contents in biohazard container before it got full to ensure safety and to make sure it was irretrievable. During an interview on [DATE] at 5:14 p.m. with the DON, DON stated the staff should have followed the facility's medication disposal policy by disposing of the empty heparin vials in the red sharps container but also covered with water or powder to make them irretrievable and discarded when it was three-quarters (3/4) full. DON stated the container with tablets and empty capsule shells should have been emptied out by staff frequently so that it became irretrievable. During a review of the facility's P&P titled, Medication Administration, dated 4/2025, the P&P indicated, The expiration date on the medication label must be checked prior to administration. When a multi-dose container is opened, the date opened should be recorded on the container. Vials labeled as single dose, or single use should not be used on multiple residents. These vials will only be used for one resident in a single procedure.During a review of the facility's P&P titled, Storage of Medications, dated 4/2008, the P&P indicated, Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized. The P&P indicated, M. Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication disposal, and reordered from the pharmacy if a current order exists. N. Medication storage areas are kept clean, well-lit, and free of clutter and extreme temperatures.During a review of the facility's P&P titled, Vials and Ampules of Injectable Medications, dated 4/2008, the P&P indicated, Vials and ampules of injectable medications are used in accordance with the manufacturer's recommendations or the provider pharmacy's directions for storage, use, and disposal. B. The date opened and the initials of the first person to use the vial are recorded on multi-dose vials (on the vial label or an accessory label affixed for that purpose). C. Ampules and single-use vials (containing no preservative) are discarded immediately after use.During a review of the facility's P&P titled, Medication Destruction, dated 4/2008, the P&P indicated, All medications are placed in the proper waste container per facility policy. Medication destruction occurs in the presence of two licensed nurses.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain a medication error rate of less than 5% (percent) during medication pass for two of seven sampled residents (Residents 40 and 80) by failing to:1. Administer Resident 40's artificial tears eye drops in the correct eye in accordance with physician orders.2. Administer Resident 80's metformin (a medication used to treat high blood glucose) within one hour of its scheduled time of administration as per facility's policy and procedure (P&P) titled, Medication Administration, dated 4/2025.These deficient practices resulted in a medication administration error rate of 5.71%, which exceeded the 5% threshold and had the potential to cause eye complications for Resident 40, hyperglycemia (high blood glucose) for Resident 80 and hospitalization for Residents 40 and 80.Findings:1. During a review of Resident 40's admission Record, dated 7/16/2025, the admission Record indicated Resident 40 was originally admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including tracheostomy (a surgical procedure to create an opening in the neck and into the trachea [windpipe] to allow for breathing when the upper airway is blocked or when prolonged breathing assistance is needed) status and unspecified glaucoma (an eye condition that increased eye pressure).During a review of Resident 40's Minimum Data Set (MDS -resident assessment tool), dated 6/13/2025, the MDS indicated Resident 40's cognition (ability to think, understand, learn, and remember) was intact. The MDS indicated Resident 40 needed setup or clean-up assistance from the facility staff for activities of daily living (ADLs) such as eating, supervision assistance for oral hygiene, moderate assistance for upper body dressing and personal hygiene, maximal assistance for lower body dressing, putting on or taking off footwear, and dependent for toileting hygiene.During a concurrent observation and interview on 7/16/2025 at 9:45 a.m. with Licensed Vocational Nurse (LVN) 4, LVN 4 prepared the following six medications to be administered to Resident 40:a. A vial of artificial tears eye drops to administer one drop for the right eyeb. One tablet of calcium carbonate (a medication used to treat symptoms of acid reflux) 500 milligrams ([mg] a unit of measurement for mass)c. One tablet of prednisone (a medication used to treat inflammation and pain) 5 mg.d. One tablet of Eliquis (generic name - apixaban] a medication used to treat blood clots) 2.5 mge. One tablet of midodrine 2.5 mgf. 7.5 milliliters ([mL] a unit of measurement for volume) of levetiracetam (a medication used to treat seizures [sudden, uncontrolled electrical disturbances in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness]) 100 mg per mLLVN 4 was not observed washing hands after preparing medications, before wearing gloves and before administering artificial tears eye drops to Resident 40. LVN 4 administered one drop of artificial tears into Resident 40's left eye. Resident 40 had a trach tube so she could not speak. Resident 40 signaled to LVN 4 using hand gestures to inform him that he administered the eye drops in the wrong eye. LVN 4 stated oh I'm sorry, let me administer in your right eye.During a medication reconciliation review on 7/16/2025 at 1:12 p.m., Resident 40's Order Summary Report, dated 6/1/2025 and 7/17/2025 indicated the following physician order: Artificial Tears Ophthalmic (eye) Solution (carboxymethylcellulose sodium) instill 1 drop in right eye four times a day for dry eyes/itchiness, order date 4/4/2023, start date 4/4/2023.During an interview on 7/16/2025 at 2:05 p.m. with LVN 4, LVN 4 stated he made a mistake and administered artificial tears eye drops in Resident 40's left eye instead of right eye. LVN 4 stated it was important to follow physician orders, and this mistake could have caused an eye reaction, redness or itching.During an interview on 7/17/2025 at 11:48 a.m. with the Director of Nursing (DON), the DON stated there was a risk for side effects in the eye such as redness, itching and irritation if the artificial tears eye drops were not administered in the correct eye as indicated on the physician order.2. During a review of Resident 80's admission Record, dated 7/16/2025, the admission Record indicated Resident 80 was originally admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included but not limited to, type 2 diabetes mellitus ([DM]-a disorder characterized by difficulty in blood sugar control and poor wound healing) without complications, essential (primary) hypertension (high blood pressure), acute embolism (a blood clot that can travel to other parts of the body) and thrombosis (blood clotting) of unspecified deep veins of unspecified lower extremity.During a review of Resident 80's History and Physical (H&P), dated 4/30/2025, the H&P indicated Resident 80 had the capacity to understand and make decisions.During a review of Resident 80's MDS, dated [DATE], the MDS indicated Resident 80's cognition was intact. The MDS indicated Resident 80 needed supervision or touching assistance from the facility staff for eating, moderate assistance for oral hygiene, maximal assistance for upper body dressing and personal hygiene, and dependent on staff for toileting hygiene, showering, lower body dressing and putting on or taking off footwear.During an observation on 7/16/2025 at 10:14 a.m., LVN 5 prepared the following eight medications to be administered to Resident 80:a. One tablet of vitamin D3 (a vitamin used to treat low level of vitamin D) 25 micrograms ([mcg] a unit of measurement for mass)b. One tablet of amlodipine (a medication used to treat high blood pressure) 10 mgc. One tablet of hydralazine (a medication used to treat high blood pressure) 50 mgd. One tablet of metoprolol tartrate (a medication used to treat high blood pressure) 50 mge. One tablet of lisinopril (a medication used to treat high blood pressure) 20 mgf. One tablet of levetiracetam (a medication used to treat seizures) 750 mgg. One tablet of vitamin C (a vitamin used to treat low level of vitamin C) 500 mgh. One tablet of metformin (a medication used to treat high blood glucose) 500 mgDuring a medication reconciliation review on 7/16/2025 at 1:32 p.m., Resident 80's Order Summary Report, dated 7/17/2025 indicated the following physician order scheduled to be administered daily at 8:00 a.m.: Metformin hydrochloride (HCl) oral tablet 500 mg, give 1 tablet by mouth in the morning for DM, give with breakfast, order date 6/9/2025, start date 6/10/2025.During a review of Resident 80's Medication Administration Audit Report, dated 7/1/2025 to 7/17/2025, the Medication Administration Audit Report indicated metformin 500 mg was administered late for eight times to Resident 80.During a concurrent interview and record review on 7/16/2025 at 3:30 p.m. with LVN 5, the order details and administration date and time details, dated 7/16/2025 for Resident 80's metformin 500 mg were reviewed. The order details for metformin 500 mg indicated, metformin 500 mg, one tablet by mouth every day in the morning, give with breakfast, with the specific time for administration as 8:00 a.m. The administration details indicated, metformin 500 mg was documented as administered to Resident 80 on 7/16/2025 at 10:16 a.m. LVN 5 stated Resident 80's metformin 500 mg was scheduled to be administered daily at 8:00 a.m. but she administered the medication on 7/16/2025 at 10:15 a.m. which was late on by one hour and 15 minutes. LVN 5 stated there was a risk of elevated blood glucose levels for Resident 80. During an interview on 7/17/2025 at 12:12 p.m. with the DON, the DON stated nurses were supposed to administer medications one hour before or one hour after their scheduled time of administration and it would be considered as late administration if the medication was administered later than one hour from the scheduled time of administration. The DON stated if a resident received metformin late then there would be a risk for resident to experience hyperglycemia (high blood glucose) or hypoglycemia (low blood glucose).During a review of the facility's P&P titled, Medication Administration, dated 4/2025, the P&P indicated, Medications must be administered within one (1) hour before or after their prescribed time, unless otherwise specified, i.e., before and after meal orders. The licensed nurse administering the medication must check the label to verify the right resident, the right medication, the right dosage, the right time, and route of administration before giving the medication.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 75) was free of unnecessary physical restraints (any object or device that an individual cannot remove easily which restricts freedom of movement) by failing to:1.Ensure physician order for the use of restraint was obtained before initiating a physical restraint in the form of a sock which covered the right arm and right hand with tape wrapping the fingers.2. Ensure an assessment and monitoring of the use of physical restraint for the right arm and hand were implemented and documented.This failure had the potential to place Resident 75 at risk for unnecessary prolonged use of restraints, and could lead to decline in physical functioning, impaired blood circulation, and skin injuries. Findings:During a concurrent observation and interview on 7/15/2025, at 10:35 a.m. in the room of Resident 75 with a family member (FM1), Resident 75's right arm and right hand were covered with a blue sock with white tape wrapped around the portion of the fingers. During a review of Resident 75's admission Record, the admission Record indicated the resident was initially admitted on [DATE] and was readmitted on [DATE] to the facility with diagnoses including anoxic brain damage(occurs when the brain was completely deprived of oxygen causing brain cells to die leading permanent problems like memory loss, or trouble speaking ) , diabetes mellitus(DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), gastrostomy(a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) dysphagia (difficulty of swallowing) and encephalopathy(disturbance of brain function).During a review of Resident 75's Minimum Data Set (a resident assessment tool) dated 6/7/2025, the MDS indicated Resident 75 had unclear speech and was rarely or never understood. The MDS indicated the resident was dependent (helper does all the effort to complete the activity) on the staff with bathing, dressing, dressing, toileting hygiene, bed mobility and oral hygiene.During a review of Resident 75's History and Physical (H&P) dated 3/5/2025, the H&P indicated the resident did not have the capacity to understand and make decisions.During a review of Resident 75's Order Summary Report on 7/15/2025 at 12:00 p.m., the Order Summary Report did not indicate any order for physical restraint for resident's right arm or right hand.During a review of Resident 75' medical chart on 7/15/2025 at 4:30 p.m., the medical chart did not indicate a consent for the use of a restraint for the right arm.During an interview on 7/15/2025 at 1:43 p.m. with Certified Nursing Assistant (CNA) 3 in Resident 75's , CNA 3 stated the blue sock that was applied on the right arm and hand of Resident 75 was a mitten to protect the gastrostomy tube (GT- tube inserted through the abdomen directly into the stomach for feeding and medication administration ) from being pulled out by the resident.During an interview on 7/16/2025 at 1:50 p.m. with CNA 1, CNA1 stated the blue sock on his hand was a form of restraint and could cause impairment of Resident 75's skin circulation and restrict the movement of his right arm and hand. During an interview on 7/16/2025 at 2:05 p.m. with Licensed Vocational Nurse (LVN) 1, LVN1 stated the blue sock on the right arm and hand should have been removed by the staff and obtained a physician order for a physical restraint because the blue sock could cause skin problems and poor circulation.During an interview on 7/17/2025, at 4:50 p.m. with RN Supervisor (RNS) 1, RNS 1 stated the family of Resident 75 requested the sock on the right arm of the resident. RNS1 agreed it was the responsibility of the facility to monitor and assess the use of the restraint on Resident 75. RNS 1 stated Resident 75 could develop impaired skin and poor circulation because of the skin being covered and not being checked by staff. RNS 1 stated prior to initiating a form of physical restraint on a resident, the facility should use the least restrictive measure by redirecting the behavior, checking the resident more often or utilizing the family member to watch the resident. RNS 1 stated monitoring and assessment of the use of restraints should be documented on the residents' chart.During an interview on 7/18/2025, at 10:43 a.m. with the Director of Nursing (DON), the DON stated there should be a physician order, consent for the placement of restraint, assessment and monitoring for the use of restraint and quarterly restraint assessment to ensure if the resident still requires the use of restraint. The DON stated the blue sock used a restraint was not acceptable form of restraint because the material is not breathable and could make Resident 75's skin prone to breakdown and cause restriction on the movement of his right arm and hand. The DON stated the staff should have removed the sock from Resident 75's right arm, assessed the need for the use of restraint and notified the physician that the resident required a hand mitten or restraint to obtain an order.During a review of facility's policy and procedure (P&P) titled, Physical Restraints. revised 9/2017, the P&P indicated restraints will only be used after other alternatives have been tried unsuccessfully and only after a thorough assessment, informed consent from the resident or their responsible party, a physician's order and a care plan to address the use of restraints. The P&P indicated the facility may not use restraints based on the legal surrogate or representative's request and family must be educated for the risks of restraint usage. The P&P indicated the only acceptable forms of physical restraints shall be soft ties (soft cloth which does not cause abrasions and does not restrict circulation), soft cloth mittens, seatbelts and trays with spring release devices, and to use restraints that can be easily removed under the supervision of the staff.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, Licensed Vocational Nurse (LVN) 4 failed to ensure Resident 8's Acidophilus ([generic name - lactobacillus] a probiotic supplement used to improve gut health) was completely dissolved before being administered via gastrostomy tube (g-tube - a surgically placed tube used to administer medications or food directly into the stomach). LVN 4 failed to safely administer medications via g-tube by failing to follow infection control practices throughout medications administration, for one of seven sampled residents observed during medication administration. This failure to administer g-tube medications for Resident 8 in accordance with professional standards of care and increased the risk for discomfort, clogging of g-tube, infection and contamination of medications. Findings:During a review of Resident 8's admission Record, dated 7/16/2025, the admission Record indicated, Resident 8 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included but not limited to, sepsis (a life-threatening blood infection), chronic kidney disease (a condition where the kidneys are damaged and cannot filter blood as well as they should), gastrostomy status, personal history of urinary tract infections (infection in any part of the urinary system), pneumonia (an infection/inflammation in the lungs) and history of other infectious and parasitic diseases.During a review of Resident 8's History and Physical (H&P), dated 2/4/2025, the document indicated Resident 8 did not have the capacity to understand and make decisions.During a review of Resident 8's Minimum Data Set (MDS-resident assessment tool), dated 4/21/2025, the MDS indicated Resident 8 was on g-tube feedings, fully dependent on facility staff for Activities of Daily Living (ADLs) such as oral hygiene, toileting hygiene, showering, upper and lower body dressing, putting on or taking off footwear and personal hygiene.During a concurrent observation and interview on 7/16/2025 at 9:00 a.m. with LVN 4, LVN 4 prepared the following six medications and supplements by crushing them individually using a crushing device to be administered to Resident 8 via g-tube. LVN 4 stated he used five to 10 milliliter( ml-unit of measurement) water to dissolve each medication separately.1. One tablet of buspirone (a medication used to treat anxiety [a medical condition described by feeling of fear or uneasiness]) 5 milligrams ([mg] - a unit of measurement for mass)2. One tablet of metformin (a medication used to treat diabetes mellitus [DM]-a disorder characterized by difficulty in blood sugar control and poor wound healing) 500 mg3. One tablet of metoclopramide (a medication used to treat gastroesophageal reflux disease ([GERD - digestive disorder where stomach acid frequently flows back into the esophagus, causing irritation and discomfort], and nausea and vomiting) 5 mg4. One tablet of sucralfate (a medication used to treat and prevent ulcer) 1 gram ([g] a unit of measurement for mass)5. Ferrous sulfate (a medication used to treat low level of iron) 7.5 milliliters ([mL] a unit of measurement for volume) 200 mg/5 mL 6. One capsule of AcidophilusLVN 4 started to use syringe to pull out water from water cup to use it as flush for g-tube, before starting to administer medications. The surveyor prompted LVN 4 to explain his steps, which was when LVN 4 corrected his technique by using the gravity method instead, to flush g-tube by administering 30 mL water into the syringe. The water started flowing out of the g-tube onto Resident 8's bed. LVN 4 stated Oh sorry, I didn't adjust the clamp on the g-tube for medication administration. LVN 4 fixed the issue and continued to administer medications one by one using gravity method followed by water in between each medication. LVN 4 then stepped away from the bedside with the syringe in his hand that was used to administer water and g-tube medications, and walked to the medication cart, which exposed the syringe to other factors in the environment. LVN 4 returned to bedside with the same syringe and resumed medication administration. During the administration of Acidophilus through the syringe into g-tube, the syringe looked cloudy with its powder stuck on the walls of the syringe. LVN 4 stated he will add more water to dissolve the powder. LVN 4 was not able to administer the remaining powdered solution through g-tube. LVN 4 then pushed with the syringe plunger which helped the remaining Acidophilus to be administered via g-tube to Resident 8. During a review of Resident 8's Order Summary Report, dated 7/17/2025, the Order Summary Report indicated but not limited to the following physician orders: Acidophilus oral tablet, give 1 tablet via g-tube one time a day for supplement, order date 1/31/2025, start date 2/1/2025. Buspirone hydrochloride (HCl) tablet 5 mg, give 1 tablet via g-tube every 12 hours for anxiety manifested by (m/b) inability to relax, order date 1/31/2025, start date 2/1/2025. Carafate ([generic name - sucralfate] oral tablet 1 g, give 1 tablet via g-tube four times a day for gastroesophageal reflux disease (GERD - digestive disorder where stomach acid frequently flows back into the esophagus, causing irritation and discomfort)/gastritis, order date 6/22/2025, start date 6/22/2025. Ferrous sulfate oral solution 220 (44 iron [Fe] mg per 5 ml, give 7.5 ml via g-tube one time a day for supplement, give 7.5 ml = 330 mg, order date 5/5/2025, start date 5/6/2025. Metformin HCl oral tablet 500 mg, give 1 tablet via g-tube two times a day for order date 1/31/2025, start date 2/1/2025. Metoclopramide HCl oral tablet 5 mg, give 1 tablet via g-tube every 12 hours for GERD, order date 1/31/2025, start date 2/1/2025.During an interview on 7/16/2025 at 2:47 p.m. with LVN 4, LVN 4 stated it was his mistake that he did not make sure to close the g-tube bulb so that water did not leak out of the g-tube. LVN 4 stated the Acidophilus was not properly dissolved, so it was not moving through the g-tube smoothly and was possibly getting stuck, clogging the g-tube. LVN 4 stated it was important to dissolve the medications and supplements well before administering them via g-tube. LVN 4 stated he should not have taken the syringe with him to the medication cart, away from the resident's care area. LVN 4 stated he should have changed his gloves and sanitized hands if he needed to move away from resident's care area to prevent contamination.During an interview on 7/17/2025 at 11:48 a.m. with the Director of Nursing (DON), the DON stated the facility nursing staff should make sure that the medications and supplements were dissolved well before administering via g-tube, otherwise they could clog the g-tube, prevent medications and supplements from moving through the g-tube smoothly, and gravity method might not work. The DON stated the correct technique to administer g-tube medications was by using gravity and water should not be pulled inside syringe. The DON stated LVN should have closed the clamp as they were pouring water or medications so that it did not leak out of the opening. The DON stated if the nurses used the wrong g-tube technique then the residents would not be treated for their conditions properly and would not receive medications effectively. The DON stated it would increase the risk of clogging the g-tube if the medication was not dissolved well. The DON stated the facility nurse should not be bringing the syringe away from the resident's care area to prevent contamination and infection.During a review of the facility's policy and procedure (P&P) titled, Medication Administration via Enteral Tube, dated 4/2017, the P&P indicated, Crushed tablets should be dissolved with at least 10 cc (mL) of water or other appropriate liquid. Administer medications: 1. Allow each medication to flow down the tube by gravity.During a review of the facility's P&P titled, Hand Hygiene, dated 7/2019, the P&P indicated, It is the policy of the facility that all staff members perform hand hygiene before and after direct resident care and after contact with potentially contaminated substances to prevent, to the extent possible, the spread of infection. Hand hygiene will be performed by staff as follows: during care when moving from a contaminated activity to a clean activity (for example.clothing).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 2) was free from verbal abuse when Licensed Vocational Nurse (LVN) 2 cursed at her.
This deficient practice resulted in Resident 2 feeling unsafe when LVN 2 was working in the facility. This deficient practice had the potential to cause psychosocial (mental, emotional, and social) harm.
Findings:
During a review of Resident 2's admission Record (Face Sheet), the Face Sheet indicated Resident 2 was admitted to the facility on [DATE] with a diagnosis of anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities).
During a review of Resident 2's Minimum Data Set ([MDS] resident assessment tool) dated 2/5/2025, the MDS indicated Resident 2 was mildly cognitively (ability to think and reason) impaired.
During a review of the facility's Investigation Report dated 2/26/2025, the Investigation Report indicated on 2/25/2025 Resident 2 requested to speak to Licensed Vocational Nurse (LVN) 2 regarding her (Resident 2's) medication. The Investigation Report indicated LVN 2 told Resident 2 that she had already given her, her medication. The Investigation Report indicated Resident 2 asked LVN 2 if her doctor had spoken to the psychiatrist regarding her medication. The Investigation Report indicated Resident 2 cursed at LVN 2 who cursed back at Resident 2.
During an interview on 3/5/2025 at 12:26 p.m., Resident 2 stated on 2/25/2025, sometime around 8 p.m., LVN 2 came in her room angry because she (Resident 2) requested to speak with her. Resident 2 stated LVN 2 was yelling and stated she was on her break and had already given her, her medication. Resident 2 stated she expressed to LVN 2 that she did not feel right and wanted to the dosage of her medication adjusted. Resident 2 stated LVN 2 reminded her again that she was on her break, so she (Resident 2) told her Family Member (FM) who was on the phone with her, that LVN 2 was a f****ing b**** and LVN 2 responded no you're a f****** b****. Resident 2 stated she was angry and that LVN 2 responded to her that way, when all she wanted was for LVN 2 to contact her physician about her medication. Resident 2 stated LVN 2's response triggered her which was why she cursed at LVN 2. Resident 2 stated she did not feel safe the rest of the shift with LVN 2 as her nurse.
During an interview on 3/5/2025 at 1:09 p.m., Resident 4 stated she witnessed LVN 2 curse at Resident 2 on 2/25/2025. Resident 4 stated it was upsetting to see that LVN 2 had no patience or and empathy when Resident 2 cursed at her, and she was disappointed how aggressive and brutal (yelling and curing) LVN 2's response was to Resident 2.
During an interview on 3/5/2025 at 2:13 p.m., LVN 2 stated on 2/25/2025, while she was on break, CNA 1 informed her that Resident 2 wanted to speak to her about her medication. LVN 2 stated she was on break but went to see Resident 2 to make sure it was nothing urgent. LVN 2 stated she informed Resident 2 that she had given her all of her medications, but Resident 2 told her she did not feel right and believed there had been changes made to her medication and wanted to discuss it with her physician. LVN 2 stated she asked Resident 2 if she had discussed this with any of the other nurses and began looking into her chart to see if there were any changes but was not able to find any. LVN 2 stated, Resident 2 told her next time do not come here on your break. LVN 2 stated Resident 2 called her a b**** to which she (LVN 2) replied, If I'm a b**** you are one too. LVN 2 stated she was shocked that she cursed back at Resident 2 and had not been able to sleep since it happened. LVN 2 stated she resigned from the facility after that.
During an interview on 3/5/2025 at 3:19 p.m., the Director of Nursing (DON) stated LVN 2 was suspended for verbally abusing Resident 2. The DON stated verbal abuse by LVN 2 towards Resident 2 was inappropriate and could cause mental or emotional harm. The DON stated LVN 2 resignedbefore her suspension ended.
During a review of facility's Policy and Procedure (P&P) titled Residents Rights dated 9/2017, the P&P indicated residents had the right to be free from mental and physical abuse.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement its abuse reporting and prevention policy titled, unusual Occurence Reported dated 8/2018 by failing to report an unusual occurrence of swelling of the left thigh due to unkown source, to the appropriate State Agencies, including the California Department of Public Health (CDPH) and the local Ombudsman, within 24 hours after the incident occurred for one of one sampled resident (Resident 1).
As a result of the facility's failure to report Resident 1's left thigh swelling due to unknown source CDPH ' s investigation regarding the circumstances of Resident 1's injury was delayed. This deficient practice placed Resident 1 and other totaly dependent residents with severely impaired cognition (ability to think, understand, learn, and remember), to be at-risk for abuse, neglect, or mistreatment.
During a review of Resident 1 ' s admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including dependence of renal (kidney) dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed), contracture (a stiffening/shortening at any joint, that reduces the joint's range of motion) of muscle on multiple sites, and protein and calorie malnutrition.
During a review of Resident 1 ' s History and Physical (H/P), dated 12/21/2024, the H/P indicated Resident 1 does not have the capacity to understand and make decisions.
During a review of Resident 1 ' s Minimum Data Set ([MDS], a resident assessment tool), dated 12/26/2024, the MDS indicated Resident 1 ' s cognition was severely impaired. The MDS indicated Resident 1 was dependent on facility staff on all aspects of activities of daily living (ADL: bathing, toileting, eating, dressing, personal hygiene). The MDS indicated Resident 1 had impairments bilaterally (on both sides) on the upper (arm/shoulders) and lower (hips/legs) extremities
During a review of Resident 1 ' s Situation, Background, Assessment and Recommendation ([SBAR] a form of communication between members of a health care team) dated 2/21/2025, the SBAR indicated Resident 1 had swelling on her left thigh (of unknown source).
During an interview on 2/27/2025 at 10:46 a.m., with Registered Nurse Supervisor (RNS) 3, RNS 3 stated if there was a witnessed abuse incident, she would call the police, notify the ombudsman (official appointed to investigate and resolve complaints), CDPH, and call the Administrator (ADM). RNS 3 stated any licensed nurses can fill out the Report of Suspected Dependent Adult/Elder Abuse (SOC341: form used to report suspected abuse/neglect of elder or dependent adult) and send it to the ombudsman. RNS 3 stated the incident has to be reported immediately within a two hour window. RNS 3 stated if no one reported the incident, the resident could continue to get injured or continue to experience harm.
During an interview on 2/27/2025 at 2:11 p.m., with the Director of Nursing (DON), the DON stated when she found out about Resident 1's left thigh swelling, she notified the ADM and the Medical Doctor 1 (MD 1) and did a thorough investigation with a look back period of three (3) days. The DON stated this was an unusual occurrence and the initial reporting should have happened on the same day. The DON stated staff should make an initial report to the appropriate agencies, as Resident 1's left thigh swelling was an unusual occurrence, and not reporting will compromise the residents safety.
During an interview on 2/27/2025 at 3:06p.m. with theADM, the ADM stated when she was notified of an abuse allegation, she gathered statements/claims, called the police, filled out a report and sent it to the ombudsman, State Survey Agency, and started the investigation the same day. The ADM stated facility staff would complete a body check and interview witnesses if there were any, which included staff that were assigned to the resident, staff that were close by or interacted with the resident.
The ADM stated she would interview the resident, if the resident was alert. The ADM stated, she would then submit a conclusion of the investigation within five (5) days to the appropriate parties. The ADM stated she was supposed to report this incident right away and knew she reported it late. TheADM stated she called the State Survey Agency on 2/24/2025 to report this unusual occurrence that was discovered on 2/21/2025 and on 2/25/2025 faxed the investigation report and the 5-day summary report. The ADM stated they are supposed to report and notify anything to the department that can impact those residents.
During a review of the facility's policy and procedure (P/P), titled, Abuse Reporting and Prevention dated 4/2024, the P/P indicated it is the policy of this facility to ensure that resident rights are protected by providing a method of investigation and reporting of alleged violations involving mistreatment, neglect, abuse including injuries of unknown sources, unusual occurrences. The administrator, as the abuse coordinator, will investigate each alleged violation thoroughly and report results to appropriate agencies and personnel. The administrator, or his/her designee, will report each alleged abuse to the Ombudsman's office and the Department of Public Health immediately or within 2 hours per Section 1418.91 of the Health and Safety Code. If the alleged violation does not involve abuse and does not result in serious bodily injury, the facility should report the violation within 24 hours. (Refer to number 1 and 2 below.) 1. Serious Bodily Injury - 2-hour limit: If the events that caused the reasonable suspicion of abuse resulted in serious bodily injury to a resident, the covered individual shall report the suspicion of abuse immediately, but not later than 2 hours after forming the suspicion. Any allegation of physical abuse should be reported within two hours. 2. All Others - Within 24 hours: If the alleged violation does not involve abuse and does not result in serious bodily injury to a resident. To summarize and simplify the above listed examples and definitions of abuse, this includes the following: Incidents of unknown origin. All alleged allegations and all substantiated incidents will be reported to the Department of Public Health and to all other agencies as required by State law, i.e., the local law enforcement agency, Certified Nursing Assistant certification board, appropriate licensing board and the local Ombudsman. The results of the investigation must be reported within 5 working days of the incident.
During a review of the facility's P/P, titled, Unusual Occurrence Reporting dated 8/2018, the P/P indicated It is the facility policy that, in accordance with federal and/or state regulations, unusual occurrences or other reportable events which affect the health, safety or welfare of residents, employees or visitors be reported. The facility will report the following events to the appropriate agencies: other occurrences that interfere with facility operations and affect the welfare, safety or health of residents, employees or visitors. Unusual occurrences shall be reported via telephone to appropriate agencies as required by current law and/or regulations within twenty-four (24) hours of such incident or as otherwise required by federal and state regulations. A written report detailing the incident and actions taken by the facility after the event shall be sent or delivered to the state agency (and other appropriate agencies as required by law) within forty-eight (48) hours of reporting the event or as required by federal and state regulations.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the resident, who had a history of acute stroke ([CVA]- loss of blood flow to a part of the brain) and complained of having a slurred speech, a headache, and severe pain in left arm was timely transferred to a general acute care hospital (GACH) to prevent ischemic (a condition that occurs when blood flow to an organ, muscle group, or tissue is reduced resulting in a lack of oxygen) stroke for one of three sampled residents (Resident 1).
The facility failed to:
1. Ensure Licensed Vocational Nurse (LVN unknown) assessed Resident 1 when Certified Nursing Assistant (CNA) 1, reported on 1/9/2025 at 1 p.m. Resident 1 complained of having severe pain in left arm rated 9 out of 10 on a pain scale (pain screening tool using numerical value to assess the level of pain ranging from 0 to 3-mild pain, from 4 to 6- moderate pain, and from 7 to 9-severe pain, and 10- the worse pain possible) and verbalized of not feeling right.
2. Ensure the licensed nurses transferred Resident 1 to the GACH when Resident 1's Family Member 1 (FM) 1 reported the resident was having symptoms of Transient Ischemic Attack ([TIA] - a brief period when blood flow to the brain is cut off) such as slurred speech and difficulty speaking.
3. Ensure the Nurse Practitioner (NP) 1 ordered Resident 1's transfer to GACH to prevent a delay in transferring the resident beyond acceptable three hours window to treat the resident with thrombolytic (a medical treatment used to dissolve blood clots) to prevent ischemic stroke.
4. Ensure staff follow the facility's policy and procedure (P&P) titled Emergency Care, revised 9/2017, which indicated to provide emergent care to a resident in need of urgent service; if a resident's condition is observed to have changed, assess the resident, notify the resident's attending physician, and report any changes in condition and provide emergency care as necessary.
5. Ensure staff followed the facility's P&P titled Change in Condition, revised 3/2021, which indicated the changes in the resident's condition be thoroughly assessed and evaluated with physician notification for early clinical management; thorough assessment will include all important information related to the resident such as onset of current symptoms, including vital signs.
These failures resulted in five hours delay in transferring Resident 1 to a GACH from the time Resident 1 reported having symptoms of TIA including, slurred speech, and difficulty speaking. These failures led to Resident 1 not being able to receive thrombolytic therapy to prevent from having ischemic stroke. Resident 1 was subsequently diagnosed with left frontal lobe ischemic stroke and to have permanent brain damage.
Findings:
During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body), hemiparesis (weakness on one side of the body) following a cerebral infarction (also known as a stroke, where blood flow to the brain is interrupted causing brain tissue to die) affecting the left side of the body, and trigeminal neuralgia (a chronic pain disorder affecting trigeminal nerve [provides sensation and controls muscles in the face and head]).
During a review of Resident 1's Minimum Data Set ([MDS] - resident assessment tool) dated 11/28/2024, the MDS indicated Resident 1's had intact cognition (ability to think and reason). The MDS indicated Resident 1 was dependent (helper does all the effort) on staff with lying to sitting on the side of the bed, from sitting to standing, and with transferring from the bed to chair.
During a review of Resident 1's SBAR (situation, background, assessment, recommendation - a communication tool used by healthcare workers when there is a change of condition among the residents) form dated 1/9/2025 timed at 3:00 p.m., the SBAR form indicated Licensed Vocational Nurse (LVN) 1 notified Physician (MD) 1 about Resident 1's inability to speak and a high blood pressure (BP) of 152/96 millimeters of mercury ([mm/Hg]- a unit of pressure used to measure blood pressure. Reference range for normal BP is less than 120/80 mm/Hg). The SBAR indicated MD 1 recommendations included to monitor Resident 1.
During a review of Resident 1's Nurses Progress Note dated 1/9/2025 for 7 a.m. to 3 p.m. shift, Nurses Progress Notes indicated Resident 1 was being monitored by LVN 1 when Certified Nursing Assistant (CNA) 1 reported Resident 1 was not able to speak.
During a review of Resident 1's Nurses Progress Note dated 1/9/2025 timed at 2:30 p.m., the Nurses Progress Note indicated CNA 1 reported to LVN 2 that Resident 1 wanted to speak to a supervisor or desk nurse. The Nursing Progress Note indicated LVN 2 assessed Resident 1 and Resident 1 did not have any new onset of symptoms.
During a review of phone text messages dated 1/9/2025 timed at 2:31 p.m., between LVN 2 and the Nurse Practitioner (NP) 1, the text messages indicated LVN 2 wrote Resident 1 complaint of hard time speaking after lunch and felt she was having another TIA. LVN 2 wrote Resident 1 was speaking right now and feels fine. NP 1 wrote back to keep an eye on Resident 1 and do neuro checks (series of tests that assess the nervous system [brain, spinal cord] that can help identify disorders of the brain) every four hours.
During a review of Resident 1's Nurses Progress Note dated 1/9/2025 and timed at 3:15 p.m., the Nurses Progress Note indicated, LVN 2 asked RN 1 to assess Resident 1 as family member (FM) 1 voiced concerns of Resident 1 having slurred speech (a condition where a person's speech is difficult to understand). The Nursing Progress Note indicated Resident 1's blood pressure was 152/88 mm/Hg. The Nurses Progress Note indicated Resident 1 was awake, alert, oriented to person, place, and time, was coherent, had clear speech, and did not have expressive aphasia (a language disorder that makes it difficult to understand or express language).
During a review of phone text message dated 1/9/2025 timed at 3:43 p.m., between LVN 2 to NP 1, the phone text message indicated LVN 2 informed NP 1 of Resident 1's having slurred speech and difficulty remembering. LVN 2 wrote RN 1 assessed Resident 1 which revealed no slurred speech, strong hand grip on the right hand and weak hand grip on the left hand due to previous stroke. Resident 1 was able to move right side extremities with no problem and no impaired vision. NP 1 responded Resident 1 was fine when she saw the resident the morning of 1/9/2025. NP 1 wrote if LVN 2 felt there was a change Resident 1 should have a Computerized Tomography (CT scan- medical imaging). LVN 2 responded that she did not see any issue with Resident 1 now.
During a review of phone text message dated 1/9/2025 timed at 3:50 p.m. between LVN 2 to NP 1, the phone text message indicated LVN 2 wrote FM 1 was adamant that something was wrong with Resident 1. LVN 2 wrote FM 1 was requesting Resident 1 be transfer to GACH, NP 1 responded fine.
During a review of Resident 1's Nurses Progress Note dated 1/9/2025, the Nurses Progress Note indicated 911 was called at 4:43 p.m. and Resident 1 was transferred to the GACH for slurred speech at 5:08 p.m.
During a review of Resident 1's Emergency Transport Record (Paramedic Run Sheet) dated 1/9/2025, the Emergency Transport Record records indicated Paramedics were dispatched to the facility at 4:42 p.m. The Emergency Transport Record indicated at 4:55 p.m. Resident 1 had a blood pressure of 210/110 mmHg. The Emergency Transport Record indicated Resident 1 reported to the Paramedics of having trouble speaking around noon on 1/9/2025, and headache that has been unresolved throughout the day.
During a review of Resident 1's Emergency Department (ED) Encounter Notes dated 1/9/2025, the ED Encounter Notes indicated Resident 1 presented to the GACH at 5:16 p.m. with a complaint of expressive aphasia (a disorder that makes it difficult to speak, usually seen in patients who are experiencing a TIA or stroke) and inability to speak full sentences. The ED note indicated Resident 1 had a last known well time (medical term used to describe the last time a patient was known to be free of stroke symptoms) of 12 p.m. and was not a candidate for intravenous ([IV] - medication and/or fluids given directly into the vein) thrombolytic due to the last known well time of greater than three hours.
During a review of Resident 1's GACH Magnetic Resonance Imaging ([MRI] - a non-invasive test that uses radio waves and magnets to create a detailed image of the brain) dated 1/10/2025 and timed at 1:01 a.m., the MRI indicated Resident 1 had a new six millimeter (mm-unit of measurement) focus of restricted diffusion in the left frontal (at the front) cortical (outer layer of the cerebrum)/subcortical (region of the brain below the cortex ) region suggesting small acute or subacute infarct (lack of adequate blood supply to the brain )
During a review of Resident 1's GACH Discharge Summary Note dated 1/14/2025 and timed at 3:36 p.m., the GACH Discharge Summary indicated Resident 1's principal diagnosis was acute left frontal lobe (the largest section of the brain which is located in the front of the head) ischemic stroke (when a blood vessel that supplies blood to the brain is blocked, cutting off oxygen and nutrients to brain cells).
During an interview on 1/22/2025 at 10:16 a.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated after lunch, around 1 p.m. to 1:30 p.m. Resident 1 verbalized not wanting to go back to bed which was unusual for Resident 1. CNA 1 stated Resident 1 complained of having severe pain 9 out of10 on a pain rating scale on her left arm. CNA 1 stated Resident 1 verbalized not feeling right. CNA 1 stated she reported it to a charge nurse (LVN) but could not remember which LVN she spoke to.
During an interview on 1/22/2025 at 10:53 p.m. with FM 1, the FM 1 stated on 1/9/2025 around 1:30 p.m. he received a phone call from Resident 1 stating she believed she was having a stroke. FM 1 arrived at the facility around 2:30 p.m. and noticed Resident 1 was having slurred speech, difficulty in finishing her sentences, and difficulty remembering events throughout the day. FM 1 stated he asked the nurses to talk to the doctor, as he was concerned about Resident 1's worsening condition and requested Resident 1 to be transfer to the GACH as soon as possible FM 1 stated the nurse (unknown) told him the NP 1 said to continue to monitor Resident 1. FM 1 stated he insisted a second time to the licensed nurses to transfer Resident 1 to the GACH and Resident 1 was eventually transferred to the GACH at 5:03 p.m. via 911 (four hours after Resident 1 started to verbalize having difficulty to talk and not feeling well).
During an interview on 1/22/2025 at 1:35 p.m., the NP 1 stated she saw Resident 1 on 1/9/2025 in the a.m. (time unknown) when Resident 1 reported to have a headache. The NP 1 stated Resident 1 had a history of trigeminal neuralgia, so she ordered her pain medication. NP 1 stated she had received a phone text messages around 2:30 p.m. on 1/9/2025 from unknown nursing staff who stated Resident 1 complained of difficulty to talk. The NP 1 stated vital signs were not provided in the phone text messages, but nurse (LVN 2) stated Resident 1 seems fine, so she recommended to monitor Resident 1 every four hours. The NP 1 stated she believed Resident 1 was having a transient ischemic attack ([TIA] known as a mini stroke with a temporary interruption of blood flow to the brain which causes stroke like symptoms but usually resolves within 24 hours). The NP 1 stated it was not a medical emergency because she did not present neurological symptoms based on nurse's report and therefore it must have resolved. The NP 1 stated the reason why she did not recommend sending Resident 1 to the GACH emergency department was because they would just treat it with blood thinners, and the resident was already on Aspirin (a blood thinner). The NP 1 stated around 3:30 p.m. she received a phone text message again from nursing staff (LVN 2) who stated FM 1 was insisting on Resident 1's transfer to the hospital, so she agreed since FM 1 insisted.
During an interview on 1/22/2025 at 2:59 p.m., MD 1 stated he does not recall getting notified about Resident 1's change of condition on 1/9/2025. The MD 1 stated if he would have been notified that Resident 1 was having a slurred speech, he would order to send the resident to the hospital right away because monitoring would be a loss of time when Resident 1 was having a cerebral infarction.
During an interview on 1/22/2025 at 3:50 p.m. RN 1 stated when she arrived to work at 3 p.m. LVN 2 reported to her Resident 1 was complaining about slurred speech. RN 1 stated she went to check on Resident 1 around that time, but her assessment was negative for any neurological changes. RN 1 stated she informed LVN 3 to check Resident 1's vital signs but did not actually witness vital signs being taken and does not know what time they were taken. RN 1 stated she was not the one to contact the physician or communicate to the physician about Resident 1's change of condition.
During an interview on 1/22/2025 at 4:22 p.m., LVN 2 stated CNA 1 reported to her around 2:30 p.m. that the Resident 1 was having trouble speaking and she was the one who was in contact with NP 1 throughout the day. LVN 2 stated she told LVN 1 to take Resident 1's vital signs and fill out the SBAR form, but she did not relay the vital signs to NP 1.
During an interview on 1/23/2025 at 9:28 a.m. RN 2 stated if Resident 1 reported having slurred speech, which could be a sign of a stroke, but she did not observe a resident have it upon assessment, she would still send a resident to the hospital right away for evaluation. RN 2 stated there is a four-hour window to treat certain stroke, such as tissue plasminogen activator ([tPA] a medication approved to treat ischemic strokes within the first 4.5 hours of a stroke.) that would help Resident 1. RN 2 stated she would monitor the resident vital signs which should be taken once there was reported change of condition.
During an interview on 1/23/2025 at 12:13 p.m. with the Director of Nursing (DON), the DON stated that vital signs should be taken when there is a change of condition and document on the SBAR form and report to the physician because vital signs could indicate what was going on with the resident and will determine the course of treatment/action. The DON stated if a resident was reporting difficulty speaking, and a family member was reporting the resident experienced slurred speech, that was enough to send Resident 1 to GACH for evalution and treatment. The DON stated when the resident exhibiting symptoms of a slurred speech the licensed nurses do not need permission from the MD to call 911 and must have immediate interventions to transfer the resident to GACH
During an interview on 1/24/2025 at 1:16 p.m. LVN 1 stated she filled out the SBAR form but did not actually speak with MD 1 or any other physician regarding Resident 1's change of condition when Resident first reported difficulty to talk. LVN 1 stated she did not check Resident 1's blood pressure upon the change of condition and documented Resident 1's vital signs taken on 1/9/2025 at 9:27 a.m. on SBAR form timed at 3 p.m. on 1/9/2025. LVN 1 stated when there was a change of condition vital signs should be done at the time of a condition change because they reflect the status of the resident for the doctor to decide what the plan of care. LVN 1 stated the reason why she did not take Resident 1's blood pressure was because she assumed another nurse did it. LVN 1 stated she did not receive any report from the CNA 1 that Resident 1 had severe headache but does recall that Resident 1 did not want to get back into bed. LVN 1 stated it was not until around 2 p.m. to 2:30 p.m. on 1/9/2025 when Resident 1 notified staff she had trouble speaking. LVN 1 stated she did not notify RN 3 when Resident 1 had a change of condition for RN 3 to assess Resident 1's slurred speech.
During a review of facility's policy and procedure (P&P) titled Emergency Care, revised 9/2017, the P&P indicated it is the policy of the facility to provide emergent care to a resident in need of urgent service. The P&P indicated if a resident's condition is observed to have changed, assess the resident, notify the resident's attending physician, and report any changes in condition and provide emergency care as necessary. Always take, report, and document the resident's vital signs when a resident is assessed to have a change in condition.
During a review of an online article titled, American Heart Association Guidelines for the Early Management of Patients With Acute Ischemic Stroke: 2019 Update to the 2018 Guidelines for the Early Management of Acute Ischemic Stroke, revised 2019, the article indicated tPA is recommended for selected patients who may be treated within 3 hours of ischemic stroke symptom onset or patient last know well or at baseline state and is also recommended for selected patients who can be treated within 3 and 4.5 hours of ischemic symptoms onset or patient last known well. The article indicated treatment should be initiated as quickly as possible within the listed time frames of 3 to 4.5 hours because time to treatment is strongly associated with outcomes. https://www.ahajournals.org/doi/10.1161/STR.0000000000000211#sec-2
During a review of facility's P&P titled Change in Condition, revised 3/2021, the P&P indicated the purpose of the policy for changes in the resident's condition be thoroughly assessed and evaluated with physician notification for early clinical management to avoid unnecessary readmissions to acute hospitals. The P&P indicated thorough assessment will include all important information related to the resident such as onset of current symptoms, including vital signs. The P&P indicated thy physician is responsible for making the decision for the resident to be treated at the facility or be transferred to the acute hospital for treatment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure resident was turned every 2 hours to prevent the progression of a pressure injury (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence)as care planned for one of three sampled Residents (Resident 3)
This failure had the potential to result in Resident 3's pressure injury to worsen and develop an avoidable pressure injury.
Findings:
During a review of Resident 3's admission Record (Face Sheet) , the Face Sheet indicated Resident 1 was originally admitted to the facility on [DATE] and re-admitted to the facility on [DATE] with diagnoses of but not limited to stage four pressure ulcer (Full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone) of the sacral (bottom of the spine) region, diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), dependence on a ventilator (a person unable to breathe on their own and requires a mechanical device called a ventilator to assist with breathing) and heart failure (a condition that develops when the heart does not pump enough blood).
During a review of Resident 3's History and Physical (H&P) dated 11/4/2024, the H&P indicated Resident 3 did not have the capacity to understand and make decisions.
During a review of Resident 3's Minimum Data Set (MDS - a resident assessment tool) , dated 11/6/2024, the MDS indicated Resident 3 was dependent on staff for oral hygiene, toileting, showering, dressing, putting on and taking of footwear, sitting, lying, and rolling from left to right. The MDS indicated Resident 3 did not attempt to eat, stand, or transfer due to medical condition or safety concerns.
During an interview on 12/11/2024 at 7:10 am with Registered Nurse Supervisor (RNS), RNS stated on 11/17/2024 he saw Resident 3 at 8 pm with his daughter. RNS stated at 9:30 pm he made rounds and peeked in the room and saw the daughter asleep. RNS stated at 10:30 pm the daughter came to him looking for Certified Nursing Assistant (CNA) 1 stating no one came to reposition her dad for 4 hours. RNS stated he called two licensed Vocational nurses to help assist him with changing Resident 3's diaper and to turn and reposition Resident 3. RNS stated Resident 3 had a bowel movement and does not know the last time Resident 3 was changed, turned, or repositioned. RNS stated Resident 3 is supposed to be turned and repositioned every two hours to prevent pressure ulcers.
During an interview on 12/11/2024 at 9:08 am with Treatment Nurse/Licensed Vocational Nurse, TX/LVN stated Resident 3 was admitted to facility on 10/25/2024 with a pressure ulcer. TX/LVN stated Resident 3 is being seen by the wound care doctor weekly for debridement. TX/LVN stated Resident 3 requires turning and repositioning every two hours and as needed and any nursing staff's responsibility TX/LVN stated two hours is the maximum a resident can go without being turned or repositioned due to a risk for further skin breakdown. TX/LVN stated the facility plays music every two hours, 24 hours a day to remind staff to turn and reposition the residents.
During an interview on 12/11/2024 at 2:48 pm with CNA 1, CNA 1 stated on 11/17/24 at 4pm he saw Resident 3 and took vital signs. CNA 1 stated at 6:30 pm he changed Resident 3's diaper. CNA 1 stated at 7:30 pm he saw the daughter at the bedside when he passed by the room on the way to take a break and she got busy in room [ROOM NUMBER] after coming from break at 8 pm. CNA 1 stated at 10 pm he saw RNS changing the resident. CNA stated at 11 pm he saw Resident 3 and his daughter after the resident was already cleaned and repositioned, charted and went home. CNA 1 stated every two hours a song plays throughout the facility to remind staff to turn and reposition residents. CNA 1 stated when came back from break he heard the song playing but was busy cleaning another resident. CNA 1 stated it is important to turn and reposition Resident 3 every two hours to avoid developing a pressure injury.
During an interview on 12/11/2024 at 3:46 pm with the Director of Nursing (DON), DON stated Resident 3 should have been repositioned every two hours for comfort and to prevent the development of pressure injury or skin breakdown. DON stated every two hours music plays to remind staff to reposition the resident every two hours. DON stated licensed nurses can reposition residents the cna's just need to communicate it's a team effort and not only the responsibility of the cna.
During a review of Resident 3's Care Plan, titled Alteration in Skin Integrity, dated 10/25/2024, the Care Plan Indicated, provide turning and repositioning at least every two hours.
During a review of Resident 3's Physician Progress Note for wound care, dated 12/3/2024, the Physician Progress Notes indicated, Resident 3 to turn resident every two hours and to keep the skin clean and dry.
During a review of Resident 3's Interdisciplinary Wound progress Notes , dated 12/4/2024, the Interdisciplinary Wound progress Notes indicated turning and repositioning every two hours and as needed to redistribute pressure.
During a review of the facility's policy and procedure (P&P), titled Pressure Injury aka Pressure Sore Management , dated 10/2027, the P&P indicated, Residents will be turned/repositioned every two hours or as needed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure Resident 2 who has repeated threatening and abusive behavior was monitored for one of three sampled residents.
This failure resulted in Resident 1 ' s being verbally abused and threatened by Resident 2.
Findings:
During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnoses of but not limited to schizophrenia (a mental illness that is characterized by disturbances in thought), diabetes (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), muscle weakness and chronic kidney diseases (progressive loss of kidney function).
During a review of Resident 1's History and Physical (H&P) dated 9/20/2024, the H&P indicated Resident 1 had the capacity to understand and make decisions.
During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 9/22/2024, the MDS indicated Resident 1 needed maximal assistance with toileting, lower body dressing, putting on and taking off footwear. The MDS indicated Resident 1 needed maximal assistance to change positions from sitting to standing and transferring. The MDS indicated Resident 1 needed moderate assistance with upper body dressing, rolling from left to right, changing positions from lying to sitting. The MDS indicated Resident 1 needed supervision wit eating, oral hygiene and personal hygiene.
During a review of Resident 2's Face Sheet, the Face Sheet indicated Resident 2 was originally admitted to the facility on [DATE] and re-admitted to the facility on [DATE] with a diagnosis of disseminated intravascular coagulation ( a condition which small blood clots develop throughout the bloodstream), muscle weakness and acute kidney failure (a sudden loss of kidney function that occurs within a few hours or days) blood cell count
During a review of Resident 2's H&P dated 10/29/2024, the H&P indicated Resident 2 had the capacity to understand and make decisions.
During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2 needed moderate assistance with showering, lower body dressing, putting on and taking off footwear. The MDS indicated Resident 2 needed supervision with transferring and changing positions from sitting to standing.
During an interview on 12/10/2024 at 2:30 pm with Restorative Nurse Assistant (RNA), RNA stated on 12/5/2024 at1 pm while in the dining room. Resident 1 was in his wheelchair sharing a table with other resident eating. RNA stated Resident 2 went to Resident 1's table and asked Resident 1 if he had a problem. RNA stated Resident 1 said no I am not saying anything. RNA stated Resident 2 said if you have a problem say it to my face and threatened to kill Resident 2. RNA stated Resident 2 stated he does not care if he gets kicked out from the facility. RNA stated Resident 2 kept pushing forward and hitting his chair against Resident 1's wheelchair.
During an interview on 12/10/2024 at 2:52 pm with Resident 1, Resident 1 stated he was seated in the dining room and Resident 2 approached him because Resident 2 was angry he was seated at a table and speaking with another resident that Resident 2 did not like. Resident 1 stated Resident 2 rammed his wheelchair into his wheelchair and threatened to kill him.
During a concurrent interview on 12/11/2024 at 9:02 am with Licensed Vocational Nurse (LVN), and record review Resident 2's Care Plan,. The Care Plan Indicated Resident 2 told another resident I will kill you. The Care Plan indicated the goal for resident 2 was for the threat not to happen again. LVN stated there is another behavior careplan dated 11/17/2024 about threatening another unknown resident and a Change of Condition (COC- change in a residents health or functioning that can be short term or significant) was not done. LVN stated a Change of Condition is done to monitor the resident's behavior. LVN stated Resident 2's behavior could have been monitored sooner if a COC was initiated was initiated and Medical Doctor(MD could have assessed sooner for any behavioral interventions. LVN stated the COC is done to monitor the resident's behavior for improvement or a decline.
During an interview on 12/11/2024 at 4:29 pm with [NAME] Administrator (Adm), Adm stated a similar incident happened one month ago between the Resident 1 and Resident 2. Adm stated supervision is needed when the Resident 1 and Resident 2 are in the dining room. Adm stated Resident 1 and Resident 2 need to be on opposite sides of the dining room and have keep their distance between them both Adm stated Resident 2 was transferred to a GACH for behavior management related to the alleged abuse.
During a review of the facility's policy and procedure (P&P) titled, Abuse reporting and Prevention, dated 1/2023, the P&P indicated Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, or mental anguish, or deprivation of an individual, including caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial wellbeing .Verbal abuse is the use of written oral, or gestured language that willfully used derogatory or disparaging terms regardless of their age, ability to comprehend or disability .Facility will monitor areas that have potential to lead to abusive situation, areas include .Residents with behaviors that may lead to abusive situations.
During a review of the facility's policy and procedure (P&P) titled, Change of Condition, dated 3/2021, the P&P indicated, It is the policy of this facility that any change in resident's condition be thoroughly assessed and evaluated with physician notification for early clinical management to avoid unnecessary readmission to acute hospitals.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to observe infection control measures by failing to perform a Covid test ( screening test to rule out Covid-19 illness) on one of four sampled residents (Resident 2) who was showing signs and symptoms of a respiratory illness in a timely manner.
This failure had the potential to put other residents and staff at risk for infection.
Findings:
During a review of Resident 2 's admission Record, the admission Record indicated the resident was admitted on [DATE] with diagnoses that included asthma( condition where a person's airways become inflamed, narrow, and swollen and produce extra mucus making harder to breathe), unspecified dementia( progressive state of decline in mental abilities), and history of Covid -19(viral and contagious respiratory illness).
During a review of Resident 2's Minimum Data Set (MDS- a resident assessment tool)dated 10/19/2024, the MDS indicated the resident had severe cognitive skills( problems with a person's ability to think, learn, remember, and make decisions) and required substantial/ maximal assistance ( helper does more than half of the effort) with bed mobility ,personal hygiene, and oral hygiene.
During a review of Resident 2's SBAR (situation, background, assessment, recommendation-a communication tool used by healthcare workers when there is a change of condition among the residents) dated 11/17/2024, the SBAR indicated the resident had a change in condition and signs observed were abnormal chest x-ray , elevated white blood count of 18,000 (WBC - a blood test that measures the number of white blood cells and an elevated WBC count can indicate the body is fighting an infection) and pneumonia (an infection /inflammation in the lungs).
During a review of Resident 2's covid Test , the covid test indicated the resident was tested for covid on 11/18/2024.
During an interview on 12/2/2024, at 10:30 a.m. with Resident 1, Resident 1 stated Resident 2 who was her roommate had been coughing a lot and she was afraid of getting sick because of Resident 2's cough.
During an interview on 12/2/2024, at 4:04 p.m. with Licensed Vocational Nurse (LVN1), LVN 1 stated she noticed Resident 2 was having episodes of productive cough(cough that produces mucus or phlegm) while sitting in the hallway on 11/16/2024. LVN 1 stated she notified RN Supervisor (RN1) and the resident was started on antibiotics(medicine used to treat infection).
During an interview on 12/2/2024, at 3:45 p.m. with RN Supervisor (RNS 1), RNS 1 stated LVN 1 and unnamed Certified Nursing Assistant notified her about Resident 2's cough on 11/16/2024. RNS 1 stated Resident 2 had productive cough and was wheezing ( shrill, coarse whistling sound your breath makes when the airway is partially blocked or narrowed) during assessment.
During a concurrent interview and record review of Resident 2's chart on 12/2/2024, at 5:16 p.m. with Infection Preventionist Nurse (IPN), IPN stated the facility screens residents manifesting symptoms of congestion, cough and fever for covid or flu. IPN stated the facility should have tested Resident 2 for covid when symptoms appeared on 11/16/2024 and not wait two days later. IPN stated it's important to screen residents who are showing symptoms like cough and congestion to prevent an outbreak or spread of infection in the facility.
During an interview on 12/2/2024, at 5:38 p.m. with Director of Staff Development (DSD), DSD stated the facility test residents for covid if manifesting any symptoms of congestion, cough, fever or lethargy ( sleepiness) . DSD stated the staff should have tested Resident 2 for covid based on her symptoms of productive cough and wheezing. DSD stated the reason the covid test was not done because the staff waited for the DSD to do the test. DSD stated all licensed nurses could do the covid test and were trained how to perform the covid test.
During a telephone interview on 12/3/2024, at 9:57 a.m. with Director of Nursing (DON), DON stated the staff should not have to wait for the IPN to do the test for Covid. DON stated the staff should call the physician for any symptoms of respiratory disease and get an order for Covid test. DON stated not screening and testing residents for covid or flu who are showing symptoms of respiratory illness could put other residents at risk for exposure to infection.
During a review of facility's policy and procedure (P&P) titled Infection Control Program System dated 1/2023, the P/P indicated the facility had an established infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections. The P&P indicated the facility maintains written standards, policies and procedures which included a system of surveillance designed to identify possible communicable diseases or infection before they can spread to other residents in the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure one of two sampled residents (Resident 1) will be offered to get out of bed in a wheelchair when resident ' s motorized wheelchair broke down.
This failure put Resident 1 at risk for immobility and feelings of isolation and sadness.
Findings:
During a review of Resident 1 ' s admission Record, the admission Record indicated the resident was initially admitted on [DATE] and was readmitted on [DATE] to the facility with diagnoses that included hemiplegia and hemiparesis following cerebrovascular disease affecting left dominant side( loss of strength or paralysis on the left side of the body after a stroke), and osteoarthritis ( progressive disorder of the joints caused by gradual loss of cartilage).
During a review of Resident 1 ' s History and Physical (H&P) dated 4/8/2024, the H&P indicated the resident had the capacity to understand and make decisions.
During a review of Resident 1 ' s Minimum Data Set (MDS- a resident assessment tool) dated 8/30/2024, the MDS indicated the resident had an intact cognition (thought process) and required substantial or maximal assistance (helper does more than half the effort) with bed mobility, dressing, and personal hygiene. The MDS indicated the resident used motorized wheelchair and was dependent on the staff with transfer to and from a bed to a chair or wheelchair.
During a review of Resident 1 ' s Order Summary Report dated 4/5/2024, the Order Summary Report indicated the resident will get up in a wheelchair as tolerated and up in a motorized wheelchair when out of bed (OOB).
During a review of Resident 1 ' s Order Summary Report dated 7/31/2024, the Order Summary Report indicated the resident may be up in an electrical wheelchair, reposition while the resident is up.
During a review of Resident 1 ' s Care Plan initiated 4/8/2024 titled Impaired Physical Mobility and Self-Care Deficit, the Care Plan ' s goals indicated the resident will be able to move to and return from off unit locations. The Care plans interventions included providing two persons assist during transfers in and out of bed, wheelchair, toilet, and encouraging the resident to get out bed daily as tolerated. The Care Plan interventions indicated to check wheelchair used for locomotion and repair if needed to ensure safety.
During a concurrent observation and interview on 12/3/2024, at 10:30 a.m. with Resident 1, Resident was lying in bed in an upright position and stated she had not gone out of bed in a wheelchair for almost a week. Resident 1 stated her motorized wheelchair was broken and she used the motorized wheelchair to get around the facility. Resident 1 stated she was not refusing to get out of bed in a manual wheelchair and the facility was not offering it to her.
During an interview on 12/2/2024, at 12:42 p.m. with Certified Nursing Assistant (CNA1), CNA1 stated Resident 1 never gets out of bed to the wheelchair since the motorized wheelchair was broken. CNA1 stated the resident would feel angry if she was not able to use a wheelchair to go to the patio or the kitchen to ask for a soda.
During an interview on12/2/2024, at 1:20 p.m. with Maintenance Supervisor (MS). MS stated he was notified by Resident 1 two weeks ago that her motorized wheelchair broke down. MS stated the facility did not have motorized wheelchair on site nor able to rent a motorized wheelchair and the issue was referred to the medical equipment company who would be coming this week to repair the wheelchair.
During a concurrent interview and record review of Resident 1 ' s chart in electronic and hard copy on 12/2/2024, at 3:19 p.m. with Licensed Vocational Nurse (LVN 2), LVN 2 stated she only saw Resident 1 was up in a manual wheelchair ever since the motorized wheelchair broke down. LVN 2 confirmed there was no documentation in the chart about resident ' s refusal to use the manual wheelchair or refusal to get out of bed to the wheelchair.
During a concurrent interview and record review of Activities of Daily living (ADL- activities such as bathing, dressing, and toileting a person performs daily) tasks on 12/2/2024, at 3:45 p.m. with RN Supervisor (RNS1), RNS 1 stated Resident 1 would usually in her motorized wheelchair every day. RNS 1 confirmed Resident 1 did not get out of bed or used the wheelchair for eight days. RNS 1 stated there are other options if the resident ' s motorized wheelchair was not available, the staff could use a Geri chair( a large , padded chair that is designed to help people with limited mobility) or manual wheelchair to get Resident 1 out of bed to the chair. RNS 1 stated Resident 1 could be at risk for depression or development of skin breakdown due to immobility.
During a review of ADL Task for Wheelchair/ Scooter Use, the ADL task indicated the resident did not use the wheelchair on 11/19/2024, 11/20/2024, 11/21/2024, 11/23/2024, 11/25/2024, 11/26/2024. 11/28/2024, 12/1/2024 and 12/2/2024.
During a concurrent interview and record review of Resident 1 ' s charts, on 12/2/2024, at 4:30 p.m. with Director of Nursing (DON), DON confirmed there was no documentation in the chart refused the manual wheelchair and if a resident refusing care like getting out of bed in a wheelchair documentation about refusal and Care planning should be in the resident ' s charts. DON stated the staff should have offered the manual wheelchair, Geri chair or recliner and not wait for the motorized wheelchair to get repaired. DON stated Resident 1 could be at risk foe feeling frustrated and sad for not able to get around the facility like she used to do.
During a review of facility ' s policy and procedure (P&P) titled Resident Rights dated 9/2017, the P&P indicated the resident has the right to reside and receive services with reasonable accommodation of needs and preferences unless it will endanger the health and safety of the resident or ither residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review the facility failed to provide rehabilitative services (services that help the resident keep, get back, or improve skills of functioning for daily living), as ordered by the physician, for one of one resident ' s (Resident 2).
The facility failed to:
a) Ensure Resident 2 received speech therapy (treatment that improve ability to talk and swallow) services three times a week, for the week of 3/5/2024.
b) Ensure Resident 2 had documented evidence of Restorative Nursing Assistant (RNA) application of the bilateral (both) knee splints (rigid material or apparatus used to support and immobilize a broken bone or impaired joint) from 3/15/2024 to 3/31/2024.
These deficient practices placed Resident 2 at risk for not restoring or maintaining highest level of function.
Findings:
During a review of Resident 2 ' s admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE] with diagnoses including acute respiratory failure (when the lungs and blood are unable to exchange gases properly), generalized muscle weakness, dysphagia (difficulty swallowing), and gastrostomy status (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems).
During a review of Resident 2 ' s Minimum Data Set (MDS), a resident assessment tool, dated 1/16/2024, the MDS indicated Resident 2 ' s cognitive skills (ability to think and reason) for daily decision-making was severely impaired. The MDS indicated Resident 2 was totally dependent on staff for all activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily).
During a record review of Resident 2 ' s Order summary report, the summary indicated:
a) Ordered 1/27/2024, Speech Therapy, clarification of order, every day three times a week for 4 weeks dysphagia treatment to improve swallow safety, diet texture analysis, diet trials, Orofacial Myofunctional Therapy (OM – type of therapy with facial muscles) training and patient/care giver education.
b) Ordered 2/27/2024, Continue Speech Therapy, clarification of order, every day three times a week for 4 weeks dysphagia treatment to improve swallow safety, diet texture analysis, diet trials, OM training and patient/care giver education from 2/24/2024.
c) Ordered 3/15/2024, start 3/16/2024, RNA Apply bilateral knee splints for up to 6 hours or as tolerated every day (Thursday to Monday).
During an interview and record review on 11/27/2024 at 2:03 p.m. with the Director of Rehabilitation Services (DOR), Resident 2 ' s Speech Therapy Treatment Encounters (1/2024 to 2/2024) were reviewed. The DOR confirmed and stated there was one week of 3/3/2024 to 3/9/2024, where Resident 2 was only seen twice, on 3/5/2024 and 3/9/2024. The DOR stated Resident 2 should have been seen three times that week to ensure the resident received the prescribed therapy to make sure increasing maximum potential.
During an interview and record review on 12/2/2024 at 10:00 a.m. with the Director of Nursing (DON) Resident 2 ' s physician order, dated 3/15/2024 at 2:20 p.m. was reviewed and the order indicated RNA: Apply bilateral knee splints up to 6 hours or as tolerated every day (Thursday to Monday) every dayshift. The DON stated there was no documented evidence splinting was done in March 2024. The DON stated if not charted it was not done.
During a review of the facility ' s policy and procedure (P&P) titled, Speech language Pathologist, reviewed 7/29/2017, the P&P indicated as part of the duty of the Speech- language pathologist was to implement treatment plans for residents to restore and maintain their highest level of functioning and reassess treatment results. The therapist will follow relevant physician orders.
During a review of the facility ' s P&P titled, Restorative Nursing Assistant referrals, revised 9/2016, the P&P indicated a resident with a limited range of motion will be assessed and provided with appropriate treatment and services to increase the range of motion.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review the facility failed to ensure one of two resident ' s (Resident 2) documentation was complete and accurate when Resident 2 ' s left lateral malleolus (the bone on the outside of the ankle joint) pressure injury (localized damage to the skin and/or underlying tissue usually over a bony prominence) was described differently. Resident 2 ' s Wound consultant notes for 3/5/2024 indicated the pressure injury was a Stage III pressure injury (full-thickness loss of skin, dead and black tissue may be visible) and Resident 2 ' s Preliminary wound consultant notes for 3/5/2024 indicated it was an unstageable (when the stage is not clear because the base of the wound is covered by a layer of dead tissue) pressure injury.
The deficient practices indicated an inaccurate depiction of Resident 2 ' s status.
Findings:
During a review of Resident 2 ' s admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE] with diagnoses including acute respiratory failure (when the lungs and blood are unable to exchange gases properly), generalized muscle weakness, hyperglycemia (a condition where there is too much glucose in the blood ), and acute kidney failure (kidneys suddenly can't filter waste products from the blood).
During a review of Resident 2 ' s Minimum Data Set (MDS), a resident assessment tool, dated 1/16/2024, the MDS indicated Resident 2 ' s cognitive skills (ability to think and reason) for daily decision-making was severely impaired. The MDS indicated Resident 2 was totally dependent on staff for all activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily). The MDS indicated Resident 2 did not have any unhealed pressure injuries. The MDS indicated Resident 2 ' s skin was intact and did not have any ulcers, wounds, and skin problems.
During a review of Resident 2 ' s Preliminary Wound Report, 3/5/2024, the report indicated the left lateral malleolus, ankle pressure injury was unstageable.
During a review of Resident 2 ' s Weekly Pressure Injury record, dated 3/5/2024, the record indicated Resident 2 ' s pressure injury in the left lateral malleolus was unstageable.
During a review of Resident 2 ' s dictated Wound Consultant Progress Notes, 3/5/2024, the notes indicated the left lateral malleolus pressure injury was a Stage III pressure injury.
During an interview and record review on 12/2/2024 with the Director of Nursing (DON) Resident 2 ' s Preliminary Wound Report and Wound Consultant Progress notes, dated 3/15/2024 were reviewed. The DON stated the wound consultant progress notes was erroneous and the facility notified the company to issue an amended progress note. The DON stated the facility needed complete and accurate medical records to get an accurate picture of the resident and accurate account of care rendered to the resident.
During a review of the facility ' s policy and procedure (P&P) titled, Record Content: Documentation Principles, dated 1/2014, the P&P indicated clinical records shall be current and kept in detail consistent with good medical and professional practice based on care provided to each resident. The P&P indicated completed entries must be accurate, timely, objective, specific, concise, legible, clear, and descriptive.
During a review of the facility ' s P&P titled, Documentation Principles, revised 10/2018, the P&P indicated it was the policy of the facility that resident's clinical records shall be current and kept in detail consistent with good medical and professional practice based on the care provided to each resident, and entries must be accurate, timely, objective, specific, concise, legible, clear, and descriptive.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a resident, who was admitted with intact skin did not develop a pressure injury (localized damage to the skin and/or underlying tissue usually over a bony prominence) while in the facility, and a resident who was admitted with a pressure injury had measures in place to prevent the existing pressure injury from getting worse for two of two residents (Resident 2 and 12). The facility failed to:
1. Implement Resident 2's care plan, titled Alteration in Skin integrity intervention to turn and reposition the resident at least every two hours and as needed from 1/2024 to 3/2024 to prevent Resident 2 from developing the pressure injuries to the right and left lateral (to the side of, or away from, the middle of the body) malleolus (the bone on the outside of the ankle joint).
2. Ensure Resident 2 was assessed by the Registered Dietician (RD -food and nutrition expert) on 2/11/2024 when the deep tissue injury (DTI - persistent non-blanchable [something does not fade when pressure is applied, such as a rash or skin discoloration] deep red, maroon, or purple discoloration, related to damage from pressure and/or shear) to the left lateral malleolus was first identified, as indicated in the care plan titled, Alteration in Skin integrity and as the Wound Consultant recommended on 2/13/2024.
3. Ensure Resident 2's Wound Consultants' recommendation to cleanse the wound to the left lateral malleolus with Normal Saline (mixture of salt and water solution) prior to applying Betadine (a solution that kills germs promptly) was implemented starting on 2/11/2024.
4. Implement Resident 12's care plan, titled Alteration in Skin integrity, intervention to turn and reposition the resident at least every two hours and as needed from 1/1/2024 to 3/31/2024 which had the potential to slow the healing of Resident 12's pressure injury to the sacrum (lower back area).
5. Implement the facility's policy and procedure (P&P) titled, Pressure Injury also known as, Pressure Sore Management, revised 10/2017, that indicated to prevent the development of skin breakdown/pressure injuries the staff need to implement the care plan to reposition the resident at least every two hours and follow the RD's and physician's recommendations.
These failures resulted in Resident 2, who was assessed as a moderate risk for developing a skin injury and had intact skin upon admission on [DATE] developing the following pressure injuries:
1a. A facility-acquired preventable Stage IV pressure injury (full-thickness skin and tissue loss with exposed muscle or bone) to the left lateral malleolus, measuring 2.2 centimeters (cm) long by 1.6 cm wide by 0.3 cm deep on 3/26/2024, 77 calendar days from admission. The wound bed was 30 percent (%) slough (yellowish material), 60% granulation (new tissues, bright red or pink, soft, moist, bumpy, and be raised), and 10% epithelial tissue (appears pink or pearly white, occurs in the final stage of healing).
1b. A Stage III pressure injury (full-thickness loss of skin, dead and black tissue may be visible), to the right lateral malleolus, measuring 1.2 cm long by 1.2cm wide with undetermined depth (UTD) with100% slough.
2. These deficient practices placed Resident 12 at risk for pressure injury to the sacrum (lower back area) delayed healing or to progress to worse.
Findings:
1. During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE] with diagnoses including acute respiratory failure (when the lungs and blood are unable to exchange gases properly), generalized muscle weakness, hyperglycemia (a condition where there is too much glucose in the blood ), acute kidney failure (kidneys suddenly can't filter waste products from the blood), with gastrostomy ([GT] - a soft tube surgically placed into the stomach to provide nutrition, hydration and medication) in place.
During a review of Resident 2's Minimum Data Set ([MDS], a resident assessment tool) dated 1/16/2024, the MDS indicated Resident 2's cognitive (ability to think and reason) skills for daily decision-making were severely impaired. The MDS indicated Resident 2 was totally dependent on staff for all activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily). The MDS indicated Resident 2's skin was intact and did not have any ulcers, wounds, and skin problems.
During a review of Resident 2's Braden Scale (a scoring tool used to predict residents' risk of developing a pressure injury, total scores range from 6 - 23. A lower score indicating a higher risk of developing a pressure injury) assessment dated [DATE], the Braden Scale Assessment indicated Resident 2's score was 14 indicating Resident 2 was at moderate risk for developing a pressure injury. The Braden Scale Assessment indicated Resident 2's skin was occasionally moist, the resident was chairfast (capable of maintaining a sitting position but lacking the capacity of bearing own weight), had very limited mobility (ability to change and control body position), was unable to make frequent or significant positional changes independently and required moderate to maximum assistance (helper does more than half the effort) when moving.
During a phone interview on 11/26/2024 at 9:04 a.m., family member (FM 1) stated Resident 2 had a pressure sores (in reference to a pressure injuries) because the facility did not turn Resident 2 frequently. FM 1 stated she remembered one incident when the resident's indwelling urinary catheter (a soft flexible tube inserted into the urinary bladder to drain urine into a collection bag outside the body) had been accidentally removed and no one discovered it until later. FM 1 sated if they were turning the resident every two hours, they would have seen it and identified the problem with skin sooner.
During a concurrent interview and record review on 11/26/2024 at 12:36 p.m. with the Assistant Director of Nursing (ADON) Resident 2's MDS, dated [DATE], Resident 2 's Initial Nursing History and Assessment, dated 1/9/2024, and Resident 2's Braden Scale Risk Assessment, dated 1/9/2024, were reviewed. The ADON stated Resident 2 's Initial Nursing History and Assessment, and Resident 2's Braden Scale Risk Assessment indicated Resident 2's skin was intact upon admission and Resident 2 was at moderate risk for developing pressure injuries. The ADON stated Resident 2 was dependent on staff for all ADL's including turning and repositioning in bed. The ADON stated Resident 2 was totally dependent on staff to implement interventions for preventing the development of pressure injuries, since Resident 2 could not independently reposition himself.
During a concurrent interview and record review on 11/26/2024 at 12:40 p.m., with the ADON, Resident 2's Situation Background Appearance Review (SBAR) Communication Form, dated 2/11/2024, was reviewed. The ADON confirmed the SBAR indicated that 32 days after the resident's admission Resident 2 developed a purplish discoloration on the left lateral malleolus measuring 2.5 cm by 2.5 cm., which was a sign of a pressure injury development.
During a concurrent interview and record review on 11/26/2024 at 12:44 p.m., with the ADON, Resident 2's Wound Consultant Progress Notes, dated 2/13/2024, were reviewed and the ADON confirmed the Wound Consultant classified the purplish discoloration on the left lateral malleolus as a DTI. The ADON stated the Wound Consultant recommended to turn and reposition the resident every two hours, keep the skin clean and dry, and to avoid massaging bony prominences (areas where bones are close to the surface). The ADON stated the Wound Consultant also recommended the RD to assess Resident 2 to ensure adequate intake of protein and calories, to maintain the current level of activity, mobility, and range of motion, to use positioning devices to prevent prolonged pressure on bony prominences. The ADON stated the treatment plan was to cleanse the left lateral malleolus DTI with sterile (free of infection causing organisms) Normal Saline, pat dry, apply Betadine directly to the wound bed of the left lateral malleolus DTI and cover with dry sterile dressing. The ADON stated the treatment plan was also to change dressing daily and as needed for loss of integrity and soiling.
During a concurrent interview and record review on 11/26/2024 at 12:47 p.m., with the ADON, Resident 2's care plan titled, Alteration in skin Integrity, started on 2/11/2024, was reviewed and the ADON confirmed the care plan goal indicated Resident 2's left lateral malleolus DTI would heal without complications. The ADON stated two of the care plan interventions included the RD's evaluation of Resident 2's nutritional needs for pressure injury healing to left lateral malleolus DTI, and to turn and reposition Resident 2 at least every two hours.
During a concurrent interview and record review on 11/26/2024 at 12:49 p.m., with the ADON, Resident 2's Wound Consultant Progress Notes, dated 2/27/2024, were reviewed. The ADON stated the Wound Consultant Progress Notes indicated Resident 2's DTI to the left lateral malleolus opened up and it was reclassified as an unstageable pressure injury (when the stage is not clear because the base of the wound is covered by a layer of dead tissue) measuring 2.9 cm long by 2.5 cm wide with UTD depth and 100% necrotic (dead tissue in the wound itself). The Wound Consultant Progress Notes indicated a recommendation to turn the resident every two hours and to follow the registered dietitian's recommendations. The ADON stated the facility should have recommended the use of a low air loss mattress (a mattrass designed to prevent and treat pressure injuries) before Resident 2's left lateral DTI worsened to an unstageable pressure injury.
During a concurrent interview and record review on 11/26/2024 at 12:50 p.m., with the ADON, Resident 2's Nutrition Care Progress Notes from 1/10/2024 to 3/29/2024 were reviewed and the Nutrition Care Progress Notes indicated the RD did not make any recommendations for Resident 2's pressure injury healing until 3/5/2024, which was 23 days after the Wound Consultant's and care plan recommendations for the RD to assess Resident 2. The ADON confirmed the RD did not assess Resident 2 and make recommendations for Resident 2's wound healing interventions until 3/5/2024. The ADON stated Resident 2 should have been seen by the RD sooner so the RD's recommendations could be implemented quicker to promote Resident 2's pressure injury to start healing.
A review of Resident 2's Nutrition Care Progress Notes, dated 3/5/2024, indicated the RD made recommendations as followed:
a. Discontinue current GT feeding of Fibersource High Nitrogen (formula for nutrition) 1.2 at 65 milliliters/hour over 20 hours and change formula with Jevity 1.5 Cal (high protein formula) 237 milliliters ([ml] a liquid weight measurement) 5 times a day via bolus (a single dose administered all at once) at 6 a.m., 10 a.m., 2 p.m., 6 p.m., 10 p.m., to provide a1185 ml equivalent to 1778 kilocalories (unit of energy), 76 grams of protein, and 901 ml of water.
b. Fluid restriction to 1500 ml was discontinued.
c. Discontinue folic acid (supplement).
d. Discontinue free water flush (water used to clear the g-tube before and after administering medications).
e. Start free water flush of 25 ml before and after each bolus feeding.
f. Zinc (supplement) 50 milligrams ([mg] weight measurement) daily for 5 days.
g. Discontinue Pro- Stat (liquid protein supplement).
During a concurrent interview and record review on 11/26/2024 at 12:58 p.m., with the ADON, Resident 2's Documentation Survey Reports for January, February, and March 2024 were reviewed. The Documentation Survey Reports indicated the column titled, Turn and Reposition Every Two Hours and As Needed indicated Resident 2 was not turned and repositioned every two hours and as needed on each shift in January, February, and March 2024. The ADON stated The Documentation Survey Reports indicated there were six eight-hour shifts in January, five shifts in February, and eight shifts in March 2024 that were left blank which meant there was no documented evidence Resident 2 was turned and repositioned every two hours on every shift in January, February, and March 2024. The ADON stated if it was not documented it was not done.
During a review of Resident 2's Wound Consultant Progress notes, the Wound Consultant Progress notes indicated following:
a. On 3/12/2024, the pressure injury on the left lateral malleolus had gotten worse and was reclassified as Stage III pressure injury (Full-thickness loss of skin, dead and black tissue may be visible) measuring 2.8 cm long by 1.5 cm wide, with undetermined depth.
b. On 3/19/2024, the pressure injury on the left lateral malleolus had gotten worse and was reclassified as Stage IV pressure injury measuring 1.5 cm long by 1.8 cm wide by 0.4 cm deep. The notes indicated a new DTI was noted on right lateral malleolus DTI measuring 2.0 cm long by 2.0 cm wide with undetermined depth.
c. On 3/26/2024, the notes indicated the Stage IV pressure injury to the left lateral malleolus measured 2.2 cm long by 1.6 cm wide and 0.3 cm. deep. The wound bed was 30% slough (yellowish material), 60% granulation (new tissues, bright red or pink, soft, moist, bumpy, and raised), and 10% epithelial tissue (appears pink or pearly white occurs in the final stage of healing). The right lateral malleolus DTI had gotten worse and was reclassified as a Stage III pressure injury measuring 1.2 cm long by 1.2 cm wide with undetermined depth and 100% slough. excisional debridement (surgical removal or cutting away of such tissue, necrosis, or slough) was performed on both right and left lateral malleolus pressure injuries.
During an interview and record review on 12/2/2024 at 10:12 a.m., with the Director of Nursing (DON), Resident 2's Wound Consultant Notes dated 2/ 13/2024 and Physician's Orders dated 2/2024 were reviewed. The Wound Consultant Notes indicated the treatment plan for the left lateral malleolus was to cleanse the wound with sterile Normal Saline, pat dry, apply Betadine directly to wound bed and cover with dry sterile dressing. Change dressing daily and as needed for loss of integrity/soiling. Resident 2's Physician Orders dated 2/11/2024, 2/16/2024, and 2/27/2024 indicated the order for the left lateral malleolus was to paint with Betadine, allow to dry and then cover with Silicone Foam (a type of wound dressing that seals the wound and absorbs any fluids) dressing every day shift. The DON stated the recommendations of the Wound Consultant to clean the DTI with sterile Normal Saline first before applying Betadine was not implemented and instead the DTI was just being painted with betadine without being cleaned with sterile Normal Saline first. The DON stated the physician's recommendations should have been followed to ensure proper wound healing. The pressure injury was just being painted with Betadine without being cleaned with normal saline first from 2/11/2024 to 3/11/2024.
During an interview on 12/2/2024 at 11:00 a.m., the DON stated residents should be turned at least every two hours to prevent the resident from getting a pressure injury or the pressure injury getting worse. The DON stated residents should not develop a pressure injuries in the facility . The DON stated the care plan meeting to plan and implement proper interventions for Resident 2 when the DTI was first identified should have included the RD. The DON stated back in January to March of 2024, the facility was going through changes in administration, and she was not sure why the RD was not involved in Resident 2's care sooner.
2. During a review of Resident 12's admission Record, the admission Record indicated Resident 12 was admitted to the facility on [DATE] with diagnoses including pressure injury of sacral (lower back) region, type 2 diabetes (a disorder characterized by difficulty in blood sugar control and poor wound healing), obesity (chronic disease when someone has excessive amount of body fat that can lead to health problems) and anemia (a condition where the body does not have enough healthy red blood cells).
During a review of Resident 12's MDS, dated [DATE], the MDS indicated Resident 12's cognitive skills for daily decision-making were intact. The MDS indicated Resident 12 needed maximal assistance (helper does more than half the effort) with toileting hygiene, showering, and rolling left and right on the bed. The MDS indicated Resident 12 was at high risk for developing pressure injuries and the resident had one or more unhealed pressure injuries.
During a review of Resident 12's Initial Nursing History and Assessment, dated 12/5/2022, the Initial Nursing History and Assessment indicated Resident 12 had an unstageable pressure injury to the sacrococcyx (lower back tailbone area) area measuring 4.5 cm long by 4 cm wide, with 3.0 cm. depth.
During a review of Resident 12's care plan titled, Alteration in skin Integrity, started on 12/6/2022, the care plan goal indicated Resident 12 would show progress towards wound healing over the next three months. One of the care plan interventions included to provide turning and repositioning at least every two hours.
During a review of the Resident Council (facility residents who meet regularly to improve their quality of life and quality of care) meeting Minutes dated 3/28/2024, the document indicated Resident 12 complained that staff was not turning and repositioning the resident every two hours.
During an interview on 11/27/2024 at 1:45 p.m., in Resident 12's room, Resident 12 stated in the beginning of the year (January to March 2024), the staff were not turning and repositioning her. Resident 12 stated she complained about staff not turning her in March 2024 at the Resident Council meeting and signed a statement.
During an interview on 11/27/2024 at 1:58 p.m., Certified Nurse Assistant (CNA 1) stated turning and repositioning the resident at least every two hours was important and documentation on turning and repositioning was completed after the resident was turned and repositioned. CNA 1 stated if it was not documented it was not done.
During an interview and record review on 11/27/2024 at 3:00 p.m., with the ADON Resident 12's Documentation Survey Report for January, February, and March 2024, were reviewed and the task indicating Resident 12 was turned and repositioned at least every 2 hours and as needed, did not indicate Resident 12 was consistently turned and repositioned every two hours and as needed on every shift for three months in January, February, and March 2024 The ADON stated there were four shifts in January, five shifts in February, and nine shifts in March 2024, that were blank which meant there was no documented evidence Resident 12 was turned and repositioned every two hours on each shift for the months of January, February, and March 2024. The ADON stated if it was not documented it was not done.
During an interview on 11/27/2024 at 3:10 p.m., the ADON stated Resident 12 consistently complained in March 2024 about not being turned every two hours. The ADON stated dependent residents should be turned at least every two hours to prevent a pressure injury development and facilitate the healing of existing pressure injuries.
During a review of Pressure Injury Prevention Points Portable Document Format (PDF) published by the National Pressure Injury Prevention Advisory Panel, copyright 2020, the PDF indicated the following pressure injury prevention recommendations:
a. Consider bedfast and chairfast individuals to be at risk for development of pressure injury.
b. Develop a plan of care based on the areas of risk, rather than on the total risk assessment score. For example, if the risk stems from immobility, address turning, repositioning, and the support surface.
c. Turn and reposition all individuals at risk for pressure injury, unless contraindicated due to medical condition or medical treatments.
d. Continue to reposition an individual when placed on any support surface.
e. Reposition weak or immobile individuals in chairs hourly (www.npiap.com)
During a review of the facility's P&P titled, Pressure Injury aka Pressure Sore Management, revised 10/2017, the P&P indicated:
a. It was the policy of the facility to provide guidelines for the treatment of pressure injuries to facilitate healing.
b. The diet of the resident with a pressure injury should contain nutrients adequate to support healing as recommended by the RD.
c. A plan of care will be initiated upon admission and identification of residents at high risk for development of pressure injuries and implemented.
d. Residents will be turned and repositioned every two hours or as needed. Frequent toileting and efforts to keep residents dry.
e. Ongoing programs including emphasis on turning schedule by supervisory staff.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a verbal altercation between two of six sampled residents (Resident 2 and Resident 2) that occurred on 9/14/2024, was investigated.
This deficient practice resulted in the incident between Resident 2 and Resident 6 not being addressed and had the potential for continued conflict between the two residents.
Findings:
During a review of Resident 2 ' s admission Record (Face Sheet), the Face Sheet indicated Resident 2 was admitted to the facility on [DATE] and readmitted on [DATE], with a diagnosis anxiety disorder (a condition in which a person has excessive worry and feelings of fear, dread, and uneasiness).
During a review of Resident 2 ' s Minimum Data Set ([MDS] a federally mandated resident assessment tool) dated 9/9/2024, the MDS indicated Resident 2 was able to make independent decisions that were reasonable and consistent.
During a review of Resident 6 ' s admission Record (Face Sheet), the Face Sheet indicated Resident 6 was admitted to the facility on [DATE] with a diagnosis of cerebral infarction (also known as stroke, a condition that occurs when blood flow in the brain is blocked or there is a sudden bleeding in the brain).
During a review of Resident 6 ' s MDS, dated [DATE], the MDS indicated Resident 6 was able to make decision, and express his needs, despite being forgetful.
During a review of Resident 6 ' s History and Physical (H&P) dated 8/27/2024, the (H&P) indicated Resident 6 had the capacity to understand and make decisions.
During an interview on 9/26/2024 at 4:23 p.m., Resident 2 stated there was a past situation between him and a previous roommate (Resident 6), that he did not want to elaborate on because he already told the Administrator about it.
During a telephone interview on 9/27/2024 at 1:28 p.m., Restorative Nursing Assistant 1 (RNA 1) stated Resident 2 and Resident 6 had a verbal altercation in the dining Room on 9/14/2024 (the time is unknown). RNA 1 stated Resident 2 approached Resident 6 and asked Resident 6 to be his friend but Resident 6 did not want to talk to Resident 2. RNA 1 stated Resident 6 started to move his hands and yell at Resident 2. RNA 1 stated Resident 2 responded to Resident 6 by using racial slurs (demeaning language that is offensive toward members of a racial or ethnic group) at Resident 6. RNA 1 stated she call the Administrator (ADM) and informed her of the incident on 9/14/2024. RNA 1 stated during the same telephone call she also informed the ADM of another incident that occurred between Resident 2 and Resident 6 on 9/13/2024 during the 7 a.m. to 3 p.m. shift, that she heard from another CNA (unknown). RNA 1 stated, the CNA told her that Resident 2 and Resident 6 were throwing oatmeal at each other in their room. RNA 1 stated it was the duty of all staff at the facility to report any alleged mistreatment and/or resident altercation to the ADM immediately because the residents ' safety is a priority.
During an interview on 9/27/2024 at 4:06 p.m., the ADM stated she did not conduct an investigation of the incident between Resident 2 and Resident 6 that occurred on 9/13/2024 because she did not see it as mistreatment of the residents, but rather a roommate incompatibility and stated the incident on 9/14/204 was not reported to her so she was not aware of it. The ADM stated there was no conclusion to submit to CDPH because no investigation was conducted. The ADM stated it was necessary to conduct a thorough investigation and send the conclusion report to CDPH, to verify the findings and find solution and/or perform a corrective action to the problem.
During a review of the facility ' s Policy and Procedure (P/P) titled, Abuse Reporting and Prevention revised 4/2024, the P/P indicated the facility must investigate all allegations and all substantiated incidents and the results of the investigation must be reported to CDPH, within 5 working days of the incident(s).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a Hemodialysis Nurse 1 ([HDN 1] licensed nurses who specialize in the care of patients with kidney failure including treatment using hemodialysis [a lifesaving treatment and procedure for kidney failure that removes waste and extra fluids from the blood and regulates blood pressure]) and a Hemodialysis Technician 1 ([HDT 1] a healthcare professional who provides care to patients with kidney failure by performing and monitoring dialysis treatments) cleansed their hands using an alcohol-based hand rub (ABHR) or soap and water, and donned proper personal protective equipment ([PPE] clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments), a gown and gloves, before providing direct care to two of six sampled residents (Resident 7 and Resident 8). Resident 7 and Resident 8, who were undergoing hemodialysis treatment, and who were on enhanced barrier precaution ([EBP] an approach of targeted gown and glove use during high contact resident care activities, designed to reduce transmission of infectious microorganisms) due to being positive for Candida Auris ([C. auris] a yeast [type of fungus] that causes severe infections and can spread in the healthcare setting).
These deficient practices resulted in HDN 1 and HDT 1 not practicing infection control methods and had the potential for the inadvertent spread of infectious microorganisms to the other residents in the facility.
Findings:
During a review of Resident 7's admission Record (Face Sheet), the Face Sheet indicated Resident 7 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis including renal dialysis dependency (a condition of relying on a treatment called hemodialysis when a person's kidneys are failing), and unspecified candidiasis (yeast infection that can affect the mouth, genitals and even the blood).
During a review of Resident 7's Microbial Diseases laboratory results dated [DATE], the Microbial Diseases Laboratory Results indicated Resident 7 tested positive for C. auris.
During a review of Resident 8's admission Record (Face sheet), the Face Sheet indicated Resident 8 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including dependency on renal dialysis, and chronic viral hepatitis c (a condition cause by a virus that spreads through contact with blood).
During a review of Resident 8's Microbial Diseases laboratory results dated [DATE], the Microbial Diseases Laboratory Results indicated Resident 8 was tested positive for C. auris.
During an observation on 9/30/2024 at 9:36 a.m., Resident 7 and Resident 8 were in their rooms when HDT 1 who was wearing a disposable gown with the front of it open, exposing his clothing that was worn under the gown, was observed sitting on a chair facing Resident 8, who was undergoing hemodialysis. HDT 1 approached Resident 8 to check on him and his exposed uniform came in contact with Resident 8's bed linens.
During an observation on 9/30/2024 at 9:39 a.m., Resident 7 and Resident 8, were in their rooms undergoing hemodialysis, when HDN 1 entered their room without using an ABHR to clean her hands and without donning a gown or gloves prior to entering the resident's room. HDN 1 was holding a tray that had medical supplies on it, and he placed the medical tray on top of Resident 8's bedside table, passed by the bedside of Resident 7 and with his bare arms and uncovered uniform touched the pillow of Resident 7. HDN 1 then proceeded to touch Resident 8's bed with his bare arms while looking at the hemodialysis machine.
During an interview on 9/30/2024 at 9:43 a.m., the HDT stated he was approved by the previous Infection Preventionist Nurse (IPN) to wear a gown and keep it open while providing hemodialysis care and assistance to the residents. HDT 1 stated he should have worn the proper PPE (gown) to prevent cross contamination between the residents in the facility.
During an interview on 9/30/2024 at 9:58 a.m., HDN 1 stated he was aware Resident 7 and Resident 8 were on EBPs however, he forgot to use the ABHR and donn the appropriate PPEs (gloves and a gown) before entering the resident's room and before providing direct care to them. HDN 1 stated all staff were responsible in following the infection control procedures of the facility to prevent the spread of infection.
During an interview on 9/30/2024 at 10:44 a.m., the IPN stated all staff in the facility, including the contracted hemodialysis staff, must abide by the infection control policies of the facility. The IPN stated non compliance with the infection control procedures could inadvertently cause an outbreak of infection in the facility.
During an interview on 9/30/2024 at 11:48 a.m., the Director of Nursing Services (DON) stated the facility and its staff, in house or under contract, must be diligent in implementing all infection control procedures to observe source control and prevent cross contamination to the vulnerable residents of the facility.
During a review of the facility's Policy and Procedure (P/P) titled, Hand Hygiene revised 7/2019, the P/P indicated the facility staff members must perform hand hygiene before and after direct resident care and after contact with potentially contaminated substances to prevent, to the extent possible, the spread of infection.
During a review of the facility's P/P titled, Enhanced Standard Precautions revised 5/2024, the P/P indicated the health care professionals (HCP) of the facility must wear gowns and gloves while performing high contact tasks with the greatest risk for contamination of HCP's hands, clothes, and the environment during any care activity where close contact with the resident is expected to occur such as morning/evening care, toileting/incontinence care, wound care, mobility assistance, cleaning of the environment as well as any care activity involving contact with environmental surfaces likely contaminated by the resident and during care for health devices, invasive procedure sites and giving medical treatment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a verbal and physical altercation between two of six sampled residents (Resident 2 and Resident 6) was reported to the Administrator (ADM) and/or to the California Department of Public Health (CDPH), when Certified Nursing Assistant witnessed Resident 2 and Resident 6 throwing oatmeal at each other on 9/13/2024, and when Restorative Nursing Assistant 1 (RNA 1) witnessed a verbal altercation between Resident 2 and Resident 6 on 9/14/2024 and reported it to the ADM.
This deficient practice resulted in the inability of CDPH to investigate the Resident to Resident altercations between Resident 2 and Resident 6 in a timely manner and had the potential for facts related to the allegations to be forgotten by staff and other witnesses.
Findings:
During a review of Resident 2's admission Record (Face Sheet), the Face Sheet indicated Resident 2 was admitted to the facility on [DATE] and readmitted on [DATE], with a diagnosis of anxiety disorder (a condition in which a person has excessive worry and feelings of fear, dread, and uneasiness).
During a review of Resident 2's Minimum Data Set ([MDS] a federally mandated resident assessment tool) dated 9/9/2024, the MDS indicated Resident 2 was able to make independent decisions that were reasonable and consistent.
During a review of Resident 6's admission Record (Face Sheet), the Face Sheet indicated Resident 6 was admitted to the facility on [DATE] with a diagnosis of cerebral infarction (also known as stroke, a condition that occurs when blood flow in the brain is blocked or there is a sudden bleeding in the brain).
During a review of Resident 6's MDS dated [DATE], the MDS indicated Resident 6 was able to make decisions and express his needs, despite being forgetful.
During a review of Resident 6's History and Physical (H&P) dated 8/27/2024, the (H&P) indicated Resident 6 had the capacity to understand and make decisions.
During an interview on 9/26/2024 at 4:23 p.m., Resident 2 stated there was a past situation between him and a previous roommate, that he did not want to elaborate on because he already told the Administrator about it.
During a telephone interview on 9/27/2024 at 1:28 p.m., Restorative Nursing Assistant 1 (RNA 1) stated Resident 2 and Resident 6 had a verbal altercation in the dining Room on 9/14/2024 (unsure of the time). RNA 1 stated Resident 2 approached Resident 6 and asked Resident 6 to be his friend, but Resident 6 did not want to talk to Resident 2 and Resident 6 started to move his hands and yell at Resident 2. RNA 1 stated Resident 2 responded to Resident 6 by using racial slurs (demeaning language that is offensive toward members of a racial or ethnic group) at Resident 6. RNA 1 stated she called the ADM on 9/14/32024 and informed her of Resident 2 and Resident 6's verbal altercation. RNA 1 stated during the same telephone call she also informed the ADM of another incident that occurred between Resident 2 and Resident 6 on 9/13/2024 during the 7 a.m. to 3 p.m. shift, that she heard from another CNA. RNA 1 stated, the CNA told her that Resident 2 and Resident 6 were throwing oatmeal at each other in their room. RNA 1 stated it is the duty of all staff at the facility to report any alleged mistreatment and/or resident altercation immediately to the ADM because the residents' safety is a priority.
During an interview on 9/27/2024 at 4:06 p.m., the ADM stated she did not report the verbal altercation that occurred on 9/14/2024 between Resident 2 and Resident 6 to CDPH because she did not see the incident as mistreatment but rather a roommate incompatibility and stated the incident on 9/13/2024 was not reported to her so she did not know about it. The ADM stated it was the duty of the facility to report any allegations of mistreatment and/or resident to resident altercation to CDPH in a timely manner.
During a review of the facility's Policy and Procedure (P/P) titled, Abuse Reporting and Prevention revised 4/2024, the P/P indicated the facility must ensure that the residents are protected by providing a method of investigation and reporting of any alleged violations involving mistreatment and resident to resident altercation by the administrator or his/her designee to the Ombudsman's office and the Department of public Health.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to re-admit one of three sampled residents (Resident 1), when Resident 1 was transferred to a General Acute Care Hospital (GACH) for evaluation of aggressive behavior, increased agitation, and refusal of care. The GACH cleared Resident 1 to return to the facility on 5/9/2024 but the facility refused to readmit her.
This deficient practice resulted in Resident 1 remaining at the GACH (over five months after being transferred) and had a potential for Resident 1's continued displacement.
Findings
During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including a gastrostomy (a surgical procedure that creates an opening in the stomach wall through the skin of the abdomen to insert a small tube used for administration of nutrition and/or medication and schizoaffective disorder (a chronic mental illness that causes a person to experience dramatic changes in their thoughts, moods and behaviors).
During a review of Resident 1's Minimum Data Set ([MDS] a standardized assessment and care screening tool) dated 1/26/2024, the MDS indicated Resident 1's cognition (the mental process involved in knowing, learning, and understanding things) was severely impaired and Resident 1 required substantial to maximal assistance (helper does more than half the effort) to complete her activities of daily living ([ADLs] task such as bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet and eating).
During a review of Resident 1's Physician's Orders dated 3/27/2024, the Physician's Orders indicated to transfer Resident 1 to a GACH for further evaluation due to aggressive behavior, increased agitation and refusing medication and gastrostomy tube (a tube inserted through the abdomen into the stomach which allows for the delivery of nutrition, fluids, and medications directly to the stomach) feedings.
During a review of the GACH's Psychiatric Progress notes, dated 5/9/2024, the Psychiatric Progress notes indicated Resident 1 intermittently (occurring at irregular interval, not continuous or steady) responded to internal stimuli (changes or feelings that occur within the body, such as hunger, thirst, or emotional states) but was not distressed and was more redirectable. The Psychiatric Progress notes indicated Resident 1 was compliant with taking her medication, was able to make simple needs known and was partially cooperative.
During an interview on 9/13/2024 at 12:29 p.m., Social Services staff at the GACH stated on 5/9/2024 she spoke to the Admissions Coordinator (AC) at the facility who told her Resident 1 was unable to return to the facility, there was no reason as to why.
During a record review of the facility's Daily Census dated 5/9/2024, the census indicated four available beds.
During an interview on 9/13/2024 at 2:51 p.m., the AC stated Resident 1 was sent to the GACH due to behavioral reasons and the Director of Nursing 1 (DON 1), who the DON during the time Resident 1 was transferred (3/27/2024), was adamant about not readmitting Resident 1 to the facility because the facility could not meet Resident 1's psychosocial needs. The AC stated when the GACH called to have Resident 1 readmitted to the facility, DON 1 reviewed Resident 1's social services notes from the GACH and found that Resident 1 was still combative, and refused care, and she (DON 1) would not allow Resident 1 readmission to the facility.
During an interview on 9/13/2024 at 4:59 p.m., DON 2 stated prior to readmitting a resident to the facility, she reviews clinical information from the GACH to determine if the facility can meet the resident's needs. DON 2 stated, if a resident is yelling and refusing care, per the GACH records, the resident cannot be readmitted because their behavior would disturb the other residents at the facility.
During a review of the facility's policy and procedure (P/P) titled Bed Hold and Notice dated 8/2018, the P/P indicated when a resident's hospital or therapeutic leave exceeds the bed-hold period, the facility will readmit a Medicaid resident requiring SNF (skilled nursing facility) services to their previous room if available or immediately upon the first availability of a bed in a semi-private room.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop a person-centered care plan (document that helps nurses and other team care members organize aspects of resident care) with interventions (actions a nurse takes to implement a care plan, intend to improve the patient's comfort and health) for three of 12 sampled residents (Resident 1, 3, and 15) by failing to:
1. Develop a care plan for Resident 3 who required maximal assistance (helper does more than half of the effort) to dependent assistance with her activities of daily living ([ADLs], self-care activities such as bathing, toileting, and eating) and had unclear speech.
2. Develop a care plan for Resident 15 who received oxygen administration.
3. Develop a care plan for Resident 65 who required maximal assistance with his ADLs.
These failures had the potential to negatively affect the delivery of necessary care and services for Resident 3, 15, and 65.
Findings:
a. During a review of Resident 3's admission Record (Face Sheet), indicated Resident 3 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses that include but not limited to heart failure (a chronic condition in which the heart does not provide adequate blood flow to meet the body's needs), aphasia(an impairment of language affecting the ability to express or understand speech), and cerebral infarction (also known as a stroke; refers to damage to the tissues in the brain due to a loss of oxygen to the area).
During a review of Resident 3's Minimum Data Set ([MDS], a standardized screening and assessment tool), dated 5/9/2024, the MDS indicated Resident 3 had unclear speech, such as slurred or mumbled words. The MDS indicated Resident 3 was usually understood by others by having difficulty communicating some words. The MDS indicated Resident 3's cognition (process of thinking) was intact. The MDS indicated Resident 3 had an impairment (decrease in function) on one side of her upper extremity (includes the shoulder, elbow, wrist, and hand) and lower extremity (includes the hip, knee, ankle, and foot).
During an interview on 7/24/2024 at 12:17 p.m., with Certified Nursing Assistant (CNA1), CNA 1 stated Resident 3 required maximal assistance with many of her ADLs and she would use the call light to ask for assistance. CNA 1 stated Resident 3 had difficulty with her speech at times due to her stroke.
During an interview on 7/25/2024 at 9:45 a.m., with Minimum Data Set Nurse (MDSN 1), MDSN 1 stated her role in the facility was to conduct assessments for the residents, which would coordinate the individualized care the residents would need. MDSN 1 stated she would also develop care plans based on the MDS triggers to direct the action that had to be taken for the issue or concern that the resident had.
During a concurrent interview and record review on 7/25/2024 at 9:49 a.m., with MDSN 1, Resident 3's care plans were reviewed. Resident 3 did not have a care plan that addressed her difficulty in speech, nor her assistance levels with her ADLs. MDSN 1 stated Resident 3 had slurred speech and had difficulty communicating at times and required maximal to dependent assistance with her ADLs. MDSN 1 stated Resident 3 did not have a care plan that addressed those issues and concerns. MDSN 1 stated a care plan should have been developed and interventions implemented to monitor Resident 3's baseline and to provide care to prevent any decline in Resident 3's status.
During an interview on 7/25/2024 at 11:09 a.m., with the Director of Nursing (DON), the DON stated the purpose of residents' care plan was to address the issue, create goals, and implement interventions to reach the goals. The DON stated many of the residents' care plans were developed based on the assessments done on their MDS. The DON stated Resident 3's assistance level with ADLs and her unclear speech should have been care planned. The DON stated a care plan for Resident 3's ADL assistance level would communicate to the staff the amount of assistance Resident 3 required and how to provide it safely. The DON stated a care plan for Resident 3's unclear speech would communicate to the staff how to provide the care necessary to ensure Resident 3 could communicate effectively. The DON stated because Resident 3 did not have that care plan, Resident 3 was at risk for a decline in her communication skills and could potentially put Resident 3 at risk for injury if the correct assistance level was not provided to her.
During a review of the facility's P&P titled, Activities of Daily Living, Quality of Care, routine Resident Monitoring, and Scope of Services, dated June 2022, the P&P indicated The facility will provide care for residents who require respiratory care, so they receive care and treatment in accordance with professional standards of practice, the comprehensive resident centered care plan, as well as the resident's goals and preferences.
b. During a review of Resident 15's Face Sheet dated 5/31/2024, the Face Sheet indicated Resident 15 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Resident 15's diagnoses included cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area), dysphagia (difficulty swallowing), gastroparesis (a disorder that slows or stops the movement of food from your stomach to the small intestine), hyperlipidemia (an excess of fats in the blood), and hypertension (high blood pressure).
During a review of Resident 15's MDS dated [DATE], the MDS indicated Resident 15's cognitive skills (ability to learn, reason, remember, understand, and make decisions) were severely impaired (never or rarely able to make decisions regarding tasks of daily life). The MDS indicated Resident 15 had impairments to both lower and upper extremities and required assistance of two or more helpers to complete activities such as eating, toileting, bathing, and personal hygiene. The MDS indicated Resident 15 received oxygen therapy while in the facility.
During a review of Resident 15's Order Summary Report, dated 6/27/2024, the order summary report indicated an active order for continuous oxygen at 3 liters per minute via nasal cannula.
During a review of Resident 15's medical records, the medical records did not include a care plan or interventions for oxygen administration or a care plan that indicated Resident 15 frequently removed the nasal cannula that provided supplemental oxygen from his nose.
During a concurrent observation and interview on 7/24/2024 at 3:35 p.m. with Licensed Vocational Nurse (LVN) 3 at Resident 15's bedside, LVN 3 stated that Resident 15 was receiving continuous oxygen.
During a concurrent interview and record review on 7/24/2024 at 4:27 p.m. with Registered Nurse (RN) 1, Resident 15's medical record was reviewed. RN 1 searched Resident 15's medical record for a care plan related to oxygen administration. RN 1 stated she was unable to find a care plan for Resident 15's oxygen therapy in the medical record. RN 1 stated if a resident is receiving oxygen, the resident should have a care plan with interventions. RN 1 stated that the care plan is important to know the oxygen parameters and to report abnormal respirations.
During an interview on 7/25/2024 at 12:46 p.m., with the Director of Nursing (DON), the DON stated that an oxygen care plan was needed for Resident 15 so the nurses would know the purpose and the interventions the resident was receiving oxygen therapy.
During a review of the facility's P&P titled, Oxygen Administration, revised March 2017, the P&P indicated to verify that there is a physician's order for oxygen administration and review the resident's care plan for any special needs of the resident. The P&P indicated if the resident refuses the administration of oxygen, document the reason(s) and ensure that the risks are explained to the resident and documented.
c. During a review of Residents 65 admission Record (Face Sheet), the admission Record indicated Resident 65 was initially admitted to the facility on [DATE] with diagnoses that include but not limited to quadriplegia (a form of paralysis that affects all four limbs plus the torso), muscle weakness (lack of muscle strength), osteoarthritis unspecified (degenerative joint disease in which the tissue in the joint break down over time), neuromuscular dysfunction of bladder (lack of bladder control due to brain or spinal cord injury).
During a review of Resident 65's Minimum Data Set ([MDS] a specialized resident screening and assessment tool), dated 4/5/2024, the MDS indicated Resident 65 was able to understand and be understood by others. The MDS indicated Resident 65 had impairments (the state of function being weakened or damaged) on both sides of his upper extremities (upper part of the body that includes the shoulder, elbow, wrist, and hand) and on both sides of the lower extremities (lower part of the body that includes the hip, knee, ankle, and foot). The MDS indicated that Resident 65 was dependent on staff for toileting, bathing, dressing, and personal hygiene.
During a review of Resident 65's History and Physical (H&P), dated 5/7/2024, the H&P indicated Resident 65 had the capacity to understand and can make medical decisions.
During a review of Resident 65's Comprehensive Assessment, dated 5/10/2024, the comprehensive assessment indicated Resident 65 required total assistance with ADL's related to quadriplegia.
During a review of resident 65's active physician orders and order summery dated 7/18/24 and 7/20/24 indicated an order for ADL's (physical therapy appts, occupational therapy appts, non-pharmacological interventions), and non-pharmacologic interventions (any assistance offered without the use of traditional medicine).
During an observation on 7/22/2024 at 10:21 a.m. and on 7/23/2024 at 9:30 a.m. in Resident 65's room. Resident 65 was sitting on his wheelchair watching television.
During a concurrent interview and record review on 7/23/2024 at 3:00 p.m. with License Vocational Nurse (LVN) 1, Resident 65's Care Plans were reviewed. LVN 1 stated, there were no Care Plans that directly addressed Resident 's total care needs, or the increased need of non-pharmacologic interventions related to Resident 65's limitations. LVN 1 stated that resident care plans are used to familiarize the staff with each individual plan of care. LVN 1 stated that specific details of care about Resident 65's limitations should have been included in care plan.
During an interview on 7/24/2024 at 10:45 a.m. Registered Nurse Supervisor (RNS), the RNS stated any new or old information obtained about the residents should always be placed in the care plan. The RNS stated this was the best way to communicate with the team about care. The RNS stated every person on a care team were responsible to help and update care records.
During an Interview with the Director of Nursing (DON) on 7/24/24 at 2.00 p.m., the DON stated for any patient that has limitation non-pharmacologic interventions are a must. The DON stated staff works as a group to keep medical records updated.
A review of the facility's policy and procedure (P&P) titled, Comprehensive care planning, revised 10/2017, the P&P indicated, A Comprehensive Care Plan will be developed for each resident. The Care Plan will include measurable objectives and timetables to meet a resident's medical, nursing, mental, and psychosocial needs.
Cross Reference F695.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure two of 12 sampled residents (Resident 15 and 77) were provided care and services to maintain good grooming and personal hygiene by failing to provide fingernail care for Residents 15 and 77 who were unable to carry out activities of daily living to maintain good personal hygiene.
This deficient practice caused Resident 15's long fingernails to dig into the palm of his right hand and had the potential to cause an open wound which could lead to infection. This deficient practice also had the potential to negatively impact Residents 15's and 77's quality of care and self-esteem.
Findings:
a. During a telephone interview on 7/24/2024 at 9:48 a.m. with Resident 15's Family Member (FM 1), FM 1 stated when they visited Resident 15, Resident 15 frequently had fingernails that were uncut. FM 1 stated that the fingernails on Resident 15's right hand would pinch his skin and cause a cut to the middle of his palm. FM 1 stated the nurses were notified of Resident 15's long fingernails several times, but Resident 15 continued to have long fingernail during their next visit to the facility. FM 1 stated the family would have to cut Resident 15's nails whenever they visited to prevent the nails from cutting his skin.
During an observation on 7/24/2024 at 3:30 p.m., in Resident 15's room, Resident 15's right hand was contracted (a shortening of muscles, tendons, skin, and nearby soft tissues that causes the joints to shorten and become very stiff, preventing normal movement). Resident 15 had long, jagged untrimmed fingernails on both hands. Resident 15's fingernails to the right contracted hand were digging into his palm causing redness to the area.
During a concurrent observation and interview on 7/24/2024 at 3:35 p.m. with Licensed Vocational Nurse (LVN) 3, LVN 3 opened up Resident 15's contracted right hand. LVN 3 stated Resident 15's long fingernails were causing redness to the to the palm of his hand which could lead to injury and cause an infection. LVN 5 stated the certified nursing assistants (CNAs) should cut Resident 15's fingernails every week.
During an interview on 7/24/2024 at 4:27 p.m. with Registered Nurse (RN) 1, RN 1 stated the CNAs were responsible for cutting the residents' fingernails and shaving the resident every Sunday. RN 1 stated that if Resident 15's fingernails were left to grow long, they could break the skin which could lead to infection.
During a review of Resident 15's admission Record, the admission Record indicated Resident 15 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Resident 15's diagnoses included cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area), dysarthria (a speech disorder where damage to the nervous system causes the muscles that produce speech to become paralyzed or weakened), anarthria (a complete loss of speech), dysphagia (difficulty swallowing), lack of coordination, muscle weakness, hemiplegia (unable to make voluntary movements on one side of the body), and hemiparesis (muscle weakness on one side of the body).
During a review of Resident 15's Minimum Data Set ([MDS] a comprehensive assessment and care-screening tool), dated 6/5/2024, the MDS indicated Resident 15's cognitive skills (ability to learn, reason, remember, understand, and make decisions) were severely impaired (never or rarely able to make decisions regarding tasks of daily life). The MDS indicated Resident 15 was totally dependent and did none of the effort to complete activities such as eating, toileting, bathing, and personal hygiene.
During a review of Resident 15's care plan titled, Self-care deficit in personal hygiene/grooming, related to cerebral vascular accident ([CVA] an interruption in the flow of blood to cells in the brain) dated 5/31/2024, the care plan indicated the staff's interventions indicated to monitor skin redness and assist in activities of daily living ([ADLs] skills required to manage basic physical needs, which include personal hygiene or grooming, dressing, toileting, and eating).
During a review of Resident 15's care plan titled, Alteration in Skin Integrity Actual Presence of: Skin ulcer/would to right palm related to Contracture dated 6/25/2024, the care plan indicated the staff's interventions included to provide treatment per physician order, provide ongoing assessment, monitor, and report for any signs/symptoms of infection, assess resident for pain manifested by facial grimacing and moaning, keep skin clean and dry, and notify doctor if no noted progress towards healing or any signs and symptoms of decline.
b. During a review of Resident 77's admission Record (Face Sheet), the admission Record indicated Resident 77 was admitted to the facility on [DATE] with diagnoses including cerebral infarction (disrupted blood flow to the brain), diabetes (high blood sugar), depression (feeling of sadness and loss of interest), generalized muscle weakness (lack of muscle strength), tachycardia (fast hear rate).
During a review of Resident 77's, Care Plan for Activities of Daily Living (ADL's) dated on 6/3/2024 and re-evaluation of ADL's completed on 9/3/2024 indicated Resident 77 had impaired self-care and functional mobility related to cerebral infarction requiring maximum assistance to perform personal hygiene.
During a review of Resident 77's History and Physical (H & P), dated 6/2/2024, indicated Resident 77 does not have the capacity to understand and make decisions.
During a review of Resident 77's MDS, dated [DATE], the MDS indicated Resident 77 was dependent (helper does all of the effort. Resident does none of the effort to complete the activity or the assistance of 2 or more helpers is required for the resident to complete the activity) on staff for eating, oral hygiene, toileting hygiene, shower/bathe self and personal hygiene.
During an observation on 7/22/20241:49 a.m. in Resident 77's room, Resident 77 was observed with brown substance underneath all ten fingers with untrimmed fingernails.
During an observation on 7/23/2024 8:45 a.m. in Resident 77's room, Resident 77 was observed with brown substance underneath all ten fingers with untrimmed fingernails.
During an observation on 7/23/2024 2:45 p.m. in Resident 77's room, Resident 77 was observed with brown substance underneath all ten fingers with untrimmed fingernails.
During an interview on 7/25/2024 at 8:20 a.m. with CNA 3, CNA 3 stated his responsibilities as a CNA included getting the residents up and ready for their activities of daily living. CNA 3 stated resident's fingernails were cleaned every day and whenever staff notices residents with dirty fingernails. CNA 3 stated that if the residents had their fingernails too long, they can injure themselves by scratching themselves or others.
During an interview on 7/25/2024 at 8:24 a.m., with LVN 2, LVN 2 stated staff makes sure they provide care with dignity and professionalism, and residents are well kept, by keeping them clean and providing good personal hygiene. LVN 2 stated staff cleans residents' fingernails every day and should be trimmed every Sunday (once a week). LVN 2 stated that if the fingernails become too long the nails may cause skin tears when residents scratch themselves and this can lead to infection.
During an interview on 7/25/2024 at 2:17 p.m., with the Director of Nursing (DON), the DON stated CNA's were responsible for performing personal hygiene and residents' fingernails were cleaned as needed and trimmed once a week.
During a concurrent interview on 7/25/2024 at 2:17 p.m., with the Assistant Director of Nursing (ADON), the ADON stated that if CNA's were not cleaning the residents' fingernails daily and as needed, it could lead to an infection if he nails were left dirty. The ADON stated if staff were not trimming the residents' fingernails, the residents could scratch themselves and end up with cuts.
During a review of the facility's policy and procedure (P&P) titled, Activities of Daily Living, Quality of Care, Routine Resident Monitoring, and Scope of Services, dated June 2022, the P&P indicated, it is the policy of the facility that each resident receive, and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being consistent with the resident's assessment and plan of care. The P&P indicated staff will ensure that ADLs are monitored, assisted with, and provided for those residents who are unable to perform ADLs. The P&P indicated if a resident is unable to carry out ADLs, they are to be provided services to maintain the food nutrition, grooming and personal and oral hygiene. The P&P indicated the facility will provide care consistent with progressional standards for residents to prevent pressure injuries and not develop pressure injures unless they are unavoidable.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 15) remained on continuous oxygen at 3 liters per minute via nasal cannula (a device that gives additional oxygen through your nose) as ordered by the physician.
This deficient practice had the potential to result in complications from lack of sufficient oxygen for Resident 15.
Findings:
During a review of Resident 15's admission Record, dated 5/31/2024, the admission record indicated Resident 15 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 15's diagnoses included cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area), dysphagia (difficulty swallowing), gastroparesis (a disorder that slows or stops the movement of food from your stomach to the small intestine), hyperlipidemia (an excess of fats in the blood), and hypertension (high blood pressure).
During a review of Resident 15's Minimum Data Set ([MDS] a comprehensive assessment and care-screening tool), dated 6/5/2024, the MDS indicated Resident 15's cognitive skills (ability to learn, reason, remember, understand, and make decisions) were severely impaired (never or rarely able to make decisions regarding tasks of daily life). The MDS indicated Resident 15 required assistance of two or more helpers to complete activities such as eating, toileting, bathing, and personal hygiene. The MDS indicated Resident 15 received oxygen therapy while in the facility.
During a review of Resident 15's Order Summary Report, dated 6/27/2024, the order summary report indicated an active order dated 5/30/2024 for oxygen at 3 liters per minute via nasal cannula continuously to keep the oxygen saturation (the amount of oxygen circulating in the blood) above 92 percent (%) for diagnosis of chronic respiratory failure (condition in which blood does not have enough oxygen or has too much carbon dioxide and makes it difficult to breath).
During a review of Resident 15's medical records, the medical records did not include a care plan or interventions for oxygen administration or a care plan that indicated Resident 15 frequently removed the nasal cannula.
During an observation on 7/22/2024 at 10:33 a.m., in Resident 15's room, Resident 15's nasal cannula was positioned under his chin.
During an observation on 7/22/2024 at 3:26 p.m., in Resident 15's room, Resident 15's nasal cannula was lying in the bed next to him.
During a concurrent observation and interview on 7/24/2024 at 3:35 p.m. with Licensed Vocational Nurse (LVN) 3, in Resident 15's room, Resident 15's nasal cannula was observed on the floor next to the bed. LVN 3 stated Resident 15 was receiving oxygen continuously but the resident always removed the nasal cannula from his nose. LVN 3 removed the nasal cannula from the floor and stated that she would get Resident 15 a clean one. LVN 3 stated how important it was to monitor Resident 15 closely to ensure he did not remove the nasal cannula from his nose. LVN 3 stated Resident 15 needed to wear his nasal cannula so that he would receive supplemental oxygen at all times. LVN 3 stated that Resident 15's supplemental oxygen was necessary to keep him alive and prevent him from having difficulty breathing.
During an interview on 7/24/2024 at 4:27 p.m. with Registered Nurse (RN) 1, RN 1 stated it was important for Resident 15 to wear his oxygen at all times to prevent shortness of breath.
During an interview on 7/25/2024 at 12:46 p.m., with the Director of Nursing (DON), the DON stated Resident 15 could develop respiratory problems if the resident was not wearing the oxygen as ordered by the physician.
During a review of the facility's policy and procedure (P&P) titled, Oxygen Administration, revised 3/2017, the P&P indicated to verify that there was a physician's order for oxygen administration and review the resident's care plan for any special needs of the resident. The P&P indicated if the resident refused the administration of oxygen, document the reason(s) and ensure that the risks were explained to the resident and documented.
During a review of the facility's P&P titled, Activities of Daily Living, Quality of Care, routine Resident Monitoring, and Scope of Services, dated 6/2022, the P&P indicated the facility would provide care for residents who require respiratory care, so they receive care and treatment in accordance with professional standards of practice, the comprehensive resident centered care plan, as well as the resident's goals and preferences.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to effectively manage resident's pain for one of one resident (Resident 27) by:
1. Failing to identify the resident's pain level after the administration of routine pain medication.
2. Failing to offer additional pain medication as ordered by the physician when Resident 27 continued to have pain 30 minutes after administering routine pain medications.
These deficient practices caused Resident 27 to experience pain that interfered with activities of daily living and resulted in Resident 27 experiencing unrelieved pain.
Findings:
During a review of Resident 27's admission Record, dated 7/2/2024, the admission record indicated Resident 27 was initially admitted to the facility on [DATE] with the following diagnoses which included type 2 diabetes (condition that results in too much sugar circulating in the blood, muscle wasting (deterioration of muscle tissue), atrophy (a condition where a body part or tissue shrinks due to lack of use or stimulation), fibromyalgia (a chronic [long-lasting] disorder that causes pain and tenderness throughout the body, as well as fatigue and trouble sleeping), and bilateral (affecting both sides) osteoarthritis (inflammation and swelling that occurs in the joints when the flexible tissue at the ends of bones begin to wear down over time) of the knee.
During a review of Resident 27's Minimum Data Set (MDS - a standardized resident assessment care screening tool), dated 6/6/2024, the MDS indicated Resident 27 was cognitively intact (ability to think, remember and reason) and was able to understand and make decisions. The MDS indicated Resident 27 was dependent (resident does none of the effort to complete the activity) related to toileting, bathing, and personal hygiene.
During a review of Resident 27's Care Plan, titled Alteration in Comfort - Pain, dated 6/22/2022 and last re-evaluated 7/6/2024, the care plan indicated Resident 27's pain would be relieved within one half hour after pain medication was given. The care plan indicated the following staff's interventions:
1. Instruct resident to report pain as soon as it begins.
2. Assess intensity of pain using a pain scale 1-10.
3. Assess non-verbal resident for possible signs and symptoms of pain such as yelling, irritability, grimaces, and sweating.
4. Administer pain medication per physician's order.
5. Provide nursing measure that will lessen intensity of pain.
6. Reassess pain 30 minutes and notify physician for possible need for increased pain medication as needed.
During a review of Resident 27's Order Summary Report, dated 6/27/2024, the order summary report indicated an active order dated 2/23/2023 to monitor Resident 27's pain from 0 to 10 on a pain scale (0 -indicated no pain, 1-3 indicated mild pain, 4-6 indicated moderate pain, 7-9 indicated severe pain, and 10 - very severe or horrible pain) every shift.
During a review of Resident 27's Order Summary Report, dated 6/27/2024, the order summary report indicated an active order dated 3/27/2024, for non-pharmacologic interventions, such as repositioning, dim light, quiet environment, hot/cold applications, relaxation techniques, distraction, music, and massage every shift.
During review of Resident 27's Order Summary Report, dated 6/27/2024, the order summary report indicated an active order dated 3/27/2024, to administer Acetaminophen (Tylenol - a medication to relieve mild to moderate pain) 325 milligrams (MG, unit of measurement), 1 tablet by mouth as needed for mild pain.
During review of Resident 27's Order Summary Report, dated 6/27/2024, the order summary report indicated an active order dated 3/27/2024, to administer Tramadol (a medication to relieve moderate to moderately severe pain) 50 MG, 0.5 tablet by mouth as needed for moderate pain.
During review of Resident 27's Order Summary Report, dated 6/27/2024, the order summary report indicated an active order dated 3/27/2024, to administer Tramadol 50 MG, 1 tablet by mouth as needed for severe pain.
During a review of Resident 27's Order Summary Report, dated 6/27/2024, the orders summary report indicated an active order dated 3/27/2024 for Lidoderm Patch 5% (Lidocaine - a mediation used to relieve nerve pain). Apply to right shoulder topically one time a day for pain management related to right shoulder pain. Apply 1 patch and remove per schedule.
During a review of Resident 27's Order Summary Report, dated 6/27/2024, the order summary report indicated an active order dated 2/19/2024 for Lyrica (Pregabalin - a medication used to treat nerve pain) Oral Capsule 50 MG. Give 1 capsule by mouth two times a day for pain management (when available).
During a review of Resident 27's Order Summary Report, dated 6/27/2024, the order summary report indicated an active order dated 3/27/2024 to administer Tramadol HCL 50 MG, give 0.5 tablet by mouth, every 4 hours as needed for moderate pain.
During a review of Resident 27's Order Summary Report, dated 6/27/2024, the order summary report indicated an active order dated 3/27/2024 to administer Tramadol HCL 50 MG, give 1 tablet by mouth, every 6 hours as needed for severe pain.
During a review of Resident 27's Order Summary Report, dated 6/27/2024, the order summary report indicated an active order dated 3/27/2024 to administer Tramadol HCL 25 MG by mouth, at bedtime for pain management related to right shoulder pain.
During a review of Resident 27's Order Summary Report, dated 6/27/2024, the order summary report indicated an active order dated 12/28/2023 to administer Tylenol oral tablet 325 MG, give 1 tablet by mouth, every 4 hours as needed for mild pain.
During a review of Resident 27's Medication Administration Record (MAR), for the month July 2024, the MAR indicated Resident 27 received Tramadol 50 MG one time for severe pain on 7/6/2024 at 9:16 a.m.
During a review of Resident 27's MAR, for the month of July 2024, the MAR indicated on 7/22/2024, Resident 27 received Tramadol 25 MG at 9 p.m. The MAR indicated Resident 27 had a pain level of 7/10 on the 3 p.m. to 11 p.m. (evening) shift and on the 11 p.m. to 7 a.m. (night) shift.
During a review of Resident 27's Initial Pain assessment dated [DATE], the initial pain assessment indicated Resident 27's pain threshold (acceptable level of pain) was 5/10 on a pain scale and to administer pain medications as ordered, monitor effectiveness, pain scale, and notify physician for significant changes.
During a concurrent observation and interview on 7/22/2024 at 10:54 a.m., with Resident 27, in Resident 27's room, Resident 27 was observed lying in bed, awake and alert. Resident 27 was observed grimacing and pointing to her left upper arm. Observed a Lidocaine patch to Resident 27's left upper arm. Resident 27 stated that she received the patch for pain in the morning along with pain medications, but she continued to have pain. Resident 27 stated the pain in her left upper arm was a 7-8/10 on the pain scale.
During a concurrent observation and interview on 7/23/2024 at 9:30 a.m., with Resident 27, in Resident 27's room, observed a Lidocaine patch to the left upper arm dated 7/23/2024. Resident 27 stated she continued to have 7-8/10 pain in her left upper arm. Resident 27 shook her head, grimaced, and rubbed her left upper arm. Resident 27 stated that she received her morning pain medication, but she continued to have pain.
During an interview on 7/23/2024 at 3:53 p.m., with Resident 27, in Resident 27's room, Resident 27 stated she continued to have 7-8/10 pain in her left upper arm. Resident 27 shook her head, grimaced, and rubbed her left upper arm.
During a concurrent interview and record review on 7/23/2024 at 3:56 p.m., with Licensed Vocational Nurses (LVN) 4, Resident 27's Nursing Progress Notes, for the month of July 2024, Resident 27's care plan titled, Alteration in Comfort - Pain, was reviewed. LVN 4 stated she last assessed Resident 27 for pain on 7/22/2024 at 9 p.m. LVN 4 stated she also gave Resident 27 routine pain medications at that time. LVN 4 stated Resident 27's pain was a 7/10. LVN 4 stated she reassessed Resident 27 one to two hours after giving the pain medication and Resident 27's pain was relieved. LVN 4 stated she did not document the pain reassessment. LVN 4 admitted she should have documented Resident 27's pain reassessment and comfort measures in the nursing progress notes. LVN 4 stated according to the pain care plan, Resident 27's pain should have been reassessed 30 minutes after administering pain medication. LVN 4 stated she should have reassessed Resident 27's pain after assessing a pain level of 7/10. LVN 4 stated that if she had reassessed Resident 27's pain, she could have offered additional pain medications or called the physician if her pain was not relieved. LVN 4 stated that the resident could become distressed from having continuous unrelieved pain.
During a concurrent observation and interview on 7/23/2024 at 4:34 p.m., with LVN 3 and Resident 27, in Resident 27's room, Resident 27 was observed lying in bed awake and alert. LVN 3 stated she worked the morning shift and Resident 27 never stated she was in pain. LVN 3 stated that she administered Resident 27's routine pain medications of Lyrica and applied the Lidocaine patch to her left arm at 9 a.m. (7/23/2024). Resident 27 pointed to her left arm and stated that she was having 8/10 pain. Resident 27 stated she had 7-8/10 pain in her left arm every day. LVN 3 stated she was not aware of Resident 27's pain. LVN 3 stated she would pay closer attention to Resident 27's pain, by making sure she reassessed the resident's pain and additional pain medications as needed if she continued to have pain. LVN 3 stated if she had reassessed Resident 27's pain, she would have known the routine pain medications were not working and offered more medication or called the physician.
During an interview on 7/24/2024 at 9:48 a.m., with Resident 27, Resident 27 stated her left upper arm pain was a little better than yesterday, but she continued to have 7/10 pain.
During an interview on 7/25/2024 at 12:49 p.m., with the Director of Nursing (DON), the DON stated when a routine pain medication was given, the pain must be reassessed to see if the pain medication was affective or if the physician needed to be notified. The DON stated when residents were experiencing pain, they did not want to participate in activities, the residents cannot sleep or move around. The DON stated pain could affect a resident's whole life.
During a review of the facility's policy and procedure (P&P) titled, Pain Management Protocol, dated 10/2017, the P&P indicated pain will be considered as the 5th vital sign and the absence or presence of pain will be documented at each nursing note entry that requires full vital signs. The P&P indicated reassessments will be conducted whenever there is a change in the dose, or the type of medications being utilized. The P&P indicated to assess effectiveness of pain medication with routine and as needed pain medication approximately 30 minutes after administration.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a dialysis (the process of removing waste products and excess fluid from the body) emergency kit ([e-kit], contains supplies such as tape, clamp, and gauze to use in case the resident experienced bleeding from their dialysis access site) was readily available at the bedside for one of three sampled residents (Resident 192).
This deficient practice had the potential for Resident 192 to receive delayed intervention during accidental bleeding and could lead to hypotension and shock.
Findings:
During a review of Resident 192's admission Record (Face Sheet), indicated Resident 192 was admitted to the facility on [DATE] with diagnoses that include but not limited to urinary tract infection ([UTI], an infection in any part of the urinary system), end stage renal disease ([ESRD], a stage where the kidneys can no longer support the body's needs for waste removal and fluid balance), and atrial fibrillation (an irregular, often rapid heart rate that can cause poor blood flow).
During a review of Resident 192's History and Physical (H&P), dated 7/23/2024, the H&P indicated Resident 192 had fluctuating (changing) capacity to understand and make decisions.
During a review of Resident 192's Order Summary Report, dated 7/20/2024, the Order Summary Report indicated Resident 192 was to receive hemodialysis (type of dialysis) every Tuesday, Thursday, and Saturday.
During a concurrent observation and interview on 7/22/2024 at 10:17 a.m. with Resident 192, in Resident 192's room, there was not a dialysis e-kit pinned to the wall nor inside the nightstand. Resident 192 stated he had not seen a dialysis e-kit anywhere in his room.
During a concurrent observation and interview on 7/23/2024 at 11:15 a.m. with Resident 192, in Resident 192's room, there was not a dialysis e-kit pinned to the wall nor inside the nightstand. Resident 192 stated he was waiting to be picked up by the transport so he could go to the dialysis center. Resident 192 stated he had not seen a dialysis e-kit inside his room.
During a concurrent observation and interview on 7/24/2024 at 11:13 a.m. with Licensed Vocational Nurse (LVN) 1, inside Resident 192's room, there was not a dialysis e-kit pinned to the wall nor inside the nightstand. LVN 1 stated there was no dialysis e-kit readily available inside Resident 192's room. LVN 1 stated every resident that received dialysis needed to have a dialysis e-kit inside their room in case the resident experienced bleeding from their access site. LVN 1 stated residents were most at risk for bleeding after their dialysis. LVN 1 stated Resident 192 had dialysis on 7/23/2024 and could have experienced excessive bleeding when he arrived back to the facility. LVN 1 stated without the dialysis e-kit at the bedside, if Resident 192 were to have bleeding from his dialysis access site, the nurses would not have the supplies to stop the bleeding.
During an interview on 7/24/2024 at 11:19 a.m., with Registered Nurse (RN) 1, RN 1 stated every dialysis resident needed a e-kit at the bedside in the event they experienced bleeding. RN 1 stated Resident 192 was a dialysis resident and received anticoagulant (blood thinner), which made him a higher risk for bleeding from his dialysis site. RN 1 stated if Resident 192 were to have bleeding from his dialysis access site and did not have a dialysis e-kit readily available, he could have excessive blood loss.
During an interview on 7/25/2024 at 11:11 a.m., with the Director of Nursing (DON), the DON stated every dialysis resident was supposed to have a dialysis e-kit readily available. The DON stated there were no reasons why an e-kit would not be inside the room. The DON stated without an e-kit in the room, if Resident 192 were to bleed from his dialysis access site, there may be a delay in stopping the bleeding. The DON stated excessive bleeding could cause a number of complications such as hypotension (low blood pressure) and hypovolemic shock (an emergency situation in which severe blood loss makes the heart unable to pump enough blood to the body).
During a review of the facility's policy and procedure (P&P) titled, Dialysis Care, revised on 9/2020, the P&P indicated, In case of an emergency, at the bedside of a dialysis resident, there should be a clamp, tape, [gauze], and Kerlix.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to document the medication administration of controlled substances (drugs with accepted medical use but with an abuse potential) for one out of three residents (Resident 27).
This deficient practice had the potential to harm Resident 27 by the likelihood of medication errors resulting from an inaccurate medical record, and also had the potential to cause Resident 27 harm by potentially not receiving the medication due to the loss of accountability which affects the control against drug loss (any loss of a controlled substance), diversion (transfer of a legally prescribed controlled substance from the individual for whom it was prescribed to another person for any illicit use), or theft.
Findings:
During a review of Resident 27's admission Record, the admission record indicated Resident 27 was admitted to the facility on [DATE]. Resident 27's admitting diagnosis included fibromyalgia (a disorder characterized by widespread musculoskeletal pain accompanied by fatigue, sleep, memory, and mood issues) and osteoarthritis (a type of arthritis that occurs when flexible tissue at the end of bones wears down) of both knees.
During a review of Resident 27's Minimum Data Set ([MDS] a standardized assessment and care screening tool) dated 6/6/2024, the MDS indicated Resident 27 was mildly cognitively impaired (ability to think and reason). The MDS indicated Resident 27 required total assistance (helper does all the effort) with toileting hygiene, showering/bathing, dressing the lower body, and personal hygiene.
During a review of Resident 27's Physician Orders dated 3/27/2024, the order indicated Resident 27 was to receive Lyrica (a brand name for Pregablin) 50 milligram (mg, unit of measurement) capsule by mouth, twice a day for pain management.
During a review of Resident 27's Physician Orders dated 3/27/2024, the order indicated Resident 27 was to receive 0.5 tablet ([1/2] one half of a tablet) of Tramadol HCL (a pain medication and controlled substance) 50 mg every four (4) hours as needed for moderate pain.
During a review of Resident 27's Medication Administration Record (MAR) dated 7/2024, the MAR indicated Resident 27 last received Pregablin 50 mg capsule on 7/25/2024 at 9:00 a.m. by Licensed Vocational Nurse (LVN) 3.
During a review of Resident 27's MAR dated 7/2024, the MAR indicated Resident 27 last received Tramadol 25 mg on 7/25/2024 at 9:07 a.m. by LVN 3.
During an observation on 7/25/2024 at 11:03 a.m., Resident 27's Pregablin 50 mg capsule blister pack (medication individually packed in a compartment to ease management and dosing) had 49 pills remaining.
During a concurrent interview and record review on 7/25/2024 at 11:04 a.m., with LVN 3, the Antibiotic or Controlled Substance Drug Record dated 7/2024, was reviewed. The record indicated Resident 27 last received Pregablin 50 mg on 7/24/2024 at 5:00 p.m. and had 50 pills remaining. LVN 3 stated she gave Resident 27 Pregablin 50 mg capsule on 7/25/2024 at 9:00 a.m. but did not document.
During an observation on 7/25/2024 at 11:05 a.m., Resident 27's Tramadol 50 mg tablet blister pack had 48 pills remaining.
During a concurrent interview and record review on 7/25/2024 at 11:06 a.m., with LVN 3, the Antibiotic or Controlled Substance Drug Record dated 7/2024, was reviewed. The record indicated Resident 27 last received Tramadol 25 mg on 7/24/2024 at 9:00 p.m., with 49 doses remaining. LVN 3 stated she gave Resident 27's Tramadol 25 mg tablet on 7/25/2024 at 9:07 a.m. but did not document.
During an interview on 7/25/2024 at 11:10 a.m., with LVN 3, LVN 3 stated when administering controlled substances, it should be signed and documented as soon as possible to prevent medication errors.
During an interview on 7/25/2025 at 1:27 p.m., with the Assistant Director of Nursing (ADON), the ADON stated administered controlled substances should be documented right away before it was forgotten to monitor drug effectiveness and to prevent discrepancies.
During a review of the facility's policy and procedure (P&P) titled, Controlled Medications 8/2014, the P&P indicated when a controlled medication was administered, the licensed nurse administering the medication immediately enters the following information on the accountability record and the medication record MAR:
a. Date and time of administration.
b. Amount administered.
c. Signature of the nurse administering the dose on the accountability record at the time the medicine is removed from the supply.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain a medication error rate of five percent or less by failing to:
1. Check for gastrostomy ([g-tube] a surgical opening into the stomach for food and medication administration) tube placement (inserting air via a syringe into the g-tube and listening with a stethoscope to ensure the g-tube has not dislodged) for Resident 50 per policy and procedures (P&P).
2. Verify Resident 50 received the correct dose of Ferrous Sulfate (an iron supplement) 330 milligrams ([mg] a unit of weight measurement) per 7.5 milliliters ([ml] a unit of liquid measurement).
3. Ensure Resident 50's head of bed was greater than 30 degrees per P&P prior to administering medication via g-tube.
4. Disinfect an open vial of insulin (hormone medication used to aid the body in lowering the blood sugar) prior to preparing and administering to Resident 75.
These deficient practices had the potential to result in an overdose of medication, infection, and aspiration (choking) of stomach contents for Resident 50, and infection for Resident 75.
Findings:
During a concurrent observation and interview on 7/24/2024 at 8:18 a.m., with Licensed Vocational Nurse (LVN) 5, LVN 5 prepared Ferrous Sulfate (supplement for a low blood count) from a liquid bottle with the dose on hand 220mg/5ml. LVN 5 prepared in error 11ml (484 mg) in a medicine cup to be administered to Resident 50. LVN 5 stated she had trouble seeing.
During an observation on 7/24/2024, at 8:40 a.m., with LVN 5 and Resident 50, Resident 50's head of bed was elevated 15 degrees. LVN 5 administered Resident 50's medication via g-tube without repositioning, and without checking the g-tube for placement.
During an interview on 7/24/2024, at 8:58 a.m., with LVN 5, LVN 5 stated she should have repositioned Resident 50's head of bed to at least 35 degrees and should have checked for g-tube placement prior to administering medications via g-tube to prevent aspiration.
During an observation on 7/24/2024, at 11:02 a.m., with LVN 6, LVN 6 was observed drawing 3 units of regular insulin (medicine for diabetes) from an opened insulin vial without disinfecting the vial with alcohol wipes/swabs. LVN 6 then administered the 3 units of regular insulin to Resident 75.
During an interview on 7/25/2024 at 1:19 p.m., with the Assistant Director of Nursing (ADON), the ADON stated Resident 50's head of bed should have been elevated at least 35 degrees because stomach contents could backflow and potentially cause aspiration. The ADON stated g-tube placement should be checked prior to each use to ensure g-tube was in place and Resident 50 does not get an infection such as cellulitis (deep tissue infection). The ADON stated nursing staff should verify resident's correct dose of medication according to the physician's order to prevent overmedicating which could have harmful consequences. The ADON stated staff must disinfect medication vials with alcohol prior to use, to prevent exposing residents to bacteria which could cause an infection.
During a review of Resident 50's admission Record, the admission Record indicated Resident 50 was a [AGE] year-old female, admitted to the facility on [DATE]. Resident 50's admitting diagnosis included gastrostomy status and gastro-esophageal reflux disease ([GERD] a digestive disorder in which stomach acid repeatedly flows back up into the tube connecting the mouth and stomach causing erosion).
During a review of Resident 50's Minimum Data Set ([MDS] a standardized assessment and care screening tool) dated 5/10/2024, the MDS indicated Resident 50 had severe cognitive impairment (ability to think and reason). The MDS indicated Resident 50 required total assistance (helper does all the effort) with all activities of daily living (ADLs) such as oral hygiene, toileting hygiene, showering/bathing, dressing, and personal hygiene.
During a review of Resident 50's Physician's Order dated 2/12/2024, the order indicated Resident 50 was to receive Ferrous Sulfate liquid 330 mg/7.5 ml via g-tube one time daily as a supplement.
During a review of Resident 75's admission Record, the admission Record indicated Resident 75 was a [AGE] year-old male, originally admitted to the facility on [DATE] and re-admitted on [DATE]. Resident 75's admitting diagnosis included sepsis (infection of the blood) and type 2 diabetes mellitus (a chronic metabolic disease that occurs when your body cannot regulate your blood sugar causing it to be too high).
During a review of Resident 75's MDS dated [DATE], the MDS indicated Resident 50 had severe cognitive impairment. The MDS indicated Resident 75 required total assistance with all ADLs such as oral hygiene, toileting hygiene, showering/bathing, dressing, and personal hygiene.
During a review of Resident 75's Physician Orders dated 4/27/2024, the order indicated Resident 75 was to receive Insulin Regular Human Injection Solution 100 units/ml per sliding scale (a pre-defined medication protocol which determines the dose based on blood sugar ranges). The order indicated if Resident 75's blood sugar was 151-200 mg/deciliter ([dL] a unit of liquid measurement) to administer 3 units of Regular Insulin.
During a review of the facility's policy and procedure (P&P) titled, Medication Administration dated 5/2019, the P&P indicated The licensed nurse administering the medication must check the label three times to verify the right resident, the right medication, the right dosage, the right time, and route of the administration before giving the medication.
During a review of the facility's P&P Medication Administration via Enteral Tube dated 4/2017, the P&P indicated the purpose of the policy was to safely and accurately administer oral medications through an enteral tube (g-tube). As part of the P&P procedure staff are to:
a. Elevate the head of bed more than 30 degrees or as directed by the physician.
b. Verify tube placement by forcefully injecting 10-30 ml of air into the tube while listening with a stethoscope to the abdomen for a loud bubbling sound.
During a review of the facility's P&P Specific Medication Administration Procedures dated 12/2015, the P&P indicated the purpose of the policy was to administer a parenteral [non-oral] medication into the subcutaneous tissue in order to promote slow medication absorption and prolong medication action and the procedure included wiping the rubber cap of a vial with an alcohol swab.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to accurately label and discard expired medications and supplies, to ensure safe medication administration and diagnostic testing by failing to:
1. Ensure 69 packets of expired (2/9/2023) Banatrol Plus ([Banatrol] an antidiarrhea prebiotic supplement) and four (4) bottles of expired (11/2023) ultrasound gel was discarded from the medication storage room.
2. Label Artificial Tears (hydrating solution for dry eyes) eyedrops and Procure Miconazole Nitrate 2% (antifungal powder) with resident name and instructions.
These deficient practices had the potential to administer expired medications with substandard therapeutic (producing a favorable result or effect) effects, administer medications not ordered, and to cross contaminate/ spread infection when medications were shared with other residents.
Findings:
During an observation on 7/25/2024 at 9:01 a.m., 4 bottles of expired (11/2023) ultrasound gel was discovered inside the bottom left cabinet in the medication storage room.
During an observation on 7/25/2024 at 9:05 a.m., one box with 69 packets of expired (2/9/2023) Banatrol was discovered inside the bottom left cabinet in the medication storage room.
During an interview on 7/25/2024, at 9:15 a.m., with Registered Nurse (RN) 1, RN 1 stated the ultrasound gel and Banatrol in the medication storage room should have been discarded to prevent potential use by staff to residents.
During an observation on 7/25/2024, at 11:02 a.m., the north medication cart was observed with Artificial Tears eye drops and Procure Miconazole Nitrate 2% that was unlabeled with a resident name or instructions.
During an interview on 7/25/2024 at 11:07 a.m., Licensed Vocational Nurse (LVN) 3 stated the Artificial Tears eyedrops belonged to Resident 15 because it had Resident 15's room number on it. LVN 3 stated all medications should be labeled with the resident's name to ensure it is not given to the wrong resident. LVN 3 states a room number label on the artificial tears eyedops is not sufficient because residents could be moved to different rooms.
During an interview on 7/25/2024, at 1:20 p.m., with the Assistant Director of Nursing (ADON), the ADON stated anything that were expired should be taken out the medication storage room or medication cart and should be discarded because expired medications when administered, will not have any therapeutic effect. The ADON stated if expired ultrasound gel is used during a bladder scan (a diagnostic device used to determine how much urine is in the bladder) for a resident, the results could be inaccurate. The ADON stated the Artificial Tears eyedrops and Miconazole Nitrite 2% should be labeled with a resident name to prevent sharing medications which could cause infection or administration of the wrong dose.
During an interview on 7/25/2024, at 3:07 p.m., with the Assistant Director of Nursing (ADON), the ADON stated the RN Supervisor should check the medication storage room every 24 hours for expired medications, foods, cleanliness, room temperature, refrigerator temperatures, and e-kits (a kit containing emergency medications). The ADON stated the LVNs (medication nurses) should check their cart every shift for expired medications, cleanliness, and unclaimed medications every shift. The ADON stated the pharmacy also comes once a month or as needed to replace inventory and discard expired medications. The ADON stated she is not sure why there were expired medications in the medication storage room and the north medication cart since staffs were supposed to check the medication storage room and the medication carts daily.
During a review of Resident 15's admission Record, the admission Record indicated Resident 15 was a [AGE] year-old female originally admitted to the facility on [DATE] and re-admitted on [DATE]. Resident 15's admitting diagnosis included a cerebral infarction (tissue death of the brain from a clot or other obstruction of blood flow) and hypertension (high blood pressure).
During a review of Resident 15's Minimum Data Set ([MDS] a standardized assessment and care screening tool), dated 6/5/2024, the MDS indicated Resident 15 was severely cognitively impaired (ability to think and reason). The MDS indicated Resident 15 required total assistance (helper does all the effort) with all activities of daily living (ADLs) such as oral hygiene, toileting hygiene, showering/bathing, dressing, and personal hygiene.
During a review of Resident 15's Physician Orders dated 5/30/2024, the orders indicated Resident 15 was to receive Artificial Tears Solution, one drop in both eyes two time a day for eye dryness.
During a review of the facility's P&P titled Medication Storage in the Facility dated 4/2008, the P&P indicated Outdated, contaminated, or deteriorated medications and those in containers that were cracked, soiled, or without secure closures should be immediately removed from stock, disposed of according to procedures for medication disposal, and reordered from the pharmacy if a current order exists. The P&P indicated Medication storage conditions are monitored on a routine basis, and corrective action taken if problems are identified.
During a review of the facility's P&P titled Medication Administration dated 5/2019, the P&P indicated The licensed nurse administering the medication must check the label three times to verify the right resident, the right medication, the right dosage, the right time, and route of the administration before giving the medication and medications ordered for a specific resident may not be administered to another resident.

Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and preparation practices for 89 of 89 residents when:
1. The inside compartment of the ice machine was observed with black residue.
2. A dented can of applesauce was not separated from the ready to use cans in the dry storage area.
These deficient practices had the potential to result in harmful bacteria growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to foodborne illnesses in all residents who received food and ice from the kitchen.
Findings:
a. During a concurrent observation and interview on 7/22/2024 at 8:40 a.m., with Certified Nursing Assistant (CNA) 2, in the dining room, a clean paper towel was used to swipe the ice storage bin ceiling and behind the plastic covering the ice dispensing area and brown and black residue was observed on the paper towel. CNA 2 stated a black and brown residue was on the paper towel after the inside of the ice machine was wiped. CNA 2 stated that kind of residue should not be inside the ice machine if it was cleaned daily. CNA 2 stated it was important to keep the ice machine clean because mold and bacteria could develop and contaminate the ice that was served to the residents. CNA 2 stated this put the residents at risk of illness.
During an interview on 7/24/2024 at 9:21 a.m. with the Maintenance Assistant (MA), the MA stated the outside of the ice machine was wiped off daily and an in-depth cleaning was done once a month where the ice was removed, and the inside was thoroughly cleaned. The MA stated black residue should not be found on the inside of the ice machine because it could indicate bacteria or mold was growing. The MA stated the bacteria could contaminate the ice, which was served to the residents in the facility, and it could make them sick.
b. During a concurrent observation and interview on 7/23/2024 at 12:15 p.m., with the Dietary Supervisor (DS), in the dry storage area, one dented can of applesauce was not separated from the ready to use cans. The DS stated the dented can of applesauce should not have been on the shelf and should have been placed in the crate designated for dented cans. The DS stated the canned foods were checked upon delivery and once a week to ensure the dented cans were placed in its designated place so it could be disposed of. The DS stated separating the dented cans was important to ensure the canned food was not prepared and served to the residents. The DS stated dented cans put that food item at risk for the growth of botulism (poisoning caused by improper sterilized canned foods), which could be transmitted to the residents and had the potential to make them very ill.
During a review of the facility's policy and procedure (P&P) titled, Cleaning the Ice Machine, revised on 4/2017, the P&P indicated, The ice machine shall be cleaned for maintenance of sanitary conditions in order to prevent food contamination and the growth of disease-producing organisms and toxins.
During a review of the facility's P&P titled, Dietary- Labeling and Dating Foods, revised on 9/2016, the P&P indicated, Damaged cans are to be set aside in a designated area for return to the vendor or disposed of.
According to 2022 Food Code: U.S. Food and Drug Administration, dated 1/18/2023, indicated, Food shall be safe, unadulterated (completely pure and has nothing added to it) . Food packages shall be in a good condition and protect the integrity of the contents so that the food is not exposed to adulteration or potential contaminants.

Based on interview and record review, the facility failed to ensure the Infection Preventionist (a person designated by the facility to be responsible for the infection prevention and control program) nurse (IPN) attended, participated, and gave findings on a regular basis to the Quality Assurance and Performance Improvement ([QAPI] a systematic, comprehensive, and data-driven approach to maintaining and improving safety and quality in nursing homes while involving all nursing home caregivers in practical and creative problem solving) committee during monthly meetings.
This deficient practice prevented the QAPI Committee from receiving updated information regarding the facility's infection prevention program which had the potential to negatively impact residents' safety regarding infection control practices and outcomes in the facility.
Findings:
During a concurrent interview and record review on 7/23/2024 at 2:30 p.m. with the Administrator (ADM) and IPN 2, the QAPI committee meeting minutes and sign in sheets on 4/8/2024, 5/16/2024 and 6/20/2024 were reviewed. The QAPI committee sign in sheets and minutes indicated the IPN did not sign and did not present any infection control reports or findings to the QAPI committee. The ADM stated the QAPI committee meets every 30 days. The ADM stated that she was a new administrator in the facility and the IPN was also new to the facility. IPN 2 stated that she had not attended any QAPI meetings since she was promoted as the IPN. The ADM agreed that it was mandatory to have an IPN to attend and participate in all QAPI committee meetings and discuss the current infection rate and infection control practices in the facility. The ADM explained that the previous IPN resigned before a new IPN could be hired. The ADM stated she received the infection control summary for the month of May 2024, but it was never presented at the QAPI committee meeting. The ADM stated she was working on improving the QAPI process. The ADM stated the facility did not have a policy and procedure for their QAPI Program.
During a review of the facility's QAPI Plan, (no date), the QAPI Plan indicated all department heads, the administrator, the director of nursing, infection control and prevention officer, medical director, consulting pharmacist, resident and/or family representatives (if appropriate), and three additional staff will provide QAPI leadership by being on the QAPI Committee.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to implement infection control practices by failing to:
1. Date Resident 29's peripheral intravenous catheter ([PIV] a small catheter placed into a vein to administer medication or fluids).
2. Change Resident 57's ventilator (a machine or device used medically to support or replace the breathing of a person who is ill, injured, or anesthetized) tubing per the facility policy.
These deficient practices had the potential to result in phlebitis (infection/inflammation of the vein) for Resident 29 and pneumonia (infection of the lungs) for Resident 57.
3. Ensure Resident 26's nebulizer (a device used to administer medication in the form of a mist inhaled into the lungs) mask and tubbing was properly stored or changed as indicated in the facility's policy and procedure (P&P).
This deficient practice had the potential to increase the risk for infection for Resident 26.
4. The incorrect isolation precaution (used to reduce the transmission of microorganisms in healthcare settings) signage was placed outside of Resident 192's room.
5. Improper hand hygiene (action of hand cleansing either with soap and water or with alcohol-based hand rub) was observed during Resident 37's wound care treatment.
6. Expired food was stored in the resident designated fridge for Resident 46.
7. Two open ice coffee bottles were not labeled and were stored in the resident designated fridge.
These deficient practices had the potential for the spread of bacteria and had the potential to cause illness.
Findings:
a. During a review of Resident 29's admission Record, the admission record indicated Resident 29 was originally admitted to the facility on [DATE] and re-admitted on [DATE]. Resident 29's admitting diagnoses included cerebral infarction (tissue death of the brain from a clot or other obstruction of blood flow), dependence on a ventilator, and respiratory failure (a condition in which your blood doesn't have enough oxygen or has too much carbon dioxide).
During a review of Resident 29's Minimum Data Set ([MDS] a standardized assessment and care screening tool), dated 6/26/2024, the MDS indicated Resident 29 was severely cognitively impaired (ability to think and reason). The MDS indicated Resident 29 required total assistance (helper does all the effort) with all activities of daily living (ADLs) such as eating, oral hygiene, toileting hygiene, showering/bathing, dressing, and personal hygiene.
During a review of Resident 29's Physician's Orders dated 7/21/2024, the orders indicated to restart Resident 29's PIV every 72 hours and as needed if without complications but may extend IV site to 7 days if no complications.
During an observation on 7/22/2024 at 9:48 a.m., Resident 29 was observed lying in bed, asleep with an undated and uninitialed peripheral intravenous catheter ([PIV] a small catheter placed into a vein to administer medication or fluids) on her left medial (inner) thigh.
During an interview on 7/23/2024 at 11:14 a.m., with Registered Nurse (RN) 2, RN 2 stated she did not know how old Resident 29's PIV was or who inserted it because there was no date or staff's initials on it. RN 2 stated if a PIV is undated nursing staff will not know when to change it. RN 2 stated if a PIV is not initialed by the nurse who inserted it questions or concerns cannot be addressed.
During an interview on 7/24/2024 at 3:05 p.m., with the Assistant Director of Nursing (ADON), the ADON stated all PIVs should be dated for nursing staff to know when to change it because PIVs must be changed periodically to prevent phlebitis. The ADON stated nursing staff should date all inserted PIVs for accountability.
b. During a review of Resident 57's admission Record, the admission record indicated Resident 57 was originally admitted to the facility on [DATE] and re-admitted on [DATE]. Resident 57's admitting diagnoses included cerebral infarction, dependence on a ventilator, and tracheostomy status (a procedure to help oxygen reach the lungs by creating an opening from outside of the neck and into the airway).
During a review of Resident 57's MDS dated [DATE], the MDS indicated Resident 57 was severely cognitively impaired. The MDS indicated Resident 57 required total assistance all ADLs such as eating, oral hygiene, toileting hygiene, showering/bathing, dressing, and personal hygiene.
During a review of Resident 57's Physician's Orders dated 5/24/2024, the orders indicated to change the circuit vent (tubing that connects the ventilator to the tracheostomy) once a month and as needed to prevent infection.
During an observation on 7/22/2024 at 10:01 a.m., Resident 57 was observed lying in bed, asleep with a tracheostomy hooked up to a ventilator. Resident 57's circuit vent was dated 6/17/2024.
During an interview on 7/24/2024 at 3:33 p.m., with Respiratory Therapist (RT) 1, RT 1 stated Resident 57's circuit vent should be changed once a month or as needed to prevent infection.
During a review of the facility's policy and procedure (P&P) titled, Tracheostomy Tube Change dated 8/2017, the P&P indicated tracheostomy tubes will be changed monthly or as ordered by the attending physician.
During a review of the facility's P&P titled, Peripheral Venous Catheter Insertion dated 6/2018, the P&P indicated PIVs must be dated, timed, and initialized by the one who inserted the PIV.
d. During a review of Resident 192's admission Record (Face Sheet), the face sheet indicated Resident 192 was admitted to the facility on [DATE] with diagnoses that include but not limited to urinary tract infection ([UTI], an infection in any part of the urinary system), end stage renal disease ([ESRD], a stage where the kidneys can no longer support the body's needs for waste removal and fluid balance), and atrial fibrillation (an irregular, often rapid heart rate that can cause poor blood flow).
During a review of Resident 192's H&P, dated 7/23/2024, the H&P indicated Resident 192 had fluctuating (changing) capacity to understand and make decisions.
During an observation on 7/22/2024 at 10:17 a.m. and on 7/23/2024 at 11:15 a.m., outside Resident 192's room, there was Enhanced Barrier Precaution signage posted next to Resident 192's door.
During a concurrent interview and record review on 7/24/2024 at 10:34 a.m., with the Infection Preventionist Nurse (IPN), Resident 192's Order Summary Report, dated 7/20/2024 was reviewed. The Order Summary Report indicated to place Resident 192 on contact precautions (type of isolation precaution) for Carbapenem-resistant Enterobacter [NAME] ([CRE], germ resistant to one or several antibiotics [medication to treat bacterial infection]). The IPN stated based on the physician's order, Resident 192 should be on contact precaution and should have the proper signage to indicate to the staff the precautions they had to adhere to. The IPN stated CRE was very resistant to many antibiotics and could be transmitted to others. The IPN stated although Resident 192 had the incorrect isolation precaution signage outside his room. The IPN stated contact precaution and enhanced barrier precaution ([EBP], type of isolation precaution) were similar with the personal protective equipment ([PPE], equipment used to protect the wearer such as a gown, gloves, and face shield) utilized, however, the indications for the use of PPE were slightly different. The IPN stated with EBP, PPE that included a gown and gloves were worn if direct care was to be provided to Resident 192, however, with contact precaution, the PPE would be worn every time the individual would enter the room, no matter the task to be completed.
During an interview on 7/25/2024 at 11:16 a.m., with the Director of Nursing (DON), the DON stated EBP, and contact precautions were used to prevent the spread of microorganisms, however, both precautions had their differences in when they were used. The DON stated EBP was used to prevent the spread of microorganisms from the staff member to the resident, whereas contact precaution was used to prevent the spread of microorganisms from the resident to the staff member. The DON stated EBP was more lenient with the use of PPE and because the incorrect signage was used for Resident 192, there could have been individuals who entered the room without donning (put on) PPE and could have been exposed to CRE. The DON stated Resident 192's physician order indicated for Resident 192 to be placed on contact precaution and that order should have been followed. The DON stated the use of the incorrect isolation precaution could increase the spread of microorganisms and infection to the staff and to other residents.
During a review of the facility's P&P titled, Infection Control Transmission-Based Precautions, revised on 2/2018, the P&P indicated, When a resident is placed on transmission-based precautions, the following should be implemented: identify the type of precautions and the appropriate PPE to be used [and] place a sign outside the resident's room on the wall next to the doorway identifying the [Centers of Disease Control and Prevention] CDC category of transmission-based precautions, instructions for the use of PPE, and/or instructions to see the nurse before entering.
e. During review of Resident 37's admission Record (Face Sheet), the admission record indicated Resident 37 was admitted to the facility on [DATE] with diagnoses that include but not limited to type 2 diabetes mellitus (a condition that results in too much sugar circulating in the blood), osteomyelitis (one infection), and peripheral vascular disease ([PVD],(a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs).
During a review of Resident 37's MDS, dated [DATE], the MDS indicated Resident 37's cognition was intact. The MDS indicated Resident 37 required setup assistance with eating and oral hygiene. The MDS indicated Resident 37 required maximal assistance (helper does more than half the effort) with toileting, showering, and dressing. The MDS indicated Resident 37 had diabetic foot ulcers (open wound on the foot that is associated to diabetes) and surgical wounds.
During a review of Resident 37's H&P dated 5/24/2024, the H&P indicated Resident 37 had the capacity to understand and make decisions
During a review of Resident 37's Order Summary Report, dated 7/25/2024, the Order Summary Report indicated the following daily wound care orders:
Cleanse the right foot surgical wound with normal saline ([NS], saltwater solution) and pat dry. Apply the Aquacel Ag Advantage External Pad (type of medicated dressing) to the wound. Cover with dry dressing and secure with rolled dressing and tubular dressing.
Cleanse the right heel arterial ulcer (wound caused by decrease in blood flow) with NS and pat dry. Apply the Aquacel Extra Hydrofiber External Pad (type of medicated dressing) to the wound bed followed by a dry dressing and secure with rolled dressing.
Apply Betadine External Solution (used to prevent and treat mild skin infections) to the right foot wound and allow to dry. Cover with dry dressing and secure with tubular dressing.
During an observation on 7/25/2024 at 8:20 a.m., with the Treatment Nurse (TN) in Resident 37's room, the TN explained that she would be doing Resident 37's wound treatment. The TN prepared her supplies, performed hand hygiene, donned a disposable gown, and applied gloves. Resident 37 was laying on his back and had his right foot dressing exposed. The TN removed the tubular dressing and wrapped dressing from Resident 37's right foot. The TN removed her right glove and applied a new glove. The TN cleansed the heel with NS, removed her gloves, and applied new gloves. The TN cleansed the wound on the plantar (bottom) part of the foot, removed her gloves, washed her hands in the restroom, and applied new gloves. The TN applied the betadine to the plantar wound, removed her gloves, and applied new gloves. The TN cleansed the heel with NS, removed her gloves, and applied new gloves. The TN applied medicated gauze to the plantar wound, removed her right glove, and applied a new glove. The TN applied medicated gauze to the heel, removed her gloves, and applied new gloves. The TN applied padded gauze to the heel and plantar foot and applied lotion to Resident 37's leg. The TN removed her gloves and applied new gloves. The TN adjusted Resident 37's linen and adjusted the bed for Resident 37's comfort. The TN cleaned her area, removed her gloves, and washed her hands in the restroom.
During an interview on 7/25/2024 at 8:50 a.m., with the TN, the TN stated the purpose of hand hygiene was to prevent the spread of infection. The TN stated she was supposed to perform hand hygiene prior to applying new gloves and when she removed old gloves. The TN stated she did not perform hand hygiene every time she took off her gloves and prior to applying new gloves. The TN stated improper hand hygiene had the potential to spread infection to Resident 37's wounds.
During an interview on 7/25/2024 at 10:25 a.m., with the IPN, the IPN stated hand hygiene was the best way to ensure the hands were free of bacteria that could be transmitted to others. The IPN stated hand hygiene was supposed to be done prior to putting on gloves and after taking them off. The IPN stated throughout a wound treatment, the TN would be removing and applying new gloves and each time, she would have to perform hand hygiene. The IPN stated performing hand hygiene was especially important throughout a wound treatment because the resident had open wounds and was prone to infection.
During an interview on 10/25/2024 at 11:19 a.m., with the DON, the DON stated hand hygiene was done to ensure the individual's hands were clean before touching the resident. The DON stated hand hygiene was done before and after glove use and done again if new gloves were applied. The DON stated new gloves were not supposed to be put on until hand hygiene was performed. The DON stated this could cause the spread of bacteria and could cause infection in the wound.
During a review of the facility's P&P titled, Enhanced Standard Precautions, revised on 5/2024, the P&P indicated, Remove gloves promptly after use, before touching non-contaminated items and environmental surfaces, and before going to another resident and wash hands immediately to avoid transfer of microorganisms to other residents or environments.
f. During a review of Resident 46's admission Record (Face Sheet), the admission record indicated Resident 46 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses that include but not limited to chronic obstructive pulmonary disease (COPD, a lung disease characterized by long-term poor airflow), end stage renal disease, and heart failure.
During a review of Resident 46's MDS, dated [DATE], the MDS indicated Resident 46's cognition was intact. The MDS indicated Resident required setup assistance with eating and oral hygiene. The MDS indicated Resident 46 was dependent on staff for toileting and dressing. The MDS indicated Resident 46 was on a mechanically altered diet (require a change in texture of food or liquids) and on a therapeutic diet (meal plan that controls the intake of certain foods or nutrients in the treatment or management of an illness or disease).
During a review of Resident 46's H&P, dated 12/26/2023, the H&P indicated Resident 46 had the capacity to understand and make decisions.
During a review of Resident 46's Order Summary Report, dated 3/6/2024, the Order Summary Report indicated to provide a No Added Salt, Consistent Carbohydrate Diet (eating the same amount of carbohydrates every day to help regular blood sugar) with mechanical soft texture (foods that are soft, and easy to chew and swallow), thin liquid consistency, and no dairy or banana.
During a concurrent observation and interview on 7/24/2024 at 9:08 a.m. with Registered Nurse (RN) 1, inside the medication preparation room, the resident fridge designated for food and drinks was located. Inside the fridge were two open ice coffee bottles that was not labeled with a resident's name nor an open date. Inside the fridge was a plastic bag labeled with Resident 46's name and dated 6/15/2024. Inside the plastic bag were the following:
1. Two yogurt cups dated 5/6/2024.
2. One packet of ready rice dated 2/24/2024
3. Three hummus single packets dated 4/11/2024
4. One packet of 12 string cheese dated 2/18/2024
5. One packet of 12 string cheese dated 2/29/2024
RN 1 stated food brought in from the outside that is opened should only be stored in the fridge for three days and when the food was brought in, it should be labeled with the resident's name, the date it was brought in, and the date it was opened. RN 1 stated if the stored food goes past the three days, it should be disposed of. RN 1 stated Resident 46's food items were sealed; however, they were all past the expiration date. RN 1 stated Resident 46's food items should have been discarded because if the food was given to Resident 46 or to another resident, they could get sick from eating expired food. RN 1 stated the two open bottles of iced coffee should have been labeled with the open date and the resident's name because now she was unsure how long they have been stored inside the fridge.
During an interview on 7/24/2024 at 10:30 a.m., with the IPN, the IPN stated expired food should not be stored, especially in the resident fridge. The IPN stated storing expired food put the resident at risk for food poisoning if the food was served to them.
During an interview on 7/25/2024 at 8:53 a.m., with the Dietary Supervisor (DS), the DS stated expired food should not be stored and should be disposed of right away. The DS stated labeling and dating food items was a way to ensure accountability of the expiration dates and to be aware whose food was whose. The DS stated the residents in the facility were very fragile and many had low immunity, so they were at high risk of food borne illness if the staff were not careful.
During an interview on 7/25/2024 at 11:13 a.m. with the DON, the DON stated the nursing department was responsible for maintaining the resident fridge. The DON stated when food items were stored in the fridge, the item had to be labeled with the resident's name, the date, and check the expiration date. The DON stated if a food item was expired, it would need to be discarded. The DON stated removing expired food was essential in preventing foodborne illnesses that could cause diarrhea and upset stomach.
During a review of the facility's P&P titled, Dietary- Refrigerator for Resident Storage of Food, revised on 1/2017, the P&P indicated, Food will be labeled with the resident's name and the date the food is placed in the refrigerator. Leftover food will be kept for 72 hours after the date on the container and will be discarded after 72 hours or discarded based on the expiration date if unopened.
c. During an observation on 7/22/2024 at 10:22 a.m., in Resident 26's room. A nebulizer machine was observed on the top of Resident 26's bedside table. The nebulizer mask and tubbing were observed on the floor next to Resident 26's bed.
During a review of Resident 26's admission Record (Face Sheet), the Face Sheet indicated Resident 26 was admitted to the facility on [DATE] with diagnoses including anxiety (a mental health condition that cause fear, and worried), chronic obstructive pulmonary disease ([COPD] a lung disease causing restricted airflow and breathing problem), and muscle weakness (a lack of strength in the muscle).
During a review of Resident 26's MDS dated [DATE], indicated Resident 26 make self-understood and had the ability to understand others. The MDS indicated Resident 26 required moderate assistance (helper does less than half the effort) from staff for toileting hygiene, shower, and setup or clean up assistance (helper sets up and cleans up; resident completes activity) from staff for oral hygiene, eating, and personal hygiene.
During a review of Resident 26's History and Physical (H&P), dated 3/8/2024, the H&P indicated Resident 26 had the capacity to understand and make decisions.
During a review of Resident 26's physician order, dated 7/16/2024, indicated Albuterol Sulfate Nebulization Solution (2.5 milligram(mg)/3-millimeter (ml) 0.083%(percentage) (medication used to treat shortness of breath caused by breathing problems), three (3) ml inhale orally via nebulizer every four (4) hours as needed for shortness of breath.
During a concurrent observation and interview 7/23/2024 at 8:57 a.m., in Resident 26's room, nebulizer tubbing, and mask was observed on Resident 26's bedside table not stored in the bag and undated. Resident 26 stated he was having shortness of breath earlier and nurse (unidentified) give him breathing treatment via nebulizer mask. Resident 26 stated when breathing treatment was done the nurse (unidentified) placed nebulizer mask on the bedside table and left the room.
During an interview on 7/23/2024 at 4:00 p.m., with Licensed Vocational Nurse (LVN) 1. LVN 1 stated the nebulizer mask should be changed weekly, dated, and placed in a plastic bag next to residents' bed when resident not using it. LVN 1 stated the mask and tubbing touching the floor was unsanitary, and infection issues. LVN 1stated if the nebulizer mask was not stored properly in the bag it could lead to possible contamination (making something dirty, containing unwanted substances). LVN 1 stated it could produce respiratory problems and placed Resident 26 at risk for infection.
During a concurrent observation and interview on 7/24/2024 at 11:15 a.m., in Resident 26's room, with RT 1. Resident 26's nebulizer mask and tubbing were observed undated, touching the floor by Resident 26's bed. RT 1 stated, This looks bad and is unacceptable and puts the resident at very high risk for respiratory infection. RT 1 stated the nebulizer [NAME] and tubbing must be changed immediately. RT 1 stated the nebulizer mask and tubing must be changed weekly, stored in a plastic bag, and dated so staff would know when it was last changed, and placed at the resident bedside when the resident was not using it per facility protocol.
During a review of the facility's P&P titled, Administering Medication through a Nebulizer or Mask, revised 8/2018, the P&P indicated:
1. The procedure is to safely, and with good infection control practice, administer aerosolizer (liquid drug that can be inhaled) particles on medication into the resident's airway.
2. When treatment is complete, turn off the nebulizer and disconnect mouthpiece (mask).
3. Rinse the nebulizer equipment and store in a plastic bag with the resident's name and the date on it.
4. Change equipment and tubing every seven days.
During a review of the facility's P&P titled, Infection Control Program System, revised 1/2023, the P&P indicated the facility has an established infection prevention and control program to provide a safe, sanitary environment to prevent the development and transmission of infections.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure one of six sampled residents' (Resident 19) call light was within reach.
This deficient practice had the potential to negatively impact Resident 19's quality of life and resident rights to have reasonable accommodations of needs.
Findings:
A review of Resident 19's, admission Record (Face Sheet), the admission Record indicated Resident 19 was admitted to the facility on [DATE] with diagnoses including cerebellar ataxia (poor muscle control that causes clumsy movements) and parkinsonism (slowed movements, stiffness, and tremors).
A review of Resident 19's, Minimum Data Set ([MDS] a standardized assessment and care screening tool), dated on 7/5/2024, the MDS indicated Resident 19 was cognitively intact (having the ability to think, learn, and remember clearly) and required substantial/maximal assistance (Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort) from staff.
During an observation on 7/22/2024 at 1:55 p.m., Resident 19 was lying on the bed and observed trying to reach for her call light. The call light was observed on the floor beside the bed.
During an observation on 7/23/2024 at 8:45 a.m., in Resident 19's room, the resident was observed watching television. The call light was observed on the floor.
During an interview on 7/25/2024 at 8:20 a.m., with Certified Nurse Assistant (CNA) 3
stated resident's call light needs to be within reach because if residents need help, staff will not know the resident is requesting for assistance.
During an interview on 7/25/23 at 8:24 a.m., with Licensed Vocational Nurse (LVN) 2 stated call lights should be within reach of residents. LVN 2 stated when residents have trouble keeping their call lights within reach, it should be clipped to the bed by staff.
During an interview on 7/25/24 at 2:17 p.m., The Director of Nursing (DON) stated the residents' call light should be within reach for all residents. The DON stated residents should not be reaching too far for the call light or they might fall.
A review of facility's Policy and Procedure (P & P) titled, Call Lights, dated 1/2017, indicated when the resident is in bed or in the wheelchair or chair in the room, staff should make sure that the call light is within easy reach of the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to transmit to Centers for Medicare & Medicaid Services (CMS) the quarterly Minimum Data Set ([MDS] a resident screening and assessment tool) according to regulatory requirements for one of one resident (Resident 65) in a timely manner due to incomplete Section D (Mood) and E (Behavior).
This deficient practice can potential negatively affect the delivery of necessary care and services for Resident 65.
Findings:
During a review of Residents 65 admission Record (Face Sheet), the admission Record indicated Resident 65 was initially admitted to the facility on [DATE] with diagnoses that include but not limited to quadriplegia (a form of paralysis that affects all four limbs plus the torso), muscle weakness (lack of muscle strength), osteoarthritis unspecified (degenerative joint disease in which the tissue in the joint break down over time), neuromuscular dysfunction of bladder (lack of bladder control due to brain or spinal cord injury).
During a review of Resident 65's History and Physical (H&P), dated 5/7/2024, the H&P indicated Resident 65 had the capacity to understand and can make decisions.
During a review of Resident 65's Minimum Data Set ([MDS] a specialized resident screening and assessment tool), dated 4/5/2024, the MDS indicated Resident 65 was able to understand and be understood by others. The MDS indicated Resident 65 had impairments (the state of function being weakened or damaged) on both sides of his upper extremities (upper part of the body that includes the shoulder, elbow, wrist, and hand) and on both sides of the lower extremities (lower part of the body that includes the hip, knee, ankle, and foot). The MDS indicated that Resident 65 was dependent on staff for toileting, bathing, dressing, and personal hygiene. Section D and E were not completed and there were missing signatures on the MDS.
During an interview on 7/24/2024 at 1:00 p.m. with the Minimum Data Set (MDS) Nurse, the MDS nurse stated completing MDS assessment withing a week of admission or during the quarterly due date allows for optimal care to be given for the resident and for billing to take place. The MDS nurse stated that MDS assessments should be completed upon admission, quarterly, and if there is a change in condition. The MDS nurse stated that all parts of the MDS assessment should be finished and completed by the date stated completed on the document. The MDS nurse stated if an assessment was not completed in a timely manner direct care of the resident was affected.
During an interview on 7/25/2024 at 11:00 a.m. with the Director of Nursing (DON), the DON stated that all dates should match when the MDS assessment was completed, and records updated. The DON stated all sections of the MDS must be completed by the two-week mark, after admission or the 3-month mark for quarterly submissions. The DON stated that residents are at an increased risk of decreased care quality when MDS assessments are delayed.
A review of the facility's policy and procedure (P&P) titled, Minimum Data Set, revised 3//2021, the P&P indicated, Providing evidence-based assessments and management of common conditions ensure timely assessments, contacts with providers and transfers to hospital in a timely update to residents care record.

Based on interview, and record review, the facility staff failed to notify the psychiatrist when resident developed episodes of yelling for one of three sampled residents (Resident 19).
This deficient practice had the potential to result in lack of necessary care, treatment, and delay medical interventions for Resident 19.
Findings:
During a review of Resident 19's admission Record ( Face Sheet), the Face Sheet indicated Resident 19 was admitted to the facility on 1218/2017 with diagnoses including schizophrenia ( a serios mental illness that effects how a person thinks, feels, and behaves), anxiety ( feeling of fear, restless, and tense), parkinsonism ( a brain condition that causes slowed movement, and tremors), and hypertension ( high blood pressure).
During a review of Resident 19's Minimum Data Set ([MDS] a standardized assessment and care planning tool), dated 7/5/2024, the MDS indicated Resident 19 require maximum assistance (helper does more than half the effort) from staff for toileting hygiene, oral hygiene, and personal hygiene.
During a review of Resident 19's History and Physical (H&P), dated 12/20/2023, the H&P indicated Resident 19 did not had the capacity to understand and make decisions.
During a review of Resident 19's Situation, Background, Assessment, and Recommendation communication form ([SBAR] a form that health professionals communicate clear elements of a patient condition), dated 7/18/2024, the SBAR indicated change in Resident 19's condition, symptoms and signs increased yelling. The SBAR indicated Primary Care Clinician (PCC) was notified on 7/18/2024 at 07:00 p.m., and PCC recommendation was psychiatrist evaluation (evaluation conducted by qualified mental health professional to assess resident emotional, psychological, and behavioral well-being).
During a concurrent interview and record review on 7/24/2024 at 7:45 a.m., with Registered Nurse (RN1), Resident 19's order summary, dated 7/18/2024 was reviewed. The order summary indicated, on 7/18/2024 PCC ordered psychiatrist evaluation for Resident 19 due to increased yelling. RN1 stated there was not documentation that facility licensed staff notified Resident 19's physiatrist. RN1 stated licensed staff should have call Resident 19's psychiatrist after the order was received from PCC and notify psychiatrist of Resident 19's change of condition. RN1 stated not notifying psychiatrist timely puts Resident 19 at risk for emotional, behavioral, and mental distress.
During an interview 7/25/2024 at 2:17 p.m., with Director of Nursing (DON). The DON stated residents' change of condition must be reported to the residents' attending physicians' right way when change of condition was observed, and when new order was received. The DON stated the PCC order must be carried out (complete it) immediately. The DON stated not notifying Resident 19's psychiatrist timely about Resident 19's change of condition puts Resident 19 at risk for delay care, treatment, and medical interventions if applicable.
During a review of facility's policy and procedure (P&P) titled Change in Condition Signs and Symptoms- SBAR, revised 3/2021, the P&P indicated:
1. Facility is responsible for a thorough assessment of the resident's change in condition signs and symptoms.
2. Ensure timely assessments, and contacts with primary care providers.
3. Assessing residents with changes in status and contact the physician.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify the physician and/or the Nurse Practitioner (NP) when one of three sampled residents (Resident 1) aspirated (accidentally inhaling food or liquid through the vocal cords into the airway instead of swallowing through the food pipe) and vomited during feeding.
This deficient practice resulted in a delay in treatment and a delay in transfer to a General Acute Care Hospital (GACH) for further evaluation and had the potential for Resident 1 to develop aspiration pneumonia (a type of pneumonia that occurs when a person breathes in food, liquid, or other substances into their lungs instead of swallowing them).
Findings:
During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnosis including acute (sudden onset) respiratory failure (a serious condition that makes it difficult to breathe on your own), tracheostomy (a hole that surgeons make though the front of the neck and into the trachea [windpipe] to insert a tube to provide an air passage to help a person breathe when the usual route for breathing is somehow blocked or reduced) status, and ventilator (a device that helps you breathe) dependence.
During a review of Resident 1's Minimum Data Set ([MDS] a standardized assessment and care screening tool) dated 12/17/2023, the MDS indicated Resident 1's cognitive skills for decision making were severely impaired and she did not have the ability to understand or be understood by others. The MDS indicated Resident 1 required mechanical ventilation, suctioning (removing mucous and other fluids from the windpipe and large airways), and oxygen (O2) therapy.
During a review of Resident 1's History and Physical (H&P) dated 12/14/2023, the H&P indicated Resident 1 did not have the capacity to understand and make decisions.
During a review of Resident 1's Continuous Ventilator Flow Sheet dated 1/15/2024 and timed at 11:30 a.m., the Continuous Ventilator Flow Sheet indicated Resident 1 aspirated during feeding.
During a review of Resident 1's Subacute Daily Nursing assessment dated [DATE], the Subacute Daily Nursing Assessment indicated Licensed Vocational Nurse 1 (LVN 1) documented Resident 1 did not tolerate the bolus feeding (a large dose of formula feedings though the feeding tube using a catheter syringe) and vomited. The Subacute Daily Nursing Assessment indicated LVN 1 notified Registered Nurse Supervisor 1 (RNS 1) of Resident 1's inability to tolerate the bolus feeding and of Resident 1's episode of vomiting.
During a review of Resident 1's clinical record, there was no documentation indicating Resident 1's physician or NP was notified by RNS 1 or LVN 1 after Resident 1's episode of vomiting and aspiration.
During a review of Resident 1's Licensed Personnel Weekly Progress Notes dated 1/15/2024 and timed at 8 p.m., the Licensed Personnel Weekly Progress Notes indicated Resident 1's respiratory rate (RR) was 40 breaths per minute (normal RR is between 18-20 breaths per minute). The Licensed Personnel Weekly Progress Notes indicated the NP was made aware of Resident 1's elevated RR, however there was no documentation indicating the NP was informed of Resident 1's episode of vomiting and aspiration. The Licensed Personnel Weekly Progress Notes indicated the NP recommended Resident 1 be transferred to a GACH for further evaluation.
During a review of Resident 1's Licensed Personnel Weekly Progress Notes dated 1/15/2024 and timed at 8:15 p.m., the Licensed Personnel Weekly Progress Notes indicated RNS 2 was notified by Respiratory Therapist 1 (RT 1) that Resident 1 aspirated during the bolus feeding at 11:30 a.m. The Licensed Personnel Weekly Progress Notes indicated there was no documentation by the RNS 2 indicating Resident 1's physician or the NP was immediately notified.
During a review of Resident 1's Licensed Personnel Weekly Progress Notes dated 1/15/2024 and timed at 8:40 p.m., the Licensed Personnel Weekly Progress Notes indicated Resident 1 was transferred to a GACH via 911.
During a telephone interview on 6/25/2024 at 9:44 p.m., RNS 2 stated he should have informed Resident 1's NP immediately after the RT 1 notified him of Resident 1's episode of vomiting and aspiration. RNS 2 stated he did not find it necessary to notify the NP that Resident 1 aspirated because he did not think Resident 1's aspiration contributed to Resident 1's elevated RR.
During an interview on 6/26/2024 at 3:29 p.m., LVN 1 stated she notified RNS 1 immediately after Resident 1 vomited during the bolus feeding but stated she did not follow up to confirm if RNS 1 notified Resident 1's physician or NP. LVN 1 stated she could have notified Resident 1's physician or NP herself, but usually the RNS' are in charge of notifying the physician or NP when a resident has a change of condition (COC).
During an interview on 6/26/2024 at 5:44 p.m., the Director of Nursing (DON) stated licensed nurses are responsible for notifying the physician or NP when residents have a COC so the physician or NP could treatment immediately and/or have the resident transferred to a GACH for further evaluation.
During a phone interview on 6/27/2024 at 12:13 p.m., the NP stated if the licensed nurses had notified her that Resident 1's aspirated and vomited, she would have recommended that Resident 1 be transferred to a GACH immediately for evaluation and treatment. The NP stated when a resident aspirates, there was a potential for respiratory distress and aspiration pneumonia if not treated promptly.
During a review of the facility's policies, the facility had no policy that addressed notifying the physician of a resident's COC.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed ensure the Respiratory Therapist ([RT] a medical professional who works with patients who have breathing problems or other lung conditions) obtained orders from the physician/nurse practitioner (NP) prior to changing ventilator settings (used ot control how much and how fast air is delivered to a patient's lungs) for one of three sampled residents (Resident 1) and Registered Nurse Supervisor 1 (RNS 1) and RNS 2 followed the recommendations of Resident 1's NP to transfer Resident 1 to a General Acute Care Hospital (GACH) when Resident 1's respiratory rate (RR) was abnormal and showed no signs of improvement.
These deficient practices resulted Resident 1 receiving treatment that was not prescribed by Resident 1's physician or NP and a delay in transferring Resident 1 to a GACH for evaluation and treatment. This deficient practice had the potential for Resident 1's respiratory status to deteriorate resulting.
Findings:
During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnosis including acute (sudden onset) respiratory failure (a serious condition that makes it difficult to breathe on your own), tracheostomy (a hole that surgeons make though the front of the neck and into the trachea [windpipe] to insert a tube to provide an air passage to help a person breathe when the usual route for breathing is somehow blocked or reduced) status, and ventilator (a device that helps you breathe) dependence.
During a review of Resident 1's History and Physical (H&P) dated 12/14/2023, the H&P indicated Resident 1 did not have the capacity to understand and make decisions.
During a review of Resident 1's Minimum Data Set ([MDS] a standardized assessment and care screening tool) dated 12/17/2023, the MDS indicated Resident 1's cognitive skills for decision making were severely impaired and she did not have the ability to understand or be understood by others. The MDS indicated Resident 1 required mechanical ventilation, suctioning (removing mucous and other fluids from the windpipe and large airways), and oxygen (O2) therapy.
During a review of Resident 1's Order Summary Report (Physician's Orders) dated 12/28/2023, the Physician's Orders indicated the following ventilator settings for Resident 1:
1. Assist Control ([AC] the number of breaths a patient is receiving from a breathing machine (ventilator)
2. Respiratory Rate ([RR] the number of breaths per minute a ventilator will deliver to a patient) of 18 breaths per minute.
3. Tidal Volume ([VT] the amount of air a person inhales during a normal breath) of 400.
4. Fraction of Inspired Oxygen ([FiO2] a ventilator setting that controls the percentage of O2 delivered to a patient) of 40% - 5 liters per minute (lpm)
5. Positive end-expiratory pressure ([PEEP] the maintenance of positive pressure at the airway opening at the end of expiration to keep the patient's lungs from collapsing when they can't breathe on their own) of +5
During a review of Resident 1's Situation, Background, Assessment a Recommendation ([SBAR] a technique which provides a framework for communication between members of the health care team about a patient's condition), dated 1/15/2024 and timed at 10:25 a.m., the SBAR indicated Registered Nurse Supervisor 2 (RNS 2) notified Resident 1's NP that Resident 1's O2 saturation rate ([O2 Sat] the level of oxygen carried by red blood cells through the arteries and delivered to internal organs was ranging from 88%-91% (normal range is between 92-98%) and shortness of breath (SOB). The SBAR indicated the NP ordered the following changes to the ventilator settings:
1. RR increased to 20 breaths per minute
2. VT increased to 450
3. Oxygen increased to eight lpm - approximately 52% FiO2.
During a review of Resident 1's Licensed Personnel Weekly Progress Notes dated 1/15/2024 and timed at 3:30 p.m., the Licensed Personnel Weekly Progress Notes indicated, RNS 1 notified Resident 1's NP of Resident 1's respiratory rate of 22 breaths per minute. The Licensed Personnel Weekly Progress Notes indicated the NP ordered a chest Xray and instructed RNS 1 to send Resident 1 to the GACH if Resident 1 needed more interventions, since Resident 1 was a full code.
During a review of Resident 1's Continuous Ventilator Flowsheet dated 1/15/2024 and timed at 7 p.m., the Continuous Ventilator Flowsheet indicated Resident 1 had a respiratory rate of 40 breaths per minute.
During a review of Resident 1's Licensed Personnel Weekly Progress Notes dated 1/15/2024 and timed at 7:30 p.m., the Licensed Personnel Weekly Progress Notes indicated RNS 2 documented Resident 1's O2 Sat was between 91-93% and Resident 1's RR was 28 breaths per minute. The Licensed Personnel Weekly Progress Notes indicated RNS 2 asked RT 1 to increase Resident 1's PEEP ventilator setting from five to eight. The Licensed Personnel Weekly Progress Notes indicated Resident 1's Family Member (FM 2) called and requested to transfer Resident 1 to a GACH. The Licensed Personnel Weekly Progress Notes indicated, RNS 2 documented Resident 1 could not be transferred via regular ambulance and would require 911 transfer if he (RNS 2) decided that Resident 1 needed to be transferred to a GACH. Continued review of Resident 1's Licensed Personnel Weekly Progress Notes indicated there was no documentation that RNS 2 obtained a physician's order prior to changing Resident 1's ventilator settings or that Resident 1 was transferred to a GACH per FM 2's request.
During a review of Resident 1's Licensed Personnel Weekly Progress Notes dated 1/15/2024 and timed at 8 p.m., the Licensed Personnel Weekly Progress Notes indicated RNS 2 informed Resident 1's NP of Resident 1's RR of 40 breaths per minute and that he (RNS 2) changed Resident 1's ventilator settings. The Licensed Personnel Weekly Progress Notes indicated Resident 1's NP was concerned with Resident 1's RR and requested that Resident 1 be transferred to a GACH. The Licensed Personnel Weekly Progress Notes indicated that RNS 2 would continue to monitor Resident 1 for improvement and if Resident 1 did not improve he (RNS 2) would transfer Resident 1 to a GACH.
During a review of Resident 1's Licensed Personnel Weekly Progress Notes dated 1/15/2024 and timed at 8:30 p.m., the Licensed Personnel Weekly Progress Notes indicated Resident 1's RR was between 35-41 breaths per minute. The Licensed Personnel Weekly Progress Notes indicated Resident 1's FM 1 and FM 2 requested that Resident 1 be transferred to a GACH.
During a review of Resident 1's Licensed Personnel Weekly Progress Notes dated 1/15/2024 and timed at 8:40 p.m., the Licensed Personnel Weekly Progress Notes indicated RNS 2 called 911 (at least an hour and 40minutes after Resident 1's RR increased as evidenced by documentation on the Licensed Personnel Progress Notes at 7 p.m.).
During an interview on 6/24/2024 at 3:02 p.m., FM 2 stated on 1/15/2024 she requested several times that Resident 1 be transferred to a GACH via 911 but the licensed nurses refused to transfer Resident 1.
During a telephone interview on 6/25/2024 at 9:44 p.m., RNS 2 stated he did not think it was necessary to transfer Resident 1 to a GACH on 1/15/2024 at 7:30 p.m. RNS 2 stated he knew ventilator settings were only to be changed with a physician's or NP's order, but he wanted to implement interventions that would hopefully stabilize Resident 1 because he (RNS 2) did not want to prematurely call 911 to transfer Resident 1 to a GACH. RNS 2 stated Resident 1 was still somewhat stable so he decided to have RT 1 change Resident 1's ventilator settings and if Resident 1's respiratory status did not improve he would call Resident 1's NP for further orders. RNS 2 stated he did not think it was necessary to transfer Resident 1 to a GACH on 1/15/2024 at 8 p.m., after Resident 1's NP's recommendation to transfer Resident 1 to a GACH because Resident 1 was not showing signs of respiratory distress and he wanted to continue the interventions to see if Resident 1's status improved.
During an interview on 6/26/2024 at 2:17 p.m., RT 1 stated on 1/15/2024, he recommended to RNS 1 on several occasions throughout the shift (7 a.m., - 7 p.m.) that Resident 1 be transferred to a GACH for further evaluation and management because Resident 1's RR was not improving, but RNS 1 did not agree with his recommendation. RT 1 stated because Resident 1 was not improving, he recommended to RNS 2 on 1/15/2024 at 7 p.m., that Resident 1 be transferred to a GACH, but RNS 2 did not agree with his recommendation.
During a phone interview on 6/26/2024 at 4:44 p.m., RNS 1 stated she did not feel the need to transfer Resident 1 to a GACH after the NP recommendation to transfer her because she (RNS 1) felt Resident 1 was stable.
During an interview on 6/26/2024 at 5:44 p.m., the Director of Nursing (DON) stated based on Resident 1's status and the recommendation made by the NP, Resident 1 should have been transferred to a GACH because Resident 1 was not improving. The DON stated licensed nurses, nor the RTs can change a ventilator setting without a physician's or NP's order because that was not within their scope of practice. The DON stated Resident 1 had the potential for cardiac arrest from increased carbon dioxide (colorless odorless gas that is a waste product of the body) in the blood due to an increased RR.
During a review of the facility's undated policy and procedure (P&P) titled, Mechanical Ventilation, the P&P indicated ventilator changes are to be made only with a written physician's order and by respiratory care provider.
During a review of the facility's P&P titled, Physician Orders and Telephone Orders, dated 11/2017, the P&P indicated physician's orders shall be obtained prior to the initiation of any medication or treatment from a person lawfully authorized to prescribe for and treat human illness.
During a review of the facility's P&P titled, Change of Condition, revised 3/2021, the P&P indicated the physician is responsible for making the decision for the resident to be treated at the facility or be transferred to the acute hospital for treatment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility ' s Quality Assessment and Assurance ([QAA] a group which develops and implements appropriate plans of action to correct identified quality deficiencies) committee and Quality Assurance Performance Improvement ([QAPI] a group who takes a systemic, interdisciplinary, comprehensive, and data driven approach to maintaining and improving safety and quality in nursing homes while involving residents and families) committee failed to:
1. Have a policy and procedure (P&P) in place regarding the management and care of residents with the diagnoses of seizures, convulsions, and epilepsy, including how to identify those residents at risk and implement seizure precautions.
2. Identify, assess, and implement seizure precautions for 24 residents, in the facility with diagnoses of seizures, convulsions, epilepsy, and on anti-seizure medications
These deficient practices placed 24 residents with diagnoses of seizure, convulsions, or epilepsy at risk for falls and injuries during seizure activities.
Findings:
a. During a review of Resident 1 ' s admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including epilepsy and systemic lupus erythematosus (SLE- when the body ' s immune system attacks the tissue and organs).
During a review of Resident 1 ' s History and Physical (H&P) dated 2/13/2024, the H&P indicated Resident 1 had a fluctuating capacity to understand and make decisions.
During a review of Resident 2 ' s admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE] with the diagnosis of unspecified convulsions.
During a review of Residents 2 ' s MDS dated [DATE], the MDS indicated Resident 2 was in a persistent vegetative state (awake with no signs of awareness). The MDS indicated Resident 2 was completely dependent on staff for activities of daily living (ADLs- eating, drinking, transferring, dressing and toileting). The MDS indicated Resident 2 had a diagnosis of a seizure disorder or epilepsy.
During a review of Resident 2 ' s physician orders dated 11/30/2023, the order indicated give 10 millimeters ([ml] unit of measurement) Levetiracetam (medication used to treat seizures) through a gastrostomy tube (tube inserted through the wall of the abdomen into the stomach for food and medication administration) every eight hours for seizure disorder.
During a review of Resident 2 ' s care plan titled High risk for trauma/injuries related to diagnosis of seizure disorder, dated 4/26/2023, the care plan goal indicated Resident 2 will not have a traumatic injury, if possible, within next 3 months. The care plan interventions included keeping environment free of safety hazards.
c. During a review of Resident 3 ' s admission Record, the admission Record indicated Resident 3 was admitted to the facility on [DATE] with the diagnosis of other seizures.
During a review of Residents 3 ' s MDS dated [DATE], the MDS indicated Resident 3 ' s cognition (ability to learn, remember, understand, and make decision) was severely impaired. The MDS indicated Resident 2 was completely dependent on staff for ADLs. The MDS indicated Resident 3 had a diagnosis of a seizure disorder or epilepsy.
During a review of Resident 3 ' s physician order dated 8/14/2023, the order indicated Levetiracetam 10 millimeters every 12 hours through gastrostomy tube for seizure disorder.
During an interview on 3/16/2024 at 9:36 a.m., with LVN 3, LVN 3 stated residents at risk for seizures were identified on admission by their diagnosis and medications ordered for seizures. LVN 3 stated seizure precautions should be implemented when residents were admitted with diagnoses of seizure, convulsion and epilepsy and were on anti-seizure medications to prevent falls and injuries seizures.
During an interview on 3/16/2024 at 10:04 a.m., with RNS 2, RNS 2 stated seizure precautions should be implemented upon admission, if a resident was identified at risk for seizure. RNS 2 stated during meetings and huddles (short daily meetings) staff were notified of residents at risk for seizures. RNS 2 stated she was unsure if the facility had a method to identify residents at risk for seizures such as a wrist band. RNS 2 stated any resident on seizure medications should be on seizure precautions because the medications could limit seizures, but not prevent them.
During an interview on 3/16/2024 at 11:45 a.m. with the DON, the DON stated upon admission a resident was identified as at risk for seizure based on the resident ' s seizure medications. The DON stated since Resident 1 was not prescribed any seizure medication, Resident 1 ' s seizure history was unknown. The DON stated if the seizure diagnosis was not identified and seizure precautions were not implemented, residents could suffer an injury during a seizure. The DON stated the MDSN and RNS should have followed up to ensure care plan interventions were implemented for seizure precautions for Resident 1. The DON stated the facility did not have a policy on seizure management and precaution. The DON stated the QAPI committee was focused on falls and pressure wounds. The DON stated the committee was collecting data regarding the number of falls, during what shift they occur on and what staff are working. The DON stated the ADM and DSD were focused on abuse training. The DON stated seizure management and prevention were not really looked at because the committee was more focused on priority items including the use of bed rails.
During a review of the facility ' s policy and procedure (P&P) titled Quality Assurance Performance Improvement Plan & Committee (QAPI) dated 9/2017, indicated the QAPI committee identifies and addresses specific care and quality issues and implements an action plan to resolve these issues. The P&P indicate the QAPI plan identifies and prioritizes problems and opportunities for improvement.
Cross reference to F689

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of four sampled residents (Resident 1), who resided at the facility and was transferred to a General Acute Care Hospital (GACH) for evaluation and treatment of an elevated heart rate, was readmitted to the facility after Resident 1 was treated and stabilized at the GACH.
This deficient practice resulted in Resident 1 remaining at the GACH for five days after Resident 1 was deemed appropriate for discharge back to the facility but was denied readmission by the facility. Resident 1 was subsequently transferred to a different facility, placing the resident at risk for confusion, disorientation and psychosocial harm related to dislocation from a place that was considered Resident 1's home.
Findings:
During a review of Resident 1's admission Record (Face Sheet) the Face Sheet indicated Resident 1 was admitted to the facility on [DATE]. Resident 1's diagnoses included cerebral infarction ([stroke] disrupted blood flow to the brain due to problems with the blood vessels that supply it), atherosclerotic heart disease (thickening or hardening of the arteries caused by a buildup of plague in the inner lining of the artery), congestive heart failure ([CHF] long-term condition in which the heart can't pump blood well enough to meet the body's needs), sick sinus syndrome (heart's pacemaker unable to generate a normal heart rate), vascular dementia (progressive memory loss caused by conditions such as stroke that disrupt blood flow to the brain and lead to problems with memory, thinking, and behavior), respiratory failure, diabetes mellitus ([DM] a disorder causing blood sugar (b/s) levels to be abnormally high) and atrial fibrillation (a type of abnormal heartbeat).
During a review of Resident 1's Minimum Data Set ([MDS] a standardized assessment and care screening tool), dated 1/9/2024, the MDS indicated Resident 1's cognitive (the ability to think, reason, and understood) skills for daily decision-making were moderately impaired.
During a review of Resident 1's History and Physical (H&P) dated 11/20/2023, the H&P indicated Resident 1 did not have the capacity to understand and make decisions.
During a review of Resident 1's Change of Condition (COC) dated 2/17/2024, the COC indicated Resident 1 had a heart rate of 134 (normal heart rate 60 to 100 beats per minute) beats per minute. The COC indicated Resident 1's physician was notified, and an order was obtained to transfer Resident 1 to s GACH's emergency room.
During a review of Resident 1's Physician's Order dated 2/17/2024 and timed at 7:35 a.m., the Physician's Order indicated to transfer Resident 1 to the GACH for an elevated heart rate.
During a review of Resident 1's Nurse Progress Note dated 2/17/2024 and timed at 8 a.m., the Progress Note indicated Resident 1 was transferred to the GACH for further evaluation.
During a review of Resident 1's Bed Hold Informed Consent, the Bed Hold Informed Consent indicated Resident 1's Responsible Party's (RP) signed acknowledging the Bed Hold Informed Consent on Resident 1's admission to the facility (11/15/2024). Continued review of the Bed Hold Informed Consent indicated there was no signature under Confirmation of Transfer & Bed Hold Provision, when Resident 1 was transferred to the GACH (2/17/2024).
During a review of Resident 1's Notice of Transfer/Discharge, the Notice of Transfer/Discharge indicated a date of 2/17/2024, the day Resident 1 was transferred to the GACH. The Notice of Transfer/Discharge indicated Resident 1 was transferred or discharged because Resident 1's welfare and needs could not be met in the facility.
During a review of the GACH admission Records, the GACH admission Records indicated Resident 1 was admitted to the emergency room on 2/17/2024, with diagnosis of tachycardia and was discharged . The admission Records indicated Resident 1 was discharged to different facility on 2/23/2024 (five days after Resident 1 was ready for transfer back to the facility she was transferred from).
During a review of the GACH's Case Coordination Note dated 2/18/2024 (one day after Resident 1 was transferred to the GACH) and timed at 10:04 a.m., and 11:50 a.m., the Case Coordination Note indicated the Market Coordinator from the facility stated the facility was not able to accept Resident 1 back to the facility.
During an interview on 2/23/204 at 1:58 p.m., the Market Coordinator stated she was instructed by the facility's Director of Nursing (DON) to tell the GACH that the facility was unable to accept Resident 1 back to the facility.
During an interview on 2/23/2024 at 2:40 p.m., and a subsequent interview on 2/26/2024 at 2:26 p.m., the DON stated we do not want to readmit Resident 1 to the facility because Resident 1's RP interferes with Resident 1's care, the RP has unrealistic demands and makes the staff nervous. The DON stated they did not offer Resident 1 or her RP a seven day bed hold because they could not meet the expectations of Resident 1's RP and knew they would not readmit Resident 1.
During a review of the facility's policy and procedure (P/P) titled Bed Hold and Notice, revised 8/2018, the P/P indicated the resident has the right to exercise the bed hold provision and the state bed-hold policy of seven (7) days, which will permit the resident to return and resume residence in the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) who experienced an assisted fall, sustained a right proximal fibula fracture (a break in the bone below the knee) and was assessed with pain, received pain medication to relieve his pain, per Resident 1's physician's order.
This deficient practice resulted in Resident 1's unrelieved and increasing pain for approximately seven hours after falling and sustain a right proximal fibula fracture (12/18/2023).
Findings:
During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses including morbid obesity (more than 100 pounds over average body weight), and diabetes ([DM] a disease characterized by elevated levels of blood glucose [sugar]).
During a review of Resident 1's Minimum Data Set ([MDS] a standardized assessment and care screening tool) dated 1/27/2024, the MDS indicated Resident 1 was able to make independent decisions that were reasonable and consistent and Resident 1 was able to make himself understood and was understood others.
During a review of Resident 1's Situation Background Assessment Recommendation ([SBAR] a communication tool where health care members share information about the condition of a resident) dated 12/18/2023, the SBAR indicated on 12/18/2023 at approximately 11:30 a.m., Resident 1 was with the Physical Therapist (PT) in Resident 1's room, when Resident 1 was unable to stand any longer or sit in his wheelchair and was assisted to the ground by the PT, a Certified Occupational Therapist Assistant (COTA) and Certified Nursing Assistant 1 (CNA 1). The SBAR indicated Resident 1 was assessed with pain rated at 4-5 out of 10 in his right knee, Resident 1's physician was notified and an Xray was ordered.
During a review of Resident 1's Physician's Order dated 12/18/2023 at 12:30 p.m., the Physician's Order indicated to obtain bilateral (both sides) knee X-rays due to Resident 1's pain.
During a review of Resident 1's undated Physician's Fracture Progress Report, the Physician's Fracture Report indicated Resident 1 sustained a proximal right fibula fracture that was stress induced and caused from spontaneous movement from ambulating (moving, walking) turning and moving extremities independently.
During a review of Resident 1's Physician's order dated 12/18/2023, and timed at 4:46 p.m., the Physician's Order indicated Resident 1 was to receive Norco (a medication used to treat moderate to moderately severe pain) tablet 5-325 milligrams ([mg] a unit of measurement), give one tablet in the evening for pain management until 12/18/2023 at 11:59 p.m., administer one dose now.
During a review of Resident 1's Physician's Order dated 12/18/2023, at 4:48 p.m., the Physician's Order indicated may transfer Resident 1 to the GACH for further evaluation and management due to his non-displaced (a bone that is broken but retains its proper alignment) proximal right fibula fracture.
During a review of Resident 1's Dailly Skilled Nurse's Note, dated 12/18/2023 (no time was indicated) the Daily Skilled Nurse's Note indicated Resident 1 had a pain level of 7 out of 10 during the 7 a.m. - 3 p.m. shift. Continued review of the Daily Skilled Nurse's Note indicated there was documentation that Resident 1 received pain medication or other interventions to relieve his pain.
During a concurrent interview and record review, on 2/15/2024 at 4:30 p.m., with the DON, Resident 1's Medication Administration Audit Report, dated 12/18/2023 was reviewed. The Medication Administration Audit Report indicated Resident 1 received one Norco 5-325 mg tablet for pain management on 12/18/2023 at 7:12 p.m. (approximately seven hours and 45 minutes after Resident 1 had an assisted fall and assessment of pain of 4-5 out of 10 and approximately two hours and 15 minutes after a physician's order to administer Norco to Resident 1 at 4:46 p.m.). The DON stated the nursing staff should have provided Resident 1 with pain medication as ordered by the physician.
During an interview on 2/14/2024, at 4 p.m., Registered Nurse 1 (RN 1) stated she started her shift at approximately 3 p.m., on 12/18/2023 and was notified of Resident 1's assisted fall by the outgoing nurse. RN 1 stated she assessed Resident 1 's pain level upon arrival of her shift and Resident 1 did complain of pain when moving his right knee but he did not have any pain when his right knee was resting and not moving. RN 1 stated she did not she did no further assessment of Resident 1's knee to determine is continued pain level when moving his right knee. RN 1 stated she did not document the pain assessment and she should have been more thorough when she assessed Resident 1 for pain, so he did not experience continued or increased pain.
During an interview on 2/16/224 at 2 p.m., the DON stated, the nursing staff should have initiated pain management interventions, such as applying ice to Resident 1's right knee, as soon as Resident 1 complained of pain after the fall. The DON stated staff should have assessed and documented Resident 1's pain level and characteristics of pain, such as what causes Resident 1 to experience pain to the right leg and the nursing staff should have notified the physician when Resident 1 experienced moderate pain during the 7am -3pm shift.
During a review of the facility's policy and procedure (P&P) titled, Pain Management Protocol, dated 10/2017, the P&P indicated the purpose of the P&P is to assess pain and evaluate the response to pain management interventions using standard pain management scale and or a description of non-verbal signs and symptoms of pain, to relieve pain which can increase mobility, activities of daily living participation, cooperation, relieve anxiety or agitation, educate staff, residents and families regarding pain management, recognizing that as needed medication may be given around the clock, intervening to treat pain before the pain becomes severe. The P&P indicated whenever the presence of pain is identified, the process of pain assessment and management will begin. The P&P indicated the pain assessment process is as follows: complete the pain assessment form, initiate the pain assessment flow sheet if applicable, documentation on the flow sheet, reflect every as needed medication administered in response to the medication and non-pharmacological intervention.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to report an allegation of physical abuse to the California Department of Health (CDPH), the State Long Term Care Ombudsman (an agency that provides support for residents of nursing homes, board and care homes and assisted living facilities) and the local Police Department within the regulated time frame of two hours for one of four sampled residents (Resident 1).
This deficient practice resulted in a delay in the CDPH ' s investigation of the physical abuse allegation and had the potential for pertinent data to be lost and/or forgotten.
Findings:
A review of Resident 1 ' s admission Record (Face Sheet) indicated Resident 1 was admitted to the facility on [DATE] with a diagnosis of dementia (the impaired ability to remember, think or make decisions which interfere with doing everyday activities).
A review of Resident 1's Minimum Data Set ([MDS] a standardized assessment and care screening tool), dated 12/5/2023, indicated Resident 1 ' s cognitive skills for daily decision-making were severely impaired.
During an interview on 1/9/2024 at 4 p.m., Resident 1 ' s Family Member (FM 1) stated on 12/22/2023 Resident 1 told FM 1 that a tall, thin, short-haired, nurse was rough with Resident 1 while changing his (Resident 1 ' s) brief then dug her nails into Resident 1 ' s left upper arm, and scratched Resident 1.
During an interview on 1/10/2024 at 12:50 p.m., the Treatment Nurse (TN 1) stated on 12/22/2023, FM 1 told her that a staff member grabbed Resident 1 ' s left arm and scratched Resident 1.
During an interview on 1/10/2024 at 3:52 p.m., the Social Services Director (SSD) stated on 12/22/2023, Resident 1 ' s FM 1 claimed a staff member scratched Resident 1. The SSD stated she did not report the allegation of abuse to the CDPH because after interviewing Resident 1 on 12/22/2023, Resident 1 stated he scratched himself.
During an interview on 1/10/2024 at 4:37 p.m., the Director of Nursing (DON) stated she was made aware of the alleged abuse allegation on 12/22/2023, but did not report the allegation to the CDPH, the Ombudsman, or the local Police Department because Resident 1 told the SSD he scratched himself. The DON stated all allegations of abuse need to be reported immediately to the CDPH, the Ombudsman and the police department.
During an interview on 1/10/2024 at 4:45 p.m., the Administrator (ADM) stated the Suspected Dependent Adult/Elder Abuse (SOC 341) form should have been faxed to the CDPH, the LTC Ombudsman within two hours of the allegation of abuse.
A review of the facility ' s policy and procedure (P/P) titled, Abuse Reporting and Prevention, revised 1/2023, indicated the ADM, or his/her designee, will report each alleged abuse to the Ombudsman ' s office and the Department of Public health immediately or within two hours and any allegation of physical abuse should be reported to law enforcement within two hours.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the Family Member (FM 1) was notified when one of four sampled residents (Resident 1) fell on [DATE] at 2:15 a.m., 4:25 a.m., and 6:30 a.m.
This deficient practice resulted in Resident 1 ' s FM 1 being unaware of Resident 1 ' s falls and had the potential to interfere with FM 1 ' s informed care decisions.
Findings:
A review of Resident 1 ' s admission Record (Face Sheet), indicated Resident 1 was admitted to the facility on [DATE] with diagnosis including rheumatoid arthritis (a condition which causes pain, swelling and stiffness in joints), dementia (the impaired ability to remember, think or make decisions which interfere with doing everyday activities), and amnesia (a loss of memories, including facts, information, and experiences).
A review of Resident 1's Minimum Data Set ([MDS] a standardized assessment and care screening tool), dated 12/5/2023, indicated Resident 1 ' s cognitive skills for daily decision-making were severely impaired.
A review of Resident 1 ' s Situation, Background, Assessment, and Recommendation Communication Form ([SBAR] a communication tool used to promote and simplify communicating important patient information to other members of the healthcare team), dated 12/18/2023, indicated Resident 1 was noted on the floor on three different occasions: at 2:15 a.m., at 4:25 a.m. and at 6:30 a.m. The SBAR indicated there was no documentation to indicate Resident 1 ' s FM 1 was notified of Resident 1 ' s falls on 12/18/2023.
A review of Resident 1 ' s Nursing Progress Notes, dated 12/2023, indicated there was no documentation indicating Resident 1 ' s FM 1 was notified of Resident 1 ' s falls on 12/18/2023.
During an interview on 1/12/2024 at 1:17 p.m., the Director of Nursing (DON) stated when a resident has a change of condition, the resident ' s responsible party or family member should be notified, and the licensed nurse must document on the SBAR the date, time, and name of the person wo was informed.
During a telephone interview on 1/17/2024 at 3:47 p.m., Resident 1 ' s FM 1 stated he had not been notified by anyone at the facility and was not aware of Resident 1 ' s falls on 12/18/2023.
A review of the facility ' s policy and procedure (P/P), titled Significant Change in Condition, revised 4/2017, indicated family members or responsible parties will be notified of a change of condition. The P/P indicated notification of the family member or responsible party shall be documented in the nursing notes including the time and name of person informed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure three of seven sampled residents (Resident 1, Resident 5, and Resident 6) living condition were:
a. free from direct/ indirect threatening remarks and acts of violence from a non-resident or visitor; and,
b. free from noise or disruption from a visitor when their respective care and treatment is being provided.
These deficient practices have resulted to Resident1, Resident 5 and Resident 6 to feel disrespected and unsafe in their environment and had the potential to negatively impact their physical and psychological well-being.
Findings:
A. During a review of Resident 1 ' s admission Record (Face sheet), the Face sheet indicated Resident 1 was admitted at the facility on 8/3/2023 with a diagnosis that included end stage renal disease (a medical condition in which a person ' s kidneys permanently stop functioning), diabetes mellitus a condition with inappropriate elevated blood sugar levels and hypertension (abnormally higher than normal blood pressure).
During a review of Resident 1 ' s Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 11/10/2023, the MDS indicated Resident 1 was able to make independent decisions that were reasonable and consistent and was independent with his activities of daily living ({ADLs} task such as eating, grooming and toileting.
During an interview on 12/6/2023 at 5:40 p.m., with Resident 1, Resident 1 stated there is a visitor (RP1) who comes in constantly in the afternoon, at 3:00 p.m. to 11:00 p.m. shift, who has been loud and disrespectful towards to the staff and disturbing the residents and has been going on for almost a month. Resident 1 stated RP1 interrupted his nurse who was giving him his medicines because the RP1 demanded attention and Resident 1 felt disrespected and was concerned that this was unsafe because his nurse could ' ve made a medication error. Resident 1 stated there was an incident on a weekend that he was not attended by his nurse for 2 hours and he found his nurse attending a resident and her visitor (RP1) in the dining room. Resident 1 stated this situation in the facility is not fair for him and the other residents.
During a review of the facility ' s document Grievance Statement od Resident 1 dated 11/27/2023, the grievance statement indicated RP1 was disruptive with the licensed vocational nurse during medication pass and was distracting the licensed vocational nurse with questions about Resident 2. The grievance statement also indicated RP1 was very loud while accusing a certified nursing assistant about Resident 2 ' s dress.
B. During a review of Resident 5 ' s the Face sheet indicated Resident 5 was admitted at the facility on 11/8/2023 with a diagnosis that included end stage renal disease, heart failure (a condition that develops when the heart does not pump enough blood for the body ' s needs) and obstructive sleep apnea (a condition that occurs when one ' s breathing is interrupted during sleep).
During a review of Resident 5 ' s MDS dated [DATE], the MDS indicated Resident 5 was able to make independent decisions that were reasonable and consistent and was totally dependent to 2- person assist to complete his activities of daily living (ADLs) such as personal hygiene and toileting.
During an interview on 12/11/2023 at 9:22 a.m., with Resident 5, Resident 5 stated he feels bothered, disrespected and unsafe every time an unruly visitor (RP1) comes to the facility in the afternoon because of her loud, rude, and demanding remarks to the nurses. Resident 5 stated this has happened several times in the afternoon and has caused his and other residents living environment to be unpeaceful.
C. During a review of Resident 6 ' s the Face sheet indicated Resident 6 was admitted at the facility on 7/29/2016 with a diagnosis that included chronic pain syndrome (pain that lasts for more than 3 months, could come and go and happens anywhere in the body), hypertension (abnormally high blood pressure) and chronic obstructive pulmonary disease (common lung disease causing blockage of airflow in the lungs and breathing problems).
During a review of Resident 6 ' s MDS, dated [DATE], the MDS indicated Resident 6 was able to make independent decisions that were reasonable and consistent and requires one-person extensive assist to complete his ADLs such as bed mobility and transfer, toileting, and personal hygiene.
During an interview on 12/11/23 at 9:57 a.m., with Resident 6, Resident 6 stated RP1 always comes loud, rude, and disrespectful to the staff whenever she comes to the facility in the afternoon shift to visit her mother (Resident 2) and this has caused him discomfort and agony whenever his sleep is interrupted. Resident 6 stated on 12/7/2023 at around past 5:00 pm, while he was at the patio of the facility, he was alarmed when he heard a loud banging inside the facility, and he saw the law enforcement talked to the visitor (RP1).
During an interview on 12/8/2023 at 9:15 a.m., with Housekeeper 1 (HK 1), HK 1 stated she have noticed a visitor of Resident 2 who, at times, comes in the morning shift and mostly in the afternoon shift, who talks very loudly and demanding to the nursing staff. HK 1 stated this facility is the residents ' home and all, including visitors, must act with respect to maintain the peace and quiet of their home.
During an interview on 12/8/2023 at 10:00 a.m., with Certified Nursing Assistant 1 (CNA 1), CNA 1 stated it is uncomfortable for the staff and the residents for the visitor (RP1) to interrupt the residents ' care because all residents must be treated and cared for equally.
During a telephone interview on 12/11/2023 at 10:10 a.m., with Certified Nursing Assistant 3 (CNA 3), CNA 3 stated on 12/7/2023 at 3:00 p.m. to 11:00 shift, she saw the visitor (RP1) was fuming (the action of expressing great anger) and she threw a folding chair across the hallway. CNA3 stated she was scared because the visitor (RP1) violent act could have caused a resident or staff their safety.
During an interview on 12/11/2023 at 10:37 a.m., with the Maintenance Director (MD), MD stated he saw the visitor (RP1) was pacing back and forth in the hallway and was talking to herself and she slammed a folding chair on the wall with no warning. Md stated the violent tendencies of the visitor (RP1) could intimidate and threaten the residents and staff.
During an interview on 12/11/2023 at 10:40 a.m., with Registered Nurse Supervisor 2 (RNS 2), stated every staff of the facility is responsible in making sure the residents ' needs are met and they are comfortable in their home environment.
During a telephone interview on 12/11/2023 at 10:42 a.m., with the Director of Nursing Services (DON), the DON stated it is not a homelike environment for the residents if they are disturbed and scared of an unruly visitor. The DON stated the facility could have discussed the visitation policy to the visitor (RP1) and enforce it immediately.
During an interview on 12/11/2023 at 11:09 a.m., with the Administrator (ADM), the ADM stated the residents must feel safe and secure in their living environment to be able to thrive. The ADM stated the facility ' s visitation policy must be always enforced for safety of all the staff and residents.
During a review of the facility ' s Policy and Procedure titled, Facility Rules revised 12/2019, the P/P indicated the visitors must keep the noise level to a minimum when in the facility so the residents are not disturbed and if the visitors do not adhere to reasonable restrictions of the facility, the facility has the right to deny access or provide limited and supervised access toa visitor for the protection and privacy of all residents. In addition, the P/P indicated the facility may limit access of a non- resident who is disruptive to the function, operation or social harmony of the facility and may request that they leave or call law enforcement for assistance, if necessary.
During a review of the facility ' s Policy and Procedure titled, Resident Rights, revised 9/2017, the P/P indicated the residents of the facility have the right to be treated with respect, consideration and full recognition of dignity, individuality, including privacy in treatment and in care of personal needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the primary physician 1(MD 1) recorded the cause of death in the progress notes; and completed and filed for a death certificate following one of one sampled resident's (Resident 1) death, as indicated in the facility ' s policy and procedure (P&P).
This deficient practice delayed the necessary post mortem (after death) services for Resident 1.
Findings:
During a review of Resident 1 ' s face sheet (admission record), the face sheet indicated Resident 1 had an initial admission date of [DATE] and was readmitted on [DATE] with the diagnosis of intracranial hemorrhage (bleeding within the brain), sepsis (serious condition in which the body responds improperly to an infection), dysphagia (difficulty swallowing), aphasia (trouble speaking or understanding other people speaking) and traumatic brain injury (brain dysfunction caused by outside force usually a violent blow to the head). The face sheet indicated Resident 1's care provider was MD 1.
During a review of Resident 1 ' s Initial Nursing Assessment, dated for [DATE], the assessment indicated Resident 1 was unable to communicate and Resident 1 needed total assistance when transferring.
During a review of Resident 1 ' s Nursing Notes, dated [DATE], the notes indicated:
a. At 12:05 a.m., Resident 1 was admitted to the facility under the care of MD 1. The notes indicated MD 1 was notified of the admission and orders were verified.
b. At 7:50 p.m., Resident 1 was found unresponsive, cardiopulmonary resuscitation ([CPR] lifesaving technique used in emergencies when someone's breathing or heartbeat has stopped) was initiated, and the universal emergency number (911) was called.
c. At 8:15 p.m., the paramedics arrived and assumed emergency care.
d. At 8:19 p.m., the paramedics pronounced Resident 1 ' s death,
e. At 8:25 p.m., MD 1 was notified of Resident 1's death and an order to release the body to the mortuary was obtained.
During a review of Resident 1 Order Summary Report, the orders indicated from [DATE] to [DATE], MD 1 gave eight pages of admission orders regarding Resident 1's care.
During an interview with Registered Nurse (RN) 1, on [DATE] at 11:23 a.m., RN 1 stated upon residents' death, the nurse ' s responsibility was to inform the physician, so the physician can pronounce the time of death. RN 1 stated the physician will then come to the facility and sign off any paperwork regarding the death.
During an interview with the Administrator (ADM), on [DATE] at 1:37 p.m., the ADM stated once a resident was in the facility, the primary physician was responsible for the care of the resident. The ADM stated MD 1 should have signed Resident 1 ' s paperwork relating to the resident's death.
During a concurrent interview with the Director of Nursing (DON) and record review of the P&P, titled Death of a Resident, Documenting (revised 5/15), on [DATE] at 2:13 p.m., the facility ' s P&P was reviewed. The P&P indicated the attending physician must record the cause of death in the progress notes and must complete and file a death certificate with the appropriate agency within twenty-four (24) hours of the resident ' s death or as may be prescribed by state law. The DON stated MD 1, did not come within 24 hours of Resident 1 ' s death to record the cause of death in the progress notes. The DON stated MD 1 did not complete and file for a death certificate with the appropriate agency.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to prevent the development of an avoidable Stage IV (skin damage that extends to the muscle, tendon, or bone) pressure sore (skin injury from prolonged pressure on the skin and tissue underneath) on the sacro-coccyx (tail bone area) area for one of two sampled residents (Resident 2) by failing to:
a. Ensure Resident 2 was repositioned at least every two hours, as indicated in the care plan to relieve the pressure from the sacro-coccyx area.
b. Ensure Licensed Vocational Nurse (LVN) 2 assessed Resident 2's sacro-coccyx pressure sore on 5/15/2023, 5/22/2023, 5/29/2023, 6/5/2023, 6/12/2023, and 6/19/2023, to reflect the size of the pressure sore and to reflect the correct classification of the pressure sore as a Stage III (damage extend to fat tissue) pressure sore.
c. Ensure the licensed nurses, in charge of resident assessments, completed Resident 2's weekly skin assessments during 4/2023, to determine the condition of Resident 2's skin.
These deficient practices resulted in Resident 2's moisture-associated skin damage ([MASD] term for inflammation or skin erosion [breakdown] caused by prolonged exposure to a source of moisture such as urine, stool, sweat, wound drainage, saliva, or mucus) on the buttocks, which was identified on 5/15/2023, progressing to a Stage III (skin damage extending to the fat tissue) pressure sore to the sacro coccyx area on 6/23/2023, then progressing to an infected Stage IV pressure sore on the sacro-coccyx area on 7/4/2023. Resident 2's sacro-coccyx pressure sore measured 1.3 cubic centimeters ([cm] a unit of measurement) in length, 0.6 cm in width, 0.4 cm in depth, with undermining (region underneath the overlying loose skin around the pressure sore) of 2.0 cm at 6 to 2 o'clock (undermining is measured by the use of the clock hand positions), with moderate purulent (consisting of, containing, or discharging pus) exudate (fluid leaking out). The infected Stage IV pressure sore required consultation from a wound specialist, excisional (cutting away) debridement (the removal of damaged tissue or foreign objects from a wound), an x-ray of the sacrum (tail bone) to rule out osteomyelitis (serious infection of the bone), and intravenous (within the vein) Clindamycin (a medication used to treat infections) for fourteen days.
Findings:
During a review of Resident 2's admission Record (Face Sheet), dated 10/6/2023, the Face Sheet indicated Resident 2 was admitted to the facility on [DATE] with diagnosed including an ulcer (an open sore) of the intestines, gastrointestinal hemorrhage (bleeding in the stomach, bowels or anus), gastrostomy (a feeding tube inserted through the belly to deliver food and/or medication directly to the stomach), hemiplegia (paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (a slight paralysis or weakness on one side of the body) following a nontraumatic intracranial (brain) hemorrhage (bleed) affecting Resident 2's left dominant side.
During a review of Resident 2's Minimum Data Set ([MDS]), a standardized assessment and care screening tool) dated 2/14/2023, the MDS indicated Resident 2's cognitive skills (ability to think and reason) for daily decision-making was intact. The MDS indicated Resident 2 required extensive assistance from one person with bed mobility, personal hygiene, and toilet use; and required the assistance of two or more persons with transfers (how resident moves between surfaces like from bed to chair). The MDS indicated Resident 2 was at risk of developing pressure ulcers/injuries. The MDS indicated Resident 2 did not have any unhealed pressure sore/injuries. The MDS indicated Resident 2 did not have any ulcers, wounds, and skin problems.
During a review of Resident 2's Braden Scale (scoring tool used to predict pressure sore risk), dated 2/14/2023, the Braden Scale indicated Resident 2's score was 13 indicating Resident 2 was at moderate risk for developing pressure sores.
During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2 was at risk of developing pressure ulcers/injuries. The MDS indicated Resident 2 did not have any unhealed pressure sore/injuries. The MDS indicated Resident 2 had a moisture associated skin damage ([MASD] term for inflammation [body's natural reaction to injury] or skin erosion [breakdown] caused by prolonged exposure to a source of moisture such as urine, stool, sweat, wound drainage, saliva, or mucus), no location was indicated.
During a review of Resident 2's Care Plan, dated 8/19/2021, the care plan goals indicated the resident will not develop a pressure ulcer. The Care Plan indicated to reposition Resident 2 every two hours.
During a review of Resident 2's Care Plan, dated 5/15/2023, the Care Plan indicated Resident 2 was at high risk for further skin breakdown related to Resident 2's moderate risk for developing pressure sores, incontinence (involuntary control of urination and defecation), poor skin turgor (elasticity), decreased mobility, hypertension (high blood pressure [force it takes for blood to pump]), history of coronavirus disease (contagious illness), and history of pressure sores. The care plan goals indicated the resident will not develop a pressure ulcer. Interventions indicated to monitor Resident 2's MASD for signs and symptoms (s/s) of redness, edema (an excess of watery fluid collecting in the tissues of the body), pain, drainage, pressure area/opening in the skin, to treat as ordered, use an LAL mattress and to notify the physician if s/s were noted and/or if no progress towards healing was noted. Interventions also indicated to check, turn, and reposition Resident 2 at least every 2 hours. The Care Plan indicated a revision date of 6/20/2023 to strictly reposition Resident 2 from side to side.
During a record review of Resident 2's Situation Background Assessment and Review ([SBAR] a form of communication between members of a health care team), dated 5/15/2023, the SBAR indicated Resident 2's buttocks had a MASD that was moist and red. The SBAR indicated the physician recommended to treat Resident 2 based on facility recommendations to reposition the resident from side to side.
During a record review of Resident 2's SBAR, dated 6/23/2023, the SBAR indicated Resident 2's wound in the sacro-coccyx deteriorated to a Stage III Pressure injury.
During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2 was at risk of developing pressure ulcers/injuries. The MDS indicated Resident 2 had one unhealed pressure sore/injuries. The MDS indicated Resident 2 had one Stage 4 pressure ulcer that was not present upon admission.
During a review of Resident 2's Weekly Summary SNF (weekly assessment of the residents' physical, behavioral, nutritional, functional, and mental condition) for 4/2023, the weekly summary indicated:
1. Resident 2's weekly skin assessment for 4/1/2023 to 4/9/2023 was not available for review in Resident 2's clinical record.
2. Resident 2's weekly skin assessment, dated 4/10/2023, was left blank without documentation of Resident 2's skin condition.
3. Resident 2's weekly skin assessment, dated 4/17/2023, did not indicate the condition of the resident's skin on the weekly summary form.
4. Resident 2's weekly skin assessment from 4/18/2023 to 4/30/2023 was not available for review in Resident 2's clinical record.
During a review of Resident 2's Non-Pressure Skin Condition Report, dated 5/2023 and 6/2023, the report indicated Resident 2 had MASD on the sacro-coccyx area and the following:
1. On 5/15/2023 and 5/22/2023, Resident 2's MASD's size was not measured (left blank), there was scant serosanguineous exudate, and the note indicated the wound bed had granulation tissue (the development of new tissue and blood vessels in a wound during the healing process, the wound may appear bright red or pink, soft, moist, bumpy, and be raised above the surrounding skin).
2. On 5/29/2023, Resident 2's MASD's size was not measured (left blank), a small amount of serosanguinous exudate was noted, and the note indicated granulation tissue was present
3. On 6/5/2023, Resident 2's MASD's size was not measured (left blank), the surrounding skin color was pink and not normal, and the note indicated granulation tissue was present.
4. On 6/12/2023, Resident 2's MASD's size was not measured (left blank), a small amount of serosanguineous exudate was noted, and the note indicated the wound bed had granulation tissue present.
5. On 6/19/2023, Resident 2's MASD's size was not measured (left blank), a small amount of serosanguineous exudate was noted, the surrounding skin color was pink and not normal, the wound bed had granulation tissue present, and Resident 2's wound was stalling (not getting better).
During a review of Resident 2's Task: Point of Care: turn and reposition at least every two hours and as needed record, from 6/5/2023 to 10/6/2023, the record indicated no documented evidence that Resident 2 was turned and repositioned at east every two hours and in what position.
During a record review of Resident 2's Weekly Pressure Injury Record, the record dated 6/23/2023 indicated Resident 2's sacro-coccyx pressure injury, measured 1.0 cm in length by 1.0 cm in width by .03 cm in depth, with moderate serosanguinous drainage, the surrounding skin was pink, the wound bed was 10% slough and 90% granulation tissue. The record indicated treatment for Resident 2's Stage III pressure injury was initiated, a foley was applied to prevent wound contamination and side to side repositioning was done.
During a review of Resident 2's order details, dated 6/23/2023 at 2:44 p.m., the order indicated to apply Medihoney wound/burn dressing external gel (type of gel that cleans and debrides [remove damaged tissue] the wound) to sacro-coccyx topically every dayshift, for the Stage III pressure injury for fourteen days. The order indicated to cleanse the pressure ulcer with Hibiclense (type of antiseptic [substance that prevent the growth of disease-causing germs] skin cleanser), rinse well and pat dry; then to apply Medihoney followed by Hydrofera blue (type of dressing) then cover with foam dressing and apply to sacro-coccyx topically as needed for soilage and dislodgement for fourteen days.
During a review of Resident 2's Wound Care Physician Progress Note, dated 6/27/2023, the note indicated Resident 2 presented with a sacro-coccyx ulcer and current treatment will be continued. The note indicated Clindamycin 450 mg, every 6 hours was ordered for suspected infection and the pressure ulcer had a foul odor.
During a review of Resident 2's Wound Care Physician Progress Note, dated 7/4/2023, the note indicated Resident 2's pressure ulcer progressed to a Stage IV pressure ulcer, measuring 1.3 cm in length by 0.6 cm in width and 0.4 cm in depth, with undermining at 2.0 cm at 6 to 2 o'clock with moderate purulent exudate which required excisional debridement. The note indicated an x-ray of Resident 2's sacrum was ordered to rule out osteomyelitis and intravenous Clindamycin 600 mg every six hours was started for an infected sacro-coccyx wound.
During observations on 10/6/2023 at 10:00 a.m. and at 12:05 p.m., Resident 2 was observed laying on her back and not on her side.
During a concurrent interview and record review on 10/6/2023 at 12:05 p.m., with the LVN 2, Resident 2's Task: Point of Care: turn and reposition at least every two hours and as needed record, dated from 6/5/2023 to 10/6/2023, was reviewed. Resident 2's record indicated there was no documented evidence to indicate if Resident 2 was turned every two hours or in what position he was turned. LVN 2 stated there was no documentation of Resident 2 being turned every 2 hours and what position the resident was in to relieve pressure to prevent injury. LVN 2 stated residents' skin was fragile and if the residents were not turned as care planned the residents could get a pressure injury. LVN 2 stated, Resident 2 had a facility acquired pressure ulcer that became infected.
During an interview on 10/6/2023 at 10:30 a.m. with Certified Nurse Assistant 1 (CNA 1), CNA 1 stated each time staff repositioned or turned residents it should have been documented in the ADL task record. CNA 1 stated all care provided to the resident needs to be documented so everyone in the facility will be aware of the type of care the resident has received.
During an interview on 10/6/2023 at 12:20 p.m., and a subsequent interview on 10/9/2023 at 12 p.m., the Director of Nursing (DON), stated she was unaware that Resident 2 was not being turned and repositioned as care planned. The DON stated staff were expected to document at least 12 times in a 24-hour period to indicate if a resident was turned and repositioned. The DON stated with all the problems identified, Resident 2 developed a facility acquired Stage IV pressure ulcer that was avoidable.
During a concurrent interview and record review on 10/9/2023 at 11:00 a.m., with LVN 2, Resident 2's Non-Pressure Skin Condition Reports from 5/15/2023 to 6/23/2023, were reviewed. Resident 2's report for 5/15/2023, 5/22/2023, 5/29/2023, 6/5/2023, 6/12/2023, and 6/19/2023 indicated the area to document the length, depth, and width of Resident 2's MASD was left blank. LVN 2 stated she did not know she had to measure Resident 2's MASD and the section was left blank because she did not measure Resident 2's wound. The report for 5/15/2023, 5/22/2023, 5/29/2023, 6/5/2023, 6/12/2023, and 6/19/2023 indicated granulation tissue was checked to indicate granulation tissue had formed in Resident 2's MASD (MASD is partial thickness [confined to the skin layers; damage does not penetrate below the top two layers of skin} with no granulation or slough). LVN 2 stated if granulation tissue was checked, it meant granulation issue was noted in Resident 2's MASD on the days it was documented. LVN 2 stated, she charted what she saw. LVN 2 stated Resident 2's MASD was moist, red, raw, with exudate. The report for 6/5/2023 indicated Resident 2's MASD had slough. LVN 2 stated, she did not remember seeing slough, she must have mistaken.
During a concurrent interview and record review on 10/9/2023 at 11:30 a.m. with the Assistant Director of Nursing (ADON), Resident 2's Weekly Summary SNF for 4/2023 was reviewed. Resident 2's weekly skin assessment for 4/1/2023 to 4/9/2023 and 4/18/2023 to 4/30/2023 was unavailable for review in Resident 2's clinical record and Resident 2's weekly skin assessment for 4/10/2023 and 4/17/2023 was left blank with no documentation of the status of Resident 2's skin. The ADON stated, if there was no weekly skin assessment in Resident 2's clinical record Resident 2's skin assessment was not completed. The ADON stated on 4/10/2023 and 4/17/20233, the skin assessment portion of the weekly skin assessment should have indicated the condition and description of Resident 2's skin. If there was no documentation of Resident 2's skin assessment, then it was not completed. The ADON stated the skin assessments should be completed weekly to track the resident's skin condition.
During a concurrent interview and record review on 10/9/2023 at 11:50 a.m., with the ADON, the description of the stages of pressure injuries on Resident 2's Weekly Pressure Injury Record and Resident 2's Non-Pressure Skin Condition Report, dated 5/15/2023 to 6/23/2023, were reviewed. The description indicated granulation tissue, slough, and eschar (dry dark scab) were not present in Stage II pressure sores/MASD; and granulation tissue, slough and eschar were often present and/or visible in Stage III pressure sores. The ADON stated according LVN 2's documented description, Resident 2's wound was a Stage III pressure injury. The ADON stated if Resident 2's sacro-coccyx MASD had granulation tissue present it progressed to a Stage III pressure ulcer and should have been reclassified as a Stage III pressure ulcer. The ADON stated there were six missed opportunities (5/15/2023, 5/22/2023, 5/29/2023, 6/5/2023, 6/12/2023, and 6/19/2023) where more aggressive interventions, such as a wound consult, a low air loss mattress (a mattress designed to distribute a patient's body weight over a broad surface area and help prevent skin breakdown), notification of Resident 2's physician, and an order for treatment of a Stage III wound not a MASD could have been ordered and/or implemented. The ADON stated the progression of Resident 2's MASD, which was acquired in the facility and progressed to a Stage IV pressure ulcer was avoidable.
During a review of the facility's P&P titled, Pressure Ulcer/Injury Management, revised 7/2019, the P&P indicated there will be an emphasis on resident's turning schedule by all supervisory staff and residents will be turn and repositioned every two hours and as needed and the P&P indicated the licensed nurses shall:
a.
Assess the pressure injury(s) and pressure sore(s) for location, size (measure length, width, and depth), sinus tracts (narrow opening or passageway of a wound underneath the skin), undermining, (region underneath the overlying loose skin around the pressure sore), tunneling (passageways) exudates (fluid leaks out of blood vessels into nearby tissues), necrotic (dead) tissue, and the presence of absence of granulation tissue and epithelialization (process of becoming covered with or converted to epithelium[covers all internal and external surfaces of the body]); and
b.
Determine the ulcer/injuries current stage of development.
c.
Assess skin weekly as part of their weekly summaries.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of two sampled residents (Resident 1), who had an ileostomy (when part of the small bowels is brought through the abdominal wall via a surgically created opening for the purpose of evacuating feces) in place, received medical and nursing services to care for Resident 1's ileostomy, by failing to:
1. Ensure Resident 1's physician was notified about Resident 1's unresolved moisture associated skin damage ([MASD] inflammation or erosion of the skin caused by prolonged exposure to various sources like stool or urine) surrounding Resident 1's ileostomy.
b. Document and assess Resident 1's MASD surrounding his ileostomy during discharge.
c. Provide treatment to Resident 1's ileostomy as ordered by physician.
These deficient practices resulted in Resident 1's physician being unaware of Resident 1's change of condition (COC), the status of Resident 1's skin surrounding his ileostomy and omission of treatment to Resident 1's ileostomy. These deficient practices place Resident 1 at risk for delay in healing and for Resident 1's MASD to become infected and increase in size.
Findings:
A review of Resident 1's admission Record (Face Sheet) indicated Resident 1 was initially admitted to the facility on [DATE] and was readmitted on [DATE]. The Face Sheet indicated Resident 1 had diagnoses that included end stage renal disease ([ESRD] gradual loss of kidney function), an acute ischemia (inadequate blood supply to an organ or part of the body) of his intestine and an ileostomy.
A review of Resident 1's Minimum Data Set ([MDS] a standardized assessment and care screening tool) dated 6/6/2023, indicated Resident 1 was able to make independent decisions that were reasonable and consistent and required a one-person physical assist with toilet use, and personal hygiene. The MDS indicated Resident 1 had an ostomy (a procedure that allows a stool to pass through a surgically created opening in the abdomen) and MASD on an unspecified site that was present during assessment.
A review of Resident 1's Non-Pressure Skin Condition (NPSC) dated 5/30/2023, indicated the skin around Resident 1's stoma was moist and denuded (an injury that occurs when the protective layer of skin is gone leaving the underlying tissue exposed due to prolonged exposure to moist). The NPSC indicated Resident 1's ileostomy bag needed constant emptying and to continue the application of a skin barrier in Resident 1's peri-stoma (area around the stoma).
A review of Resident 1's NPSC, indicated the MASD on Resident 1's peri-stoma was first observed on 9/13/2022. The NPSC indicated the last documentation of Resident 1's peri-stoma MASD was dated 6/6/2023, however, there was no documentation of Resident 1's peri-stoma MASD on the day Resident 1 was discharged from the facility (6/12/2023).
A review of Resident 1's Discharge Summary Comprehensive Assessment (DSCA) dated 6/12/2023, indicated Resident 1 had MASD to his peri-stoma. The DSCA indicated no description of how the peri-stoma looked before Resident 1 was discharged from the facility (6/12/2023).
A review of Resident 1's Physician's Order (PO) dated 6/8/2023, indicated to discharge Resident 1 to an assisted living facility (housing for elderly or disabled people that provides nursing care, housekeeping and prepared meals as needed).
A review of Resident 1's Emergency Department (ED) Physician's Note (EDPN) from the GACH indicated Resident 1 was admitted to the hospital on [DATE] due to an infected ileostomy site and cellulitis (a bacterial skin infection) of the abdominal wall.
A review of Resident 1's PO dated 9/13/2022, indicated to cleanse Resident 1's peri-stoma MASD with normal saline, pat dry and apply Calazinc (a medicated ointment used as a skin barrier to protect skin from irritation) every shift.
A review of Resident 1's Treatment Administration Record (TAR) dated 5/2023 indicated there was no documentation to indicate Resident 1's ileostomy site was monitored for signs of infection, redness, swelling, skin irritations, or discharge on the evening shift on 5/5/2023, 5/11/2023, 5/12/2023, and 5/18/2023.
A review of Resident 1's TAR dated 6/2023, indicated there was no documentation to indicate Resident 1's ileostomy site was monitored for signs of infection, redness, swelling, skin irritations, or discharge on the night shift on 6/1/2023, 6/2/2023, and 6/3/2023.
A review of Resident 1's TAR dated 5/2023, indicated Resident 1 did not receive treatment to his peri-stoma MASD during the evening shift on 5/5/2023, 5/11/2023, 5/12/2023, and 5/18/2023.
A review of Resident 1's TAR dated 6/2023, indicated Resident did not receive treatment to his peri-stoma MASD on the night shift on 6/1/2023, 6/2/2023, and 6/3/2023.
During an interview on 7/11/2023, at 3:54 p.m., Licensed Vocational Nurse 3 (LVN 3) stated she assessed Resident 1's peri-stoma MASD before he was discharged from the facility (6/12/2023) but she did not document her assessment. LVN 3 stated, the skin around Resident 1's stoma was dry, shiny, and pink. LVN 3 stated, Resident 1's peri-stoma MASD never completely healed but it did improve. LVN 3 stated, she did not notify Resident 1's physician that Resident 1's MASD was not resolving because the MASD would come and go. LVN 3 stated, there were times when the skin surrounding Resident 1's stoma would be red, most likely due to leakage of stool from his diaper during the night. LVN 3 stated if a treatment was not effective, the doctor should be notified so a new treatment could be obtained.
During an interview on 7/12/2023, at 4:29 p.m., the Director of Nursing (DON) stated, Resident 1's physician should have been notified when the treatment to Resident 1's MASD peristomal was not effective, so the treatment or intervention could be changed.
A review of facility's undated Job Description (JD) of Treatment Nurse, indicated the treatment nurse will initiate communication to physician and other disciplines regarding negative response to treatment administration or changes in resident's conditions per policy or nursing practices. It also indicated the treatment nurse will perform resident assessments, evaluate care plans, and maintain all documentation as required by federal, and state regulations and facility policy.
A review of facility's P/P titled Colostomy/ Ileostomy Care revised 10/2010, indicated the facility will review resident's care plans in order to assess any special needs of the resident. The P/P indicated to evaluate and note resident's skin for any breaks in the skin, excoriation, and signs of infection like heat swelling, pain, redness, and purulent discharge (thick and milky discharge from a wound).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop a comprehensive care plan (CP) for one of two sampled residents (Resident 1) who was assessed with moisture associated skin damage ([MASD] inflammation or erosion of the skin caused by prolonged exposure to various sources like stool or urine) of the peri-stoma (surrounding an artificial opening made into a hollow organ, and/or on the surface of the body) of his ileostomy (part of the bowel that is brought through the abdominal wall via surgical l opening).
This deficient practice resulted in no plan for treatment to Resident 1's MASD and had the potential for his skin to remain unhealed and his skin damage to increase.
Findings:
A review of Resident 1's admission Record (Face Sheet) indicated Resident 1 was initially admitted to the facility on [DATE] and was readmitted on [DATE]. The Face Sheet indicated Resident 1 had diagnoses that included end stage renal disease ([ESRD] gradual loss of kidney function) and an ileostomy.
A review of Resident 1's Minimum Data Set ([MDS] a standardized assessment and care screening tool) dated 6/6/2023, indicated Resident 1 was able to make independent decisions that were reasonable and consistent and required a one-person physical assist with toilet use, and personal hygiene. The MDS indicated Resident 1 had an ostomy (a procedure that allows a stool to pass through a surgically created opening in the abdomen) and MASD on an unspecified site that was present during assessment.
During a concurrent interview and record review on 7/12/2023, at 3:54 p.m., with LVN 3, Resident 1's CPs were reviewed. LVN 3 stated she could not find a CP related to Resident 1's MASD of his ileostomy. LVN 3 stated Resident 1's CP was not created. LVN 3 stated, a CP related to Resident 1's MASD should have been created.
During an interview on 7/12/2023, at 4:29 p.m., the Director of Nursing (DON) stated CPs are important, they ensure care is provided to Resident 1's MASD. The DON stated, CPs are created as needed depending and depending on the resident's condition.
A review of the facility's policy and procedure (P/P) titled, Comprehensive Care Planning, revised 03/2019, indicated the facility will develop a comprehensive resident-centered care plan for each resident that includes measurable objectives and timeframes to meet each resident's medical, nursing, and psychosocial needs that are identified in the comprehensive assessment. The plan of care must describe the services that are to be furnished to attain or maintain the resident's highest practicable level of well-being.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to act upon the consultant pharmacist's recommendation in the Medication Regime Review (MRR), to clarify the indication for use of Haldol and Zyprexa (psychoactive medication-any medication capable of affecting the mind, emotions, and behavior) with the physician for one of four sampled residents (Resident 28) for unnecessary medications review.
This deficient practice had the potential to cause Resident 28 to receive an unnecessary medication and can lead to adverse side effects.
Findings:
During a review of Resident 28's admission Record, the admission record indicated Resident 28 was admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses that included end stage renal disease (permanent kidney function loss), diabetes (chronic condition that affects how the body processes sugar), hypertension (condition in which the force of the blood against the artery walls is too high), and dysphagia (difficulty swallowing food or liquids).
During a review of Resident 28's History and Physical (H&P), dated 6/14/21, the H&P indicated Resident 28 was a [AGE] year-old female admitted to the facility from St. Mary's Medical Center. The H&P did not indicate the resident's cognitive status or decision-making capacity.
During a review of Resident 28's Minimum Data Set (comprehensive screening tool [MDS]), dated 9/19/21, the MDS indicated Resident 28 had a Brief Interview for Mental Status (BIMS - a tool used to calculate/assess cognition [process of thinking]; scores between 0 and 7 indicate severe cognitive impairment, scores between 8 and 12 indicate moderate impairment, and scores above 13 show little to no impairment) Score of 14. A BIMS score of 14 indicates the resident has intact cognition.
During a review of the Medication Regimen Review (MRR) dated 11/22/21, indicated the consultant pharmacist recommended review hospital records regarding the use of Haldol and Zyprexa (psychoactive medication-any medication capable of affecting the mind, emotions, and behavior). The diagnosis is psychosis disorder NOS, not schizophrenia as stated in the facility order and Psychoactive and Sedative Hypnotic Assessment tool.
A review of the physician orders and MAR did not indicate the consultant pharmacist recommendation was acted upon.
During an interview on 12/16/21 at 2:13 p.m., with Director of Nursing (DON), DON stated the process for starting psychotropic medication (medication capable of affecting the mind, emotions, and behavior) is to first obtain a consent from the doctor, resident, or resident representative, and all residents admitted on psychotropic medication is evaluated by a psychiatrist. DON stated all licensed nurses can act upon/complete the Medication Regimen Review (MRR) after receiving the recommendation from the pharmacy. The Assistant Director of Nursing is responsible for ensuring the MRR recommendations are carried out.
During a review of the facilities policy and procedure (P&P) titled Consultant Pharmacist Report, Medication Regimen Review (Monthly Report) dated June 2021, indicated recommendations are acted upon and documented by the facility staff and/or prescriber.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure nursing staff performed proper hand hygiene and disinfection of wound care supplies for one of four (4) sampled residents (Resident 240) during wound care provision.
These deficient practices had the potential to transmit infectious microorganisms and increase the risk of infection for Resident 240.
Findings:
During a review of Resident 240's Face Sheet, not dated, the document indicated the resident was admitted to the facility on [DATE] with diagnoses including cardiac arrest (abrupt loss of heart function, breathing, and consciousness), dependence on ventilator (a machine that delivers oxygen to the lungs to assist with breathing), tracheostomy (a surgically created opening through the neck into the trachea [windpipe] to help with breathing), end stage renal disease (ESRD - permanent kidney function loss), hypertension (high blood pressure), anemia (low number of red blood cells), dysphagia (difficulty swallowing food or liquids), atrophy (muscle wasting), gastrostomy tube (g-tube - a surgically placed tube inserted through the abdomen that delivers nutrition and/or medication directly to the stomach), and diabetes mellitus (chronic condition that affects how the body processes sugar).
During a review of Resident 240's Minimum Data Set (MDS - a comprehensive assessment and care-planning tool), dated October 23, 2021, the document indicated the resident is totally dependent and requires two or more persons physical assistance for bed mobility (how the resident moves to and from lying position, turns side to side, and positions body while in bed or alternate sleep furniture), and is totally dependent for transfer (how the resident moves between surfaces including to or from: bed, chair, wheelchair, standing position). Resident 240's MDS further indicated the resident has functional limitation in range of motion in which she has impairment on both sides of her upper extremities.
During a review of Resident 240's Physician Order Report, dated December 1 to December 31, 2021, the document indicated the resident's physician placed an order to cleanse the g-tube site with normal saline (a fluid), pat dry, and cover with a dry dressing every day once a day between 7 a.m. and 7 p.m., order dated October 16, 2021. This Physician Order Report also indicated the resident's physician placed an order to cleanse the resident's sacrococcyx (fusion of the sacrum and coccyx - last bones of the spinal column) stage four (4) pressure injury (full-thickness skin and tissue loss, reaching into muscle and bone, causing extensive damage; the most severe form of pressure injury) with normal saline, pat the area dry, and apply calcium alginate (a type of wound dressing) and zinc oxide (a mineral used to treat and prevent skin breakdown) daily for thirty (30) days, order dated November 15, 2021.
During a concurrent observation and interview, on December 16, 2021, at 9:09 a.m., during a body check with Certified Nurse Assistant (CNA) 1, CNA1 stated the resident is not alert and requires total care (requiring assistance in meeting all their needs). CNA1 stated Resident 240 has a pressure ulcer (localized injury to the skin and underlying tissue resulting from prolonged pressure) on her coccyx (a small triangular bone at the base of the spinal column; commonly referred to as the tailbone).
During a concurrent observation, interview, and record review, on December 16, 2021, at 9:23 a.m., during provision of wound care with Licensed Vocational Nurse (LVN) 1, LVN1 reviewed the resident's Medication Administration Record (MAR), dated December 2021, and stated the resident received Tylenol (a pain medication) 500 milligrams (a unit of measurement) one tablet via gastrostomy tube (g-tube - a surgically placed tube inserted through the abdomen that delivers nutrition and/or medication directly to the stomach) at 8 a.m., LVN1 was observed preparing the wound care supplies to perform a dressing change of Resident 240's pressure ulcer. LVN1 was observed laying a paper sheet on the resident's table to establish a clean field (an area created to place supplies or products in an effort to reduce the number of microbes to as few as possible) on which to place her wound care supplies. LVN 1 was then observed cutting calcium alginate with scissors retrieved from the treatment cart without being disinfected first. LVN1 then placed the uncleaned scissors onto the clean field along with gauze, the cut calcium alginate, and zinc oxide. LVN1 was observed cleaning Resident 240's g-tube site, then placing a new clean dressing to the area without washing her hands in between cleaning the site, touching the clean dressing, and putting on new gloves. LVN1 was then observed cleaning Resident 240's pressure ulcer on her coccyx, then placing the zinc oxide, calcium alginate, and a clean dry dressing to the area without performing hand hygiene again between cleaning the area, touching the medications and clean dressing, and changing her gloves. After the wound care was completed, LVN1 was observed documenting completion of the wound care for the day in Resident 240's TAR, dated December 2021. When asked when scissors are supposed to be cleaned, LVN1 stated they should be sanitized before and after treatments to prevent germs from spreading from one resident to another. LVN1 stated she forgot to disinfect the scissors during the wound care preparation for Resident 240. When asked the correct process for cleaning and dressing wounds, LVN1 stated the wound first needs to be visually inspected - remove the dressing and wash hands. LVN1 then stated hands should be washed after cleaning wounds, but further stated she needed to check if that was correct.
During an interview, on December 17, 2021, at 12:04 p.m., with the Director of Staff Development (DSD), the DSD stated nurses are supposed to wash their hangs prior to a procedure, setting up supplies, putting on gloves, and providing wound care treatment. The DSD stated during wound care, the nurse needs to change their gloves and wash their hands before putting on a new dressing because they would have just removed the dirty dressing. The DSD stated equipment needs to be cleaned while setting it up and after treatment is completed. The DSD further stated the general practice is to clean equipment before and after each use to prevent cross contamination. The DSD stated when cutting gauze, scissors still need to be cleaned; a nurse cannot use a dressing that was cut with uncleaned scissors.
A review of the facility's policy and procedure (P&P), entitled Handwashing, dated October 2017, indicated, It is the policy of the facility that all staff members wash their hands before and after direct resident care and after contact with potentially contaminated substances to prevent, to the extent possible, the spread of infection. This P&P also indicated handwashing will be performed by staff before and after touching any kinds of wounds; after contact with mucous membranes, blood and body fluids, secretions and/or excretions; and before and after giving personal care to residents. This P&P further indicated If gloves are worn for a procedure, hands are to be washed before putting gloves on and after removal and disposal of gloves.
A review of the facility's P&P, entitled Wound Care, dated April 2017, indicated when providing wound care, the nurse must put on gloves prior to removing a dressing, then after removing the dressing, pull the glove over the dressing and discard into appropriate receptacle; then wash and dry hands to put on new gloves. This P&P also indicated the nurse must be certain all items on the clean field are clean and that reusable supplies, including scissors, are cleaned before being returned to the treatment cart.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** B. During a review of Resident 237's Face Sheet, not dated, the document indicated the resident was admitted to the facility on [DATE] with diagnoses including cardiac arrest (abrupt loss of heart function, breathing, and consciousness), end stage renal disease (ESRD - permanent kidney function loss), dependence on renal dialysis (treatment to filter wastes, salts, and fluid from blood for those with kidney failure), dependence on ventilator (a machine that delivers oxygen to the lungs to assist with breathing), tracheostomy (a surgically created opening through the neck into the trachea [windpipe] to help with breathing), atrophy (muscle wasting), dysphagia (difficulty swallowing food or liquids), and anemia (low number of red blood cells).
During a review of Resident 237's Comprehensive Resident Assessment, dated December 9, 2021, the document indicated the resident had generalized edema (swelling caused by excess fluid trapped in the body's tissues); there was no indication the resident had localized swelling to the left side of her face.
During a review of Resident 237's physician telephone order, dated December 16, 2021, indicated the resident's physician placed an order for the resident to be transferred to the acute care hospital via 9-1-1 for evaluation of respiratory distress.
During a review of Resident 237's SBAR (abbreviation for Situation, Background, Assessment, Recommendation - a communication tool used among healthcare professionals) Communication Form, dated December 16, 2021, the document indicated the resident had a COC with observed/evaluated swollen left side of the face with facial grimacing and blood inside the mouth.
During a review of Resident 237's SBAR Communication Form, dated December 16, 2021, the document indicated the resident had a COC with observed/evaluated respiratory distress for respiratory rate of thirty-four (34) [regular respiratory rate for adults is twelve (12) to twenty (20) breaths per minute]. This document indicated there was no recorded oxygen saturation (indicates the amount of oxygen traveling throughout the body with red blood cells; normal range is ninety-five [95] to one hundred [100] percent [%]) for the resident.
During a review of Resident 237's Subacute Daily Nursing Assessment forms, dated December 10 to December 15, 2021 for both 7 a.m. to 7 p.m., and 7 p.m. to 7 a.m., shifts indicated there was no nursing notes regarding the resident had left facial swelling, and no COC.
During a review of Resident 237's Continuous Ventilator Flow Sheet, dated December 16, 2021, the document indicated the resident had an episode of dyspnea (difficulty breathing) during a ventilator weaning (accustom to manage without something on which someone has become dependent of excessively fond) trial at 6 p.m. This document also indicated the resident had a COC in which her oxygen saturation dropped to sixty-nine (69) % while on the ventilator at 8:03 p.m. This document further indicated emergency medical services (EMS - ambulance) was activated via 9-1-1 due to the resident's unstable condition.
During a concurrent observation and interview, on December 14, 2021, at 12:28 p.m., in room fourteen (14), of Resident 237, with the resident's Family Member (FM) 1, FM1 and three other family members were observed conducting a visit with the resident outside of the room with the family able to view the resident from outside the glass sliding door. FM1 stated she and her family were concerned about swelling they observed on the left side of the resident's face and the discoloration they noticed on her right lower lip, which the family did not observe on December 11, 2021, the last time they had visited Resident 237. FM1 stated the family was not notified of Resident 237's left facial swelling or discoloration on her right lower lip.
During an interview, on December 14, 2021, at 3:41 p.m., with both Resident 237's FM1 and FM2, FM2 stated Resident 237 was admitted to the facility on [DATE]. FM2 stated the family last visited Resident 237 on December 11, 2021 and today the resident looks swollen, especially the left side of her face, and stated the resident appeared to have a bruise on her right lower lip. FM2 stated they notified staff (but could not recall whom) of their concerns, to which staff informed the family they would look into it, then called the family via video chat to show them the Resident 237's face and stated there was nothing wrong with the resident. FM1 stated staff had not notified the family about Resident 237's facial swelling or lip discoloration. FM1 stated Resident 237's parents were concerned for the resident because her face was not swollen at their last visit on December 11, 2021.
During a concurrent observation and interview, on December 16, 2021, at 8:35 a.m., in room [ROOM NUMBER], of Resident 237, with Certified Nurse Assistant (CNA) 2, the resident was observed lying in bed. CNA2 stated the resident was a new admission and has been at the facility for approximately two weeks. CNA2 stated Resident 237 is young, not alert, and non-verbal. CNA2 stated he was not sure why the resident was at the facility, and was not sure what type of therapy the resident is receiving. CNA2 stated when a resident is newly admitted , a licensed nurse performs a full body assessment to check for skin issues and takes measurements if present. CNA2 stated the charge nurses tell CNAs about the residents in report, and the treatment nurse or charge nurse communicates if there are changes in residents' treatment plans with the CNAs. When asked about Resident 237's facial swelling, CNA2 confirmed the resident has localized facial swelling on the left side. CNA2 stated Resident 237 had facial swelling because she receives dialysis. CNA2 then stated maybe Resident 237 had a stroke and that she was admitted with the facial swelling. CNA2 stated Resident 237 usually turns her head to the left so nursing staff try to reposition the resident's head by placing a towel underneath her pillow to keep her head straight to avoid excess saliva because it can cause a skin rash. CNA2 repositioned Resident 237's head in a straight position then let go, to which the resident's head turned to the left. CNA2 stated there were no unusual occurrences or COC reported to him regarding Resident 237; CNA2 stated there was nothing different with the resident to his knowledge.
During a concurrent interview and record review, on December 16, 2021, at 11:28 a.m., with Licensed Vocational Nurse (LVN) 2, LVN2 stated when a resident is observed to have a COC, the licensed nurses assess the issue, call the physician, notify the family, carry out the physician's orders, care plan the COC, and monitor the resident for three days. LVN2 stated the licensed nurses communicate with all nursing staff if a resident had a COC during huddle every beginning of the shift to ensure nurses are keeping an eye on the issue and be on top of the care, especially if there are skin issues. LVN2 stated if CNAs are not made aware of COCs, they would not know how to prevent further damage. LVN2 stated if a COC occurs during the day, another small huddle is conducted to inform all nursing staff. LVN2 stated nurses follow COC procedures to prevent further problems for the resident and for other residents. LVN2 stated she was not aware of any COC for Resident 237 who was newly admitted a week or two ago. LVN2 reviewed Resident 237's medical chart and stated the resident was admitted to the facility on [DATE]. LVN2 again stated she did not hear about any COC for Resident 237 in the morning huddle.
During a concurrent interview and record review, on December 16, 2021, at 11:59 a.m., of Resident 237's medical chart, with LVN2, LVN2 reviewed the resident's care plan and stated there were no care plans addressing facial swelling. LVN2 reviewed Resident 237's Comprehensive Resident Assessment, dated December 9, 2021, and stated the document indicated the resident had generalized swelling. LVN2 reviewed Resident 237's medical chart and stated there was no Situation, Background, Assessment, Recommendation (SBAR) form completed for facial swelling.
During a concurrent observation and interview, on December 17, 2021, at 8:19 a.m., in room [ROOM NUMBER], with LVN1, it was observed Resident 237 was not in bed, nor in the room. LVN1 stated Resident 237 was sent to the hospital yesterday evening.
During a concurrent interview and record review, on December 17, 2021, at 8:20 a.m., of Resident 237's medical chart, with Registered Nurse (RN) 1, RN1 reviewed the resident's Transfer Sheet, dated December 16, 2021, and stated Resident 237 was sent to a local acute care hospital yesterday at 8:40 p.m. RN1 reviewed Resident 237's SBAR, dated December 16, 2021, and stated the document indicated the resident was transferred to a local acute care hospital for respiratory distress. RN1 reviewed another SBAR for Resident 237, dated December 16, 2021, and stated the document indicated the resident was transferred to a local acute care hospital for swelling on the left side of the resident's face. RN1 stated her first day working with Resident 237 was on December 11, 2021, and further stated the resident did not have facial swelling. RN2 then stated Resident 237 did not have facial swelling that she observed on December 12, 2021, nor did she have facial swelling on December 15, 2021. RN1 stated she did not receive any reports that Resident 237 had facial swelling. Upon showing RN1 three pictures of Resident 237's face, dated December 14, 15, and 16, 2021, RN1 stated it appeared that the resident had facial swelling on the left side. RN2 again stated she did not receive report about the swelling and that she did not notice it. RN2 stated she performs rounds to check on the residents every two hours in which she checks the residents' breathing, how they look - to see if they are grimacing or if they appear to be in distress.
During an interview, on December 17, 2021, at 12:04, with the Director of Staff Development (DSD), the DSD stated when a resident has a COC, nursing staff need to report it to the doctor and family immediately, and initiate a care plan for the COC as soon as possible so the care team knows how to care for the resident.
A review of the facility's policy and procedure (P&P), entitled Resident Rights, dated September 2017, indicated residents have the right to reside and receive services with reasonable accommodation of resident needs and preferences unless to do so would endanger the health or safety of the resident or other residents.
A review of the facility's P&P, entitled Comprehensive Care Planning, dated March 2019, indicated the following:
It is the policy of this facility that a comprehensive resident-centered care plan be developed for each resident that includes measurable objectives and timeframes to meet each resident's medical, nursing and mental and psychosocial needs that are identified in the comprehensive assessment . The care plan must be reviewed and revised periodically, at least quarterly, and on an ongoing basis to reflect changes in the resident and the services provided or arranged must be consistent with each resident's written plan.
A review of the facility's P&P, entitled Change of Condition, dated march 2021, indicated the following:
It is the policy of this facility that any changes in a resident's condition be thoroughly assessed and evaluated with physician notification for early clinical management to avoid unnecessary readmissions to acute hospitals .
If there is a significant change in a resident's physical or mental condition, a thorough assessment of the resident's condition must be done by a licensed nurse.
A review of the facility's job description, entitled Certified Nursing Assistant Job Description, not dated, indicated it is the CNA's duty and responsibility to report significant changes in the resident's condition to an LVN or RN as soon as practical.
A review of the facility's job description, entitled Charge Nurse Job Description, not dated, indicated it is the RN's duty and responsibility to perform resident assessments and develop, implement and evaluate care plans as necessary per state, federal, and facility policies; notify the physician timely as needed; maintain all documentation as required by federal and state regulations and facility policy; and evaluate quality and quantity of resident care service by nursing assistants.
Based on observation, interview and record review, the facility failed to identify, provide a comprehensive assessment and treatment for a change of condition (COC) for one of two (2) sampled residents (Resident 55 and 237) with hypoxia (not enough oxygen in the tissues to sustain bodily functions) and altered mental status(confusion/disorientation).
These deficient practices resulted in Resident 55 and 237 receiving delayed provision of care and treatment, and transfer to a local acute care hospital.
Findings:
A. During an observation on 12/14/21 at 10:25 a.m., R55 was observed wearing a non- rebreather mask (a special medical device that helps provide oxygen in emergencies) on with the oxygen tank flow meter at 6 liters. Oxygen saturation monitor (machine used to measure oxygen in the blood) was on Resident 55 (R55) finger measuring at 90% (normal levels are greater than 92%) and the monitor was beeping continuously. R55 was observed with his eyes closed, hard to arouse (stay awake) and head of the bed elevated.
During a concurrent observation and interview on 12/14/21 at 10:30 a.m. with LVN 4, LVN 4 confirmed R55 had on a non-rebreather mask, that the bag of the mask was deflated and R55 oxygen saturation was at 90%. LVN 4 stated, The doctor didn't order the non-rebreather mask, when we called 911, the paramedics said to put it on, but I am going to switch him back to nasal cannula (device used to deliver supplemental oxygen). LVN 4 confirmed that the oxygen tank that the non-rebreather mask was attached to, to deliver oxygen to R55 was empty and out of oxygen but didn't know how long the oxygen tank was empty. LVN 4 then brought another oxygen tank in R55 room and placed R55 back on nasal cannula at 5 liters. R55 oxygen saturation was observed at 95%. LVN 4 stated, she was unaware R55 was left by himself and his oxygen saturation was at 90%. LVN stated, my supervisor said someone would stay with him and I didn't know he was left alone, otherwise I would have known the tank was empty.
During a review of Resident 55's Face Sheet, not dated, it indicated that Resident 55 (R55) was admitted to the facility on [DATE] with diagnoses including: end stage renal disease (kidney failure), Acute respiratory failure (a condition in which your blood doesn't have enough oxygen or has too much carbon dioxide) with hypercapnia (excessive carbon dioxide in the blood), atrial fibrillation, pneumonia, cardiac arrest (heart suddenly stops beating) and pulmonary embolism (blood clot in the lungs).
During a review of the facility record titled, Respiratory orders December 14, 2021, it indicated that R55 has an order for oxygen at 4 liters continuous by nasal cannula to keep oxygen saturation (amount of oxygen in your body) greater than 90 %.
During a review of the physician order, dated December 14, 2021 at 8:43 a.m., it indicated to transfer R55 via 911 ambulance transport to the General Acute Care Hospital (GACH) due to oxygen desaturation (percentage of oxygen in your blood is lower than it should be) and altered level of consciousness (mental confusion) for further evaluation.
During a review of the SBAR (abbreviation for Situation, Background, Assessment, Recommendation-a communication tool used among healthcare professionals) communication form dated December 14, 2021, it indicated that R55 had a change of condition with signs observed with oxygen desaturation of 87-89 percent. It also indicated that R55 was on oxygen at 2 liters nasal cannula (current physician order for 4 liters nasal cannula).
During a review of the facility care plan short term problems, dated December 14, 2021, it indicated that R55 had problems of, oxygen desaturation and altered level of consciousness, documented by licensed nursing staff.
During a review of the facility nursing notes dated December 14, 2021 at 2:45 p.m., it was documented that R55 eyes were closed and hard to arouse. It was documented that R55 was on O2 at 5 liters nasal cannula. No oxygen saturation result was documented at this time.
During a review of the facility transfer record dated December 14, 2021, it indicated that R55 was transferred to the GACH (General Acute Care Hospital) via 911 ambulance, with a diagnosis of altered level of consciousness and oxygen desaturation.
During a review of the GACH records dated December 14, 2021, it indicated R55 was admitted to the emergency room with a diagnosis of altered level of consciousness, acute mild distress, oxygen saturation of 87-89 percent while receiving oxygen at 4 liters via nasal cannula, hypoxic encephalopathy (occurs when the brain doesn't get enough oxygen) Acute hypoxic respiratory failure (a condition in which your blood doesn't have enough oxygen or has too much carbon dioxide). It indicated R55 was given the medication Narcan on admission (medication used to the initial reversal of respiratory depression to produce adequate ventilation and alertness). It also indicated R55 was somnolent (sleepy or drowsy) on arrival to the emergency room.
During a review of the GACH document arterial blood gas (test to measure oxygen and carbon dioxide levels in the blood) dated December 14, 2021, it indicated that R55 had a carbon dioxide level of 52.7 (normal levels 35.0-45.0) on admission to the emergency room.
During a concurrent observation and interview on 12/14/21 at 10:51 a.m. with Registered Nurse 2 (RN2), RN 2 stated that R55 is currently on 5 liters of humidified oxygen but the physician order is for 4 Liters.
During an interview on 12/16/21 at 12:35 p.m. with LVN 4, LVN 4 stated that I noticed after breakfast, he wasn't fully alert. LVN 4 stated R55 oxygen saturation was checked, and he had a nasal cannula on 4 liters, that was the order. LVN 4 stated, the facility called 911 and put R55 on non-rebreather mask at 12 liters then R55 oxygen saturation went up to 98%. LVN 4 then stated that she and the RN 2 lowered the liters of oxygen to 6 liters, with the non-rebreather mask on. LVN 4 stated, our protocol when we call 911, is to put the resident on a non-rebreather mask. LVN 4 stated that a non-rebreather mask at 6 liters is effective. LVN 4 stated, I am the charge nurse, I assessed him and it's my responsibility.
During an interview on 12/17/21 at 11:27 a.m. with the Assistant Director of Nurses (ADON), the ADON stated that as a nursing measure in an emergency, the facility staff can put a resident on a non-rebreather mask without a physician order and after that, they need to obtain an order. The ADON stated a non-rebreather mask should be on at least 10-15 liters of oxygen and it should not be at 6 liters of oxygen. The ADON stated that if the non-rebreather mask is on at 6 liters of oxygen, the resident will desaturate (lose more oxygen in the blood).
During an interview on 12/17/21 at 11:34 a.m. with the Clinical Director (CD), it was stated, in an emergency, the facility staff will put on a non-rebreather mask on first at 10-15 liters of oxygen. The CD stated that you cannot have a resident on a non-rebreather mask at six liters because they can become hypoxic.
During an interview on 12/17/21 at 11:48 a.m. with RN 2, it was stated that during morning rounds, it was observed that R55 was fatigued. R55 oxygen saturation was checked, and it was between 87-89%. RN 2 stated, R55 was put on a non-rebreather mask at 12 liters and his oxygen saturation went up to 96-98%. RN 2 stated, she then reduced the oxygen flow rate to 6 liters per minute. RN 2 stated she is not sure if a non-rebreather mask is safe at 6 liters per minute. RN 2 stated if R55 could have hypoxia (deficiency in the amount of oxygen reaching the tissues) or altered mental status (confusion) if his oxygen levels are low for a long period of time.
During a review of the facility policy titled Oxygen Administration, dated 3/2017, it indicated that it is the policy of the facility to provide guidelines for the administration of oxygen. It indicated that the facility should verify that there is a physician's order for oxygen administration and the non-rebreather mask requires that the resident can breathe unassisted but allows for the delivery of higher concentrations of oxygen.
During a review of the facility policy titled Change of Condition, dated 3/21, it indicated that if there is a significant change in a resident's physical or mental condition, a through assessment of the resident's condition must be done by a licensed nurse. The licensed nurse is to thoroughly assess the change in the resident's condition and notify the resident's attending physician.
During a review of an article in Nursing Times dated October 2007, it indicated that it is important to ensure that a sufficient oxygen flow rate is used with the non-rebreather mask so the reservoir bag does not collapse (deflate) and a flow rate of 12-15 liters per minute is recommended. It also indicated that the non-rebreather oxygen mask enables the delivery of high concentrations of oxygen and is recommended for use I patients who are critically ill.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure nutritional interventions were evaluated to prevent unplanned weight loss for 1 of 1 resident (Resident 42) by failing to:
1.
Ensure facility developed a comprehensive care plan for Resident 42 to include past medical history/surgery and identify the resident's food preference.
2.
Revise and develop an effective care plan after Resident 42 had significant weight loss and prevent further weight loss.
3.
Provide a therapeutic diet, that considers the resident's clinical condition, and preferences, when there is a nutritional indication.
These deficient practices resulted in Resident 42 (R42) to experience severe unplanned weight loss of 5.39% in 3 months and 12% in 90 days (previous admit weight was 186 pounds).
Findings:
During a concurrent observation and interview on 12/14/21 at 09:48 a.m. with R42, R42 stated, the food is the one down button. R42 stated, the facility should look at their menu because I have lost a lot of weight because, I don't really eat the food. R42 stated, his current weight is 158 pounds and he normally weigh in the 200's. Resident 42 further stated he did not want to lose any more weight and has spoken to staff on several occasions.
During a review of Resident 42's Monthly Weight Form, the Monthly Weight Form indicated the following:
September 2021: 186 pounds.
October 2021: 167 pounds.
November 2021: 168 pounds.
December 3, 2021: 164 pounds.
During a review of Resident 42 Face sheet, undated, the face sheet indicated Resident 42 was re-admitted to the facility on [DATE] with diagnoses of muscle wasting (loss of muscle mass due to the muscles wasting or shrinking) , protein-calorie malnutrition (lack of proper nutrition), metabolic encephalopathy (chemical imbalance in the brain), adult failure to thrive (poor nutrition, weight loss, inactivity, depression and decreasing functional ability) and sepsis (infection in the blood).
During a review of Resident 42 Minimum Data Set (MDS - a comprehensive assessment and care-planning tool), Section C dated 10/16/21, indicated that R42 is alert and oriented.
During a review of the Physician orders dated October 9, 2021, the orders indicated that the diet order was for a regular, low fat diet.
During a review of weekly weight record dated 10/9/21-12/8/21, the weight record indicated that the re-admit weight for R42 was 167 pounds on 10/9/21. On 12/8/21, R42 weight was 158 pounds. R42 original admit weight in August 2021 was 186 pounds. R42 Ideal body weight (IBW) is between 176-216 pounds based on his height of 74 inches.
During a review of the facility care plan titled Nutritional Risk, dated 10/13/21, it indicated that R42 was at nutritional risk for weight loss, malnutrition and dehydration (loss of electrolytes in the blood). The care plan also indicated that R42 loss 13-28 pounds (7%-14% weight loss) in 4 months.
During a review of the lab pre-albumin (lab test to see if you are getting enough nutrients) test result dated 10/27/21, the result was 10.5 (low), normal levels are 17-34.
During a review of the lab report for R42, dated 11/2/21, it indicated that R42, hemoglobin was 7.4 (normal value 13.5-16.9) and hematocrit was 22.4 (normal value 39.5-50.0).
During a review of the facility Weight Variance progress notes, dated 11/4/21, the progress notes indicated R42 had an 18-pound weight loss in 90 days.
During a review of the meal percentage record, starting date 12/1/21-12/6/21, the record indicated the following with multiple missed entries:
12/1/21 Breakfast- 26-50%
12/1/21 Lunch- 26-50%
12/2/21 Dinner- 26-50%
12/3/21 Breakfast- 51-75%
12/4/21 Breakfast- 26-50%
12/5/21 Dinner- 51-75%
12/6/21 Lunch- 0%
12/6/21 Dinner-26-50%
During a review of the weekly Weight Variance Review dated 12/16/21, by the Registered Dietician (RD), it indicated that R42 was on a regular, fortified diet with ice cream with lunch and dinner. The record indicated, R42 generally eats between 26-75% of meals. It also indicated that R42 diet preferences were updated by the Dietary Supervisor (DS).
During an interview on 12/15/21 at 4:08 p.m. with R42, R42 stated he didn't eat much of his lunch because it's the same old thing. R42 stated, he was not offered anything else or substitutes.
During a concurrent interview on 12/15/21 at 4:14 p.m. with the Dietary Supervisor (DS) and R42, the DS stated, she was aware of R42 losing weight and R42 has been discussed on the weight variance meeting. The DS stated, nursing staff and the RD was aware too. The DS stated, she seen R42 on admission and got his food preferences. The DS offered R42 a tuna sandwich as a substitute choice. R42 stated he didn't eat bread because he can't digest it and it gets lodged in his stomach and causes pain. R42 informed the DS that he (R42) had gastric bypass surgery 7 or 8 years ago and can't eat bread. The DS stated, you didn't tell me before, I didn't know you didn't eat waffles, pancakes or toast. R42 stated, we never talked like this before.
During an interview on 12/16/21 at 8:32 a.m. with CNA 4, CNA 4 stated, R42 eats ok, usually 70 or 80 % of his meals. CNA 4 stated that sometimes R42, doesn't like what he gets but he gets house nourishments (milk supplements supplied by the facility that provides extra calories) daily. CNA 4 stated that it was important to get nourishments when you don't eat much so you won't lose weight. CNA 4 stated, the facility staff always offer R42 a sandwich, sometimes he takes it and at times R42 states he doesn't like the food. CNA 4 stated, I report it to the Charge Nurse when he doesn't like to eat.
During an interview on 12/16/21 at 8:44 a.m. with R 42, R42 stated he has not spoken with the DS since October 2021 and that no one asked if he had gastric bypass. R42 stated, he doesn't tolerate bread, it gets lodge in his stomach and makes him sick. When the facility serves sandwiches, he eats what's inside of it, but doesn't eat the bread.
During an interview on 12/16/21 at 8:47 a.m. with LVN 4, LVN 4 stated, R42 was picky with his food. LVN 4 stated she was aware R42 had lost weight and it is important to prevent weight loss. LVN 4 stated R42 might get confused, lose electrolytes (minerals in your body that have an electric charge), and become dehydrated (harmful reduction of water in the body). LVN 4 stated that R42 ate 30% for dinner and 20% for breakfast and lunch on 12/15/21.
During an interview on 12/16/21 at 9:03 a.m. with DS, the DS stated, she didn't know R42 had gastric bypass and was surprised yesterday. DS said, it wasn't on the chart that R42 had gastric bypass surgery 7 or 8 years ago. The DS says she sees residents and check their food preferences on every admission. DS stated, I have 3 days to do an assessment, but I haven't seen him since October 2021. DS stated that R42 is on the weight variance meeting weekly.
During an interview on 12/16/21 at 9:12 a.m. with the Assistant Director of Nurses (ADON), the ADON stated she was aware that R42 was losing weight and that is why he was on the weight variance weekly meeting. The ADON stated, R42 told her he had gastric bypass, just recently on December 7, 2021. The ADON stated, the Weight Variance Committee will have another weight variance meeting today and she will let the team (RD, DS and licensed nurse) know today that R42 had gastric bypass. The ADON stated, I am the only person that knows, that he shared it with, but he didn't tell me he can't eat bread. The ADON stated that R42 was choosy with his food.
During an interview on 12/16/21 at 9:58 a.m. with the Registered Dietician (RD), the RD stated in the weekly weight loss variance meetings, residents with significant weight changes like 5% or 5 pounds in one month, 7.5% in 90 days and 10% in 180 days or anyone that was a concern with poor oral intake. RD stated that R42 had a significant weight loss when he was readmitted on [DATE] from the hospital of 19 pounds, from 186 to 164 for the month of November 2021. The RD stated, R42 had a 12% weight loss percentage from September 2021, weighing 186 to December 2021, weighing 164. The RD stated that she did not know that R42 had gastric bypass surgery because it wasn't in the chart. RD stated that the DS told me yesterday (12/15). The RD stated that R42 preferences should be individualized because he could decline. RD stated the last line of defense for weight loss, is taking an oral (by mouth) appetite stimulant.
During a review of the facility policy Dietary-Food and Nutrition Preparation and Service dated 1/2017, the policy indicated that:
1.
The resident centered care plan will identify preferences of the resident.
2.
Each resident will be provided a nourishing, palatable, well balanced diet that meets their daily nutritional and dietary needs while considering the preferences of the resident.
During a review of the facility policy Weight Variance Committee, dated 10/2018, the policy indicated that the facility would review and monitor residents with weight variances at an interdisciplinary team meeting (IDT) on a regular scheduled basis and observe residents to determine reason for weight loss:
1.
Inadequate meal portions
2.
Dislikes of food; food preferences have changed
3.
Improper meal texture due to chewing or difficulty swallowing

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure a spare tracheostomy tube kit was at the bedside for emergency use for one of three sampled residents (Resident 9).
This failure had the potential to delay emergency treatment and further complicate resident 9's respiratory status.
Findings:
During a review of Resident 9's admission Record, the admission record indicated Resident 9 was admitted to the facility on [DATE], and was readmitted on [DATE] with diagnoses that included acute respiratory failure (condition in which the blood does not have enough oxygen or has too much carbon dioxide), tracheostomy (surgical opening created through the neck into the trachea (windpipe) to allow direct access to the breathing tube), cerebral infarction (stroke; damage to tissues in the brain), and hydrocephalus (a build-up of fluid deep within the brain).
During a review of Resident 9's History and Physical (H&P), dated 7/15/21, the H&P indicated Resident 9 was in a chronic vegetative state (complete unawareness of the self and the environment), and does not have the capacity to understand and make decisions.
During a review of Resident 9's Minimum Data Set (comprehensive screening tool [MDS]), dated 11/26/21, the MDS indicated Resident 9 required special treatment that included oxygen therapy (a treatment that provides supplemental or extra oxygen), suctioning (a process used to clear the airway so that a patient may breathe), and tracheostomy care (care done to keep your trach tube and the surrounding skin clean.
During a concurrent observation and interview on 12/15/2021, at 8:29 a.m., with Respiratory Care Practitioner (RCP) 2, in room [ROOM NUMBER], RCP2 was observed suctioning the trach of Resident 9. RCP2 was asked to show the surveyor the emergency trach kit that should be stored at the bedside. RCP2 was observed looking through the drawers and behind the bedside table, RCP2 stated he cannot find the emergency trach. RCP2 stated it is important to have an emergency trach kit at the bedside in case the resident's trach accidentally come out; if there is an emergency the emergency trach kit should be readily available.
During an interview on 12/16/21 at 12:25 p.m., with Respiratory Care Practitioner Supervisor (RCPS), RCPS stated she was informed by RCP2 he could not find the emergency trach at Resident 9's bedside. RCPS stated there should be an emergency trach kit at he bedside of all residents in the facility with tracheostomy's. It is important in case a residents trach come out we want to prevent the stoma from closing and the resident having respiratory distress. Trach or inner cannula changing must be done by two staff Respiratory Care Practitioner or Registered Nurses. RCPS stated respiratory in-services and training is conducted by the facility's respiratory consultant upon hiring, quarterly, and annually.
During a review of the facility's policy and procedure (P&P) titled, Tracheostomy Tube, Reserve Tube for Emergency Use, dated 5/2013, the P&P indicated it is the policy of the facility to maintain a tracheostomy tube of the appropriate size at the bedside of all intubated residents. The tracheostomy tube can be used for routine trach change but must be replaced immediately.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure one of four sampled residents (Resident 75) who received hemodialysis (a medical procedure to remove fluid and waste products from the body) had the necessary supplies (clamp) to stop bleeding in the emergency kit at Resident 75's bedside.
This deficient practice had the potential for resident 75 to receive delayed intervention during accidental bleeding.
Findings:
During a review of Resident 75's admission Record, the admission record indicated Resident 75 was admitted to the facility on [DATE] with diagnoses that included acute respiratory failure (condition in which the blood doesn't have enough oxygen or has too much carbon dioxide), tracheostomy (surgical opening created through the neck into the trachea (windpipe) to allow direct access to the breathing tube) cerebral infarction (stroke; damage to tissues in the brain), and end stage renal disease (permanent kidney function loss).
During a review of Resident 75's History and Physical (H&P), dated 8/12/21, the H&P indicated Resident 75 was alert, spoke English, and had the capacity to understand and make decisions.
During a review of Resident 75's Minimum Data Set (comprehensive screening tool [MDS]), dated 11/17/21, the MDS indicated Resident 75's cognition level for daily decision-making was intact and he required special treatment that included oxygen therapy (a treatment that provides supplemental or extra oxygen), suctioning (a process used to clear the airway so that a patient may breathe), tracheostomy care (care done to keep the trach tube and the surrounding skin clean), and dialysis (treatment in which waste and excess fluid is filtered from the blood).
During a review of Resident 75's Physician Order, dated 11/30/21, the Physician Order indicated Resident 75 required hemodialysis two times per week on Monday and Friday for two and a half hours.
During a review of Resident 75's Care Plan, dated 8/10/21, the Care Plan indicated Resident 75 is on hemodialysis and the facility will monitor the access site for bleeding. A dialysis emergency kit will be kept at bedside.
During a concurrent observation and interview on 12/16/21 at 10:23 a.m., with Registered Nurse (RN) 4 in room [ROOM NUMBER], RN1 was not able to locate the emergency clamp at the bedside of Resident 75. RN4 stated there is no clamp in the emergency dialysis kit at the resident's bedside. RN4 stated it is the responsible of the RN to check the dialysis emergency kit on a weekly basis. Resident 75 emergency kit was dated 12/12/21. RN4 stated it is important to have an emergency kit with a clamp at the bedside to stop bleeding in an emergency.
During a review of the facilities policy and procedure (P&P) titled Dialysis Care, revised 2/2018, indicated in the case of an emergency, at the bedside of a dialysis resident there should be a clamp, tape, 4x4's (bandage) and kerlix.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to assess, obtain consent and orders for, and care plan restraint use for one of two (2) sampled residents (Resident 240).
This deficient practice had the potential to result in Resident 240 sustaining injuries from being caught in between the rails or falling in attempts to climb over the rails, which would require additional care and treatment.
Findings:
During a review of Resident 240's Face Sheet, not dated, the document indicated the resident was admitted to the facility on [DATE] with diagnoses including cardiac arrest (abrupt loss of heart function, breathing, and consciousness), dependence on ventilator (a machine that delivers oxygen to the lungs to assist with breathing), tracheostomy (a surgically created opening through the neck into the trachea [windpipe] to help with breathing), end stage renal disease (ESRD - permanent kidney function loss), hypertension (high blood pressure), anemia (low number of red blood cells), dysphagia (difficulty swallowing food or liquids), atrophy (muscle wasting), and diabetes mellitus (chronic condition that affects how the body processes sugar).
During a review of Resident 240's Minimum Data Set (MDS - a comprehensive assessment and care-planning tool), dated October 23, 2021, the document indicated the resident is totally dependent and requires two or more persons physical assistance for bed mobility (how the resident moves to and from lying position, turns side to side, and positions body while in bed or alternate sleep furniture), and is totally dependent for transfer (how the resident moves between surfaces including to or from: bed, chair, wheelchair, standing position). Resident 240's MDS further indicated the resident has functional limitation in range of motion in which she has impairment on both sides of her upper extremities.
During a review of Resident 240's Physician Order Report, dated December 1 to December 31, 2021, the document indicated there were no physician orders regarding bed rails.
During a review of Resident 240's physician telephone order, dated December 16, 2021, the document indicated the resident's physician placed on order for bilateral (right and left) half side rails up while in bed per family's request to attain personal sense of security for safety with monitoring every shift.
During a review of Resident 240's Physical Restraint Assessment, dated December 16, 2021, the document indicated the assessment was completed on December 16, 2021.
During a review of Resident 240's Bedrail/Grab Bar Use and Entrapment Risk Evaluation, dated December 16, 2021, the document indicated the assessment was competed on December 16, 2021.
During a review of Resident 240's Informed Consent for the Use of Bedrails/Siderails, dated December 16, 2021, the document indicated the consent was obtained on December 16, 2021.
During a review of Resident 240's Resident Care Plan, dated December 16, 2021, the document indicated the care plan was created on December 16, 2021.
During an observation, on December 14, 2021, at 11:01 a.m., in room fourteen (14), of Resident 240, the resident was observed sleeping on her left side in bed with bilateral (left and right) side rails up.
During a concurrent observation and interview, on December 16, 2021, at 9:48 a.m., in room [ROOM NUMBER], of Resident 240, with Certified Nurse Assistant (CNA) 1, CNA1 confirmed the resident had bilateral side rails up on her bed but stated she was not sure why. CNA1 then stated when Resident 240 coughs she tends to move to one side so she puts pillows to the side that she moves. CNA1 stated a physician order is required to have bilateral side rails up because it restrains the resident in bed.
During an interview, on December 16, 2021, at 11:28 a.m., with Licensed Vocational Nurse (LVN) 2, LVN2 stated the use of bedrails requires consent from the resident if self-responsible, or their family because bed rails are considered as a restraint. lVN1 further stated restraints affect mobility and can cause a resident to not be able to move. LVN1 stated the use of bed rails also requires a physician order, care planning, and monitoring which is signed off on the resident's Medication Administration Record (MAR). LVN1 stated bed rails cannot be used if there is no order or consent for it.
During a concurrent observation, interview, and record review, on December 16, 2021, at 12:15 p.m., in room [ROOM NUMBER], of Resident 240, with LVN1, LVN1 confirmed the resident has bilateral half side rails up on her bed. LVN1 stated she was not sure how long the resident has been using the side rails. LVN1 stated when a resident has bilateral side rails up, it needs to be care planned because the rails restrain the resident. LVN1 reviewed Resident 249's medical chart and stated the resident has a physician order, consent, and a care plan for the side rails use, all three documents dated December 16, 2021. LVN1 stated licensed nurses can call family obtain consent for side rail use. LVN1 confirmed there was no other physician order, consent, or care plan for the side rail use dated from another time.
During an interview, on December 16, 2021, at 12:26 p.m., with CNA1, CNA1 stated Resident 240 has been using bilateral side rails in bed since she came back from the hospital, and was also using them prior to going to the hospital.
During an interview, on December 17, 2021, at 12:04 p.m., with the Director of Staff Development (DSD), the DSD stated restraint use requires consent and an order that reflects the duration of use. The DSD stated the standard of practice for restraints includes removing them every two hours to check for circulation and ensure the restraint is not too tight. The DSD stated if restraints are not removed routinely, the resident may become frustrated, and if restraints are tight it can cut off circulation causing the area to become blue, further causing potential to have the area where the restraints were applied to be removed.
During an interview, on December 17, 2021, at 12:43 p.m., with the Director of Nursing (DON), the DON stated it was brought to her attention yesterday that Resident 240 had issues with her side rails. The DON stated she instructed staff to assess the resident for the need for restraints, call the family and physician, obtain consent, and develop a care plan for the restraints. The DON stated the family needed to be called to be aware of the risks and benefits of having restraints. The DON stated placing a resident on restraints is risky because the resident can get entangled in between side rails or fall from a higher distance because of the side rails, which could cause more injury.
A review of the facility's policy and procedure (P&P), entitled Physical Restraints, dated September 2017, indicated the following:
Informed consent for the physical restraint, including the use of bed or siderails is required to be obtained from the resident or legal representative. Potential negative outcomes and benefits should be discussed. The use of anything attached to a normal bed (i.e., one-fourth rails as an enabler, grab bar attached to the bed, any assistive device, etc.) requires a comprehensive assessment, physician's order, informed consent, and a care plan to address the use. The risks and benefits of the use of bed or siderails or anything attached to the bed needs to be discussed prior to obtaining informed consent . The potential for serious injury is more likely from a fall from a bed with raised siderails than from a fall from a bed where siderails are not used.
The Physical Restraints P&P also indicated the following:
The use of restraints should be identified on the resident's plan of care and should include:
a. The medical symptoms that warrant the need for the restraint.
b. The symptoms that are being treated.
c. The type of restraint.
d. When the restraint is to be used.
e. The plan for release of the device for exercise and toileting every two (2) hours.
f. How the restraint will assist the resident in reaching his/her highest level of physical and psychosocial well-
being.
g. The resident's plan of care must indicate that the continued use of a restraint has been re-evaluated.
A review of the facility's P&P, entitled Informed Consent, dated September 2018, indicated the following:
If the physician, PA [abbreviation for Physician Assistant], or NP [abbreviation for Nurse Practitioner] determines that the resident requires and orders the use of siderails for the resident as a restraint, enabler, or assistive device, or the use of anything attached to a normal bed the facility may obtain informed consent from the resident or their responsible party . The facility shall verify that informed consent has been obtained prior to the administration of psychotherapeutic medication, use of siderails as a restraint, enabler or assistive device of the use of anything attached to a normal bed.
A review of the facility's P&P, entitled Comprehensive Care Planning, dated March 2019, indicated the following:
It is the policy of this facility that a comprehensive resident-centered care plan be developed for each resident that includes measurable objectives and timeframes to meet each resident's medical, nursing and mental and psychosocial needs that are identified in the comprehensive assessment .
The care plan must be reviewed and revised periodically, at least quarterly, and on an ongoing basis to reflect changes in the resident and the services provided or arranged must be consistent with each resident's written plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the physicians initial face-to-face visit was made within 72 hours after admission for one of 18 sampled residents (Resident 28).
This deficient practice had the potential to result in an undetected decline in medical, health or psychosocial condition and can lead to a delay in necessary care, treatment, and services.
Findings:
During a review of Resident 28's admission Record, the admission record indicated Resident 28 was admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses that included end stage renal disease (permanent kidney function loss), diabetes (chronic condition that affects how the body processes sugar), hypertension (condition in which the force of the blood against the artery walls is too high), and dysphagia (difficulty swallowing food or liquids).
During a review of Resident 28's History and Physical (H&P), dated 6/14/21, the H&P indicated Resident 28 was a [AGE] year-old female admitted to the facility from St. Mary's Medical Center. The H&P did not indicate the resident's cognitive status or decision-making capacity.
During a review of Resident 28's Minimum Data Set (comprehensive screening tool [MDS]), dated 9/19/21, the MDS indicated Resident 28 had a Brief Interview for Mental Status (BIMS - a tool used to calculate/assess cognition [process of thinking]; scores between 0 and 7 indicate severe cognitive impairment, scores between 8 and 12 indicate moderate impairment, and scores above 13 show little to no impairment) Score of 14. A BIMS score of 14 indicates the resident has intact cognition.
During a concurrent interview and record review on 12/17/21 10:25 a.m., with Director of Nursing (DON), Resident 28's History and Physical (H&P), dated 6/14/21 is the only H&P noted in the residents chart. A review of the physician progress notes dated, 11/15/21, 11/18/21, 11/22/21, and 12/2021 indicated Resident 28 was only seen via telehealth visits since her 11/10/2021 admission. DON stated it is requested the doctor come to the facility to see the residents within 72 hours after being admitted , H&Ps cannot be completed via telehealth visit, and the admission H&P must be an in person visit. DON stated it is important to have a timely H&P because the doctor need to access the resident, review and revise the hospital orders, and update the admitting orders and diagnoses. DON also stated medical records department is responsible for reviewing resident's charts and ensuring the H&P is in the chart within 72 hours after admission.
During an interview on 12/17/21 at 10:36 a.m., with Director of Medical Records (DMR), DMR stated there is not a new History and Physical (H&P) in Resident 28's chart. When a resident is admitted DMR stated she ensure the doctor come to the facility within 72 hours to compete the H&P and if the H&P is not received DMR post a list in the doctors charting room indicating what H&Ps are needed. If the H&P is still not received DMR call, fax, and email the doctor requesting the H&P.
During a review of the facilities policy and procedure (P&P) titled Physician Documentation, dated January 2014 indicated a current H&P shall be provided by the attending physician within 5 days prior to admission or within 72 hours following the admission.
During a review of the facilities policy and procedure (P&P) titled Physician Services and Orders, dated January 2017 indicated the resident must be seen by the physician on admission and at least every 30 days for the first 90 days and at least once every 30 days thereafter.